Surgical treatment of nonmalignant tracheoesophageal fistula: a thirty-five year experience

Abstract

Background: Acquired nonmalignant tracheoesophageal fistula in the adult patient develops in a variety of conditions. We have applied surgical closure with success for 35 years.

Methods: From 1975 to 1991, 38 patients underwent surgical repair of a tracheoesophageal fistula. A retrospective study of 36 additional patients undergoing surgical repair from 1992 to 2010 was conducted.

Results: The most common causes were postintubation injury (n=17, 47%), trauma (n=6, 17%), prior laryngectomy (n=6, 17%), and prior esophagectomy (n=4, 11%). Four patients presented after failing fistula control with an endoluminal stent. The tracheal defect was closed with resection and reconstruction (n=17, 41%), laryngotracheal resection (n=5, 12%), membranous tracheal repair (n=17, 41%), or repair over a tracheal T tube (n=2, 5%), while esophageal repair consisted of 2-layer closure (n=31, 78%), 1-layer closure (n=6, 15%), esophagostomy (n=1, 3%), end-to-end esophageal anastomosis (n=1, 3%), or full thickness skin graft reconstruction (n=1, 3%). The esophageal and tracheal repairs were buttressed by interposing pedicled muscle or omental flaps in all patients. There was 1 postoperative death (3%). Recurrence after repair developed only in fistulas arising after esophagectomy or laryngectomy (n=4, 11%). Fistula closure was ultimately successful in 34 patients (94%). Twenty-nine patients (83%) resumed oral intake and 25 patients (71%) were breathing without a tracheal appliance.

Conclusions: Successful closure of benign tracheoesophageal fistula is achieved with several surgical techniques based on buttressed repair and restoration of normal breathing and swallowing. Closure of complex postsurgical fistula may fail. Endoluminal stenting was not found useful.