Endoscopic treatment of congenital H-Type and recurrent tracheoesophageal fistula with electrocautery and histoacryl glue

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Summary

Objective

Congenital H-Type tracheoesophageal fistulae (H-Type TEF) and recurrent fistulae after primary repair of esophageal atresia represent a difficult problem in diagnosis and management. The treatment traditionally involved an open technique via a cervical or thoracic route, approaches with high morbidity and mortality rates of up to 50%. Endoscopic closure of fistulae has been reported with various techniques such as tissue adhesives, electrocautery, sclerosants and laser. However, the published case series contain a small number of patients with usually short-term follow-up. The aim of this paper is to present the experience of a decade at Toronto's Hospital for Sick Children, using diathermy and histoacryl tissue adhesive and discuss the indications and limitations of this technique.

Methods

Since 1995, 192 patients have been managed in this institution with tracheoesophageal fistulae of which 10 patients have been treated endoscopically. The fistulae were both of H-Type and recurrent tracheoesophageal fistulae following surgery for esophageal atresia and fistula division. One fistula occurred following trauma. The procedure was undertaken under general anesthesia in the image guided therapy suite under fluoroscopic control. Flexible ball electrocautery and injection of histoacryl glue were used either on their own or in combination.

Results

Fistula closure was achieved in 9 out of 10 fistulae. Four patients had a second endoscopic procedure. No major respiratory or other complications were encountered in association with the procedure. Follow-up has been between 3 months and 9 years.

Conclusion

We conclude, endoscopic treatment of tracheoesophageal fistulae with electrocautery and histoacryl glue has been a safe and successful technique of managing H-Type and recurrent tracheoesophageal fistulae. In this paper, we discuss the indications and the surgical steps of the procedure. We highlight that diathermy should be carefully controlled and applied preferably in the small non-patulous fistulae. A fistula that has not closed after two endoscopic attempts is not suitable for further endoscopic treatment and therefore an external approach should be recommended.

Introduction

Congenital tracheo-esophageal fistula (TEF) has a reported incidence of 1 in 3000–4500 live births [1], [2].

H-Type tracheoesophageal fistula (H-Type TEF) without atresia represents 4% of congenital esophageal anomalies [3]. This term refers to a fistula between the posterior wall of the trachea and a more caudal position on the anterior wall of the esophagus. The classical symptoms include coughing and aspiration, abdominal distention, repeated cyanosis and chronic lung disease. The diagnosis is usually made before the third year of life, however in extreme cases can be made in adulthood with a chronic cough [4]. The diagnosis requires strong clinical suspicion and investigation with contrast study and rigid endoscopy [5]. Traditionally, the treatment has been by an open approach usually cervical and sometimes via a thoracotomy. Depending on the level of fistula, a cervical approach is recommended for a fistula at T2 level or higher and a thoracotomy for a fistula at T3 level and lower [5], [6]. Thoracotomy caries a higher risk, mortality rate of 50% [7].

Recurrent tracheoesophageal fistulae (RTEF) occur following primary repair of esophageal atresia and distal TEF. Recurrence rates vary between 5 and 15% [8], [9]. The incidence has been reported to be from zero up to 40%, the average seems to be 10% [8]. The mortality rates have been as high as 60% [10], particularly in the 1970s. Therefore, several authors have tried to address this problem endoscopically using tissue adhesives [11], [12], [14], sclerosants [15], electrocautery [16], and [17] laser. However, the published series have a very small number of patients and short-term follow-up [1].

The aim of this paper is to present the experience of a decade at Toronto's Hospital for Sick Children, on endoscopic management of H-Type and RTEF and discuss the indications and limitations of our preferred technique of electrocautery and histoacryl tissue adhesive.

Section snippets

Patients and method

This study is a retrospective search of hospital database for tracheoesophageal fistulae. Patient charts were reviewed for demographic details, presentation, medical history, management and follow-up.

During the 10-year period 1995–2005, 192 patients had TEF repaired at the Hospital for Sick Children, Toronto. Ten of these repairs were treated endoscopically. There were four males and six females. The type of TEF included two H-Type, one traumatic and seven recurrent TEF's following primary

Results

All fistulae had removal of the epithelial lining either using suction or the electrocautery wire. This is considered an essential step of the procedure. Histoacryl glue application without electrocautery was used on four occasions and this group represents our technique during the earlier years of the study. Current technique involves a combination of electrocautery and histoacryl glue application (Fig. 2) and this was used for six patients. For very small fistulae electrocautery alone can be

Discussion

Gans and Berci in 1971 [20], reported the use of Hopkins telescopes in pediatric surgery, which improved diagnostic accuracy and management of the anomalies of the aerodigestive tract. The literature on endoscopic management of H-Type TEF and RTEF contains reports of small series (maximum of three cases) with usually short follow-up [11], [12], [13], [14], [15], [16], [17].

Willets et al. [1], reported that long term results of endoscopic treatment for H-Type and RTEF are absent from the

Conclusion

We conclude, endoscopic treatment of tracheoesophageal fistulae with electrocautery and histoacryl glue has been a safe and successful technique of managing H-Type and recurrent tracheoesophageal fistulae with good long-term outcome. Therefore, we do recommend this technique providing care is taken when applying electrocautery in the upper airway. Endoscopic management of small H-Type fistulae can be considered as primary treatment modality providing adequate facilities are available. However,

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