Aerodigestive & Esophageal Surgery - Difficult Tracheal Esophageal Fistula
With Dr. Michael Rutter & Dr. Bob Wood & Dr. Phil Putnam & Dr. Dan von Elman · hosted by Dr. Todd Ponsky · StayCurrentMD
Cued at 30:20 · stops at 31:05 · press play
Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
Most children who aspirate have a functional or neurological problem (cerebral palsy, CHARGE syndrome); some have anatomical problems (TEF, laryngeal cleft, pharyngeal scar, esophageal stenosis).
Lipid-laden macrophages are non-specific markers of aspiration; their recovery depends on the lipid content of aspirated material, the amount aspirated, and time since aspiration.
Multi-channel intraluminal impedance testing detects reflux but does not diagnose aspiration; it tells you whether something is delivered from the stomach to the esophagus, not what happens after.
If a patient is aspirating from above (oropharyngeal or esophageal source), an anti-reflux procedure does not help and may make them worse.
A 3-French bugbee cautery is a smooth, excellent probe for identifying subtle tracheoesophageal fistulas.
A 70-degree endoscope is a difficult tool to use but can visualize TEFs that are otherwise hard to see with standard forward-viewing scopes.
Routine bronchoscopy is now standard practice for all type C TEF repairs at Cincinnati Children's, often done in collaboration with ENT colleagues.
Pediatric surgery fellows at Cincinnati Children's complete a one-month attachment with ENT to perform bronchoscopies and gain airway expertise.
Dual scoping (simultaneous bronchoscopy and esophagoscopy) allows scopes to 'shake hands' across a fistula, light transillumination through tissue, and injection of saline or air to reveal subtle openings.
A 2.8 mm flexible bronchoscope and a 5.4–6 mm infant gastroscope are the typical scopes used for combined airway-esophageal examination in small children.
Endoscopic TEF closure requires demucosalization of the tract (mucosa is a non-stick surface); the goal is raw-against-raw apposition with minimal fibrin glue (0.1 mL) to seal the tract while scarring occurs.
Trichloroacetic acid (TCA) can be used to demucosalize TEF tracts, but control is less precise than with bugbee cautery; TCA is applied on a pledget and can cause unintended burns if it contacts tissue during insertion.
A 3-French bugbee cautery fits through the 1.2 mm suction channel of a 2.8 mm flexible bronchoscope, allowing precise control and steering of the cautery tip.
Positive-pressure air insufflation (30 cm H₂O) via an endotracheal tube in the esophagus can reveal a TEF by causing air to bubble out of the tracheal opening.
Endoscopic TEF repair success rate is approximately 80%, typically requiring 2 attempts; after 3–4 failed attempts, open repair should be considered.
When cauterizing in the airway with a bugbee, oxygen concentration should be kept below 30% to minimize fire risk; brief periods of lower oxygen saturation are tolerable.
Injection of an inert material (e.g., Radiesse voice gel) into the walls adjacent to a TEF tract can obliterate the potential space and promote raw-on-raw apposition; the material is absorbed over a few weeks.
Slide tracheoplasty for TEF involves transecting the trachea above and below the fistula, beveling the edges, turning in the tracheal wings to repair the esophagus, interposing sternal periosteum, and reconnecting the trachea; it is a three-layer repair.
Sternal periosteum is an excellent interposition graft material: it is abundant, in the surgical field, and extremely strong ('like Kevlar'), though difficult to suture.
Button batteries can cause ongoing tissue injury for weeks after ingestion, even if 'dead' (they retain ~2 volts); institutional protocol mandates removal within 2 hours of identification.
Two slide tracheoplasty repairs for button battery TEF both dehisced (one at 10 days, one at 3 months); both were successfully revised. This may be more than coincidence, suggesting button battery injuries pose unique challenges.
Button battery injuries in the esophagus can progress to aortoesophageal fistula; CT angiography and close follow-up for 6 weeks post-removal are recommended, especially if the battery was at the aortoesophageal junction.
Transtracheal repair technique: anterior tracheotomy, identify the fistula from within the trachea, separate tracheal and esophageal layers, three-layer closure (esophageal mucosa with knots in lumen, sternal periosteum, tracheal wall with knots in lumen).
Transtracheal TEF repair is a two-dimensional operation with lower complication risk than slide tracheoplasty; the primary complication is re-fistulization, whereas slide tracheoplasty dehiscence is a more serious event.
Slide tracheoplasty appears to be a learning-curve, surgeon-dependent operation; revision cases have been necessary as experience was gained.
When repairing a high TEF from a thoracic approach, ligation of the fistula on the esophageal side can leave a large tracheal pouch; if the patient has tracheomalacia and requires a tracheostomy, the tube may enter the pouch, causing life-threatening obstruction.
The degree of angulation at the tip of a flexible bronchoscope is much greater in one direction (retroflexion) than the other; rotating the scope 180° (Sabode maneuver) can reveal posterior tracheal pathology more easily.
Insufflation with oxygen at 2 L/min through the suction channel of a flexible bronchoscope spreads tissue apart, improves visualization, and does not impair respirations.
When examining the cervical trachea and subglottis with a flexible bronchoscope, it is easier to see pathology while slowly withdrawing the scope than while advancing it, due to the need to flex and extend the tip to navigate the glottis.
In patients with retroesophageal subclavian artery, the right recurrent laryngeal nerve is non-recurrent and at higher risk during neck dissection; awareness is critical during transtracheal or slide tracheoplasty approaches.
After 7 years of aspiration through a TEF, a child may have significant bronchiectasis; repair of the fistula does not immediately resolve lower airway disease, and ongoing chest physiotherapy and airway clearance are required.
Hearing aid molds are radiolucent and can be missed on chest X-ray; high clinical suspicion is required when a foreign body ingestion is reported but not visualized.
Pectus excavatum can worsen tracheobronchomalacia; placement of a pectus bar can improve airway support and reduce the need for stenting or tracheostomy.
Airway stents can erode into the esophagus, creating secondary fistulas; long-term stent management requires vigilance and may necessitate alternative strategies (e.g., Y-stent with tracheostomy tube within the stent).
A Y-shaped airway stent from both bronchi into the trachea, with the tracheostomy tube sitting within the stent, can effectively bypass a bronchoesophageal fistula and allow clinical stability when further repair is not feasible.
Endoscopic closure of bronchoesophageal fistulas is feasible but challenging; proximity to large vessels (e.g., pulmonary artery branches) may preclude safe cautery and necessitate surgical resection.
Anal fistula plugs (biologic, cone-shaped, made of Surgisis) can theoretically be used to occlude distal airway fistulas; they are wrapped with barbed suture and inserted into the tract to promote collagen matrix formation and scarring.
In a patient with multiple bronchoesophageal fistulas and chronic bronchiectasis, lobectomy with resection of the esophageal pseudo-diverticulum can be performed safely; the esophagus can be primarily closed if not strictured.
Flexible bronchoscopy cannot reliably diagnose laryngeal clefts; rigid microlaryngoscopy with active probing is mandatory when posterior glottic pathology is suspected.
Tracheal pouches (diverticula) can be marsupialized endoscopically using a Storz ClickLine laparoscopic biopsy forceps with cautery at 40 watts; the technique is quick, well-tolerated, and eliminates the risk of tracheostomy tube misplacement.