followed by empyema necessitating chest tube drainage and IV antibiotics dyspnea emphysema pain and chylothorax like drainage Nowadays the main treatment options are conservative interventional or surgical repair The usual treatment includes establishing a line for elemental or parenteral alimentation including not only gastrostomy tubes but also a jejunostomy feeding tube An indwelling gastric or jejunal tube can be a good alternative especially if accompanied by broad spectrum antibiotics airway secretion suctioning and or TPN The interventional radiologist or endoscopist plays a crucial role in the treatment with bronchoscopy and endoscopy using stents glue laser argon plasma coagulation or over scope clips The surgical options include direct fistula repair closure with a pedicled muscle flap or omentum esophageal bypass surgery and lesion resection and re anastomosis 3 8 12 Muniappan and colleagues14 described laryngotracheal resection and reconstruction membranous tracheal repair and repair over a tracheal T tube
The esophageal repair consisted of 2 layer closure 1 layer closure esophagostomy end to end esophageal anastomosis or full thickness skin graft reconstruction Buttressing of the repair was performed using interposed pedicled muscle or omental flaps 14 As described by Ke and colleagues 3 interventional therapy via endoscopy is the main option to relieve symptoms and improve survival The surgical procedures include fistula tract repair using a pedicled muscle flap or omentum Esophageal bypass or exclusion surgery is a valid option as well Resection surgery is performed mainly for benign lesions Gastrostomy jejunostomy indwelling gastric or jejunal tubes antibiotics elimination of airway secretions and IV hyperalimentation are often needed and help a lot 3 4 We adopted a multidisciplinary team approach to management through stabilization of the general condition of the patient in the form of absolute NPO IV antibiotics drainage of collections TPN percutaneous endoscopic gastrostomy tube nasojejunal tube or jejunostomy feeding tube followed by exploration of the leakage site with or without drainage trial sealing of the tear laparoscopically surgically or through stenting
We faced many complications in the form of mortality in 6 33 3 cases repeat stenting in 6 for 2 fistula recurrences and 4 failures of closure with the need to re intervene through surgical exploration in one enterocutaneous fistula and 5 wound infections In a previous study we had a mortality rate of 20 but this cohort of patients was different and the risk factors were less 15 Muniappan and colleagues14 reported 3 mortality and 3 recurrence and unsuccessful endoluminal stenting because they were managing benign lesions only
Mortality in the series of Shen and colleagues 16 was 5 7 and it ranged from 0 to 10 5 in other series 17 18 Our higher mortality may have been due to late presentation to our center all patients were from other centers in poor general condition or septic shock on presentation as well a high body mass index because most of these deaths were after laparoscopic gastric sleeve insertion Nonsurgical intervention is increasingly applied Endoscopic intervention to occlude or reduce leakage across the fistula with endoluminal stents or clips is sometimes attempted 3 4 14 17 There are few reports of healing of mature TEF with stents there is a real potential for exacerbation because stents have been implicated in the creation of giant TEF In some cases tracheal stenting predisposes to extensive TEF and may extend the airway injury so it should be avoided It may be preferable to optimize the patient's pulmonary status and undertake prompt surgical repair to stent the fistula This necessitates removal of the nasogastric tube tracheal tube cuff advancement and inflation distal to the fistula opening and a gastrostomy tube may be helpful to improve the lung condition 14 18 This was a retrospective observational study of 27 cases of fistulae of different etiologies at different levels and in a nonhomogeneous cohort of patients lacking randomization It was managed in 2 centers with some differences in practice However we concluded that an aerodigestive tract fistula is a major problem not only for thoracic surgeons but also for general surgeons endoscopists interventional radiologists anesthetists and nutritionists A multidisciplinary approach is necessary consisting mainly of absolute NPO drainage of any collection whether thoracic or abdominal TPN IV antibiotics according to culture sensitivity and early intervention by thoracic surgeons general surgeons and or interventionalists which may be needed more than once Declaration of conflicting interests The author s declared no potential conflicts of interest with respect to the research authorship and or publication of this article Funding The author s received no financial support for the research authorship and or publication of this article References 1 Gudovsky LM Koroleva NS Biryukov YB Chernousov AF and Perelman MI Tracheoesophageal fistulas Ann Thorac Surg 1993 55 868 875 2 Reed MF and Mathisen DJ Tracheoesophageal fistula Chest Surg Clin N Am 2003 13 271 289 3 Ke M Wu X and Zeng J The treatment strategy for tracheoesophageal fistula J Thorac Dis 2015 7 S389 S397
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