How is acquired nonmalignant tracheoesophageal fistula (TEF) treated surgically?

Updated: Nov 07, 2018
  • Author: Sat Sharma, MD, FRCPC; Chief Editor: Vinay Kumar Kapoor, MBBS, MS, FRCS, FAMS  more...
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Answer

Gastric decompression is achieved via a nasogastric tube. Patients who are not fit enough to withstand early surgery are treated conservatively with decompressing gastrostomy and feeding jejunostomy. If a patient is critically ill and reparative surgery cannot be undertaken in a timely manner, consider esophageal ligation, creation of a high salivary fistula, and feeding gastrostomy.

Operative repair and patient management

Note the following:

  • Before the actual procedure, a clinical decision is made regarding whether the fistula can be simply resected and closed or whether tracheal resection and reconstruction is required. A low collar incision is used for the repair of most fistulas; however, a right lateral thoracotomy is used for fistulas around the carina. A small fistula and normal trachea does not require tracheal resection. The fistula is identified and divided, and the esophageal defect is closed in layers. During fistula repair, the esophagus and trachea are closed primarily. The strap muscle pedicle flaps are positioned between the trachea and esophagus to reinforce the closure. The muscles used for pedicle interposition are sternohyoid or sternothyroid muscles. In the lower thorax, following closure of the esophagus, reinforcement with a flap comprised of pleura, intercostal muscle, and rib periosteum is commonly performed.

  • A large defect with tracheal damage often requires tracheal resection and reconstruction. Following resection of the trachea, the esophageal defect is closed longitudinally in 2 layers, tracheal reconstruction is carefully performed, and anastomotic tension is avoided. The strap muscle is used to cover the esophageal suture line and to separate it from tracheal suture line in order to prevent recurrence.

  • Postoperative management is determined by the patient's general health status. If the patient requires prolonged intubation, care is taken to avoid positioning the cuff at the suture line. The patient should not have a simultaneous nasogastric tube in order to prevent a risk of recurrence.


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