Postintubation tracheoesophageal fistulae usually result from erosive injury by a cuff, which concurrently causes circumferential tracheal injury (see Chapter 12, "Acquired Tracheoesophageal and Bronchoesophageal Fistula") (Figure 26-1). Fistulae very rarely can also result from erosion by the tip of a posteriorly angulated tracheostomy tube, without circumferential injury. Tracheal injuries, when present, should be corrected at the same time as closure of the fistula. An attempt to do this in stages demands two difficult operations, the second compounded by surgical reaction to the first intervention. Furthermore, resection of a tracheal stenosis provides incomparable access to an esophageal fistula. If a patient is still on a respirator when the fistula is discovered, the patient should be weaned prior to repair. Attempts to seal a fistula in a ventilated patient with muscle flaps or the defunctioned esophagus are likely to fail. Any tube in the esophagus is removed and ventilation is continued with the lowest cuff pressure that will provide a gentle seal of the trachea. If the cuff can be placed below the fistula, so much the better. A gastrostomy tube drains the stomach to prevent reflux and aspiration, and a jejunostomy tube is used for feeding. After weaning from the respirator, single-stage repair is done. Esophageal diversion by cervical esophagostomy or exclusion is almost never necessary. In the case of high fistulae close to the cricopharyngeus (as many of these are), diversion is impossible anyway. Elec-
figure 26-1 Postintubation tracheoesophageal fistula. A, Fistula resulting from pressure damage to the trachea by the sealing cuff on a tracheostomy tube used for ventilatory support. a = cricoid cartilage. The stoma (b) lies above the area of circumferential injury (d) caused by the cuff. The fistula (c) is located posteriorly in this segment. The length of relatively normal trachea between the stoma and segmental injury varies but is most often short. B, Diagram of the sagittal section of A. Note the relative levels of stoma and fistula, and also the damage to the cartilaginous tracheal wall at the same level as the fistula. Due to the gradual and inflammatory nature of the fistulization, the membranous wall of trachea is fused to the anterior esophageal wall and the margin of the fistula is epithelized.
tive diversion is to be avoided, since it complicates treatment and may be difficult to reverse regardless of whether the esophagus is transected proximally or exteriorized in continuity.
Anesthesia for repair may be initiated through an existing tracheostomy, which is usually present. The gastrostomy tube is put on suction. If neither is present, the stomach is aspirated, placed on suction, and endotracheal intubation is accomplished rapidly. Bronchoscopy and esophagoscopy are performed, if not previously done by the surgeon, using rigid endoscopes. An endotracheal tube is then positioned, preferably perorally, so that its cuff seals the fistula during initial dissection. The endotracheal tube must not be allowed to slip into the esophagus via the fistula. Gastrostomy tube or nasogastric tube suction is continued to control leakage of gas through the fistula. A nasogastric tube is also useful as a guide for esophageal dissection. Most postintubation fistulae are high since they result from erosion related to the cuff on a tracheostomy tube (see Figure 26-1).2 They are approachable, therefore, through a collar incision, and rarely require even upper sternal division except in the aged and kyphotic patient.
The collar incision usually circumcises the stoma. Initial dissection, as described for anterior tracheal resection, is kept very close to the trachea at the level of the lesion (see Chapter 24, "Tracheal Reconstruction: Anterior Approach and Extended Resection"). The recurrent laryngeal nerves will fall away with the lateral tissues and must not be individually dissected or identified. The trachea is dissected circumferen-tially, just inferior to the fistula. This plane can usually be established with gentle and persistent dissection despite inflammatory adherence of the posterior wall of the trachea to the esophagus, which may extend for varying distances below the fistula (Figure 26-2A). Only 1 or 2 cm of trachea that will remain should be dissected circumferentially. The esophagus does not have to be circumferentially dissected, but it is necessary to free enough esophageal wall lateral to the fistula on both sides so that esophageal closure can be done in two layers without tension on the suture line. As much dissection as can be accomplished superiorly is also performed prior to division of the trachea. Proximity to the cricoid often inhibits posterior superior dissection at this stage. The thyroid gland is separated from the trachea only to the extent needed for tracheal resection and excision of fistula. This dissection is described in Chapter 24, "Tracheal Reconstruction: Anterior Approach and Extended Resection." The recurrent nerves are not visualized but are displaced laterally, because the plane of dissection is immediately on the trachea and then the esophagus.
The trachea is transected below the distal margin of the stenotic segment. The proximal specimen is elevated with two laterally placed Allis forceps and dissection continued until the fistulous connection is completely freed circumferentially, preferably before it is opened into (Figure 26-2B). Occasionally, the proximal end of the fistula commences immediately below the cricoid cartilage, making it impossible or unwise to dissect over the top of the fistula until it is incised from below on each side. Otherwise, recurrent nerve injury could result near their entry points into the larynx posterolaterally. In many cases, a tracheal stoma is so close to the injured segment of trachea that it is most conveniently included in the resection of the tracheal segment. If, however, there is a segment of normal trachea between the stoma and the stenotic segment, the stoma may be left in place to avoid excessively lengthy resection. If the lower border of the fistula is coincidental with the lower margin of the tracheal stenosis, the fistula is entered at the point where it joins the esophagus, and it is excised upward in an elliptical fashion, saving all esophageal wall that is of good quality (see Figure 26-2B). The trachea is divided above and the excision of the fistula completed.
Postintubation fistulae are sometimes described as "giant" fistulae. They may involve the entire width of the membranous tracheal wall. A large fistula may also involve the membranous wall to a level considerably below the level of circumferential damage to the cartilaginous wall of trachea. In such a case, it is often best to preserve normal cartilages rather than extend the tracheal resection to a length that might produce hazardous anastomotic tension (Figure 26-3A). With a giant fistula, the remaining membranous wall will be insufficient at the level of the fistula to allow simple closure of the posterior wall of the trachea. The distal line of excision of the fistula, at the level of the tracheal cartilages that are to be salvaged, is therefore tailored into the esophagus, "stealing" portions of esophageal wall for reconstruction of a membranous trachea (Figures 26-3B,C). These flaps are dissected very carefully in order not to injure their effectively parasitic blood supply from the trachea. The "U" gap in the posterior membranous wall is closed by suturing the attached segments of esophageal wall vertically together in the midline using 4-0 Vicryl sutures (Figures 26-3D-F). The knots are placed posteriorly rather than in the lumen. There is more than adequate esophageal circumference, so that loss of this tissue will not adversely affect esophageal closure or function (see Figure 26-3E). It is a mistake to pull the trachea together under tension in an attempt to close a wide defect in the membranous wall.
The esophagus is closed longitudinally with two layers of 4-0 silk or Vicryl, using the technique of Sweet.3 The inner layer of sutures is placed so that the knots will lie inside the esophageal lumen (Figure 26-4A). These sutures include only the esophageal mucosa, which is of strong consistency. They are started from above, then from below, inverting each successive suture. The final suture is placed in the middle of the esophageal closure and inverted with a Connell suture. The second layer closure of Lembert sutures includes the esophageal muscularis (Figure 26-4B). Enough esophageal circumference should be dissected so that closure is without tension, but no more than that.
If the superior margin of the esophageal fistula is close to the lower border of the cricoid, closure may be difficult. Dissection may be carefully made a few millimeters cephalad behind the posterior plate of the cricoid.
figure 26-2 Resection of tracheoesophageal fistula. Since tracheostomy is usually high in the trachea, the fistula resulting from cuff injury is not far below and approach is most often by collar incision only. In older patients or where a stoma was placed too low in a young patient, upper sternotomy may be required. Usually, the collar incision circumcises the stoma in its midpoint. If the stoma is very high, the collar incision is placed low in the neck (see Figure 23-2 in Chapter 23, "Surgical Approaches"), and the stoma is excised later through a separate short incision, as the upper flap of skin and platysma are elevated. Dissection of the trachea is initially done as described in Chapter 24, "Tracheal Reconstruction: Anterior Approach and Extended Resection." Recurrent laryngeal nerves are not dissected out. A, Circumferential dissection is accomplished just below the stenotic segment, freeing no more than two intact tracheal rings. Note preserved lateral attachments which carry tracheal blood supply. Proximal circumferential dissection is also limited if a tracheal segment below the stoma is to be preserved. In this case, the "isthmus" between the stoma and stenosis is too limited and involved by stomal granulations and inflammation to be useful in reconstruction. The total length of resection when stenosis, stoma, and residual segment are added together must not prohibit safe reconstruction. If more than one satisfactory cartilaginous ring is present below the stoma, this segment should be saved. Remember, the surgeon can always remove more trachea later in the operation, so initial resection should be conservative. Often, circumferential dissection above the fistula is very difficult due to inflammatory adhesion or proximity to cricoid. In such case, it should be deferred and accomplished later as the fistula is excised and the divided trachea is retracted upward. The esophagus is freed bilaterally enough to provide for tension-free closure. It is not usually necessary to dissect it circumferentially. If this is required, short segment esophageal mobilization will not injure its blood supply. Note the lateral traction sutures (2-0 Vicryl) placed one or two rings away from the anticipated level of tracheal transection. Proximal sutures may be placed in lateral cricoid laminae, if the stoma is just below the cricoid or has injured it (see Chapter 24, "Tracheal Reconstruction: Anterior Approach and Extended Resection" and Chapter 25, "Laryngotracheal Reconstruction"). B, The trachea has been transected and intubated distally. The damaged trachea is elevated by placing Allis forceps on either side (only one is shown for clarity) of the specimen. The fistula is circumcised following its margins on either side. This dissection allows easier development of the plane above the fistula between trachea and intact esophagus. (See text for description of dissection when superior margin of fistula is adjacent to the posterior cricoid lamina.) Resection is completed by proximal division of trachea (see Figure 12-8 in Chapter 12, "Acquired Tracheoesophageal and Bronchoesophageal Fistula").
Posterolateral dissection at this level is inhibited by concern for recurrent laryngeal nerves. This limited dissection should provide sufficient mobility to commence apical closure. In a single patient with laryngotracheal stenosis and what appeared to be iatrogenic fistulization through the posterior cricoid plate, closure finally required elevation of laryngeal mucosa over the plate and removal of some posterior cricoid cartilage to give access for pharyngoesophageal closure. Strap muscle was interposed and a posterior membranous tracheal wall flap was anastomosed to the laryngeal mucosa (see Chapter 25, "Laryngotracheal Reconstruction").
figure 26-3 Preservation of tracheal length where giant fistula extends distal to the level of cartilaginous injury, and where extension of tracheal resection would increase the prospect of excessive anastomotic tension. A, Here, the distal extremity of a giant fistula is below the level of distal intact tracheal rings. Since the proximal stoma must also be resected because of proximity to the stenosis, further removal of two distal tracheal rings to encompass the fistula would result in possibly excessive anastomotic tension. B, Stenotic, severely damaged tracheal segment has been excised, saving distal anterolateral undamaged trachea despite extension of a giant posterior tracheoesophageal fistula below this level. In order to reconstruct the membranous wall and so salvage a functional length of trachea, full thickness flaps of esophageal wall are created bilaterally (dashed lines), extending from the level of tracheal division to the bottom of the membranous wall defect. In the initial dissection, and in raising these flaps, care is taken not to thin the tissues at the junction of the fistulous margin between trachea and esophagus, since this will be the source of blood supply for the flaps. A minimal amount of distal dissection opens the plane between intact membranous tracheal wall and esophagus to allow linear closure of the esophagus. Two-layered closure is done, as shown in Figure 26-4. C, Cross-sectional diagram of membranous wall reconstruction at the level of the fistula. Flaps of esophageal wall are outlined on each side, with care to preserve blood supply at the junction of esophageal and tracheal walls. D, Defect repaired by inversion of esophageal wall flaps. The esophageal defect is repaired in its entire length. The slight esophageal narrowing is of no consequence. E, After layered esophageal closure, the suture line is covered with a flap of strap muscle. F, Esophageal closure has been completed (dotted line) and covered with a sternohyoid muscle flap. The posterior tracheal wall is reconstructed by turning the bilateral esophageal flaps medially, approximated with interrupted 4-0 Vicryl sutures placed with knots outside the tracheal lumen. The tracheal anastomosis completes the repair, performed as described in Chapter 24, "Tracheal Reconstruction: Anterior Approach and Extended Resection." A mattress suture (4-0 Vicryl) is used at the junction point of the circumferential tracheal anastomosis and the vertical suture line of the membranous wall repair.
A sternohyoid muscle or, less commonly, a sternothyroid muscle, is divided high and rotated to provide a flap over the esophageal suture line, to interpose healthy tissue between esophageal and tracheal suture lines (Figure 26-4C). As little muscle is dissected free as is needed, in order to protect blood supply. Even slightly dusky muscle survives. It is sutured with interrupted 4-0 silk or Vicryl around the entire length of the esophageal closure as if it were an anastomosis. The tracheal anastomosis is next completed as previously described. If a vertical closure of "membranous wall" of the trachea has been necessary, as shown in Figure 26-3F, special care is taken at the meeting point of that suture line with the tracheal anastomotic line, using a mattress suture in this case. The gastrostomy and jejunostomy are left in place until healing figure 26-4 Esophageal closure. A, Sutures (4-0 silk or Vicryl) mark the proximal and distal limits of the defect, which will be closed vertically. Mucosal closure (same sutures) is made with inverting interrupted sutures, placed as shown. As each mucosal suture is tied, the prior suture is held on slight tension, thus inverting the mucosa. The excess suture is then cut, preserving the last suture's length for successive inversion of the next. All knots lie inside the lumen. Suturing is begun from both ends of the defect with a final Connell suture placed at the midpoint. B, A second layer of interrupted Lembert sutures approximates the esophageal muscle coats. C, Pedicle of sternohyoid muscle, detached from the hyoid bone, is sutured over the esophageal closure (dotted line) with multiple fine interrupted 4-0 sutures placed with the proximity of anastomotic sutures. Reconstruction is completed with end-to-end tracheal anastomosis.
has occurred. If these adjunctive tubes are not present, they are inserted at completion of the operation. This approach has been successfully applied by a number of surgeons.2,4-7
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