It hardly needs to be said that major efforts must be made in all of these patients to clear up local and pulmonary sepses and to improve nutrition prior to surgical procedures. Benign fistulae not related to ventilation are individually managed depending on their cause, size, location, and degree of surrounding pathology. Cervical (with the possibility of partial upper sternal division) or, less frequently, right transthoracic approaches are used, depending upon the level of the fistula (Figure 12-7). Only a supracarinal fistula requires thoracotomy. Principles of closure of the TEF include complete dissection of the fistula, its division, effectively planned

figure 12-5 Small chronic upper tracheoesophageal fistula in a 66-year-old woman resulting from foreign body ingestion at age 8, which when she was age 25 was endoscopically removed by Dr. Chevalier Jackson. A, The upper arrow in the contrast esophagogram indicates the crico-pharyngeus, and the lower arrow indicates the fistula, in anterior view. B, Lateral view; fistula is indicated by the arrow.

figure 12-5 Small chronic upper tracheoesophageal fistula in a 66-year-old woman resulting from foreign body ingestion at age 8, which when she was age 25 was endoscopically removed by Dr. Chevalier Jackson. A, The upper arrow in the contrast esophagogram indicates the crico-pharyngeus, and the lower arrow indicates the fistula, in anterior view. B, Lateral view; fistula is indicated by the arrow.

figure 12-6 Bronchoscopic view of postintubation tracheoesophageal fistula. Note the large size of the membranous wall defect and also that there is circumferential tracheal damage at the level of the fistula. Normal tracheal rings are visible distally. One-stage repair was done with esophageal closure and tracheal resection and reconstruction. Also, see Figures 31 and 32 (Color Plate 15).

membranous wall suture closure which is tension-free, and two-layered esophageal closure (see Chapter 26, "Repair of Acquired Tracheoesophageal and Bronchoesophageal Fistula").14 Recurrent fistulization is avoided by interposition of healthy pedicled tissue (such as a strap muscle in the neck or intercostal muscle in the chest) between the tracheal and esophageal suture lines. The technique of borrowing adjacent esophageal wall to facilitate closure without tension is also discussed in Chapter 26, "Repair of Acquired Tracheoesophageal and Bronchoesophageal Fistula." Recurrent laryngeal nerves must be carefully avoided. If the fistula is of any extent, the trachea may be best and most safely managed by resection of the segment containing the fistula, with end-to-end tracheal anastomosis after esophageal closure, even if circumferential tracheal damage is not present.

Post-traumatic fistulae may be extensive, accompanied by mediastinal injury and infection. Decision on therapy in these injuries must be individualized (see Chapter 9, "Tracheal and Bronchial Trauma"). In the most severe and delayed post-traumatic cases, esophageal exclusion may have to be considered, an alternative that is usually unnecessary in other types of TEF.14 Surgical technique is described in Chapter 26, "Repair of Acquired Tracheoesophageal and Bronchoesophageal Fistula."

Postsurgical fistulae following esophagectomy are treated with respect to the location and size of the fistula, the presence or absence of necrosis in the neoesophagus, mediastinitis, and the severity of symptoms. Treatment may range from drainage with conservative management, local tissue excision with buttressed closures, to removal of the neoesophagus, and reconstruction of a new esophageal replacement, possibly in stages.4 Esophagorespiratory fistula due to necrotizing esophagitis, from infection in immunocompromised patients, requires esophagectomy.8

An attempt to close a postintubation fistula in a patient who is still on a respirator is almost certain to fail. Prolonged ventilation after tracheal reconstruction is likely to encourage dehiscence or stenosis. These patients are best managed conservatively, with every effort made to wean them from mechanical ventilation to permit later definitive surgical repair. If an esophageal tube is present, it is withdrawn. If possible, the tra-cheostomy cuff is situated just below the fistula, using as little pressure as possible to obtain a seal. A draining gastrostomy is positioned to avoid aspiration of gastric contents and a jejunostomy is placed for feeding. The head of the bed is kept in an elevated position. Vigorous efforts are made to clear any pulmonary infection. Under this regimen, the situation usually improves quite rapidly. The small amount of saliva that continues to trickle into the respiratory tree seems to be handled comparatively well with the help of frequent

figure 12-7 Chronic fistula due to foreign body ingestion in childhood shown in Figure 12-5. Endoscopic findings and treatment. A, Bronchoscopic visualization of the small fistula (arrow) demonstrated in Figure 12-5, due to foreign body erosion. Compare this with the postintubation tracheoesophageal fistula in Figure 12-6. B, Esophagoscopic view of the same fistula (arrow). The small lesion is difficult to see in the esophageal folds. C, Right cervical operative exposure. The diagram clarifies the anatomy. A Penrose drain passes beneath the fistulous tract, which emerges from the posterolateral wall of the trachea on the right. Sutures have been placed in the tract closer to the esophagus (on the left) to leave more tissue for closure of the tracheal wall. The vascular loop passes beneath a nonrecurrent right inferior laryngeal nerve. This was critical since the left nerve had been injured in a prior failed attempt at another hospital to close the fistula from the left side. The right lobe of thyroid is retracted with a heavy suture at the left. Pedicled sternohyoid muscle was interposed between the tracheal and esophageal suture lines.

tracheal suctioning. Esophageal diversion is almost never necessary. If it is required under highly unusual circumstances and is feasible, a disconnecting procedure is preferred to in-continuity esophagostomy. The proximal end of the esophagus is brought out laterally (left neck) as a salivary fistula and the distal end turned in with care. Since most of these fistulae are high in location, the point of division should be immediately above the fistula to simplify later reconstruction by leaving sufficient proximal esophagus. More often than not, however, the fistula is located so close to the cricopharyngeus that exteriorized esophagostomy is impossible. The lower end of the esophagus at the gastric inlet should not be ligated, stapled, or divided. Continuous suction on the gastrostomy is usually sufficient to protect the trachea from reflux of gastric juices. The gastrostomy also serves to keep the stomach from becoming distended.

After weaning, surgical correction includes closure of the esophageal fistula in layers, resection of the circumferentially damaged tracheal segment and its reconstruction, plus interposition of viable tissue between the two suture lines. This is all performed in a single stage (Figure 12-8).15,16 Even though the transverse tracheal anastomotic suture line and the vertical esophageal suture line may be at different levels, it always seems safer to use an interposition flap, as described. I have seen no difficulties arising from these flaps. The precise technique of repair and methods of dealing with special technical problems are detailed in Chapter 26, "Repair of Acquired Tracheoesophageal and Bronchoesophageal Fistula." In rare cases where the tracheal injury is too long to permit tracheal reanastomosis, the esophagus is closed nonetheless to eliminate the fistula and tracheal patency, and function is restored with a permanent T tube. If laryngotracheal stenosis is present, that is managed in the usual way for such lesions after closure of the esophagus (see Figure 12-4) (see Chapter 25, "Laryngotracheal Reconstruction").

In the past, it was recommended by some authors that the esophageal aperture be closed in an initial operation, and that any tracheal process be dealt with at a second procedure.2 There is no justification for this approach.14-16 Not only does the tracheal lesion require resection in any case, but both the proposed initial and later operations become much more difficult if staged.

Malignant fistula is most often best treated by palliative bypass intubation, given the patient's limited expectation for life. Exclusion of a segment of fistulized esophagus, with concomitant intestinal bypass of the esophagus, is only very rarely advisable either in a patient in very good condition or in

one with a rare slow-moving tumor of unusual type. An intermediate alternative of intubation with partial exclusion by esophagostomy and with gastrostomy plus jejunostomy (for prevention of aspiration and for nutrition) may be considered, with the possibility of a later restitution of gastrointestinal continuity by substernal gastric or colonic transposition. Duranceau and Jamieson carefully reviewed these options in 1984, and Burt and colleagues described their experiences in 1991.11,17 In a terminal and debilitated patient, abstinence from any intervention may be the kindest therapeutic choice. If intubation through the tumor is elected, pulsion rather than traction (via a gastrostomy) seems to be the best palliative maneuver. Intubation techniques are not without morbidity and mortality. Tubes must be of impervious material or be coated if of an expandable type, in order to prevent prompt ingrowth of tumor through interstices.

In 1920, Kirschner used the stomach anastomosed to the cervical esophagus to bypass a malignant fistula.18 Many variations have since been employed, using the stomach, jejunum, and colon for interposition as well as extracorporeal synthetic tubes. An esophagus excluded above the fistula, and below by occlusion of the gastroesophageal junction, has too often produced copious secretions, leaked, or ruptured. A residual esophagus should therefore be drained with a loop or arm of jejunum if left in situ. A preferable technique is to divide the esophagus just below the fistula as well as above, creating a smaller "diverticulum" at the fistulous site, and excise the distal esophagus (via a transhiatal approach). The stomach and colon are the favored gastrointestinal replacement conduits, and are placed substernally (see Chapter 26, "Repair of Acquired Tracheoesophageal and Bronchoesophageal Fistula").11,17,19 Each patient must be carefully evaluated and treatment individualized, bearing in mind that any treatment will at best be palliative and usually for a short term. If radical treatment is to be offered, it should be instituted promptly.

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