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Tracheoesophageal Fistula(TEF), Tracheostomy, Nasogastric Tube, Esophageal Stent, Trichloroacetic Acid (TCA)

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Tracheoesophageal Fistula(TEF), Tracheostomy, Nasogastric Tube, Esophageal Stent, Trichloroacetic Acid (TCA) hf RACI PHAGEAL FISTULA: ON IN MANAGEMENT Surinder K. Singhal,* Ramandeep S.Virk, ** Arjun Dass,*** Biinaljit Singh Sandhu**** Key words: Tracheoesophageal fistula(TEF), Tracheostomy, Nasogastric tube, esophageal stent, trichloroacetic Acid (TCA). INTRODUCTION: & vomiting after taking food. The patient was a known diabetic and hypertensive on regular treatment. She had undergone a Tracheoesophageal fistula (TEF) is a communication between the medical termination of pregnancy and developed a faecal fistula. esophagus and trachea which can be congenital or acquired. She was operated for the fecal fistula and a colostomy was also About 80% of the acquired tracheoesophageal fistulae are done but on the second post operative day she had cardiac malignant and rest non-malignant' . arrest. She was intubated and revived. Later she underwent a Nonmalignant fistulae are usually due to trauma which can be tracheostomy and remained on ventilatory support for two iatrogenic, internal or external. latrogenic fistulae may occur weeks. She was gradually weaned off the ventilator and on 19` 1 following mechanical ventilation or as a complication of day of tracheostomy she was decanulated and discharged. tracheostomy. Internal trauma may be due to cuffed endotracheal She came back after a week with the complaints of violent cough, tube or nasogastric tubes or a combination of both. It may be regurgitation and vomiting after meals. Systemic examination external trauma from penetrating foreign bodies, open or closed was within normal limits. Colostomy bag was in situ. Local aero digestive tract injuries' .There are many risk factors examination revealed a tracheostomy scar. Oral cavity and associated with post intubation tracheoesophageal fistula like Oropharynx were unremarkable. Indirect Laryngoscopy revealed elevated tracheal cuff pressure, excessive motion of the tube, secretions in both pyrifom fossae and both the cords were mobile. infection, hypotension, corticosteroids, and diabetes mellitus3,4 . A sip of water was given to the patient and it was immediately TEF at the level of stoma are usually a complication of followed by violent cough suggestive of aspiration. A clinical tracheostomy where the injury is caused on the posterior tracheal possibility of post tracheostomy tracheoesophageal fistula was wall while making the tracheostome or in a patient who has a thought and a Ryle's tube was inserted. The patient was nasogastric tube in the esophagus and the opening is made in the investigated. Barium swallow was done which revealed a oesophagus accidentally. TEF from cuffed endotracheal tubes communication between trachea and esophagus. Endoscopic usually occurs between the sixth cervical and first thoracic vertebra assessment under general anesthesia was done. Bronchoscopy and manifests only after seven days or mores . revealed a defect in the post tracheal wall approximately 0.75cm With the advent of high volume, low pressure tubes the incidence x 0.5cm in size and about 2.5cms the vocal cords. On of post intubation TEF has been reduced markedly yet the risk is esophagoscopy a defect about 2 cm distal to upper esophageal not eliminated totally. Contamination of the tracheobronchial tree sphincter of the same size was seen. The patient was planned for and interference with nutrition are life threatening aspects of this repair of fistula under general anesthesia. condition. Till date there is no report to suggest that the fistula Two weeks later the patient was taken up for repair of fistula. A can heal spontaneously and a large number of surgical techniques revision tracheostomy was done. The fistula was approached have been described in the literature. These include direct closure via lateral cervical route and taking care to save the recurrent of both defects, esophageal diversion, closure of the defect with laryngeal nerve the fistula was excised and the defect was closed muscle flap and tracheal closure with dysfunctional oesophagus 6' 7 ' 8 primarily. Sternal head of the sternocleidomastoid muscle was We describe a, different technique of closure of TEF which has rotated and was sutured over the suture line to give it vascularity not been mentioned earlier. and strength. CASE REPORT On the third postoperative day there was wound breakdown A 21 year old female patient presented to the out patient with recurrence of fistula. The nasogastric tube was removed department of Ear, Nose & Throat at Government Medical College and gastrostomy was done. On the tenth postoperative day & Hospital, Chandigarh with the complaint of cough, regurgitation flexible upper gastro intestinal endoscopy was done and it _* Senior Lecturer, ** Senior Resident, *** Prof. & Head, ENT, **** Senior Lecturer, Dept. of Medicine Department of Otolaryngology & Medicine 300 Government Medical College & Hospital Chandigarh, India, 160 030 Indian Journal of Otolaryngology and Head and Neck Surgery Vol. 58, No. 3, July-September 2006 Tracheoesophageal Fistula:New Option in Management below the upper esophageal sphincter and the size was approximately 1cm x 0.5cm. During this period she had an anterior wall myocardial infarction which was successfully managed. Keeping in view the patients poor nutritional status it was decided to insert an esophageal non-metallic stent to bypass the fistula. A non-metallic stent having a length of 12.4cm was placed under fluoroscopic guidance. The outer diameter was 16mm and the inner diameter was 12mm.To prevent its migration down the oesophagus it was secured by two silk sutures passed through the funnel of the stent and tied around the columella. The size of the tracheostomy tube was reduced and an uncuffed tube was Photograph showing the non metallic esophageal stent with funnel shaped inserted to prevent rubbing of the stent and tracheostomy against top which prevented migration. each other and causing pressure necrosis. Next day trichloroacetic acid cautery was touched to the fistula edges through the The nasogastric tube may also act as an abrasive against the tracheostome and repeated weekly to promote healing of the anterior esophageal wall. This leads to ulcerative tracheal fistula. The fistula was regularly evaluated as it was clearly seen inflammation and necrosis. Position of the head also alters amount from the tracheostomy. The fistula size gradually reduced and of pressure exerted by the cuff on the tracheal wall. Flexion causes three weeks later there was complete healing. The stent was more pressure to the anterior wall of the trachea, where as extension removed and endoscopy revealed granulation tissue at site of the causes more pressure posteriorly 15 .There were several of these fistula. The patient was started on oral feeds gradually from liquids risk factors in our patient. to semisolids and later normal feeds were given. Once she was accepting all feeds orally the feeding gastrostomy was closed. Diagnosis of TEF is suggested by many symptoms. Among them She was discharged and was admitted for colostomy closure 5 are violent coughing after swallowing, food at the tracheostomy site, abnormal passage of catheters or tubes and air escape into months later which was done successfully. the hypopharynx despite adequate cuff inflation. Thomas' has DISCUSSION outlined definite diagnostic criteria Tracheoesophageal fistula can be either congenital or acquired. A. Direct visualization with a special feature such as Acquired fistulae can be malignant or non malignant. Acquired 1)Ryle's tube or posterior wall mucosa seen on tracheostomy. non-malignant tracheoesophageal fistula occurs in approximately 2) Tracheal tube seen on esophagoscopy. 0.5% of patients undergoing tracheostomy 9 .This condition is 3) Well defined edges of fistula seen moving on respiration. unusual, serious and poses a challenging problem. Contamination of the tracheo- bronchial tree and interference with nutrition are B. Radiology: Demonstration of contrast at the site of fistula life threatening aspect of this condition. All patients not surgically C. Operative or autopsy confirmation. managed die of their disease. After extensive investigations and reviews it became clear that cuffed tubes were the most frequent False negative rate of 12.5% has been reported for contrast studies cause of this problem and the fistula occurred while patients were Zz . Esophagoscopy is recommended in all patients having receiving positive pressure ventilation for respiratory failure 10 .The suspicion of fistula. Till date there is no report to suggest that the advent of high volume, low pressure cuffs has reduced the incident fistula can heal spontaneously and hence surgery is now accepted but not eliminated it. Risk factors which have been reported for as the treatment for proven cases 5,7,23 . This includes direct closure tracheal damage are shown in Table 1. High intra cuff pressure is of defects, esophageal diversion, closure of the defect with muscle probably the single most important factor in development of an flaps and tracheal closure with dysfunctional esophagus. acquired TEF"• 12,13 . Cuff pressures above 22mm of Hg have been However there is disagreement over the timing. Some advocate shown to cause decreased capillary perfusion of the tracheal immediate interventions whereas others advocate staged mucosa and pressure of 40mm of Hg may result in total obstruction procedures"'24 . Esophageal stents have been widely used for the of blood flow to tracheal epithelium 14. treatment of strictures & malignant obstruction. Table I: Risk factors for development
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