Tracheoesophageal Fistula

A tracheoesophageal fistula is an abnormal communication between the tracheobronchial tree and oesophagus.

Most congenital fistulas occur with oesophageal atresia, particularly a distal fistula associated with type C atresia.

An isolated fistula with intact oesophageal continuity is termed an H type tracheoesophageal fistula.

The physiological consequences depend on the pressure gradient between airway and oesophagus.

Air can enter the gastrointestinal tract during ventilation, while gastric or oesophageal contents can enter the airway during swallowing.

A fistula associated with oesophageal atresia usually presents in the neonatal period as described above.

An isolated H type fistula can be considerably more difficult to diagnose.

Typical features include:

• Coughing during feeds
• Choking
• Cyanotic episodes with feeding
• Recurrent lower respiratory infection
• Persistent wheeze
• Recurrent aspiration pneumonia
• Abdominal distension during positive pressure ventilation

Symptoms may be intermittent, and some children are diagnosed months or years later.

For suspected H type fistula, a routine contrast swallow can miss the lesion.

A carefully performed prone or oblique pullback contrast oesophagram can improve detection.

Bronchoscopy is particularly useful because it can:

• Identify the tracheal opening
• Determine its relationship to the vocal cords and carina
• Exclude additional airway pathology
• Permit catheterisation of the fistula before surgery

Oesophagoscopy can provide complementary localisation.

Repeated normal routine contrast studies do not reliably exclude an H type fistula when clinical suspicion remains high.

Initial management

Prevent aspiration.

Use:

• Appropriate feed modification or temporary cessation of oral feeds when severe
• Enteral access distal to the fistula when necessary
• Treatment of aspiration pneumonia

A significant symptomatic congenital fistula requires definitive closure.

H type fistula repair

The operative approach depends on fistula level.

Most H type fistulas lie in the lower cervical or upper thoracic region.

A cervical fistula can be approached through a neck incision.

Identify and protect:

• Recurrent laryngeal nerve
• Trachea
• Oesophagus

Divide the fistula.

Close both defects separately.

Interpose vascularised tissue, such as strap muscle, between the tracheal and oesophageal suture lines where feasible to reduce recurrence.

Lower fistulas can require thoracic or thoracoscopic exposure.

Recurrent fistula

Recurrent fistulation after neonatal EA repair is challenging because the mediastinum is scarred.

Initial stabilisation includes control of aspiration and respiratory infection.

Definitive repair can require:

• Open or thoracoscopic fistula division
• Tracheal repair
• Oesophageal repair
• Interposition of pleura, pericardium, muscle or other vascularised tissue

Endoscopic obliteration techniques using cautery, adhesive or other methods can be used in selected small recurrent fistulas, but persistent disease often requires formal surgical division.

Complications

Important postoperative problems are:

• Recurrent laryngeal nerve injury
• Fistula recurrence
• Oesophageal leak
• Stricture
• Tracheomalacia
• Continued aspiration from dysmotility or reflux despite successful fistula closure