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