Management Of Recurrent Tracheoesophageal Fistula After Esophageal Atresia And Follow-up

BACKGROUND & AIMS: Recurrent tracheoesophageal fistula(r TEF)is a complex complication after repair of esophageal atresia(EA)and remains a challenge because of the difficulties in the preoperative management and substantial rates of morbidity and repeat recurrence after reoperation.By reviewing a single institution's experience in management of r TEF and accessing the outcome,we aimed to provide an optimal approach in managing r TEF and evaluate growth and feeding problems after reoperations.METHODS: Medical records of 35 patients with r TEF treated at a single institution from June 2012 to December 2015 were reviewed,and follow-up data was collected from all survivors.RESULTS: Among 35 patients,20(57.1%)experienced anastomotic leak and 21(60.0%)had anastomotic stricture after primary surgery.33 r TEFs were confirmed by a modified esophaogram.One recurrent fistula with severe anastomotic stricture was not revealed before reoperations and were confirmed intraoperatively.Before reoperation,all survivors received gastric/fistula decompression and enteral nutrition via jejunal feeding tube.Placing a guide wire through fistula was performed in all confirmed r TEF patients at the day of reoperation.Twenty-eight patients received placing a glide wire via a combined bronchoscopy and esophagoscopy method,and 5 patients had a successful placement via threading the guide wire through fistula through esophageal site under fluoroscopy.Thirtyfive patients received a total of 41 reoperations,including 12 resection of fistula only,28re-anastomosis and 1 esophageal replacement.Different types of tissues(pleural,muscle flap,pericardium and lymph node)were placed between the suture lines intraoperatively for preventing future leaks and recurrences.The incidence of postoperative anastomotic leak(AL),anastomotic stricture(AS)and repeat recurrences was 40.0%,17.1% and11.4%,respectively.The mortality rate was 8.6%.Multivariable analysis showed that different surgical techniques and interposed tissues were not related with the occurrence of postoperative complications.All survivors achieved full oral intake.Mid-term follow-up(median of 18 months)revealed that 7(21.9%)presented prolonged meal times,6(18.8%)had feeding refusal,8(25.0%)experienced choking with feeding and 7(21.9%)had vomiting during feeding,whereas these feeding problems would resolve spontaneously when solid food was induced.According to the growth data,5 patients had growth retardation,including 1 stunting,2 wasting and 2 underweight.CONCLUSION: The modified esophaogram is an effective and reliable method in diagnosing r TEF.Before surgery,a novel technique with placing a guide wire through fistula from esophagus under fluoroscopy is an effective method for those who experienced an unsuccessful bronchoscopy and esophagoscopy method.Optimized preoperative management and surgical techniques leads to a satisfactory outcome.Nevertheless,nutritional evaluation and feeding guidance under nutritionist after reoperation are recommended.