Acquired Tracheoesophageal Fistula

Granulomatous infection, foreign bodies, and trauma used to be the most common causes of benign acquired tracheoesophageal fistula (TEF). Added to these were fistulae from complications of surgical procedures such as anterior cervical spine fusion and laryngectomy. With widespread use of cuffed tubes for ventilation, postintubation fistulae became predominant. In 1968, in a review of acquired nonmalignant esophagotracheal and esophagobronchial fistulae, Wesselhoeft and Keshishian reported no cases of tracheoesophageal fistula related to cuffs.1 By 1973, Thomas collected 46 such cases (30 fully documented), including 7 of his own.2 Although the use of low-pressure, large-volume cuffs has reduced the incidence, fistulae from this source remain the most common. Immunodeficiency syndromes may also result in fistulae.

In fistulae due to granuloma and foreign body, the pathology involves the membranous wall of the trachea and is often limited in extent.3 Traumatic fistulae may be very extensive and be accompanied by mediastinal inflammation and infection. A postintubation fistula results from erosion of the membranous wall of the trachea and the adjacent esophageal wall, "the party wall," because of pressure from the ventilatory cuff usually exerted against a firm nasogastric tube lying in the esophagus (Figures 12-1, 12-2) (see Chapter 11, "Postintubation Stenosis"). Overinflation of a large-volume cuff by even a small, added volume of air converts it to a high-pressure cuff. The fistula may erode the entire width of the membranous wall; these are often termed "giant fistulae." Since the inflammatory process is progressive, there is never leakage into the mediastinum in the way there is in a traumatic fistula. Spontaneous healing of such fistulae has not been documented, although on rare occasion, a small recent traumatic fistula may close spontaneously. Circumferential injury to the trachea is almost always present concurrently with a postintubation TEF due to pressure necrosis caused by the cuff.

Fistula from the neoesophagus to trachea after esophagectomy is fortunately rare.4 These may follow anastomotic leakage, dilation of stenosis, or tracheal or enteric ischemia as a result of surgical dissection.5 Cervical anastomotic leakage is a principal cause. Symptoms range from cough associated with ingestion to life threatening aspiration pneumonia.

Stenosis The Trachea With Balloon

figure 12-1 Origin and anatomy of postintubation tracheoesophageal fistula. Lateral diagrams of the trachea and esophagus. A, The overdis-tended cuff has injured the trachea circumferentially. The "party wall" posteriorly has become devascularized and has necrosed by being pinched between the cuff and a firm nasogastric tube in the esophagus. B, The fistula is usually below the stoma, at the level of the balloon cuff.

figure 12-1 Origin and anatomy of postintubation tracheoesophageal fistula. Lateral diagrams of the trachea and esophagus. A, The overdis-tended cuff has injured the trachea circumferentially. The "party wall" posteriorly has become devascularized and has necrosed by being pinched between the cuff and a firm nasogastric tube in the esophagus. B, The fistula is usually below the stoma, at the level of the balloon cuff.

More recently, expandable stents have caused TEF spontaneously, after placement of an expandable coated esophageal stent, and as a consequence of difficult removal of a tracheal stent which has become severely obstructive.6,7

The rare but devastating occurrence of necrotizing esophagitis that occurs in immunodeficiency states produces both TEF and bronchoesophageal fistula (BEF), with a high mortality rate.8

Malignant TEF often results from carcinoma of the esophagus, and less so from carcinoma of the lung or lymphoma. Isolated instances have been associated with adenoid cystic carcinoma and even carcinoid tumor. Irradiation treatment of esophageal carcinoma that involves the tracheal wall may accelerate fistula formation.

The topic of congenital tracheoesophageal fistula and esophageal atresia has been extensively treated in many textbooks of surgery and pediatric surgery. It is not included in this book, especially since the reconstructive problem is largely esophageal. Rarely, a small recurrent fistula may become symptomatic many years after repair of a congenital TEF in infancy. Attention should be called, however, to the very rare and usually cervical congenital H-type fistula without esophageal atresia, which may give symptoms later in life (see Chapter 6, "Congenital and Acquired Tracheal Lesions in Children"). The signs are principally cough or choking episodes after ingestion of liquid or other food. The fistula may be very small and clini cal presentation not obvious. Repeated bouts of respiratory infection may occur. Suspicion leads to diagnosis by bronchoscopy and radiography.9,10 A description is included at the end of this chapter of the rare entity of bronchoesophageal fistula, both congenital and acquired.

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