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H-type congenital tracheoesophageal fistula
The American Journal of Surgery 185 (2003) 599 – 600
Clinical image
H-Type congenital tracheoesophageal fistula Jeffrey S. Upperman, M.D.*, Barbara Gaines, M.D., David Hackam, M.D. Department of Surgery, Division of Pediatric Surgery, University of Pittsburgh, 3705 Fifth Ave., 4A493, Pittsburgh, PA 15213, USA Manuscript received August 19, 2002; revised manuscript November 21, 2002
At birth, the Apgar scores of a full-term male infant born to a first-gestation, first-pregnancy mother were 8 at 1 minute and 9 at 5 minutes. With his initial feeding, he was noted to have excessive drooling and oxygen desaturation. The neonatologist was unable to pass an oral gastric tube. The patient was subsequently transferred to our tertiary care facility. On physical examination, the infant was pink and had no other apparent congenital anomalies. An esophagram revealed an H-type tracheoesophageal fistula (Figs. 1 and 2). He had additional work-up for cardiac, skeletal, and renal anomalies; this evaluation was negative. He was taken to the operating room and underwent a bronchoscopy. After the fistula was identified, a no. 4 ureteral catheter was threaded into the fistula tract (Fig. 3). The patient was then intubated and we proceeded to ligate the fistula through the standard transcervical approach. Postoperatively, the patient had some initial respiratory distress that resolved and after several days he was discharged home. Congenital tracheoesophageal fistula without esophageal atresia (H-type) accounts for approximately 4% of esophageal anomalies [1]. The fistula connects the trachea and esophagus at an oblique angle, anatomically depicting an “N”-type fistula but it is commonly referred to as the Htype. Neonates usually have choking episodes and cyanotic spells. In some cases, infants may present when they are older with recurrent bouts of right upper lobe pneumonia. Neonates who are suspected of having an abnormal connection between the trachea and esophagus should have a plain x-ray film made. The plain film often shows evidence of aspiration and gastric dilatation. The diagnosis is established by an experienced pediatric radiologist who performs a tube esophagram with infant in the prone position. The radiologist passes the tube past the presumed defect into the stomach then slowly withdraws the tube while injecting
contrast. Bronchoscopy and esophagoscopy can confirm the diagnosis by demonstrating the fistula opening [2]. Most H-type tracheoesophageal fistulas are approached through a cervical incision. A right-sided incision is made low on the neck. A catheter placed through the fistula assists the operator in identifying the abnormal connection. Another helpful maneuver is to surround the esophagus while avoiding damage to the recurrent larygeal nerve. Once the fistula is identified, stay sutures are placed on the esophageal side and the fistula is divided. The trachea can be closed with 5-0 polypropylene sutures. The esophageal side
* Corresponding author. Tel.: ⫹1-412-692-7282; fax: ⫹1-412-6926069. E-mail address: [email protected] 0002-9610/03/$ – see front matter © 2003 Excerpta Medica, Inc. All rights reserved. doi:10.1016/S0002-9610(03)00065-5
Fig. 1. Esophagram demonstrating tracheoesophageal fistula.
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J.S. Upperman et al. / The American Journal of Surgery 185 (2003) 599 – 600
may be closed with absorbable polyglycolic acid sutures. Postoperatively, the infant may experience respiratory distress secondary to trachea swelling or injury to the recurrent laryngeal nerves. Most infants with H-type tracheoesophageal fistulas do well, as do most infants with the more common C-type tracheoesophageal fistula [3].
References
Fig. 2. Chest plain x-ray film after barium swallow.
[1] Tsai JY, Berkery L, Wesson DE, et al. Esophageal atresia and tracheoesophageal fistula: surgical experience over two decades. Ann Thorac Surg 1997;64:778 – 84. [2] Benjamin B. Endoscopy in esophageal atresia and tracheoesophageal fistula. Ann Otol Rhinol Laryngol 1981;90:376 – 82. [3] Dunn JC, Fonkalsrud EW, Atkinson JB. Simplifying the Waterston’s stratification of infants with tracheoesophageal fistula. Am Surg 1999; 65:908 –10.
Fig. 3. Bronchoscopy demonstrating cannulation of tracheoesophageal fistula by Fogarty catheter.
Clinical image
H-Type congenital tracheoesophageal fistula Jeffrey S. Upperman, M.D.*, Barbara Gaines, M.D., David Hackam, M.D. Department of Surgery, Division of Pediatric Surgery, University of Pittsburgh, 3705 Fifth Ave., 4A493, Pittsburgh, PA 15213, USA Manuscript received August 19, 2002; revised manuscript November 21, 2002
At birth, the Apgar scores of a full-term male infant born to a first-gestation, first-pregnancy mother were 8 at 1 minute and 9 at 5 minutes. With his initial feeding, he was noted to have excessive drooling and oxygen desaturation. The neonatologist was unable to pass an oral gastric tube. The patient was subsequently transferred to our tertiary care facility. On physical examination, the infant was pink and had no other apparent congenital anomalies. An esophagram revealed an H-type tracheoesophageal fistula (Figs. 1 and 2). He had additional work-up for cardiac, skeletal, and renal anomalies; this evaluation was negative. He was taken to the operating room and underwent a bronchoscopy. After the fistula was identified, a no. 4 ureteral catheter was threaded into the fistula tract (Fig. 3). The patient was then intubated and we proceeded to ligate the fistula through the standard transcervical approach. Postoperatively, the patient had some initial respiratory distress that resolved and after several days he was discharged home. Congenital tracheoesophageal fistula without esophageal atresia (H-type) accounts for approximately 4% of esophageal anomalies [1]. The fistula connects the trachea and esophagus at an oblique angle, anatomically depicting an “N”-type fistula but it is commonly referred to as the Htype. Neonates usually have choking episodes and cyanotic spells. In some cases, infants may present when they are older with recurrent bouts of right upper lobe pneumonia. Neonates who are suspected of having an abnormal connection between the trachea and esophagus should have a plain x-ray film made. The plain film often shows evidence of aspiration and gastric dilatation. The diagnosis is established by an experienced pediatric radiologist who performs a tube esophagram with infant in the prone position. The radiologist passes the tube past the presumed defect into the stomach then slowly withdraws the tube while injecting
contrast. Bronchoscopy and esophagoscopy can confirm the diagnosis by demonstrating the fistula opening [2]. Most H-type tracheoesophageal fistulas are approached through a cervical incision. A right-sided incision is made low on the neck. A catheter placed through the fistula assists the operator in identifying the abnormal connection. Another helpful maneuver is to surround the esophagus while avoiding damage to the recurrent larygeal nerve. Once the fistula is identified, stay sutures are placed on the esophageal side and the fistula is divided. The trachea can be closed with 5-0 polypropylene sutures. The esophageal side
* Corresponding author. Tel.: ⫹1-412-692-7282; fax: ⫹1-412-6926069. E-mail address: [email protected] 0002-9610/03/$ – see front matter © 2003 Excerpta Medica, Inc. All rights reserved. doi:10.1016/S0002-9610(03)00065-5
Fig. 1. Esophagram demonstrating tracheoesophageal fistula.
600
J.S. Upperman et al. / The American Journal of Surgery 185 (2003) 599 – 600
may be closed with absorbable polyglycolic acid sutures. Postoperatively, the infant may experience respiratory distress secondary to trachea swelling or injury to the recurrent laryngeal nerves. Most infants with H-type tracheoesophageal fistulas do well, as do most infants with the more common C-type tracheoesophageal fistula [3].
References
Fig. 2. Chest plain x-ray film after barium swallow.
[1] Tsai JY, Berkery L, Wesson DE, et al. Esophageal atresia and tracheoesophageal fistula: surgical experience over two decades. Ann Thorac Surg 1997;64:778 – 84. [2] Benjamin B. Endoscopy in esophageal atresia and tracheoesophageal fistula. Ann Otol Rhinol Laryngol 1981;90:376 – 82. [3] Dunn JC, Fonkalsrud EW, Atkinson JB. Simplifying the Waterston’s stratification of infants with tracheoesophageal fistula. Am Surg 1999; 65:908 –10.
Fig. 3. Bronchoscopy demonstrating cannulation of tracheoesophageal fistula by Fogarty catheter.