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 , 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. and trachea which can be congenital or acquired. She was operated for the fecal fistula and a 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 was done. On the tenth postoperative day & Hospital, Chandigarh with the complaint of cough, regurgitation flexible upper gastro intestinal 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 , 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 have been widely used for the of blood flow to tracheal epithelium 14. treatment of strictures & malignant obstruction. Table I: Risk factors for development of Tracheo-esophageal Fistula We used a different technique to close the TEF by putting a stent , ", " High cuff pressure's in the esophagus & making the edges of fistula raw with chemical Advanced age 16 . cautery to promote granulation tissue and healing. The stent Nasogastric tube 9•". prevented the salivary secretions from coming in contact with the High airway pressure 18 . fistula and interfering with healing. The nutrition of the patient, Excessive motion of tracheal tube's. however, was managed with gastrostomy feeds. The approach Prolonged duration of intubation 19 . can be used in selected patients only, depending upon the size Steroids". and site of TEF. Larger fistulae and those situated lower down • Respiratory infections 20 . e.g. supra carinal can not be managed by this technique. Another • Hypotension 20 . important thing to remember is the size and shape of the stent. • Female sex 21 .

M Indian Journal of Otolaryngology and Head and Neck Surgery Vol. 58, No. 3, July-September 2006 Tracheoesophageal Fistula:New Option in Management

If it is over sized then the stent will itself cause ischemia and 13. Kastanos N, Estopa Miro R, Marin Perez A, et al. necrosis leading to increase in size of the fistula. Anteriorly the Laryngotracheal injury due to endotracheal intubation: tracheostomy tube and posteriorly the stent can cause the same Incidence, evolution and pre disposing factors. A long term damage. To avoid this injury once the stent is inserted the size of study. Crit Care Med 1983;11:362-67. the tracheostomy tube is reduced and preferably an uncuffed tube is inserted. The shape of the stent is funnel shaped (Fig. ) 14. Seegobin RD, van Hasselt GL. Endostracheal cuff pressure and it helps to retain the stent superior to the site of fistula and and tracheal mucosal blood flow: Endoscopic study of at the same time not exerting pressure over the party wall. effects of four large volume cuffs. Br Med J. 1984;288:965- 68. To conclude this technique can be used in selective group of 15. Knowlson GTG, Bassett HEM. The pressures exerted on the patients keeping in view the general condition of the patient. trachea by endotracheal inflatable cuffs. Br J Anaesth 1970;42.34-37. REFERENCES: 16. Stauffer JL, Olsen DE, Petty TL. Complications and 1. Green RP, Biller HF, Sicular A. Cervical consequences of endotracheal intubation and Tracheoesophageal fistula. Laryngoscope 1983;93:364- tracheostomy. Am J Med. 1981;70:65-76. 369. 17. Hilgenberg AD, Grillo HC. Acquired non malignant 2. Mellins, R.: Acquired fistula between the Esophagus and Tracheoesophageal fistula. J Thorac Cardiovasc Surg the respiratory tract. New Engl.J.Med. 1983;85:492-98. 1952;246(23):896-901. 18. Bugge-Asperhiem B, Birkeland S, Storen G. 3. Gudovsky LM, Koroleva NS, Biryukov YB. Tracheoesophageal fistula caused by cuffed endotracheal Tracheoesophageal fistulas. Ann Thorac Surg. tubes. Scand J Thorac Cardiovasc Surg 1981;15::315-319. 1993;55:868-875. 19. El-Naggar M, Sadagopan S, Levine H, et al. Factor 4. Mathisen DJ, Grillo HC, Wain JC. Management of acquired influencing choice between tracheostomy and prolonged non malignant Tracheoesophageal fistula. Ann Thorac translaryngeal intubation in acute respiratory failure : a Surg 1991;52:759:765. prospective study. Anesth and Analg 1976;55:195-201.

5. Thomas AN. The diagnosis and treatment of 20. Miguel RV, Graybar G, Subaiya L,et al. Emergency Tracheoesophageal fistula caused by cuffed tracheal tube. management of tracheal rupture. South Med Jour J Thorac Cardiovasc Surg. 1973;65:612-619. 1985; 78:1132-35. 6. Thomas AN. Management of Tracheoesophageal fistula 21. Gaynor EB, Greenberg SB, Untoward sequelae of prolonged caused by cuffed tracheal tubes. Am J Surg 1972;124:181. intubation. Laryngoscope 198595:1461-67. 7. Bartlett RH. A procedure for management of acquired 22. Kelly JP, Webb WR, Moulder PVet al. Management of Tracheoesophageal fistula in ventilator patients. J Thorac airway trauma. II: Combined injury of the trachea and Cardiovasc Surg 1976;71:89. esophagus. Annals of Thoracic Surgery 1987;43:160-63. 8. Utley JR, Dillon ML, Todd EP, et al. Giant 23. Grillo H.C., Moncure AC, McEnany MT. Repair of Tracheoesophageal fistula. J Thorac Cardiovasc Surg inflammatory Tracheoesophageal fistula. Annals of 1978;75:373. Thoracic Surg 1976;22:112-19. 9. Harley HR. Ulcerative Tracheoesophageal fistula during 24. Shaari Christopher, Biller HF Staged repair of cervical treatment by tracheostomy and intermittent positive tracheoesophageal fistulae. Laryngoscope pressure ventilation. Thorax 1972;27:338-52. 1996; 106:1398-1402. 10. Flege JB: Tracheoesophageal fistula caused by cuffed Address for correspondence tracheostomy tube. Ann Surg 1967;166:153. Dr.Surinder K.Singhal Senior Lecturer 11. Cooper J.D., Grillo HC. The evolution of tracheal injury Department of ENT due to ventilatory assistance through cuffed tubes : a Government Medical College & pathological study. Anals of Surgery. 1969;169:334-48. Hospital, Sector-32-A 12. Hedden M, Ersoz CJ, Safar P. Tracheoesophageal fistulas Chandigarh -160 030 following prolonged artificial ventilation via cuffed INDIA tracheostomy tubes. Anaesthesiology. 1 969;31:281-89.

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