Stapled Repair of Benign Acquired Tracheoesophageal Fistula: Description of Novel Technique and Assessment of Outcomes

Abstract

Compared to less invasive measures, surgical repair is the most effective modality for managing benign acquired tracheoesophageal fistula (TEF). Traditionally, this involves dismantling of the fistula and suture repair of tracheal and esophageal defects using a lateral or direct approach. However, the best approach remains a subject of debate. We describe a novel and simple technique for dismantling a benign acquired TEF with the use of an endo-stapler and interposition with sternocleidomastoid (SCM) muscle flap. Eleven TEF patients underwent repair using this stapled repair technique. Retrospectively, the perioperative and long-term outcomes were assessed in these patients. There were no cases of procedure-related mortality or airway-related complications. Two patients developed transient vocal cord palsy and one developed esophageal leak. At a mean follow-up of 21.4 months, no fistula recurrence, dysphagia, or tracheal stenosis was observed. Hence stapled dismantling and SCM muscle interposition is a simple and safe technique for repair of benign acquired TEF.

Keywords: benign acquired tracheoesophageal fistula; lateral approach; prolonged mechanical ventilation; stapled dismantling; sternocleidomastoid muscle flap; tef; tracheoesophageal fistula.

Figure 1. CECT demonstrating tracheoesophageal fistula (arrow highlighting fistula)

CECT - Contrast-enhanced computerized tomography

Figure 2. Intraoperative picture showing tracheoesophageal fistula and esophagus (arrow) looped by umbilical tape both proximal and distal to the fistula

Figure 3. Laparoscopic linear stapler being used to divide the fistula

Black arrow – oesophagus, green arrow – trachea, yellow arrow head- fistula incorporated into stapler.

Figure 4. Staple lines after completer division of fistula

Green arrow- esophageal staple line, Black arrow- tracheal staple line

Figure 5. Sternocleidomastoid muscle flap (highlighted by star) is fixed to prevertebral fascia between trachea (highlighted by arrow head) and oesophagus (highlighted by arrow)

Figure 6. A) Preoperative oral contrast study showing fistula(arrow) B) Post-operative oral contrast study of same patient showing no evidence of either fistula or leak