esophagus and trachea which can be congenital or acquired. About 80% of the ... to insert an esophageal non-metallic stent to bypass the fistula. A non-metallic ...
PHAGEAL FISTULA: ON IN MANAGEMENT
Surinder K. Singhal,* Ramandeep S.Virk, ** Arjun Dass, *** Biinaljit Singh Sandhu ****
Key words: Tracheoesophageal fistula(TEF), Tracheostomy, Nasogastric tube, esophageal stent, trichloroacetic Acid (TCA).
Tracheoesophageal fistula (TEF) is a communication between the esophagus and trachea which can be congenital or acquired. About 80% of the acquired tracheoesophageal fistulae are malignant and rest non-malignant' . Nonmalignant fistulae are usually due to trauma which can be iatrogenic, internal or external. latrogenic fistulae may occur following mechanical ventilation or as a complication of tracheostomy. Internal trauma may be due to cuffed endotracheal tube or nasogastric tubes or a combination of both. It may be external trauma from penetrating foreign bodies, open or closed aero digestive tract injuries' .There are many risk factors associated with post intubation tracheoesophageal fistula like elevated tracheal cuff pressure, excessive motion of the tube, infection, hypotension, corticosteroids, and diabetes mellitus3,4 . TEF at the level of stoma are usually a complication of tracheostomy where the injury is caused on the posterior tracheal wall while making the tracheostome or in a patient who has a nasogastric tube in the esophagus and the opening is made in the oesophagus accidentally. TEF from cuffed endotracheal tubes usually occurs between the sixth cervical and first thoracic vertebra and manifests only after seven days or mores . With the advent of high volume, low pressure tubes the incidence of post intubation TEF has been reduced markedly yet the risk is not eliminated totally. Contamination of the tracheobronchial tree and interference with nutrition are life threatening aspects of this condition. Till date there is no report to suggest that the fistula can heal spontaneously and a large number of surgical techniques have been described in the literature. These include direct closure of both defects, esophageal diversion, closure of the defect with muscle flap and tracheal closure with dysfunctional oesophagus 6 7 8 We describe a, different technique of closure of TEF which has not been mentioned earlier. '
A 21 year old female patient presented to the out patient department of Ear, Nose & Throat at Government Medical College & Hospital, Chandigarh with the complaint of cough, regurgitation
& vomiting after taking food. The patient was a known diabetic and hypertensive on regular treatment. She had undergone a medical termination of pregnancy and developed a faecal fistula. She was operated for the fecal fistula and a colostomy was also done but on the second post operative day she had cardiac arrest. She was intubated and revived. Later she underwent a tracheostomy and remained on ventilatory support for two weeks. She was gradually weaned off the ventilator and on 19` 1 day of tracheostomy she was decanulated and discharged. She came back after a week with the complaints of violent cough, regurgitation and vomiting after meals. Systemic examination was within normal limits. Colostomy bag was in situ. Local examination revealed a tracheostomy scar. Oral cavity and Oropharynx were unremarkable. Indirect Laryngoscopy revealed secretions in both pyrifom fossae and both the cords were mobile. A sip of water was given to the patient and it was immediately followed by violent cough suggestive of aspiration. A clinical possibility of post tracheostomy tracheoesophageal fistula was thought and a Ryle's tube was inserted. The patient was investigated. Barium swallow was done which revealed a communication between trachea and esophagus. Endoscopic assessment under general anesthesia was done. Bronchoscopy revealed a defect in the post tracheal wall approximately 0.75cm x 0.5cm in size and about 2.5cms the vocal cords. On esophagoscopy a defect about 2 cm distal to upper esophageal sphincter of the same size was seen. The patient was planned for repair of fistula under general anesthesia. Two weeks later the patient was taken up for repair of fistula. A revision tracheostomy was done. The fistula was approached via lateral cervical route and taking care to save the recurrent laryngeal nerve the fistula was excised and the defect was closed primarily. Sternal head of the sternocleidomastoid muscle was rotated and was sutured over the suture line to give it vascularity and strength. On the third postoperative day there was wound breakdown with recurrence of fistula. The nasogastric tube was removed and gastrostomy was done. On the tenth postoperative day flexible upper gastro intestinal endoscopy was done and it
Medicine Department Senior Lecturer, ** Senior Resident, *** Prof. & Head, ENT, **** Senior Lecturer, Dept. Government Medical College & Hospital Chandigarh, India, 160 030 Otolaryngology and Head and Neck Surgery Vol. 58, No. 3, July-September 2006 Indian Journal
Otolaryngology & Medicine
Tracheoesophageal Fistula:New Option in Management
below the upper esophageal sphincter and the size was approximately 1cm x 0.5cm. During this period she had an anterior wall myocardial infarction which was successfully managed. Keeping in view the patients poor nutritional status it was decided to insert an esophageal non-metallic stent to bypass the fistula. A non-metallic stent having a length of 12.4cm was placed under fluoroscopic guidance. The outer diameter was 16mm and the inner diameter was 12mm.To prevent its migration down the oesophagus it was secured by two silk sutures passed through the funnel of the stent and tied around the columella. The size of the tracheostomy tube was reduced and an uncuffed tube was Photograph showing the non metallic esophageal stent with funnel shaped inserted to prevent rubbing of the stent and tracheostomy against top which prevented migration. each other and causing pressure necrosis. Next day trichloroacetic acid cautery was touched to the fistula edges through the The nasogastric tube may also act as an abrasive against the tracheostome and repeated weekly to promote healing of the anterior esophageal wall. This leads to ulcerative tracheal fistula. The fistula was regularly evaluated as it was clearly seen inflammation and necrosis. Position of the head also alters amount from the tracheostomy. The fistula size gradually reduced and of pressure exerted by the cuff on the tracheal wall. Flexion causes three weeks later there was complete healing. The stent was more pressure to the anterior wall of the trachea, where as extension removed and endoscopy revealed granulation tissue at site of the causes more pressure posteriorly 15 .There were several of these fistula. The patient was started on oral feeds gradually from liquids risk factors in our patient. to semisolids and later normal feeds were given. Once she was accepting all feeds orally the feeding gastrostomy was closed. Diagnosis of TEF is suggested by many symptoms. Among them She was discharged and was admitted for colostomy closure 5 are violent coughing after swallowing, food at the tracheostomy site, abnormal passage of catheters or tubes and air escape into months later which was done successfully. the hypopharynx despite adequate cuff inflation. Thomas' has outlined definite diagnostic criteria DISCUSSION Tracheoesophageal fistula can be either congenital or acquired. Acquired fistulae can be malignant or non malignant. Acquired non-malignant tracheoesophageal fistula occurs in approximately 0.5% of patients undergoing tracheostomy 9 .This condition is unusual, serious and poses a challenging problem. Contamination of the tracheo- bronchial tree and interference with nutrition are life threatening aspect of this condition. All patients not surgically managed die of their disease. After extensive investigations and reviews it became clear that cuffed tubes were the most frequent cause of this problem and the fistula occurred while patients were receiving positive pressure ventilation for respiratory failure 10 .The advent of high volume, low pressure cuffs has reduced the incident but not eliminated it. Risk factors which have been reported for tracheal damage are shown in Table 1. High intra cuff pressure is probably the single most important factor in development of an acquired TEF"• 12,13 . Cuff pressures above 22mm of Hg have been shown to cause decreased capillary perfusion of the tracheal mucosa and pressure of 40mm of Hg may result in total obstruction of blood flow to tracheal epithelium 14 . Table I: Risk factors for development of Tracheo-esophageal Fistula
High cuff pressure's " " Advanced age 16 . Nasogastric tube 9•". High airway pressure 18 . Excessive motion of tracheal tube's. Prolonged duration of intubation 19 . Steroids". • Respiratory infections 20 . • Hypotension 20 . • Female sex 21 . ,
A. Direct visualization with a special feature such as 1)Ryle's tube or posterior wall mucosa seen on tracheostomy. 2) Tracheal tube seen on esophagoscopy. 3) Well defined edges of fistula seen moving on respiration. B. Radiology: Demonstration of contrast at the site of fistula C. Operative or autopsy confirmation. False negative rate of 12.5% has been reported for contrast studies Zz . Esophagoscopy is recommended in all patients having suspicion of fistula. Till date there is no report to suggest that the fistula can heal spontaneously and hence surgery is now accepted as the treatment for proven cases 5,7,23 . This includes direct closure of defects, esophageal diversion, closure of the defect with muscle flaps and tracheal closure with dysfunctional esophagus. However there is disagreement over the timing. Some advocate immediate interventions whereas others advocate staged procedures"' 24 . Esophageal stents have been widely used for the treatment of strictures & malignant obstruction. We used a different technique to close the TEF by putting a stent in the esophagus & making the edges of fistula raw with chemical cautery to promote granulation tissue and healing. The stent prevented the salivary secretions from coming in contact with the fistula and interfering with healing. The nutrition of the patient, however, was managed with gastrostomy feeds. The approach can be used in selected patients only, depending upon the size and site of TEF. Larger fistulae and those situated lower down e.g. supra carinal can not be managed by this technique. Another important thing to remember is the size and shape of the stent. M
Indian Journal of Otolaryngology and Head and Neck Surgery Vol. 58, No. 3, July-September 2006
Tracheoesophageal Fistula:New Option in Management
If it is over sized then the stent will itself cause ischemia and necrosis leading to increase in size of the fistula. Anteriorly the tracheostomy tube and posteriorly the stent can cause the same damage. To avoid this injury once the stent is inserted the size of the tracheostomy tube is reduced and preferably an uncuffed tube is inserted. The shape of the stent is funnel shaped (Fig. ) and it helps to retain the stent superior to the site of fistula and at the same time not exerting pressure over the party wall. To conclude this technique can be used in selective group of patients keeping in view the general condition of the patient. REFERENCES: 1.
Green RP, Biller HF, Sicular A. Cervical Tracheoesophageal fistula. Laryngoscope 1983;93:364369.
Mellins, R.: Acquired fistula between the Esophagus and the respiratory tract. New Engl.J.Med. 1952;246(23):896-901.
Gudovsky LM, Koroleva NS, Biryukov YB. Tracheoesophageal fistulas. Ann Thorac Surg. 1993;55:868-875.
13. Kastanos N, Estopa Miro R, Marin Perez A, et al. Laryngotracheal injury due to endotracheal intubation: Incidence, evolution and pre disposing factors. A long term study. Crit Care Med 1983;11:362-67. 14. Seegobin RD, van Hasselt GL. Endostracheal cuff pressure and tracheal mucosal blood flow: Endoscopic study of effects of four large volume cuffs. Br Med J. 1984;288:96568. 15. Knowlson GTG, Bassett HEM. The pressures exerted on the trachea by endotracheal inflatable cuffs. Br J Anaesth 1970;42.34-37. 16. Stauffer JL, Olsen DE, Petty TL. Complications and consequences of endotracheal intubation and tracheostomy. Am J Med. 1981;70:65-76. 17. Hilgenberg AD, Grillo HC. Acquired non malignant Tracheoesophageal fistula. J Thorac Cardiovasc Surg 1983;85:492-98. 18. Bugge-Asperhiem B, Birkeland S, Storen G. Tracheoesophageal fistula caused by cuffed endotracheal tubes. Scand J Thorac Cardiovasc Surg 1981;15::315-319.
Mathisen DJ, Grillo HC, Wain JC. Management of acquired non malignant Tracheoesophageal fistula. Ann Thorac Surg 1991;52:759:765.
19. El-Naggar M, Sadagopan S, Levine H, et al. Factor influencing choice between tracheostomy and prolonged translaryngeal intubation in acute respiratory failure : a prospective study. Anesth and Analg 1976;55:195-201.
Thomas AN. The diagnosis and treatment of Tracheoesophageal fistula caused by cuffed tracheal tube. J Thorac Cardiovasc Surg. 1973;65:612-619.
20. Miguel RV, Graybar G, Subaiya L,et al. Emergency management of tracheal rupture. South Med Jour 1985; 78:1132-35.
Thomas AN. Management of Tracheoesophageal fistula caused by cuffed tracheal tubes. Am J Surg 1972;124:181.
21. Gaynor EB, Greenberg SB, Untoward sequelae of prolonged intubation. Laryngoscope 198595:1461-67.
Bartlett RH. A procedure for management of acquired Tracheoesophageal fistula in ventilator patients. J Thorac Cardiovasc Surg 1976;71:89.
22. Kelly JP, Webb WR, Moulder PVet al. Management of airway trauma. II: Combined injury of the trachea and esophagus. Annals of Thoracic Surgery 1987;43:160-63.
Utley JR, Dillon ML, Todd EP, et al. Giant Tracheoesophageal fistula. J Thorac Cardiovasc Surg 1978;75:373.
23. Grillo H.C., Moncure AC, McEnany MT. Repair of inflammatory Tracheoesophageal fistula. Annals of Thoracic Surg 1976;22:112-19.
Harley HR. Ulcerative Tracheoesophageal fistula during treatment by tracheostomy and intermittent positive pressure ventilation. Thorax 1972;27:338-52.
24. Shaari Christopher, Biller HF Staged repair of cervical tracheoesophageal Laryngoscope fistulae. 1996; 106:1398-1402.
10. Flege JB: Tracheoesophageal fistula caused by cuffed tracheostomy tube. Ann Surg 1967;166:153.
Address for correspondence
11. Cooper J.D., Grillo HC. The evolution of tracheal injury due to ventilatory assistance through cuffed tubes : a pathological study. Anals of Surgery. 1969;169:334-48. 12. Hedden M, Ersoz CJ, Safar P. Tracheoesophageal fistulas following prolonged artificial ventilation via cuffed tracheostomy tubes. Anaesthesiology. 1 969;31:281-89.
l Indian Journal
of Otolaryngology and Head and Neck Surgery Vol. 58, No. 3, July-September 2006
Dr.Surinder K.Singhal Senior Lecturer Department of ENT Government Medical College & Hospital, Sector-32-A Chandigarh -160 030 INDIA