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Management of tracheoesophageal fistula as a complication of esophageal dilatations in caustic esophageal burns
Management of Tracheoesophageal Fistula as a Complication of Esophageal Dilatations in Caustic Esophageal Burns By Oktay Mutaf, Ali Avano(~lu, Aydin Mevsim, and Geylani Ozok
]zmir, Turkey • The authors report on eight patients with caustic esophageal burns in whom tracheoesophageal fistula (TEF) developed during dilatation programs. This study covered a period of 17 years between 1975 and 1992. The age of the patients ranged from 1.5 to 8 years (mean age, 3.4 years). TEF developed after 5 to 43 months after injury (mean, 20.05 months). In each case, after documentation of the fistula by esophagography, esophagoscopy, and / or bronchoscopy, the fistula was blocked by an intraluminal esophageal stent, a polytetrafluoroethylene (PTFE) tube with a large lumen (10-mm diameter maximum). In this period, patients were fed via a jejunostomy tube and by total parenteral nutrition (TPN) if indicated, while the existing pneumonia was being treated. In one patient, fistula closed spontaneously during the stent application program, which ended with a patent esophagus. In two patients primary closure of TEF was attempted. In one of them fistula recurred and in the other it was technically impossible to separate the esophagus from trachea safely because of the very tight adhesions. In five patients a two-stage coloesophagoplasty was performed to bypass the fistulated esophagus. In the first stage, retrosterhal pull-through of the colon and coloesophagogastric anastomosis was performed. In the second stage, closure of the distal esophagus and cervical coloesophagostomy was carried out. The patient with the primary closure attempt and one patient with stage 1 coloesophagoplasty died 3 and 4 months, respectively, after the operations. The cause of death was uncontrollable pneumonia in both cases. Follow-up of the four patients showed no complications. Another fistula patient is currently on stent treatment program with pneumonia under control. The most important factor that influences survival in these patients is the degree of pneumonia caused by esophagotracheal leak. Primary repair of the fistula is technically difficult and dangerous in caustic esophageal burns because of extensive and tight adhesions between trachea and esophagus. On the other hand, an intraesophageal stent blocks the fistula, thus rendering the pneumonia curable, and also there is a good chance that the fistula will close spontaneously while the esophagus is being stented. Therefore, a stent trial is essential before a surgical attempt is made to obliterate the proximal esophagus with an esophageal bypass procedure.
Copyright © 1995by W.B. Saunders Company INDEX WORDS: Caustic esophageal burns, acquired tracheoesophageal fistula, esophagus, colonic bypass.
RACHEOESOPHAGEAL F I S T U L A ( T E F ) is an u n c o m m o n c o m p l i c a t i o n of caustic e s o p h a g e a l burns. T E F can o c c u r e i t h e r in t h e a c u t e p h a s e o f t h e caustic i n g e s t i o n o r as a result of t h e c h r o n i c d i l a t a t i o n s o f t h e severely s t r i c t u r e d e s o p h a g u s . This study r e p o r t s t h e m a n a g e m e n t o f T E F as a c o m p l i c a tion o f e s o p h a g e a l d i l a t a t i o n s in caustic e s o p h a g e a l burn treatment.
T
Journal of PediatricSurgery, Vol 30, No 6 (June), 1995: pp 823-826
MATERIALS AND METHODS
Between the years 1975 and 1992, 932 patients with caustic esophageal burns were admitted to our institution. In eight of these patients (0.85%), TEF developed during various phases of the treatment program. The age of the patients ranged from 1.5 to 8 years with a mean of 3.4 years. All eight patients had accidentally ingested sodium hydroxide solution as the caustic agent, and were severely burned. After detecting the site of the fistula by esophagography, esophagoscopy, or bronchoscopy, a gastrostomy and transpyloric tube jejunostomy were performed as the standard initial surgical procedures in all the patients. Then, a special intraluminal polytetrafluorethylane (PTFE) stent designed by one of the authors (OM) was used to block the fistula with the expectation that it would close spontaneously (Fig 1). When this was not possible, a radical operation was planned. In patients in whom spontaneous closure was not possible, a primary closure of the fistula with a transthoracic approach was selected initiallyin apparently suitable cases. When this failed or in cases in which it was thought that a direct approach would probably be unsuccessful, retrosternal colonic bypasses were performed in two stages. In the first stage, transverse colon was anastomosed to the anterior wall of the stomach and pulled through a retrosternal tunnel to the cervical region. Esophageal transection at the sternal level, closure of the distal esophagus, and end-to-end cervical coloesophageal anastomosis were performed as a separate procedure. The stent was kept in place until the second-stage operation to prevent any esophagotracheal leakage. RESULTS
P a t i e n t s w e r e d i l a t e d 10 to 27 t i m e s ( m e a n , 17.8) d u r i n g a p e r i o d o f 5 to 43 m o n t h s ( m e a n , 20.05 m o n t h s ) b e f o r e t h e fistulae o p e n e d . T h e m e a n d u r a tion of t h e stent a p p l i c a t i o n a f t e r t h e d e t e c t i o n of t h e fistula was 11.4 m o n t h s ( T a b l e 1). T h e p a t i e n t with p r i m a r y c l o s u r e a n d o n e of t h e p a t i e n t s with stage o n e c o l o e s o p h a g o p l a s t y d i e d 3 a n d 4 m o n t h s , respectively, a f t e r t h e o p e r a t i o n because o f severe p n e u m o n i a a n d e v e n t u a l sepsis with m u l t i p l e o r g a n failure. F o l l o w - u p o f t h e o t h e r f o u r p a t i e n t s with c o l o e s o p h a g o p l a s t y s h o w e d no c o m p l i cations. In o n e p a t i e n t t h e T E F h e a l e d a f t e r 9 m o n t h s o f stent a p p l i c a t i o n . In this p a t i e n t , e s o p h a g u s was p a t e n t a n d n e e d e d no m o r e dilatations. O n e p a t i e n t is s t e n t e d at the m o m e n t , waiting for s p o n t a n e o u s closure. T h e results a r e s u m m a r i z e d in T a b l e 2.
From Ege UniversityFaculty of Medicine, Department of Pediatric Surgery, Izmir, Turkey. Address reprint requests to Oktay Mutaf, Ege (Jniversitesi Tip Fakiiltesi, ~ocuk Cerrahisi Anabilim Dah, 35100, Bomova, izmir, Turkey. Copyright © 1995 by W.B. Saunders Company 0022-3468/95/3006-0013503.00/0 823
MUTAF ET AL
824
Table 2. Present Status of the Cases Case No.
Procedure
Result
1 2 3 4 5 6 7 8
G/J-PR G/J-PR-CBI-CB2 G/J-CBI-CB2 G/J-CB1 G/J-CBI-CB2 G/J-CB1-CB2 G/J G/J
Died Good Good Died Good Good Good *
Abbreviations: G/J, gastrostomy plus transpyloric tube jejunoatomy; PR, primary repair of the fistula via a transthoracic approach; CB1, colonic by-pass stage one; CB2, colonic by-pass stage two. *Waiting for spontaneous closure with an intraesophageal PTFE stent.
Fig 1. PTFEstent.
DISCUSSION
The main symptoms of TEF are persistent pneumonia, choking, and cyanosis while feeding and air exit through the gastrostomy tube. TEF can be easily documented by an esophagogram; however, it is not always possible to show the exact localization of the fistula because of the quick transition of contrast material from the esophagus into the bronchial tree. During esophagoscopy, saline is given into the lumen of the esophagus and the esophagoscope is moved Table i. Clinical Evaluation of Seven TEF Cases Mean No. of dilatations before detection of the fistula Duration of dilatations before detection of the fistula Duration of postfistula stent applications
10-27 times 5-43 months 4-34 months
i7.8 20.05 11.4
backward gradually, until air bubbling is observed from the anterior wall of the lumen during a prolonged, forced inspiration provided by the anesthesiologist. This is considered to be the most reliable method in detecting the exact site of the fistula. In only two patients we were able to show the site of the fistula by bronchoscopy alone. Before the definitive operation, a certain period of time is required for the inflammatory process to subside and for the pneumonia to become manageable, as well as to support the patient. In this period, oral feedings should be discontinued and broadspectrum antibiotics must be administered. Chest physiotherapy is valuable. Caloric and fluid intake can be maintained by enteral feedings via a gastrostomy/jejunostomy tube or total parenteral nutrition when needed. Gastrostomy with a feeding jejunostomy should be considered to drain the stomach in cases of gastroesophageal reflux (GER). After localizing the fistula, an intraluminal PTFE stent can be used to block the fistula. This technique is commonly used in malignant perforations of esophagus to palliate the patients without an expectation of spontaneous closure. 1,2 PTFE is inert physiologically and has very good nonstick properties. It can be safely placed into the esophageal lumen after the acute phase of the caustic insult, ie, after the epitheiization is completed. Stent closes the fistula only temporarily in most of the patients. In the usual Patient, after removal of the stent, esophageal lumen contracts but the fistula persists. In one of our patients, TEF dosed after 9 months of stent application. This patient's treatment resulted with a patent esophagus, and the patient did not need additional dilatations or show any evidence of a recurrent TEF as of end 1993. A stent can prevent leakage of the intraesophageal secretions into the bronchial system and is an alternative to cervical esophagostomy. Stents, on the other hand, can increase GER to the upper esophagus and may be a cause of acid aspiration. Therefore in all
ACQUIRED TRACHEOESOPHAGEAL FISTULA
TEF cases GER must be investigated. In our eight patients acid reflux could not be shown with 24-hour distal esophageal pH measurements with the esophageal probe introduced into the distal esophagus through the lumen of the stent. In TEF patients with GER, stent therapy should not be considered as an initial trial. In two patients, primary closure of TEF was attempted. In one of these patients fistula recurred in the early postoperative period; in the other, it was technically impossible to separate the esophagus from the trachea because they were virtually sharing the same lumen. Burrington and Raffensperger 3 reported six cases with early TEF resulting from ingestion of caustic material and concluded that transthoracic primary repair was not a reliable method. Various fistula conditions in the chest can be successfully treated with muscle flaps. 4,5 Division of the fistula and repair with an intercostal muscle flap may also be carried out in patients with TEF caused by foreign bodies and recurrent congenital TEF. 6-8 In these patients, the initial inflammation and the resultant cicatrix is usually limited, compared with a postcaustic scarring; therefore, primary repair of a caustic originated fistula is technically difficult and has a high risk of recurrence. Therefore, the method of choice in the management of severe caustic burns with TEF should be bypassing of the fistula with a segment of colon, jejunum, or gastric tube. The vascular structure of jejunum is not reliable for a safe bypass operation in children. 9 Gastric tubes can be used, but we preferred colonic segments in this prospective work for the sake of homogeneity in the series. In our institution we perform the coloesophagoplasty in two stages. Our procedure of choice for cases of extensive esophageal stricture is retrosternal colon transposition and a staged esophagocolostomy. By staging this operation, the incidence of cervical anastomotic stenosis can be significantly reduced. The hemodynamic basis of this hypothesis and its clinical application is discussed elsewhere. 1°-12 We believe that the most important factor that influences survival in these patients is the degree of pneumonia caused by the esophageal-tracheal leakage. So, a stent must be used until the operative closure of the proximal esophagus. This prevents an unnecessary cervical esophagostomy. At this stage a question arises: can we feed these patients orally while stented? We are not able to give a definite answer to this question, although we encouraged fluid and pureed diet orally in these patients under strict supervision, and apparently this route is safe, but we cannot be sure if our patients can
825
use this route on a routine basis. Therefore, the accepted routine at present is some oral feedings under supervision plus regular jejunostomy feedings. The feeding data of these patients after the completion of the treatment program is not different from any other coloesophagoplasty case. These patients were normal swallowers before the caustic insult. Therefore, after reconstruction of the new orogastric tract, they quickly develop normal swallowing habits. The response of the case of spontaneous closure after stenting did not differ from those of the rest of the series. An important point that should be noted is that we find it very difficult to separate a TEF originating from a severe caustic burn, and we think that the safest method of eliminating this kind of TEF is to bypass it. After dividing the upper esophagus at the sternal level and bypassing the fistula with a segment of colon, the remaining densely fibrotic esophagus
Fig 2. Gastric radiograph of a patient with retrosternal colon transplant without TEF, showing gastroesophageal and gastrocolic reflux. Stomach was filled with barium via gastrostomy. Note the complete obliteration of the distal esophagus. C, colon transplant; E, esophagus; S, stomach.
MUTAF ET AL
826
scleroses together with the TEF. If there is an undiscovered GER, this will accelerate the sclerosing rate of the bypassed esophageal lumen (Fig 2). In conclusion, we suggest the following plan for the management of TEF as a complication of the treatment of esophageal strictures: (1) Broad-spectrum antibiotics should be prescribed to combat severe pneumonia; (2) Oral feedings should be ceased, and
gastrostomy should be performed for gastric decompression; (3) Jejunal feeding should be commenced via a gastrostomy/jejunostomy tube or TPN as indicated; (4) A special intraluminal PTFE stent should be placed to seal off the fistula temporarily or with the expectation of spontaneous closure until the pneumonia subsides; and (5) Two-stage colonic bypass of the esophagus should be performed in unresponsive cases.
REFERENCES
1. Smith JL, Michaletz PA, Tabibian N, et al: Improved palliation of a respiratory-esophageal fistula with a cuffed esophageal prosthesis. Am J Gastroentero182:1175-1176, 1987 2. Ooldschmid S, Boyce HW, Nord HJ, et al: Treatment of pharyngoesophageal stenosis by polyvinyl prosthesis. Am J Gastroenterol 83:513-518, 1988 3. Burrington JD, Raffensperger JG: Surgical management of tracheoesophageal fistula complicating caustic ingestion. Surgery 84:329-334, 1978 4. Fell SC, Mollenkopf FP, Montefusco CM, et al: Revascularization of ischemic bronchial anastomoses by an intercostal pedicle flap. J Thorac Cardiovasc Surg 90:172-178, 1985 5. Azizkhan RG, Roberson JB, Powers SK: Successful use of a vascularized intercostal muscle flap to seal a persistent intrapleural cerebrospinal fluid leak in a child. J Pediatr Surg 26:744-746, 1991
6. Rahbar A, Farha SJ: Acquired tracheoesophageal fistula. J Pediatr Surg 13:375-376, 1978 7. Szold A, Udassin R, Seror D, et al: Acquired tracheoesophageal fistula in infancy and childhood. J Pediatr Surg 26:672-675, 1991 8. Soriano A, Hernandez-Siverio N, Carrillo A: Intercostal pedicled flap in esophageal atresia. J Pediatr Surg 22:115-116, 1987 9. Mutaf O: Esophagoplasty for caustic esophageal burns in children. Pediatr Surg Int 7:106-108, 1992 10. Weale FE: An Introduction to Surgical Haemodynamics. London, Lloyd-Luke, 1966, pp 35-41 11. Ba§ar E, Weiss C: Vasculature and Circulation. Amsterdam, Elsevier/North-Holland Biomedical Press, 1981, pp 92-93 12. Mutaf O, t~zok G, Avano~lu A: Oesophagoplasty for benign oesophageal strictures in chiidl'en. Third European Congress of Surgery, London. Br J Surg 80 (suppl): (abstr) 1993
]zmir, Turkey • The authors report on eight patients with caustic esophageal burns in whom tracheoesophageal fistula (TEF) developed during dilatation programs. This study covered a period of 17 years between 1975 and 1992. The age of the patients ranged from 1.5 to 8 years (mean age, 3.4 years). TEF developed after 5 to 43 months after injury (mean, 20.05 months). In each case, after documentation of the fistula by esophagography, esophagoscopy, and / or bronchoscopy, the fistula was blocked by an intraluminal esophageal stent, a polytetrafluoroethylene (PTFE) tube with a large lumen (10-mm diameter maximum). In this period, patients were fed via a jejunostomy tube and by total parenteral nutrition (TPN) if indicated, while the existing pneumonia was being treated. In one patient, fistula closed spontaneously during the stent application program, which ended with a patent esophagus. In two patients primary closure of TEF was attempted. In one of them fistula recurred and in the other it was technically impossible to separate the esophagus from trachea safely because of the very tight adhesions. In five patients a two-stage coloesophagoplasty was performed to bypass the fistulated esophagus. In the first stage, retrosterhal pull-through of the colon and coloesophagogastric anastomosis was performed. In the second stage, closure of the distal esophagus and cervical coloesophagostomy was carried out. The patient with the primary closure attempt and one patient with stage 1 coloesophagoplasty died 3 and 4 months, respectively, after the operations. The cause of death was uncontrollable pneumonia in both cases. Follow-up of the four patients showed no complications. Another fistula patient is currently on stent treatment program with pneumonia under control. The most important factor that influences survival in these patients is the degree of pneumonia caused by esophagotracheal leak. Primary repair of the fistula is technically difficult and dangerous in caustic esophageal burns because of extensive and tight adhesions between trachea and esophagus. On the other hand, an intraesophageal stent blocks the fistula, thus rendering the pneumonia curable, and also there is a good chance that the fistula will close spontaneously while the esophagus is being stented. Therefore, a stent trial is essential before a surgical attempt is made to obliterate the proximal esophagus with an esophageal bypass procedure.
Copyright © 1995by W.B. Saunders Company INDEX WORDS: Caustic esophageal burns, acquired tracheoesophageal fistula, esophagus, colonic bypass.
RACHEOESOPHAGEAL F I S T U L A ( T E F ) is an u n c o m m o n c o m p l i c a t i o n of caustic e s o p h a g e a l burns. T E F can o c c u r e i t h e r in t h e a c u t e p h a s e o f t h e caustic i n g e s t i o n o r as a result of t h e c h r o n i c d i l a t a t i o n s o f t h e severely s t r i c t u r e d e s o p h a g u s . This study r e p o r t s t h e m a n a g e m e n t o f T E F as a c o m p l i c a tion o f e s o p h a g e a l d i l a t a t i o n s in caustic e s o p h a g e a l burn treatment.
T
Journal of PediatricSurgery, Vol 30, No 6 (June), 1995: pp 823-826
MATERIALS AND METHODS
Between the years 1975 and 1992, 932 patients with caustic esophageal burns were admitted to our institution. In eight of these patients (0.85%), TEF developed during various phases of the treatment program. The age of the patients ranged from 1.5 to 8 years with a mean of 3.4 years. All eight patients had accidentally ingested sodium hydroxide solution as the caustic agent, and were severely burned. After detecting the site of the fistula by esophagography, esophagoscopy, or bronchoscopy, a gastrostomy and transpyloric tube jejunostomy were performed as the standard initial surgical procedures in all the patients. Then, a special intraluminal polytetrafluorethylane (PTFE) stent designed by one of the authors (OM) was used to block the fistula with the expectation that it would close spontaneously (Fig 1). When this was not possible, a radical operation was planned. In patients in whom spontaneous closure was not possible, a primary closure of the fistula with a transthoracic approach was selected initiallyin apparently suitable cases. When this failed or in cases in which it was thought that a direct approach would probably be unsuccessful, retrosternal colonic bypasses were performed in two stages. In the first stage, transverse colon was anastomosed to the anterior wall of the stomach and pulled through a retrosternal tunnel to the cervical region. Esophageal transection at the sternal level, closure of the distal esophagus, and end-to-end cervical coloesophageal anastomosis were performed as a separate procedure. The stent was kept in place until the second-stage operation to prevent any esophagotracheal leakage. RESULTS
P a t i e n t s w e r e d i l a t e d 10 to 27 t i m e s ( m e a n , 17.8) d u r i n g a p e r i o d o f 5 to 43 m o n t h s ( m e a n , 20.05 m o n t h s ) b e f o r e t h e fistulae o p e n e d . T h e m e a n d u r a tion of t h e stent a p p l i c a t i o n a f t e r t h e d e t e c t i o n of t h e fistula was 11.4 m o n t h s ( T a b l e 1). T h e p a t i e n t with p r i m a r y c l o s u r e a n d o n e of t h e p a t i e n t s with stage o n e c o l o e s o p h a g o p l a s t y d i e d 3 a n d 4 m o n t h s , respectively, a f t e r t h e o p e r a t i o n because o f severe p n e u m o n i a a n d e v e n t u a l sepsis with m u l t i p l e o r g a n failure. F o l l o w - u p o f t h e o t h e r f o u r p a t i e n t s with c o l o e s o p h a g o p l a s t y s h o w e d no c o m p l i cations. In o n e p a t i e n t t h e T E F h e a l e d a f t e r 9 m o n t h s o f stent a p p l i c a t i o n . In this p a t i e n t , e s o p h a g u s was p a t e n t a n d n e e d e d no m o r e dilatations. O n e p a t i e n t is s t e n t e d at the m o m e n t , waiting for s p o n t a n e o u s closure. T h e results a r e s u m m a r i z e d in T a b l e 2.
From Ege UniversityFaculty of Medicine, Department of Pediatric Surgery, Izmir, Turkey. Address reprint requests to Oktay Mutaf, Ege (Jniversitesi Tip Fakiiltesi, ~ocuk Cerrahisi Anabilim Dah, 35100, Bomova, izmir, Turkey. Copyright © 1995 by W.B. Saunders Company 0022-3468/95/3006-0013503.00/0 823
MUTAF ET AL
824
Table 2. Present Status of the Cases Case No.
Procedure
Result
1 2 3 4 5 6 7 8
G/J-PR G/J-PR-CBI-CB2 G/J-CBI-CB2 G/J-CB1 G/J-CBI-CB2 G/J-CB1-CB2 G/J G/J
Died Good Good Died Good Good Good *
Abbreviations: G/J, gastrostomy plus transpyloric tube jejunoatomy; PR, primary repair of the fistula via a transthoracic approach; CB1, colonic by-pass stage one; CB2, colonic by-pass stage two. *Waiting for spontaneous closure with an intraesophageal PTFE stent.
Fig 1. PTFEstent.
DISCUSSION
The main symptoms of TEF are persistent pneumonia, choking, and cyanosis while feeding and air exit through the gastrostomy tube. TEF can be easily documented by an esophagogram; however, it is not always possible to show the exact localization of the fistula because of the quick transition of contrast material from the esophagus into the bronchial tree. During esophagoscopy, saline is given into the lumen of the esophagus and the esophagoscope is moved Table i. Clinical Evaluation of Seven TEF Cases Mean No. of dilatations before detection of the fistula Duration of dilatations before detection of the fistula Duration of postfistula stent applications
10-27 times 5-43 months 4-34 months
i7.8 20.05 11.4
backward gradually, until air bubbling is observed from the anterior wall of the lumen during a prolonged, forced inspiration provided by the anesthesiologist. This is considered to be the most reliable method in detecting the exact site of the fistula. In only two patients we were able to show the site of the fistula by bronchoscopy alone. Before the definitive operation, a certain period of time is required for the inflammatory process to subside and for the pneumonia to become manageable, as well as to support the patient. In this period, oral feedings should be discontinued and broadspectrum antibiotics must be administered. Chest physiotherapy is valuable. Caloric and fluid intake can be maintained by enteral feedings via a gastrostomy/jejunostomy tube or total parenteral nutrition when needed. Gastrostomy with a feeding jejunostomy should be considered to drain the stomach in cases of gastroesophageal reflux (GER). After localizing the fistula, an intraluminal PTFE stent can be used to block the fistula. This technique is commonly used in malignant perforations of esophagus to palliate the patients without an expectation of spontaneous closure. 1,2 PTFE is inert physiologically and has very good nonstick properties. It can be safely placed into the esophageal lumen after the acute phase of the caustic insult, ie, after the epitheiization is completed. Stent closes the fistula only temporarily in most of the patients. In the usual Patient, after removal of the stent, esophageal lumen contracts but the fistula persists. In one of our patients, TEF dosed after 9 months of stent application. This patient's treatment resulted with a patent esophagus, and the patient did not need additional dilatations or show any evidence of a recurrent TEF as of end 1993. A stent can prevent leakage of the intraesophageal secretions into the bronchial system and is an alternative to cervical esophagostomy. Stents, on the other hand, can increase GER to the upper esophagus and may be a cause of acid aspiration. Therefore in all
ACQUIRED TRACHEOESOPHAGEAL FISTULA
TEF cases GER must be investigated. In our eight patients acid reflux could not be shown with 24-hour distal esophageal pH measurements with the esophageal probe introduced into the distal esophagus through the lumen of the stent. In TEF patients with GER, stent therapy should not be considered as an initial trial. In two patients, primary closure of TEF was attempted. In one of these patients fistula recurred in the early postoperative period; in the other, it was technically impossible to separate the esophagus from the trachea because they were virtually sharing the same lumen. Burrington and Raffensperger 3 reported six cases with early TEF resulting from ingestion of caustic material and concluded that transthoracic primary repair was not a reliable method. Various fistula conditions in the chest can be successfully treated with muscle flaps. 4,5 Division of the fistula and repair with an intercostal muscle flap may also be carried out in patients with TEF caused by foreign bodies and recurrent congenital TEF. 6-8 In these patients, the initial inflammation and the resultant cicatrix is usually limited, compared with a postcaustic scarring; therefore, primary repair of a caustic originated fistula is technically difficult and has a high risk of recurrence. Therefore, the method of choice in the management of severe caustic burns with TEF should be bypassing of the fistula with a segment of colon, jejunum, or gastric tube. The vascular structure of jejunum is not reliable for a safe bypass operation in children. 9 Gastric tubes can be used, but we preferred colonic segments in this prospective work for the sake of homogeneity in the series. In our institution we perform the coloesophagoplasty in two stages. Our procedure of choice for cases of extensive esophageal stricture is retrosternal colon transposition and a staged esophagocolostomy. By staging this operation, the incidence of cervical anastomotic stenosis can be significantly reduced. The hemodynamic basis of this hypothesis and its clinical application is discussed elsewhere. 1°-12 We believe that the most important factor that influences survival in these patients is the degree of pneumonia caused by the esophageal-tracheal leakage. So, a stent must be used until the operative closure of the proximal esophagus. This prevents an unnecessary cervical esophagostomy. At this stage a question arises: can we feed these patients orally while stented? We are not able to give a definite answer to this question, although we encouraged fluid and pureed diet orally in these patients under strict supervision, and apparently this route is safe, but we cannot be sure if our patients can
825
use this route on a routine basis. Therefore, the accepted routine at present is some oral feedings under supervision plus regular jejunostomy feedings. The feeding data of these patients after the completion of the treatment program is not different from any other coloesophagoplasty case. These patients were normal swallowers before the caustic insult. Therefore, after reconstruction of the new orogastric tract, they quickly develop normal swallowing habits. The response of the case of spontaneous closure after stenting did not differ from those of the rest of the series. An important point that should be noted is that we find it very difficult to separate a TEF originating from a severe caustic burn, and we think that the safest method of eliminating this kind of TEF is to bypass it. After dividing the upper esophagus at the sternal level and bypassing the fistula with a segment of colon, the remaining densely fibrotic esophagus
Fig 2. Gastric radiograph of a patient with retrosternal colon transplant without TEF, showing gastroesophageal and gastrocolic reflux. Stomach was filled with barium via gastrostomy. Note the complete obliteration of the distal esophagus. C, colon transplant; E, esophagus; S, stomach.
MUTAF ET AL
826
scleroses together with the TEF. If there is an undiscovered GER, this will accelerate the sclerosing rate of the bypassed esophageal lumen (Fig 2). In conclusion, we suggest the following plan for the management of TEF as a complication of the treatment of esophageal strictures: (1) Broad-spectrum antibiotics should be prescribed to combat severe pneumonia; (2) Oral feedings should be ceased, and
gastrostomy should be performed for gastric decompression; (3) Jejunal feeding should be commenced via a gastrostomy/jejunostomy tube or TPN as indicated; (4) A special intraluminal PTFE stent should be placed to seal off the fistula temporarily or with the expectation of spontaneous closure until the pneumonia subsides; and (5) Two-stage colonic bypass of the esophagus should be performed in unresponsive cases.
REFERENCES
1. Smith JL, Michaletz PA, Tabibian N, et al: Improved palliation of a respiratory-esophageal fistula with a cuffed esophageal prosthesis. Am J Gastroentero182:1175-1176, 1987 2. Ooldschmid S, Boyce HW, Nord HJ, et al: Treatment of pharyngoesophageal stenosis by polyvinyl prosthesis. Am J Gastroenterol 83:513-518, 1988 3. Burrington JD, Raffensperger JG: Surgical management of tracheoesophageal fistula complicating caustic ingestion. Surgery 84:329-334, 1978 4. Fell SC, Mollenkopf FP, Montefusco CM, et al: Revascularization of ischemic bronchial anastomoses by an intercostal pedicle flap. J Thorac Cardiovasc Surg 90:172-178, 1985 5. Azizkhan RG, Roberson JB, Powers SK: Successful use of a vascularized intercostal muscle flap to seal a persistent intrapleural cerebrospinal fluid leak in a child. J Pediatr Surg 26:744-746, 1991
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