Surgical Treatment Outcomes of Acquired Benign Tracheoesophageal Fistula: A Literature Review

Abstract

Background: Tracheoesophageal fistula (TEFs) is a rare condition that requires complex surgical treatment. We analyzed the surgical outcomes of TEF reported in the literature and at Pusan National University Yangsan Hospital using standardized techniques.

Methods: This retrospective study included 8 patients diagnosed with acquired benign TEF between March 2010 and December 2019. The surgical method was determined based on the size of the fistula observed within the endoscope.

Results: TEF occurred in 7 patients (87.5%) after intubation or tracheostomy and in 1 patient (12.5%) after esophageal surgery due to conduit necrosis. For tracheal management, 5 and 2 patients underwent tracheal resection and end-to-end anastomosis and primary repair, respectively. The median length of resection was 2.5 cm (range, 1.3-3.4 cm). For esophageal management, 6 patients underwent primary repair and 1 patient underwent esophageal diversion. One patient underwent TEF division with a stapler. Interposition of a muscle flap was performed in 2 patients. TEF recurrence, esophageal stenosis, and dehiscence or granulation occurred in 1, 1, and 2 patients, respectively. A long-term tracheostomy tube or T-tube was used in 2 patients for >2 months.

Conclusion: Although TEF surgery is complex and challenging, good results can be achieved if surgical standards are established and experience is accumulated.

Keywords: Esophagus; Trachea; Tracheal resection; Tracheoesophageal fistula.

Fig. 1

Schematic diagram of tracheal resection and end-to-end anastomosis. (A) The trachea is resected below and above the site of the fistula. The fistulous site in the esophagus is exposed between the proximal trachea and distal trachea. (B) The edges of the esophageal defect are debrided and a double-layer closure is made. (C) Because the repair site of the esophageal defect and the anastomosis site of trachea reconstruction are located at different levels, an additional muscle flap interposition is not performed.

Fig. 2

Schematic diagram of fistula division and direct closure of the tracheal and esophageal defect. (A) The fistulous tract is divided and the fistula between the esophagus and trachea is exposed. (B) The membranous tracheal defect is closed directly with interrupted sutures. The esophageal defect is closed by a double layer. (C) To avoid close contact with both repair sites, a flap of strap muscle is interposed between the esophagus and trachea. (D) In 1 case, division of the fistula was performed using a stapler due to a large fistula (>5 cm). We decided that the fistula would be divided by a stapler as a modification of primary repair. Tracheal resection was impossible because the fistula size was >5 cm; hence, division using a stapler was performed.