Giant tracheoesophageal fistula Management by esophageal diversion Giant tracheoesophageal fistulas complicating the management of respiratory insufficiency are often difficult to close successfully because of suture line tension and narrowing of the trachea or esophagus or both. Recovery of lung function often depends on successful diversion of gastrointestinal contents from the tracheobrachial tree. We have managed six patients with giant tracheoesophageal fistula. In three cases the lesions were related to overinflation of low-pressure balloon cuffs. The only survivors were two of three patients managed by esophageal diversion and reconstruction through extrathoracic incisions. The techniques, advantages, and disadvantages of esophageal diversion for giant tracheoesophageal fistula are presented.
Joe R. Utley, M.D., Marcus L. Dillon, M.D., Edward P. Todd, M.D., Ward O. Griffen, M.D., and John V. Zeok, M.D., Lexington, Ky.
TracheoeSOPhageal fistula complicating mechanical ventilation for respiratory insufficiency may contribute to the progression of respiratory insufficiency. Improvement of the lung failure often depends on successful diversion of the esophageal contents from the trachea. 1, 2 Closure of the trachea often is jeopardized by the need for continued mechanical ventilation. Bartlett" has employed negative-pressure ventilation in an iron lung to diminish pressure on the tracheal closure. In this paper, we describe our experience with six patients with large tracheoesophageal fistulas. In two surviving patients the lesion was surgically managed by diversion of the esophagus, so that a segment of esophagus was left in continuity with the tracheoesophageal fistula and a tracheal suture line was avoided.
Patients and results Table I describes the features of the six patients with giant tracheoesophageal fistula who were treated at the University of Kentucky Medical Center and the Cooper Drive Veterans Administration Hospital from 1972 to From the Division of Cardiothoracic Surgery, University of Kentucky School of Medicine, Lexington, Ky. 40506. Presented at the Third Annual Meeting of The Samson Thoracic Surgical Society, Colorado Springs, Colorado, June 4-7, 1977. Address for reprints: Joe R. Utley, M.D., Department of Surgery, University of California, 225 Dickinson Street, San Diego, Calif. 92103.
0022-5223/78/0375-0373$00.50/0 © 1978 The C. V. Mosby Co.
1976. All patients had severe respiratory insufficiency, and five were respirator dependent when the fistula was recognized. Two early patients were treated nonoperatively. Both had circumferential erosion of the trachea (Fig. 1) with overinflation of low-pressure cuffs. Figs. 2 and 3 are chest x-ray films showing over-inflated balloon cuffs in two patients. Overinflation of lowpressure balloon cuffs was important in the development of fistula in three patients. In one patient the predominant lesion was erosion of the anterior and posterior walls of the trachea, with the lateral tracheal walls remaining intact (Figs. 4 and 5). Repair of the circumferential tracheal erosion associated with tracheoesophageal fistula in two patients was not attempted. In one patient, repair was attempted by esophageal closure, muscle flap, and skin graft to the tracheal defect (Fig. 6). The fistula recurred and the patient died of respiratory insufficiency. The presence of severe respiratory insufficiency in patients dependent on mechanical ventilation led us to manage the more recent patients by esophageal diversion and thereby avoid a tracheal suture line at the time of operation; all patients were respirator dependent because of lung failure .. In two patients, the esophagus was divided above and below the fistula and a cervical esophagostomy and gastrostomy were performed. One died of continued respiratory insufficiency, but the second is alive with a cervical esophagostomy and gastrostomy. Reconstruc373
The Joumal of
Utley et al.
Thoracic and Cardiovascular Surgery
Fig. 3. Chest x-ray film shows overinflation of tracheostomy tube cuff in patient with circumferential erosion of trachea and giant tracheoesophageal fistula.
1. Circumferential tracheal erosion with giant tracheoesophageal fistula . This most severe form of cuff injury occurred in two patients. Fig.
fistula 1 cm. above the carina as a result of blunt trauma (Fig . 7). The fistula was closed at another hospital, but 4 weeks later the patient was transferred to the University of Kentucky Medical Center with bilateral bacterial pneumonia and respiratory insufficiency. All attempts to occlude the fistula with balloon devices were unsuccessful. Continuous catheter suctioning of the proximal esophagus failed to diminish the aspiration of esophageal contents through the fistula. In one stage the esophagus was divided in the neck and at the esophagogastric junction. The ends of the esophageal segment in continuity with the trachea were closed. A reversed gastric tube (Heimlich) was used to establish gastrointestinal continuity (Fig. 7). A pyloroplasty and gastrostomy were also performed. The patient's postoperative recovery was prolonged and complicated by intestinal obstruction and sepsis. However, the patient is alive and well 36 months later. Fig. 8 shows a barium contrast study of the Heimlich tube. Discussion
Fig. 2. Lateralchest x-ray film shows overinflation of cuff on tracheostomy tube.
tion of the esophagus has not been attempted because of the radiation reaction and possible persistent carcinoma in the neck. The sixth patient sustained a tear between the trachea and esophagus and developed a tracheoesophageal
Large , low-pressure cuffs have decreased the incidence and severity of tracheal injury accompanying cuffed intubation.": 5 Overinflation of large cuffs may produce injuries of greater magnitude than small cuffs. Severe overinflation of large balloon cuffs occurred in patients requiring prolonged high-pressure ventilation and positive end-expiratory pressure. The iron lung as employed by Bartlett may diminish the pressures required in such patients and perhaps should be used at the earliest radiographic signs of overinflation. The progression of erosion in our patients suggests that the
Giant tracheoesophageaL fistuLa
Fig. 4. Giant tracheoesophageal fistula with erosion of anterior wall of trachea. Lateral walls are intact. Anterior wall was eroded by motion of tracheostomy tube as well as balloon cuff in this patient.
Fig. 5. Posterior erosion of balloon cuff with anterior and lateral walls intact.
Table I. Giant tracheoesophageaL fistuLa Case No.
High-velocity gunshot wound of right lung
Emphysema, acute bacterial pneumonia
Intestinal bypass for obesity
Laryngeal and esophageal stricture after resection and radiation of pharyngeal carcinoma Intestional obstruction
Factors predi spos ing to giant fistula
High-pressure, prolonged mechanical ventilation; overinflation of cuff High-pressure, prolonged mechanical ventilation; overinflation of cuff
Pathological anatomy of fi stula
Surgical manag ement offistula
Large fistula, circumferential erosion
Death; respiratory insufficiency, sepsis
Large TE fistula, circumferential erosion
Death, respiratory insufficiency, sepsis
Defect in membranous wall
Closure of esophagus, muscle flap, skin graft of trachea Cervical esophagostomy , division of esophagus at stomach , gastrostomy Cervical esophagostomy, division of esophagus at stomach, gastrostomy
Recurrent TE fistula; death ; respiratory insufficiency, sepsis Death; respiratory insufficiency
High-pressure, prolonged mechanical ventilation; overinflation of cuff Radiation; high-pressure , prolonged mechanical ventilation
Erosion of anterior and posterior walls; lateral walls intact
Recurrent TE fistula after blunt trauma
Large defect in membranous wall of intrathoracic trachea
Large fistula in postradiation esophageal stricture
Division of esophagus above and below fistula, reconstruction with reversed gastric tube
Alive; nutrition stable with gastrostomy feedings 6 months later Doing well 36 months later
Utley et al.
The Journal of Thoracic and Cardiovascular Surgery
Fig. 6. Recurrent post-traumatic tracheoesophageal fistula in intrathoracic trachea near carina . Fig. 7. Surgical procedure for giant tracheoesophageal fistula included division and closure of esophagus above and below fistula, reconstruction of esophagus with reversed gastric tube, and pyloroplasty . Gastrostomy not shown .
portion of the tracheal wall most susceptible to erosion is the membranous wall and that the anterior and lateral walls are progressively less susceptible to erosion. Thomas'-" has described in detail the diagnosis and management of tracheoesophageal fistulas associated with mechanical ventilation. Lawrence" described two groups of patients with acquired tracheoesophageal fistula: The first comprised patients with small fistula and contained infection. The second group included patients with large defects and rampant pneumonitis . Our six patients are in this latter group . Nonoperative management of these patients is almost always fatal. Muscle flap closure is often not successful with large defects and is associated with a 65 percent chance of tracheal stenosis .': 2 Diversion of esophageal contents and exclusion of a segment of esophagus in continuity with the fistula offers several advantages: A tracheal suture line, often under tension and in an area of acute infection, is avoided . The risk of subsequent tracheal stenosis may be diminished. Since the procedure can be performed without entering the thorax, lung function is preserved.
Fig. 8. Postoperative barium swallow shows functioning reversed gastric tube.
The procedure can be performed during management of significant respiratory insufficiency. Among the disadvantages of the esophageal diversion procedure is the presence of a blind segment of esophagus in continuity with the trachea. This has not been a source of recurring sepsis in our two survivors. In our experience , the advantages of this approach outweigh the disadvantages in selected patients. REFERENCES Thomas, AN: The diagnosis and treatment of tracheoesophageal fistula caused by cuffed tracheal tubes. J THoRAc CARDIOVASC SURG 65:612 -619, 1973 2 Thomas , AN: Management of tracheoesophageal fistula caused by cuffed tracheal tubes. Am J Surg 124:181-189, 1972
Giant tracheoesophageal fistula
3 Bartlett, RH: A procedure for management of acquired tracheoesophageal fistula in ventilator patients. J THORAC CARDIOVASC SURG 71:89-95, 1976 4 Cooper, JD, Grillo, HC: Analysis of problems related to cuffs on intratracheal tubes. Chest 62:Suppl:2lS-27S, 1972 5 Grillo, HC, Cooper, JD, Geffin, B, Pontoppidan, H: A low-pressure cuff for tracheostomy tubes to minimize tracheal injury. J THORAC CARDIOVASC SURG 62:898-907, 1971 6 Lawrence, GH: Discussion of Bartlett"
The one patient with malignant disease had a carcinoma of the esophagus eroding into the left main-stem bronchus. Ordinarily, this would have been a hopeless situation. We treated her by diversion and exclusion techniques and irradiation therapy. Because she was doing well, with prolonged survival, we resected the left lung and middle esophagus and performed a colon interposition. She is still alive 6 years after the original procedure, which obviously demonstrates that she had a very low-grade carcinoma and very good resistance. I would like to congratulate Dr. Utley on reporting this important technical consideration in the management of tracheoesophageal fistulas.
DR. RICHARD M. PETERS
DR. HAROLD C. URSCHEL, JR.
San Diego, Calif.
I agree entirely with this method of dealing with the problem after it occurs, but would like to say something about prevention. In a patient who does require high pressures on a ventilator, we have a compulsion to make sure that there is no leak around the tracheostomy cuff. When we all started with the Moersch respirators, we never used a cuff at all. We just turned the respirator up to provide enough ventilation and let the leak occur. It is wise to hold the cuff pressure down, put up with some leaks, and turn the volume of the ventilator up. With low-pressure cuffs, the idea has grown that they cannot be made high-pressure cuffs. They can, however, if they are overdistended. We will make a significant number of them high-pressure cuffs if we always insist on a tight seal at the trachea.
I want to thank The Samson Thoracic Surgical Society for inviting the STS Council to this meeting. It has been a pleasure to see how well you do things in the West. For Texans, this is the first time we are not considered in the West, and that is a real advantage to you, I am sure. Patients with tracheoesophageal fistulas are difficult to manage successfully. As our reports have stated in the past, our management has favored exclusion and diversion. We have recently reviewed cases from three hospitals in which we found 47 large fistulas out of 520 cases of esophageal carcinoma. In addition, nine "benign" fistulas were reviewed secondary to trauma, tracheostomy tube pressure cuffs, and granulomatous disease. Our management included supportive treatment, Celestin tube insertion, gastrostomy, and tracheotomy, and six were treated by exclusion and diversion. In our management of large esophageal perforations which were debilitating because of gastroesophageal reflux, we employed cervical esophageal diversion and exclusion of the distal esophagus to prevent reflux and to allow healing. This technique has also worked well for these patients with large tracheoesophageal fistulas. Of those 56 patients with large tracheoesophageal fistulas, there were six survivors, five of them with benign lesions and one with malignant disease who has now lived more than 5 years after the operation. They all had exclusion and diversion procedures. There were no survivors from this group who were not treated by this technique with or without subsequent esophageal replacement. From a technical point of view, leaving the blind pouch in place has caused no problems. We also learned from the esophageal perforation diversion that just a side-to-side esophagocutaneous anastomosis provides almost total diversion in every case.
DR. UT LEY (Closing) I would like to thank the discussers for their comments. Dr. Urschel's work in the management of esophageal perforation is closely related to ours. Many of us have the idea that a blind segment in the gastrointestinal tract is bad, but we may find that a blind segment of esophagus is totally benign. I agree entirely with Dr. Peters that prevention is the most important issue. In our experience, there is a trade-off between achieving good oxygenation in patients with severe lung failure and damaging the trachea. The patients in whom we saw this lesion had undergone very aggressive respiratory management, with increasing volumes and increasing positive end-expiratory pressure over a period of many weeks. These interventions to maintain oxygenation damaged the trachea. If a giant tracheoesophageal fistula begins to develop, perhaps alternatives to the ventilator should be considered. The alternatives would be either membrane oxygenation or putting the patient in an iron lung and using negativepressure ventilation.