Tracheoesophageal fistula--a complication of prolonged tracheal intubation

Abstract

Tracheoesophageal fistula most commonly occurs as a complication of prolonged tracheal intubation. The incidence decreased after the use of low pressure and high volume endotracheal cuffs, but the intensive care units continue to provide such cases. The abnormal tracheoesophageal communication causes pulmonary contamination (with severe suppuration) and impossibility to feed the patient. The prognosis is reserved, because most patients are debilitated and ventilator dependent, with severe neurological and cardiovascular diseases. The therapeutic options are elected based on respiratory, neurological and nutritional status. The aim of conservative treatment is to stop the contamination (drainage gastrostomy, feeding jejunostomy) and to treat the pulmonary infection and biological deficits. Endoscopic therapies can be tried in cases with surgical contraindication. Operation is addressed to selected cases and consists in the dissolution of the fistula, esophageal suture with or without segmental tracheal resection associated. Esophageal diversion is rarely required. The correct indication and timing of surgery, proper surgical technique and postoperative care are prerequisites for adequate results.

Keywords: conservative treatment; prolonged tracheal intubation; surgical treatment; trachea-esophageal fistula.

Fig. 1

Tracheoesofageal fistula formation in a cannulated patient. The fistula lies few centimeters below the stoma and associates tracheal stenosis. From Grillo HC. Surgery of the tracheal and bronchi, 2004, BC Decker Inc. Hamilton London

Fig. 2

Endoscopic appearance of a huge fistula (bigger than the tracheal lumen). Nasogastric tube can be observed in the esophageal lumen

Fig. 3

CT scan of a giant trachea-esophageal fistula. Large communication and total destruction of the cartilaginous structure of the trachea

Fig. 4

Esophagotracheal fistula associated with complete segmental destruction of trachea both at the site of stoma and at the cannula cuff. Approach by ”Y” cervicotomy. After distal tracheal section, intubation through the operative field is done. Note the tracheal segment to be resected, pulled up from the esophagus. Esophageal orifice opened with traction sutures. Proximal tracheal lumen shown with Kocher forceps

Fig. 5

Tracheal resection and esophageal suture completed. Note the normal caliber and structure of the proximal tracheal end

Fig. 6

Fistula without tracheal stenosis. Approach by ”Y” cervicotomy and partial sternotomy. Fistula is encircled

Fig. 7

Fistula excision with esophageal orifice opened

Fig. 8

Tracheal and esophageal sutures