Trache-oesophageal fistula

• Any communication between the respiratory tract and oesophagus

Pathogenesis (acquired)

• • Tissue necrosis and breakdown of respiratory tract and oesophagus
  • Most commonly upper third of oesophagus where the membransou wall of trachea lies adjacent

Aetiology

• • Acquired
    • Benign
      • Iatrogenic
        • Prolonged intubation - require surgical management
        • Intubation injuries
        • Tracheostomy tube placement
        • Oesophageal/laryngeal resection
        • Dilatation procedures/stenting
      • Infectious
        • Anything that causes granulomatous inflammation - histoplasmosis, TB
      • Traumatic
        • Foreign body impaction/erosion
        • Caustic agent ingestion
        • Penetrating or blunt trauma to neck
    • Malignant - probably need palliation

Presentation

• • Chronic cough, exacerbated by PO intake
  • Expectoration of food
  • Recurrent LRTI (aspiration)
  • Ventilated patient - inadequate tidal volume return, with gastric distension or a large gastric bubble on imaging. Increased secretions, aspiration of tube feeds from airway, difficulty maintaining seal with the cuff of endobronchial tube, persistent sepsis/pneumonia.

Diagnosis

• • Start with CXR: can see sequelae, including aspiration pneumonitis, dilated stomach/distal oesophagus.
  • With recurrent aspiration pneumonitis, swallow evaluation may be beneficial to exclude oropharyngeal dysphagia
  • Barium swallow - using dilute barium - especially for small fistulae (<1cm)
  • Large fistulae best diagnosed with bronchoscopy/endoscopy, which also allows proper inspection of the airway, and biopsy if indicated

Pre-op

• • Treat and resolve pulmonary sepsis
  • If mechanical ventilation can be weaned - do so - will minimise positive pressure within reconstructed trachea
  • If patient is intubated, cuff should be below fistula, to prevent further contamination
  • Optimise nutrition

Treatment

Benign TOF are primarily managed with surgery

• • • Anterior collar incision. May require sternotomy for access to distal trachea.
    • Single-stage is preferable when possible
    • Two-stage repair (tracheal resection and reconstruction with oesophageal diversion via cervical oesophagostomy, followed by interval primary oesophageal reconstruction)

Malignant TOF  are palliative

• • • Surgery is not worthwhile in almost all cases - prognosis of weeks to months
    • Palliative stenting is effective for symptomatic fistulae
      • Individual or combination of stents placed across the fistula, to prevent passage of enteric contents
        • Barium swallow will be necessary in identifying anatomy
        • Optimise patient as much as possible, as for benign fistulae
        • Most malignant TOFs can be sealed using self-expanding metal or plastic covered or partially covered oesophageal stent
        • In some cases, tracheal stents may also be needed
        • Stents not recommended for stents at or above cricopharyngeus, because this will result in significant discomfort and dysphagia. In such cases, a definitive tracheostomy may be placed.
        • Fistulae to lobar or segmental bronchi are difficult to seal via bronchial stenting, so would be normally treated with oesophageal stent alone
        • Need minimal IV sedation and topical or nebulised anaesthetic