Rigid Bronchoscopy for Diagnosis and Treatment of Proximal Pouch Fistula in...

Proximal fistulas in esophageal atresia can be missed even when rigid bronchoscopy is performed routinely prior to repair of presumed type C esophageal atresia with distal tracheoesophageal fistula.

Proximal tracheoesophageal fistulas are often subtle and look quite different from distal fistulas.

The distal fistula in this case was located 1.5 to 2 centimeters proximal to the carina on initial rigid bronchoscopy.

A routine esophagogram performed 6 days after repair showed a tracheoesophageal fistula despite the absence of a leak or significant stenosis.

Rigid bronchoscopy to evaluate for missed proximal fistula was performed a week after initial repair to minimize the chances of traumatizing the recently ligated fistula.

The proximal fistula appeared as a subtle fold approximately 1 centimeter proximal to the distal fistula site on bronchoscopy.

A thin suction catheter could not be passed through the proximal fistula fold, but a glide wire was easily passed, confirming the presence of a proximal fistula.

Endoscopic treatment involved using a glide wire to stent the fistula open while cauterizing the tract with bugby cautery until the tract and fistula wall were fully cauterized.

Following cauterization, Deflux (dextranomer hyaluronic acid copolymer) was injected into the fistula tract.

The endoscopic procedure was unsuccessful, and the proximal fistula remained patent on esophagogram two weeks later.

The patient subsequently underwent successful repair of the proximal fistula through a right neck incision.

If any suspicion of proximal fistula is seen on rigid bronchoscopy, insufflation of air through the esophageal pouch or installation of methylene blue may help confirm a proximal fistula.