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Background Acquired aerodigestive fistula (ADF) are rare, but associated with significant morbidity. Surgery affords the best prospect of cure. We present our experience of the surgical management of ADFs at a specialist unit, highlighting operative techniques, challenges and assess clinical outcomes following intervention. We also illustrate findings of a Hospital Episodes Statistics search for ADFs. Methods A prospectively-maintained database was searched to identify all patients diagnosed with an ADF who were managed at our institution. Of 48 patients with an ADF, eight underwent surgical intervention. Results Four patients underwent an exploration of the ADF with primary repair of the defect. Two of these patients had proximal ADFs, amenable to repair through a neck incision, and two required a thoracotomy. Two patients suffered fistulae secondary to endoscopic therapy and underwent oesophageal exclusion surgery, with subsequent staged reconstruction. Two patients with previous Tuberculosis had a lung segmentectomy and lobectomy respectively, and a further patient in remission after treatment for lymphoma underwent oesophageal resection with synchronous reconstruction. Three patients suffered a complication, with one post-operative mortality. The remaining seven patients all achieved normal oral alimentation, with no evidence of ADF recurrence at a median follow-up of 32 months. Conclusions Surgery to manage ADFs is effective in restoring normal alimentation and alleviates soiling of the airway, with a very low risk of recurrence. Several operative techniques can be utilised dependent on the features of the ADF. Early referral to specialist units is advocated, where the expertise to facilitate the complete management of patients is present, within a multi-disciplinary setting.
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R E S E A R C H A R T I C L E Open Access
The surgical management of non-
malignant aerodigestive fistula
Yassar A. Qureshi
, M. Muntzer Mughal
, Sheraz R. Markar
, Borzoueh Mohammadi
, Jeremy George
Martin Hayward
and David Lawrence
Background: Acquired aerodigestive fistula (ADF) are rare, but associated with significant morbidity. Surgery affords
the best prospect of cure. We present our experience of the surgical management of ADFs at a specialist unit, highlighting
operative techniques, challenges and assess clinical outcomes following intervention. We also illustrate findings of a Hospital
Episodes Statistics search for ADFs.
Methods: A prospectively-maintained database was searched to identify all patients diagnosed with an ADF who were
managed at our institution. Of 48 patients with an ADF, eight underwent surgical intervention.
Results: Four patients underwent an exploration of the ADF with primary repair of the defect. Two of these patients had
proximal ADFs, amenable to repair through a neck incision, and two required a thoracotomy. Two patients suffered fistulae
secondary to endoscopic therapy and underwent oesophageal exclusion surgery, with subsequent staged reconstruction.
Two patients with previous Tuberculosis had a lung segmentectomy and lobectomy respectively, and a further patient in
remission after treatment for lymphoma underwent oesophageal resection with synchronous reconstruction. Three patients
suffered a complication, with one post-operative mortality. The remaining seven patients all achieved normal oral
alimentation, with no evidence of ADF recurrence at a median follow-up of 32 months.
Conclusions: Surgery to manage ADFs is effective in restoring normal alimentation and alleviates soiling of the airway, with
a very low risk of recurrence. Several operative techniques can be utilised dependent on the features of the ADF. Early
referral to specialist units is advocated, where the expertise to facilitate the complete management of patients is
present, within a multi-disciplinary setting.
Keywords: Aerodigestive fistula, Tracheo-oesophageal fistula, Oesophageal cancer, Oesophageal surgery
Surgical intervention affords the best prospect of
long-term cure of aerodigestive fistulae (ADF). Although
several operative techniques can be used to treat this de-
bilitating condition, they can only be utilised in selected
patients owing to both the underlying diagnosis and the
risks associated with such surgery [14]. However, with
ADFs becoming an increasing health problem, with
improving diagnosis and evolving peri-operative care, it
is likely that surgery will play a more important role in
the management of ADFs.
The choice of operative technique to treat ADFs is
dependent on several factors. However, the most import-
ant facet relates to the underlying oesophageal or airway
disease, which determines the state of tissue and its
amenability to repair and future surveillance, if required
[1,2,5,6]. Patients often present in a physiologically
challenged state owing to the nature of the disease, and
many will not be candidates for surgery. However, fo-
cused pre-operative intervention and nutritional support
may enable some patients to proceed to surgery. For
these reasons, a multi-disciplinary (MDT) approach is
necessary, and underscores why these patients should be
managed in dedicated centralised units. The range of op-
erations include resection and reconstruction, exclusion
and bypass of the affected segment of oesophagus, and
exploration and repair of the ADF. The expertise of head
* Correspondence:
Department of Oesophago-Gastric Surgery, University College London
Hospital, 250 Euston Road, London NW1 2BU, UK
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Qureshi et al. Journal of Cardiothoracic Surgery (2018) 13:113
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and neck, thoracic and oesophago-gastric surgeons is re-
quired to manage these patients.
In this study, we present our experience of surgical
intervention in patients diagnosed with an ADF. We
explore the background leading to the development of
an ADF, and relate how this can impact on the nature of
surgery performed. Furthermore, we describe the opera-
tive technique, challenges and outcomes following inter-
vention. We review the pertinent literature to enable an
evidence-based approach to the surgical management of
ADFs. We also illustrate findings of a Hospital Episodes
Statistics (HES) search for ADFs, highlighting the
challenges of diagnosis, management and reporting in
contemporary practise.
We interrogated a prospectively-maintained database to
identify patients diagnosed with an ADF and managed at
our institution between January 2005 and January 2017.
A total of 48 patients with an ADF were identified, of
whom eight patients have undergone surgery to treat
their fistula. All patients were discussed at a specialist
MDT where a consensus on optimal management was
reached. Of the 40 patients managed non-surgically, 31
were treated with endoscopic intervention (oesophageal
or tracheal stent), mostly owing to the presence of ad-
vanced malignancy not amenable to curative treatment.
Endoscopic treatment facilitated an alleviation of re-
spiratory soiling, whilst allowing oncological treatment
to be commenced. A further seven patients were man-
aged in palliative setting after presenting in e xtremis,
and two patients with very small asymptomatic ADFs
were managed conservatively with regular surveillance.
Follow-up refers to time from diagnosis of ADF (or
underlying disease where specified) to last clinical en-
gagement or death. Median follow-up was 32 months.
Local ethical approval for retrieval and use of clinical
data for this study was granted.
Operative technique
When considering surgery as treatment for ADF, several
factors should be specifically assessed for. It is impera-
tive that a careful search for malignancy is performed
prior to surgery, particularly as many patients will have a
preceding history of proximal oesophageal squamous
cell carcinoma (SCC) treated with chemo-radiotherapy.
If active malignancy is present in the context of an ADF,
this represents locally advanced disease with poor out-
come, rarely amenable to curative surgical intervention.
In these patients, endocopic treatment should be considered
to alleviate symptoms, coupled with chemo-radiotherapy if
appropriate. The physiological state of the patient must also
be thoroughly assessed, to ensure that the risks of major
morbidity and mortality after surgery are minimised, and
vention. Patients should be carefully optimised, and where
indicated, the pre-operative placement of a feeding jejunost-
omy and a venting gastrostomy to improve the nutritional
and metabolic state, and to minimise continued soiling of
the airway, should be performed.
Once a patient is deemed to have an ADF curable by
surgery, secondary factors relating to the ADF and
surrounding tissue become important considerations. A
larger defect, a history of previous local radiotherapy and
endoscopic intervention are all factors which make sur-
gery more challenging. Also, the location of the ADF is
important, as more proximally sited fistulae are amenable
to repair through a neck incision, yet for distal ADF a
thoracotomy is mandated, carrying a greater risk of major
morbidity and mortality. If there has been significant local
contamination, then it may be prudent not perform a
synchronous reconstruction, as the likelihood of an anas-
tomotic dehiscence increases. In these patients, a delayed
reconstruction confers improved chances of better reco-
very. However, given the heterogenous aetiology of ADF,
each case should be considered with a view to an indivi-
dualised treatment plan.
At induction, for tracheo-oesophageal fistulae (TOF),
it is important that the endotracheal tube balloon is sited
distal to the fistula. This will avoid inadvertent damage
to the cuff whilst dissecting and exposing the fistula, and
negate the possibility of ventilatory embarrassment
intra-operatively. Furthermore, this manoeuvre mini-
mises further contamination of the respiratory tract by
manipulation of the affected structures during surgery.
ADF exploration and repair
This may involve either an incision in the neck for proximal
fistulae, or a thoracotomy for more distal ADFs. In the neck,
dissection must proceed to mobilise the thyroid with careful
identification and preservation of the recurrent laryngeal
nerves and parathyroid glands. The oesophagus should be
circumferentially mobilised, as this manoeuvre will allow the
pharyngo-laryngeal complex to be gently pulled superiorly
and away from the thoracic inlet, to provide good access to
the fistula. Once the fistula has been identified, it can be dis-
sected free and a primary repair of the oesophagus and tra-
chea with absorbable sutures can be performed. It is critical
that the fistula is accessible from both sides of the neck to
ensure complete control of the airway during the repair,
whilst also facilitating a pedicled strap muscle interposition
flap. This reinforces the repair by providing a physical bar-
rier between the two suture lines.
In the thorax, a similar approach is used with an inter-
costal flap which is carefully prepared at the time of
thoracotomy. Once the fistula has been identified, again,
it is dissected free and a primary repair performed, with
the intercostal flap placed between the suture lines.
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Exclusion surgery involves isolating the oesophagus from
alimentary tract continuity, both proximal and distal to
the fistula. This involves an incision in the neck to ac-
cess the proximal oesophagus, where, once circumferen-
tially mobilised, it is transected above the fistula and
brought to the skin as an oesophagostomy. If the fistula
is very proximal, then the superior oesophagus may be
left in situ, and a large T-tube placed in the lumen with
the distal limb of the tube brought to the skin.
Next, a laparotomy is performed where the oesohago-
gastric junction (OGJ) is mobilised and the stomach
transected below this, from the lesser curve through to
the GI tract entirely, whilst preserving the majority of the
stomach for future reconstruction. The small stomach
remnant attached to the OGJ is brought to the abdominal
wall, where a generous gastrostomy is fashioned. This al-
lows retrograde access to the excluded oesophagus, for both
endoscopic surveillance and therapy, and facilitates venting
of oesophageal mucous.
Our unit policy is to defer reconstruction as a second,
staged procedure. This allows the patient a period of re-
covery, whilst respiratory and nutritional optimisation
continues. Furthermore, by fashioning an anastomosis at
the index operation in a potentially contaminated surgi-
cal field, there is a higher chance of a leak. If this were
to occur, there is substantial risk of fistula recurrence.
Where possible, the stomach is used a conduit, and is
brought to the neck through the retrosternal space, thus
avoiding the need for a repeat thoracotomy. If there is
insufficient proximal oesophagus, the stomach may be
anastomosed directly to the inferior pharyngeal
This is normally reserved for large or recurrent fistulae.
For proximally sited ADF - those affecting the trachea,
this will involve resection of the oesophagus, via a trans-
thoracic approach. The fistula is identified, and the
oesophagus dissected away around it. However, the
oesophageal tissue intimately involved with the fistula is
left in situ, thus avoiding direct dissection of the trachea
and minimising the risk of an air leak. The tracheal defect
with the overlying oesophageal tissue is then primarily
closed, with the latter acting as a buttress reinforcing the
tracheal repair. Typically, a gastric conduit is utilised for
reconstruction, necessitating a laparotomy.
For more distal ADF, those affecting the bronchus inter-
medius and more distal, a thoracotomy is performed to
identify the fistula. A segmentectomy or lobectomy of the
lung can be performed, dependent on the size of the de-
fect and the quality of the surrounding parenchyma. Thus,
the affected distal airway and the fistula are excised en
bloc. The oesophageal defect can be repaired primarily,
utilising an intercostal flap to reinforce the repair, or an
oesophageal resection is performed if the defect is very
large and unlikely to heal. In these instances, given the
anastomosis will be at a distinct site from the ADF, a syn-
chronous reconstruction can be performed safely.
In our experience, tracheal resection is a very challen-
ging operation, with the risk of significant short and
long-term complications [2,3]. Owing to the limited
vascularity of the trachea, healing, particularly in this co-
hort of patients, may be protracted, necessitating pro-
longed mechanical ventilation. Thus, we have preferred
to avoid such an operative intervention. However, for
very large TOFs, or those where a circumferential injury
to the trachea is present (such as cuff related fistulae), or
where other intervention has failed, tracheal resection
and reconstruction may be indicated. Mathisen et al pro-
vide an operative description and experience of this
technique [3].
Preceding history and previous intervention
The median age at diagnosis of ADF was 56 years (range
2973 years). Three patients had a previous diagnosis of
oesophageal malignancy; all were treated with chemo-
and/or radiotherapy, and one with surgical resection in
addition. Two patients had a prior diagnosis of Tubercu-
losis (TB) and had received anti-microbial therapy in the
past, and one patient previously had surgical interven-
tion following a post-emetic oesophageal leak. In two pa-
tients, no obvious cause of ADF was identified, likely
representing congenital fistulae that had persisted into
adulthood. Of these cases, two patients (1 and 6) devel-
oped oesophageal strictures after their initial treatment.
Patient 1 had undergone several balloon dilations and
stent placements, with the stent subsequently eroding
into the airway (Fig. 1). Similarly, patient 6 also received
a stent which directly caused the fistula. Table 1summa-
rises key patient factors.
ADF characteristics
The two patients with an unknown cause of fistula had a
very long history of symptoms, and had been managed
in the community with a diagnosis of asthma (Table 2).
The median time to ADF development for the three pa-
tients with a malignancy was 15 months (range 321),
with the shortest time affecting a patient who had an
oesophageal lymphoma (Patient 7). She had a complete
response to chemotherapy, with a residual fistula persist-
ing (Fig. 2). Both patients with TB had a long interval
after curative medical therapy, although they had sug-
gestive symptoms for some time prior to referral. Most
patients presented with recurrent chest infections and
symptoms suggestive of aspiration. Of these, one patient
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(4) presented with acute respiratory failure owing to
overwhelming infection caused by aspiration. Of interest,
he had a fistula affecting the very proximal trachea
(Fig. 3).
The size of the fistula ranged from 3 to 16 mm, with
the larger defects affecting those who had a prior diag-
nosis of carcinoma or who underwent surgical treat-
ment. The location of the fistula in relation to the airway
too was variable, reflecting the site of underlying disease.
Those thought to be congenital were very proximal.
Those secondary to TB were both distal, involving the
smaller bronchi and lung parenchyma at the original
Ghon focus. Patient 6 presented with Boerhaaves
Syndrome, and was initially managed with surgery to re-
pair the oesophageal defect. However, he subsequently
re-leaked, which again was managed surgically with a re-
pair over a T-tube, but then developed a stricture at the
site of injury, which was treated with an oesophageal
stent. This eroded into the airway at its proximal extent,
causing a fistula at 24 cm, with subsequent referral to
our unit (Fig. 4).
After the diagnosis of ADF, three patients underwent
further endotherapy in an attempt to manage the fistula
prior to referral to our unit. Patient 1 had 3 oesophageal
stents placed, but given the proximal location of the
ADF, these all slipped distally. Patient 3, who had devel-
oped an ADF between the airway and a gastric conduit,
most likely after a sub-clinical leak, had endoclips placed
via flexible gastroscopy which failed to close the ADF.
Patient 6 too had a stent
placed to treat the fistula with-
out the desired effect.
Surgical intervention for ADF treatment
Three patients (3, 4, 8) underwent a primary repair of
their ADF. Patient 3 required a thoracotomy given that
the ADF was communicating with a gastric conduit and
Patients 4 and 8 had proximally-sited fistulae
approached through the neck. For the former case, an
intercostal flap was interposed between the suture lines
and for the latter two, the strap muscles were similarly
utilised. These fistulae were small and the quality of tis-
sue was sufficiently good to enable primary repair. Pa-
tient 4 presented as an acute emergency following
aspiration -intubated- and a laparotomy was performed
prior to repair, in order to place a feeding jejunostomy
and venting gastrostomy (Table 3).
Fig. 1 CT scan of Patient 1 demonstrating the aerodigestive fistula (arrows)
Table 1 Preceding history and intervention, prior to the diagnosis of ADF
Patient Age at ADF
Diagnosis (years)
Sex Preceding Diagnosis Preceding
Chemo-Radiotherapy Preceding Treatment
Related Complication
1 60 F SSC
Proximal Oesophagus Definitive
Chemo-radiotherapy Radiotherapy
related stricture
-×2 stents
-×3 dilations
257 MTB
Medical therapy –– –
3 59 M Adenocarcinoma Distal
Anastomotic leak
4 73 M Unknown –– –
532 FTB
Medical Therapy –– –
6 33 M Boerhaaves Syndrome Repair of leak Re-leak; stricture -× 1 stent
7 55 F Oesophageal B Cell
Chemotherapy Chemotherapy ––
8 29 F Unknown –– –
SCC- Squamous Cell Carcinoma;
TB- Tuberculosis
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Two patients (1 and 6) underwent an oesophageal ex-
clusion operation. These were both performed as staged
procedures with delayed reconstruction. The reason for
performing this operation was that in both patients there
was sufficient concern regarding the state of tissue.
Patient 1 had previous radiotherapy for an oesophageal
SCC, on a background of achalasia requiring a myotomy
via thoracotomy several years previously. The degree of
tissue inflammation, scarring and adhesions precluded a
transthoracic resection. Thus, through a neck incision,
the oesophagus was transected above the fistula and an
oesophagostomy fashioned with a synchronous repair of
the fistula. Distally, the oesophagus and OGJ was trans-
ected and a venting gastrostomy fashioned. After a
period of optimisation and treatment of longstanding re-
spiratory disease, the patient underwent reconstruction
utilising a gastric conduit through the retrosternal space.
Patient 6 too had severe inflammation and adhesions in
the chest following his surgical management of Boer-
haaves syndrome. Exclusion and subsequent reconstruc-
tion with a colonic conduit (he had previously
undergone a distal gastrectomy for benign ulcer disease)
was performed. In both cases, the native tissues were
poor enough to carry a high risk of leak with primary
anastomosis at index surgery.
Patient 2 had a distal ADF, approached through a thora-
cotomy. The right bronchus intermedius was involved,
and the ADF and affected parenchyma was excised as a
segmentectomy, with oesophageal repair. Patient 5 under-
went an exploration of the fistula through a thoractomy
with a lobectomy. The fistula, along with associated nec-
rotic parenchyma was excised en bloc,withasubsequent
suture repair of the oesophagus. Patient 7, after chemo-
therapy for lymphoma, underwent an oesophageal resec-
tion. Again, severe residual inflammation was noted at the
time of the surgery precluding repair of a small (5 mm)
fistula. In addition, our oncology colleagues felt there was
Table 2 Anatomical and Clinical Features of the ADFs
Patient Time to ADF
Development (months)
Fistula Site Fistula Size
Main Symptoms Endotherapy to
Treat ADF
1 15 Proximal trachea
20 cm
12 Aspiration ×3 stents
2 > 30 years Oesophagus-right bronchus intermedius
30 cm
12 Recurrent chest infections
3 21 Gastric conduit-lung 25 cm 16 Recurrent chest infections Endoclip
4 > 30 years Proximal trachea 17 cm 5 Aspiration; Respiratory
5 144 Distal oesophagus-lung 38 cm 15 Haemoptysis
6 3 Oesophagus-carina 24 cm 15 Recurrent chest infections ×3 stents
7 3 Oesophagus- left main bronchus 26 cm 5 Recurrent chest infections
8 > 20 years Proximal trachea 17 cm 3 Recurrent chest infections
Fig. 2 Residual ADF (arrow) following treatment for
oesophageal lymphoma
Fig. 3 ADF (arrow) in a proximal location, as seen
by oesophagoscopy
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a reasonable risk of future recurrence of lymphoma, thus
a resection was advocated. A primary repair of the left
main bronchus was performed, utilising a flap muscle
graft. A single-phase operation was performed as the
anastomosis was at a distinct site to the fistula.
Morbidity and mortality
Three patients suffered from complications following sur-
gery. Patient 2 developed a severe respiratory infection on
Day 4 following surgery, requiring bronchoscopic wash-
out. Patient 7 suffered a small anastomotic leak, necessi-
tating prolonged nil oral alimentation. Her nutrition was
maintained with jejunal feeding, and a contrast swallow at
7 weeks confirmed complete healing of the leak, after
which gradual oral feeding was commenced.
Patient 4, who presented with respiratory failure, was af-
fected by severe post-operative recurrent chest infections,
and an inability to wean off mechanical ventilation. This
had been anticipated, and hence a tracheostomy had been
placed at the time of surgery. Despite 4 months of inten-
sive management, he passed away with respiratory failure
and multiple organ dysfunction. He represents the only
mortality in this series.
Normal oral alimentation following surgery was
achieved in all patients, bar patient 4. The time to attain
this milestone ranged from 2 to 3 weeks in all cases,
with the exception of patient 7 who had suffered a leak.
She required supplemental enteral feeding at home for a
short period. We reserve the use of contrast studies and
formal swallow assessment for the very proximal fistulae,
where the risk of leak and aspiration is highest. At the
time of last follow-up, no patient demonstrated clinical
evidence of recurrent ADF.
Hospital episodes statistics (HES)
We performed a search of the English national HES
database to assess the reported incidence of ADFs in the
UK between 2000 and 2012 (Table 4). Only 71 cases
were found. However, we noted that the terms used in
the HES system to record an episode or event related to
an ADF were difficult to identify and, we suspect, many
patients with an ADF were not coded correctly and thus
not recorded. Of the 71 cases, 17 (23.9%) underwent
documented treatment: 9 (12.7%) were treated surgically
and 8 (11.3%) underwent oesophageal stent placement.
Most patients (56.4%) presented with respiratory
symptoms. The 30-day and 90-day mortality rates
were 32.4 and 42.3% respectively, although for cases
Fig. 4 A bronchoscopic image of the ADF (arrow) close to
the carina
Table 3 Surgical Intervention for the Correction of ADF, and Post-Operative Complications
Patient Operation Incision Phases Reconstruction Complications
1 Oesophageal Exclusion and fistula repair
with strap muscle
Left collar
Right PL
2 phase Retrosternal Gastric conduit
2 Fistula Repair with intercostal muscle Right PL
thoracotomy 1 phase n/a Respiratory infection
3 Fistula Repair with intercostal muscle Right PL
thoracotomy 1 phase n/a
4 Fistula Repair with strap muscle Bilateral collar
1 phase n/a Respiratory failure
5 Right lower lobe resection and fistula repair Right PL
mini-thoracotomy 1 phase n/a
6 Oesophageal Exclusion and fistula repair Left collar
Right PL
2 phase Retrosternal Colonic conduit
7 Oesophagectomy and fistula repair with
intercostal muscle
Left collar
Right PL
1 phase Retrosternal Gastric conduit Anastomotic leak
8 Fistula Repair with strap muscle Bilateral collar 1 phase n/a
PL- Postero-lateral
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managed in high-volumes centres this fell to 25 and
31.3% respectively.
This series demonstrates the techniques, challenges and
strategies utilised in the surgical management of ADFs.
The key aspect in the approach to such intervention is
the multi-disciplinary nature of care, utilising the experi-
ence of several distinct surgical specialities.
Pre-operative respiratory optimisation should be aggres-
sive, and ideally patients should be weaned off artificial
ventilation prior to surgery [2,3]. As the HES data dem-
onstrates, apart from being rare, there is a deficiency in
accurate diagnosis, coding and documentation of this
The range of operations that can be utilised reflect the
nature of underlying disease [14]. The determinants of
which operation will be performed are mainly the site
and size of the ADF, and the state of the affected tissue-
itself a reflection of the preceding disease and treatment.
For the most proximal ADFs, an approach through a
neck incision is the most desirable. A pivotal stratagem
here involves mobilising the oesophagus circumferen-
tially. This manoeuvre allows the more distal structures
to be brought superiorly into the wound, making further
surgery easier and away from the rigid confines of the
thoracic inlet. If necessary, the medial clavicle and ster-
noclavicular joint can be excised, a procedure which
does not cause future disability [7]. Distal ADFs necessi-
tate a thoracotomy. These ADFs can cause significant
damage to the lung parenchyma, affecting the compli-
ance by causing fibrosis [8]. Thus, where necessary, we
advocate a lobar or segmental resection, with closure of
the associated distal bronchi. Where an oesophagectomy
is indicated, we favour leaving a cuff of oesophageal tis-
sue around the trachea. This enables a dissection plane
away from the airway, and the remnant tissue can be in-
corporated into the repair. This manoeuvre also lessens
the future risk of tracheal stenosis [3].
Although not universally favoured, we have found the
oesophageal exclusion operation a beneficial option in
specific patients. Gross contamination of the airway, or
in patients who have had a previous leak or radiother-
apy, results in significant inflammation and adhesions in
the thorax. Attempting a resection in this circumstance
is hazardous, and if there is no definite indication to
resect, the oesophagus can be safely left in situ. It is im-
portant that a generous venting gastrostomy is sited,
from where the oesophagus can be accessed. We have
successfully performed a retrograde endoscopy through
this, and administered therapeutic agents required for
treatment of disuse oesophagitis. Most importantly, it
enables venting of oesophageal mucous. Some authors
favour a single operation rather than a staged approach
for resection or repair and reconstruction [3,7]. In our
experience, fashioning an anastomosis in a contaminated
field increases the chance of a leak. In such an event, the
fistula has a high chance of recurrence. Most import-
antly, however, a significant leak may necessitate a far
more morbid operative intervention. Indeed, any result-
ant fistula is likely to be more difficult to treat, if this
remains at all possible.
Several other series also demonstrate the complexity
of surgical intervention [14,9]. A feature of these re-
ports is that experience is limited to a few specialist
units where an expertise in ADF management is present.
This results in better outcomes, and facilitates an envir-
onment where management is continually improved. In
our series, there was one post-operative death. The
remaining patients all achieved normal alimentation
soon after surgery, with no evidence of ADF recurrence
at a median of 32 months. These results are comparable
to other dedicated units. Mathisen et al demonstrated a
mortality rate of 10.5% in a series of 38 patients, many
of whom underwent tracheal reconstruction, with excel-
lent long-term outcomes [3]. In a subsequent report,
highlighting 35 yearsexperience in the management of
ADFs, the operative mortality rate fell to 2.8%, reflecting
the effect of concentrating cases in specialist units [1].
Table 4 HES data search for ADFs between 2000 and 2012
denotes hospitals that perform 20 oesophageal cancer
resections per year)
HES data (20002012) n%p
Age 70 years 35 49.3
Female 35 49.3
Male 36 50.7
Treatment 17 24
Surgery 9 12.7
Stenting of oesophagus 8 11.3
Unknown 54 76
Presenting Clinical Feature
Pneumonia 18 25.4
Pleural effusion 22 31
Pulmonary embolus 1 1.4
Ischaemic cardiac event 1 1.4
Unknown 29 40.8
All Hospitals
30-day mortality 23 32.4
90-day mortality 30 42.3
Specialist Centres
16 22.5
30-day mortality 4 25 0.473
90-day mortality 5 31.3 0.311
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Shen et al similarly report a low mortality rate of 5.7%,
with a post-operative complication rate of 54.3%, and an
oesophageal leak rate of 11.4% [9]. Baisi et al reported
on 31 patients, of whom 26 underwent simple closure of
the oesophageal and tracheal defects. Operative morta-
lity was 3.2%, with a recurrence rate of 6.4% [10].
Non-operative techniques can be used to manage
ADFs. Oesophageal stenting is the most common inter-
vention, and although it plays a key role in some pa-
tients, they can themselves cause fistulae and may affect
future surgical intervention [11,12]. Newer endoscopic
techniques utilising endoscopic suturing, clip placement
or tissue glue, may have an increasing role in the
management of ADFs in the future. Thus, early referral
to a dedicated unit is advocated, as the whole manage-
ment of the patient can be pursued where the complete
skill-set, including access to novel treatments, is present.
By focusing care in specific units, the expertise in all
facets of management and outcomes can continually
In summary, for a select group of patients an operative ap-
proach can be a truly life-saving intervention. Although
surgery is not without risk, it offers the best chance of
cure of ADF with a very low risk of recurrence and a
return to normal oral alimentation.
ADF: Aerodigestive Fistula; HES: Hospital Episodes Statistics;
MDT: Multidisciplinary Team; OGJ: Oesophago-Gastric Junction;
TB: Tuberculosis; TOF: Tracheo-Oesophageal Fistula
No funding to declare
Availability of data and materials
Made available through UCL research depository (open access)
Each author has participated sufficiently in the work to take public
responsibility for this manuscript as per the guidelines of the International
Committee of Medical Journal Editors (ICMJE) criteria. YQ and MM designed
the study, acquired and analysed the data and drafted the manuscript; SM
collected HES data and assisted in writing the manuscript; BM, JG, MH and
DL assisted in interpretation of the data and critically revising the intellectual
content. All authors approved the final version of the manuscript and are
accountable for all aspects of accuracy and integrity related to this work.
Ethics approval and consent to participate
Ethical approval was granted for anonymised patient data under University
College London Hospital research ethics policy.
Consent for publication
Not required
Competing interests
The authors declare that they have no competing interests.
Springer Nature remains neutral with regard to jurisdictional claims in
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Author details
Department of Oesophago-Gastric Surgery, University College London
Hospital, 250 Euston Road, London NW1 2BU, UK.
Department of Surgery
and Cancer, Imperial College London, London, UK.
Department of Thoracic
Medicine, University College London Hospital, London, UK.
Department of
Thoracic Surgery, University College London Hospital, London, UK.
Received: 10 April 2018 Accepted: 5 November 2018
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2. Macchiarini P, Verhoye J-P, Chapelier A, et al. Evaluation and outcome of
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4. Meunier B, Stasik C, Raoul JL, et al. Gastric bypass for malignant
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esophageal discontinuity operations. Ann Thorac Surg. 2003;76:98995.
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Qureshi et al. Journal of Cardiothoracic Surgery (2018) 13:113 Page 8 of 8
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... as the fistula in the upper part of the esophagus requires a cervical approach (cervicotomy), while a thoracotomy is necessary for distal fistulas. 11 However, the latter type might damage lung parenchyma. Consequently, as a result of bron� chiectasis, pneumonitis or abscesses, together with fistulec� tomy, a lung parenchyma resection would be required. ...
... Consequently, as a result of bron� chiectasis, pneumonitis or abscesses, together with fistulec� tomy, a lung parenchyma resection would be required. 8,11 Depending on the size of damage, segments, lobes or a whole lung may be resected. 12,13 In the presented case, the two right lower lobes with tissues of the fistula were removed. ...
... 14 Ex� clusion and bypass of fistulous fragments of the esophagus is another strategy. 11 Non�surgical treatment of benign ERFs is not popular, but possible in the case of poor condition of the patient. 15 Furthermore, spontaneous closure of the fistu� la might also be observed during treatment of an underlying disease. ...
Full-text available
Introduction: An esophagorespiratory fistula is a pathological communication between the esophagus and respiratory tract. The most common type is a communication with the trachea, while the least common is with lung parenchyma. These fistulas are classified as congenital or acquired while etiology is benign or malignant. Aim: We present a case report of a patient who developed esophagopulmonary fistula several years after gunshot in the right side of the chest. Additionally, we discuss the treatment methods and compare the outcomes with other case studies and analyses from world literature. Case study: A 48-year-old male patient was admitted to the Department of Thoracic Surgery and Transplantation due to bleeding from the respiratory tract. Radiological images revealed a fistula between the esophagus and right lung parenchyma. Furthermore, bronchiectasis in the right lung was found. Tissues of the fistula, right middle and lower lobes were resected. The patient required renewed hospitalization due to pleural empyema. Furthermore, recurrence of the fistula was observed. Results and discussion: Treatment of esophagorespiratory fistula depends on the etiology and location of the pathological communication. Surgery provides the best possible outcomes in patients with a benign fistula. Proximal location requires cervicotomy, while distal location a thoracotomy. In addition, a distal fistula may damage lung parenchyma. Conclusions: A long-term distal fistula may require pulmonary resection, but early diagnosis would help to avoid more invasive procedures. As symptoms are non-specific and benign etiology is not frequent, thorough examination in search of malignancy is required.
... Small size TEF may close spontaneously, while fistulas over 20 mm in size are associated with poor survival [57]. Therefore, prompt therapeutic intervention is needed in order to arrest the contamination of the airway and enabling normal oral alimentation. ...
... Therefore, prompt therapeutic intervention is needed in order to arrest the contamination of the airway and enabling normal oral alimentation. Different approaches have been developed for the management of both acquired non-malignant [57] and malignant TEF [44,46,55]. Surgical interventions include esophageal stent placement, bypass, resection, and surgical repair. ...
Full-text available
Respiratory tract fistulas (or fistulae) are abnormal communications between the respiratory system and the digestive tract or the adjacent organs. The origin can be congenital or, more frequently, iatrogenic and the clinical presentation is heterogeneous. Respiratory tract fistulas can lead to severely reduced health-related quality of life and short survival. Therapy mainly relies on endoscopic surgical interventions but patients often require prolonged hospitalization and may develop complications. Therefore, more conservative regenerative medicine approaches, mainly based on lipotransfer, have also been investigated. Adipose tissue can be delivered either as unprocessed tissue, or after enzymatic treatment to derive the cellular stromal vascular fraction. In the current narrative review, we provide an overview of the main tissue/cell-based clinical studies for the management of various types of respiratory tract fistulas or injuries. Clinical experience is limited, as most of the studies were performed on a small number of patients. Albeit a conclusive proof of efficacy cannot be drawn, the reviewed studies suggest that grafting of adipose tissue-derived material may represent a minimally invasive and conservative treatment option, alternative to more aggressive surgical procedures. Knowledge on safety and tolerability acquired in prior studies can lead to the design of future, larger trials that may exploit innovative procedures for tissue processing to further improve the clinical outcome.
... Tracheal fistula occurs in cases of prolonged mechanical ventilation and excessive cuff pressure of the endotracheal tube or tracheostomy tube, blunt trauma, infections, stent-related injuries, ingestion of foreign bodies or corrosive products, and cancers arising from the esophagus, trachea, lungs, larynx, and thyroid [2][3][4]. Sometimes, small fistulas can close spontaneously, while fistulas larger than 20 mm rarely heal spontaneously, resulting in a low survival rate [5]. Currently, the most common treatments for TF are surgery, interventional therapy, and conservative treatments [6]. ...
Full-text available
Background Tracheal fistulas (TF) can be dangerous and even fatal in patients. The current treatment is really challenging. Previous studies reported that mesenchymal stem cells (MSCs) could be used to treat respiratory tract fistulas. Stem cells from human exfoliated deciduous teeth (SHED) are considered to be MSC-like cells that may also have the potential to treat the tracheal fistulas. In this study, we investigated the therapeutic effects of SHED in rat tracheal fistula models. Methods A total of 80 SD rats were randomly divided into five groups: a sham-operated group, a local PBS group (L-PBS), an intravenous PBS group (I-PBS), a local SHED treatment group (L-SHED), and an intravenous SHED treatment group (I-SHED). The L-SHED and I-SHED groups were given a topical application around the fistula or an intravenous injection of 1*10 ⁷ SHED via the tail vein, respectively, while the L-PBS and I-PBS groups were given an equivalent volume of PBS through local or intravenous administration. A stereomicroscope was used to observe fistula healing on the 2nd, 3rd, and 5th days following transplantation. On the 7th day, the survival of SHED was observed by immunofluorescence. The pathology of the lungs and fistulas was observed by hematoxylin and eosin (H&E) and Masson staining. The expression levels of the Toll-like receptor 4 (TLR4), interleukin (IL)-1β, IL-33, and IL-4 were measured using immunohistochemistry. The expression levels of TLR4, high mobility group box 1 (HMGB1), and myeloid differentiation factor 88 (MYD88) were studied using western blotting. On day 14, airway responsiveness of rats was detected and analyzed. Results Fistula healing in the L-SHED and I-SHED groups was faster than that in their respective PBS groups after transplantation. The fistula diameters in the L-SHED and I-SHED groups were significantly smaller than those in the L-PBS and I-PBS groups on the 3rd day. Moreover, the phenomenon of fibroblast proliferation and new blood vessel growth around the fistula seemed more pronounced in the L-SHED and I-SHED groups. Although no discernible difference was found in airway responsiveness after SHED treatment, the degree of inflammation in the lungs was reduced by intravenous SHED treatment. However, there was no significant reduction in lung inflammation by local SHED treatment. The expression levels of IL-1β and IL-33 were decreased in the I-SHED group, while IL-4 was elevated compared with the I-PBS group. Interestingly, intravenous SHED treatment inhibited the activation of HMGB1/TLR4/MYD88 in the lung tissues of TF rats. Conclusions SHED transplantation accelerated the rate of fistula healing in rats. Intravenous SHED treatment reduced lung inflammation. Thus, SHED may have potential in the treatment of tracheal fistula, providing hope for future therapeutic development for TF.
... and are pathological connections between the esophagus and the trachea or a major bronchus. While EAF are rare, they cause significant morbidity and mortality due to recurrent respiratory infections and malnutrition (1,2). ...
Full-text available
Background: Esophago-airway fistula (EAF) is an abnormal connection between the esophagus and the trachea or a major bronchus. While contrast esophagography remains the primary radiographic tool for the diagnosis of EAF, computed tomography (CT) is often employed in its evaluation. A systematic analysis of CT findings of EAF in adults has not been previously published. The goal of our study is to determine the direct and indirect CT findings of EAF in adults. Methods: We identified patients with EAF detected on CT at our institution between January 1, 2001 and December 31, 2019, with endoscopic or surgical confirmation. We collected patient clinicopathologic characteristics and assessed CTs for direct and indirect imaging features of EAF in these patients. Results: Twenty-six patients (median age: 56 years; range, 25-79 years; F=13, 50% and M=13, 50%) with confirmed EAF were identified. Half of the patients had an underlying malignancy. On CT, a direct connection between the esophagus and the airway was identified in most cases (22/26; 85%). Common indirect CT findings of EAF included esophageal wall thickening (21/26, 81%), mediastinal fatty stranding (21/26, 81%), airway wall thickening (20/26, 77%), fluid or debris within the airways (17/26, 65%), and focal or diffuse esophageal dilation with air (17/26, 65%). Mediastinal fluid collections were infrequently seen (4/26, 15%), but findings of aspiration or other pneumonia were common (19/26, 73%). Conclusions: CT plays an essential role in both the primary and secondary evaluation of adult EAF resulting from both malignant and benign etiologies. CT may be the first diagnostic exam to suggest and detect the presence of EAF and may precede clinical suspicion, and it can detect a subset of fistulas not demonstrated on esophagography. There are several direct and indirect imaging findings on CT that can help in the detection of EAF.
Fistulas of various etiologies are one of the severe and life-threatening diseases of the upper respiratory tract. The most common cause is bronchial stump failure after pulmonary resection, usually pneumonectomy. The incidence and mortality of this complication is 3 %-4 % and 12.5 %-71.2 %, respectively. Despite the fact that many devices and methods have been described to date, it is usually treated with surgical closure. Standard surgical approaches are associated with significant morbidity and mortality and are not reliably successful. In recent years, cell therapies aimed to stimulate tissue healing rose to prominence and can be considered a potential treatment method. We review current trends in bronchopleural fistula treatment using cell therapy and report cases of the bronchopleural fistula treatment according to the research protocol developed in our clinic. Although clinical experience is quite limited owing to a small number of patients in the most studies, the information on safety and tolerance can help plan future larger trials with innovative methods to further improve clinical results.
Tracheobronchial surgery is widely performed in emerging countries mainly as a consequence of the high number of airway-related complications and poor management in intensive care units. This has led to great expertise in the surgical management of postintubation tracheal stenosis, and opportunity for advancing scientific knowledge. Nonetheless, tracheal stenosis has a severe impact on a patient's quality of life, is a major burden to the health system, and should be prevented. Incorporation of innovative techniques, technologies, and prospective databases should prompt earlier diagnosis and lead to fewer complications.
Esophagobronchial and esophagotracheal fistulas are rare but complex diseases with a heterogeneous spectrum of underlying etiologies. Common causes are locally advanced tumors of the esophagus and larynx, traumatic perforation from the esophageal or tracheal side as well as postoperative fistulas. The management of esophagotracheal and esophagobronchial fistulas always involves different health care providers and in most cases patients require a multidisciplinary treatment on the intensive care unit. The therapeutic concept primarily depends on the underlying cause, localization and size of the fistula but decision making is also influenced by the severity of the course of sepsis and the extent of the respiratory dysfunction. Endoscopic management with esophageal and/or tracheobronchial stenting is the most common treatment. Surgical reconstructive procedures are predominantly reserved for patients with a treatment refractory fistula or a septic multiple organ failure. The prognosis is particularly influenced by the underlying disease.
Background Esophagotracheal and esophagobronchial fistulas are pathological communications between the airway system and the digestive tract, which often lead to major pulmonary complications with a high mortality. Endoscopic treatment is the primary therapeutic approach; however, in cases of failure early surgical treatment is obligatory. Methods This article describes the clinical course of patients with esophagotracheal and esophagobronchial fistulas treated in this hospital over a period of 10 years. Patients were retrospectively analyzed with respect to the etiology of fistulas, management, in particular to the operative procedures, complications and outcome. Results Between 2009 and 2019, a total of 15 patients with esophagotracheal and esophagobronchial fistula were treated in this hospital. Of these 12 underwent an endoscopic intervention, of which 5 were successful. In total, eight patients needed surgical intervention, six of the eight surgically treated patients recovered fully, one had a recurrent fistula, which was successfully treated by subsequent endoscopy after surgery and one patient died. Discussion Management of esophagotracheal and esophagobronchial fistulas is challenging. This retrospective analysis reflects the published data with a success rate of endoscopic treatment in approximately 50%. Surgical intervention should be carried out after unsuccessful endoscopic treatment or if endoscopic treatment is primarily not feasible. Direct closure with resorbable sutures or reconstruction with alloplastic or allogeneic material should be preferred. For larger defects or high proximal esophagotracheal fistulas local transposition of muscular flaps or free muscular flaps play a major role. During operative closure of high intrathoracic or cervical fistulas, intraoperative neuromonitoring can be useful to prevent nerve damage.
Full-text available
Patients with cancer of the esophagus who develop an esophagotracheal fistula die within 1 month in dramatic conditions of malnutrition and asphyxia. We assessed the beneficial palliative effect of the Kirschner operation in the treatment of esophagotracheal fistula. Between January 1980 and August 1995, 21 patients among a continuous series of 847 with cancer of the esophagus developed an esophagotracheal fistula. Prior to surgery, 2 patients had an esophageal prosthesis followed by radio- and/or radiochemotherapy and 6 had radio- and/or chemotherapy at curative doses. The Kirschner operation was carried out in all patients with exclusion of the lower end of the esophagus using a Roux-en Y-loop (n = 19) or ligature (n = 2). Within 1 month of surgery, 8 patients (38%) died. Median length of stay in the intensive care unit and hospitalization was 6 days (1-30) and 17 days (3-57), respectively. Among the 13 survivors, pulmonary infections (n = 2) and cervical fistulae (n = 5) complicated the postoperative period. Among the cervical fistula, 3 of them resolved favorably. Radio- and/or chemotherapy was given postoperatively in 7 patients without any improvement in survival. Among the 13 patients surviving beyond the postoperative period, median survival was 109 days; 7 were able to resume oral nutrition and quality of life was assessed as excellent in 6 of them. The Kirschner operation can provide a beneficial palliative effect in patients with an esophagotracheal fistula despite the high risk of operative mortality. Ideally, the Kirschner should be carried out in young patients who are still in good general health, before the development of respiratory complications compromises surgery.
Full-text available
Acquired fistulas between the trachea and the esophagus (TEFs) are unusual, serious and still challenging clinical entities. Between 1980 and 1997, 31 patients with acquired benign TEF were evaluated and treated in our department. The definitive treatment was undertaken when patients were weaned from the ventilator. Dissection of the fistula and closure of the tracheal and esophageal defect was performed in 26 patients. Esophagogastroplasty plus closure of the tracheal defect and omental interposition was performed in two patients. Tracheal resection and reconstruction plus of the sternocleidomastoid muscle interposition was carried out in one patient with circumferential tracheal damage. In two patients, no surgical treatment was carried out. One patient died after surgical treatment. In 23 patients, long-term follow-up was excellent, with normal post-operative function of both the esophagus and the airway. Two failures of treatment occurred which required definitive tracheostomy plus T-tube. Management of TEFs can be safely carried out after weaning patients from the ventilator.
A case of broncho-oesophageal fistula, an uncommon presentation of carcinoma esophagus is being reported.
Background Acquired nonmalignant tracheoesophageal fistula in the adult patient develops in a variety of conditions. We have applied surgical closure with success for 35 years. Methods From 1975 to 1991, 38 patients underwent surgical repair of a tracheoesophageal fistula. A retrospective study of 36 additional patients undergoing surgical repair from 1992 to 2010 was conducted. Results The most common causes were postintubation injury (n = 17, 47%), trauma (n = 6, 17%), prior laryngectomy (n = 6, 17%), and prior esophagectomy (n = 4, 11%). Four patients presented after failing fistula control with an endoluminal stent. The tracheal defect was closed with resection and reconstruction (n = 17, 41%), laryngotracheal resection (n = 5, 12%), membranous tracheal repair (n = 17, 41%), or repair over a tracheal T tube (n = 2, 5%), while esophageal repair consisted of 2-layer closure (n = 31, 78%), 1-layer closure (n = 6, 15%), esophagostomy (n = 1, 3%), end-to-end esophageal anastomosis (n = 1, 3%), or full thickness skin graft reconstruction (n = 1, 3%). The esophageal and tracheal repairs were buttressed by interposing pedicled muscle or omental flaps in all patients. There was 1 postoperative death (3%). Recurrence after repair developed only in fistulas arising after esophagectomy or laryngectomy (n = 4, 11%). Fistula closure was ultimately successful in 34 patients (94%). Twenty-nine patients (83%) resumed oral intake and 25 patients (71%) were breathing without a tracheal appliance. Conclusions Successful closure of benign tracheoesophageal fistula is achieved with several surgical techniques based on buttressed repair and restoration of normal breathing and swallowing. Closure of complex postsurgical fistula may fail. Endoluminal stenting was not found useful.
Palliation of oesophageal carcinoma consists mainly of the treatment of dysphagia. However, 5 per cent of patients with oesophageal cancer also develop a fistula between the oesophagus and trachea. The symptoms of aspiration are devastating and are difficult to treat with low morbidity. Untreated, most patients die from a combination of respiratory infection and starvation1. Recently, covered expanding metal stents have been shown to be an excellent treatment for oesophageal fistula and perforation2,3 and seem to be more effective than conservative treatment, plastic tubes or surgical bypass treatment methods. However, patients who present with a high tracheo-oesophageal complex fistula adjacent to the cricopharyngeal sphincter are particularly difficult to treat. A method is described that enables control of high tracheo-oesophageal fistulas.
Lesions of the trachea or main-stem bronchi with air leakage are a grave complication of oesophagectomy. Prevalence, predisposing factors and outcome of non-malignant lesions of the trachea or main-stem bronchi were analysed retrospectively in a consecutive series of 785 patients who had oesophagectomy for oesophageal cancer. Overall 31 of 785 patients developed a tracheobronchial fistula 1-30 days after oesophagectomy. Based on the location of the lesions and clinical circumstances, the tracheobronchial fistulas were thought to be due to surgical injury (four patients), cuff pressure of the tracheostomy tube (two), local peritracheal infection resulting from a cervical anastomotic leak (seven) or 'ischaemia' after extensive peritracheal dissection (18). On multivariate analysis, transthoracic en bloc resection (P < 0.01) and preoperative radiochemotherapy for locally advanced tumours located at or above the level of the tracheal bifurcation (P < 0.01) predisposed to this complication. Non-malignant tracheobronchial lesions are a serious complication of transthoracic oesophagectomy with extensive lymph node dissection, particularly in patients undergoing preoperative radiochemotherapy for locally advanced tumours.
Acquired nonmalignant fistulae between the airway and esophagus (tracheoesophageal fistulae [TEF]) are rare life-threatening conditions. Several management approaches have been proposed, while the optimal strategy remains controversial. This study is a retrospective review of all patients with TEF treated at our institution from 1978 through 2007. Thirty-five patients (22 men, 13 women) underwent surgical repair of acquired nonmalignant TEF. Median age was 55 years (range, 5 to 78). Most common causes were the following: complications of esophageal surgery (11), trauma (6), granulomatous infection (5), stent erosion (4), and prolonged mechanical ventilation (2). Location was proximal trachea in 7, mid-trachea in 5, and distal trachea or bronchus in 23. Fifty-six operations were performed. Six patients had staged repair, with 1 patient requiring 4 operations for recurrent TEF. TEF division and primary repair was performed in 18 patients, esophageal resection with reconstruction in 4, and esophageal diversion in 6. Four patients had suture closure of the esophageal or tracheal defect only, and 3 required segmental tracheal or bronchial resection. Four patients were ventilator dependent at the time of repair. Pedicled tissue flaps were used in 28 patients (80%). Operative mortality was 5.7% (2 of 35). Nineteen patients (54.3%) had complications. Median hospital stay was 14 days (range, 4 to 209). Median follow-up was 30.4 months (range, 0.5 to 233) and complete in 34 (97.1%). Three patients (8.6%) developed recurrent TEF. Twenty-nine patients resumed oral intake. One patient required a permanent tracheal T tube. Single-stage primary repair of both airway and esophageal defects with tissue flap interposition can safely be performed successfully in the majority of patients with acquired nonmalignant TEF.
Acquired, nonmalignant tracheoesophageal fistula is an uncommon and difficult problem to manage. The most common cause is a complication of endotracheal or tracheostomy tubes. Most are diagnosed while patients still require mechanical ventilation. We use a conservative approach until patients are weaned from ventilation. A tracheostomy tube is placed so that the balloon rests below the fistula, if possible, to prevent contamination of the tracheobronchial tree. A gastrostomy tube is placed for drainage and a separate jejunostomy tube for nutrition. Single-stage repair is done after the patient is weaned from mechanical ventilation. Esophageal diversion is rarely required. We have performed 41 operations on 38 patients. Simple division and closure of the fistula was done in 9 patients and tracheal resection and reconstruction in the remainder. The esophageal defect was closed in two layers and a viable strap muscle interposed between the two suture lines. There were four deaths (10.9%). There were three recurrent fistulas and one delayed tracheal stenosis. All were successfully managed. Of the 34 surviving patients, 33 aliment themselves orally and 32 breathe without the need for a tracheal appliance.
Tracheoesophageal fistulae (TEF) are severe lesions leading to serious and eventually fatal pulmonary complications. Currently, TEF are mainly iatrogenic, occurring in the course of tracheal intubation for resuscitation or malignant after invasion of both esophageal and tracheal walls. Difficulty in treatment results from the need to manage both the consequences of esophagotracheal communication and those of the illness responsible for fistula. Various carefully selected means may be used to achieve this aim: division and closure of the TEF, esophageal exclusion followed by gastric or colic bypass or push-through intubation. Abstention from treatment may be appropriate in hopeless situations.