Ann Thorac Surg 2006;81:1899-1901
© 2006 The Society of Thoracic Surgeons
Case report
Thoracoscopic Repair of Tracheoesophageal Fistula in a Septuagenarian
Susan A. Garand, DO
a
,
*
,
Lakshmipath Rao Kareti, MD
a
,
Travis M. Dumont, BA
b
,
Christopher Seip, MD
a
a Department of Surgery, Michigan State University, Lansing, Michigan
b Tufts University School of Medicine, Boston, Massachusetts
Accepted for publication May 19, 2005.
* Address correspondence to Dr Garand, Michigan State University, Department of Surgery, 1200 E Michigan Ave, Suite 655, Lansing, MI 48912 (Email: susan.garand{at}ht.msu.edu).
 |
Abstract
|
|---|
We report the case of a 79-year-old female with clinical and radiographic evidence of congenital H-type tracheoesophageal fistula. Past medical history included recurrent pneumonia and episodic cough with food or fluid intake. She exhibited Ohno's sign during the dysphagia evaluation. A video swallow study demonstrated evidence of aspiration. Esophagogram and bronchoscopy identified the fistulous tract. Repair of the anomaly was performed using a minimally invasive thoracoscopic approach. In our experience, excellent visualization and magnification of the anatomic field with use of thoracoscopy allowed for relative ease of dissection and resection of the tract with minimal postoperative morbidity.
|
Introduction
|
|---|
Congenital tracheoesophageal fistulas (TEFs) without associated esophageal atresia, known as the H-type fistula, extend obliquely from the trachea to the esophagus as an "N" shaped pattern. These anomalous tracts occur approximately once in 100,000 births and account for less than 5% of congenital esophageal anomalies [1, 2]. Most TEFs are diagnosed and repaired in the neonatal period, but few remain undiagnosed into adulthood.
Historically, the primary approach to surgical repair of TEF in such patients has been through a thoracotomy or an open transcervical approach along the anterior border of the sternocleidomastoid muscle [1–4]. After extensive literature review, we were encouraged to find evidence of minimally invasive surgical repair of congenital tracheoesophageal in the pediatric and neonatal populations [5, 6]. We describe the successful thoracoscopic repair of a congenital H-type TEF newly diagnosed in an adult.
A 79-year-old female was admitted to the general medical service with shortness of breath and back pain. Clinical and roentgenographic examination demonstrated pneumonia and lumbar compression fracture. Review of her past medical history was notable for episodic cough and dysphagia with both solids and liquids. She had had multiple hospitalizations for pneumonia dating back to childhood and had been on long-term oral and inhaled steroids for chronic obstructive pulmonary disease. She had never smoked.
She exhibited Ohno's sign (cough while swallowing) during the dysphagia evaluation. A video swallow study demonstrated evidence of aspiration. A follow-up chest roentgenogram evidenced bilateral air bronchograms in the lower lung fields. An esophagogram using thin barium delineated the 4 to 5 mm diameter mid-intrathoracic TEF (Fig 1).
The anomalous opening was visualized on bronchoscopy, just below the midpoint of the trachea. During bronchoscopy, diluted methylene blue was placed through a nasogastric tube positioned in the proximal esophagus to establish the course of the fistulous tract; the secretions were tracked through the tracheal opening (Fig 2). Because of her notable past medical history with the absence of local findings of malignancy, inflammation, or trauma, we concluded this to be a congenital H-type TEF extending obliquely from the trachea to the esophagus. Plans for resection of the fistula were made to prevent future bouts of pneumonia and bronchitis.
A double lumen endotracheal tube was placed. The patient was placed in the left lateral decubitus position. A 10-mm port was placed in the sixth intercostal (IC) space mid-axillary. The right lung was deflated, the pleural space was insufflated to a pressure of 12 mm Hg, and the thoracoscope was advanced through the port. Three additional 5-mm ports were then placed under direct visualization. Two ports were positioned in the fourth IC space, one at the lateral border of the mid-clavicular line, the other at the posterior axillary line. The fourth port was placed in the seventh IC space along the anterior axillary line.
After minimal lysis of adhesions along the lateral wall, the lung was retracted infero-laterally. The pleura overlying the trachea and the esophagus was entered. The common wall between the esophagus and trachea was carefully dissected free in a cranial to caudal direction until the fistula was identified (Fig 3). The fistulous tract was then delineated circumferentially. Using a 45-mm endoscopic gastro intestinal anastamosis with a 3.5-mm depth staple, two separate loads were placed (ie, one proximal to the trachea and the other to the esophagus), and the anomalous tract was centrally divided with endoscopic scissors. An 8 x 0.8 cm bovine pericardial graft was then interpositioned at the site of the transected fistula to buttress the staple lines and prevent refistulization. A 30-French chest tube was placed through the anterior axillary port site. Procedure time was 116 minutes.
An air contrast upper gastro intestinal study was completed on postoperative day 4, which demonstrated no evidence of fistula. The patient's postoperative course was unremarkable.
|
Comment
|
|---|
Congenital TEF is a rare anomaly generally diagnosed and surgically repaired in the neonatal period. It occurs secondary to a defect in the cephalad progression of an embryonic septum that divides the foregut into the trachea and the esophagus [1, 6]. Though rare, several cases of TEF first diagnosed in adulthood have been reported [2–4]. The hallmark of adult congenital TEF is Ohno's sign [3, 4] and evidence of recurrent respiratory infections [1–4]. A high index of suspicion is needed to diagnose this uncommon, yet potentially debilitating condition. Diagnosis is generally confirmed with esophageal contrast studies or bronchoscopy, or both.
Historically, TEF repair in the adult was undertaken through a thoracotomy or an open transcervical approach; the course was dependent on the anatomic site of the tract [1–3]. Interposition of a pleural or muscle flap was used to augment the repair [3]. In an effort to minimize postoperative pain and immobility, we planned a thoracoscopic approach, encouraged by the work of Rothenberg [5], and Bax and van Der Zee [6] detailing successful thoracoscopic repair of TEFs in the pediatric population. Use of the bovine pericardial graft was prompted by its accessibility, was documented as successfully used after lung resection to minimize air leak [7], without a need for further tissue dissection, thereby decreasing operative time. In our experience, thoracoscopy provided excellent visualization and magnification to clearly delineate the 4 to 5 mm anomalous tract. The minimally invasive approach markedly reduced postoperative morbidity. At discharge our patient was tolerating a regular diet without cough or dysphagia.
|
References
|
|---|
- Albuquerque KV, Deshpande RK, Desai PB. Cervical approach for repair of congenital tracheo-esophageal fistula presenting in an adult J Postgrad Med 1993;39(4):216-217.[Medline]
- Holman WL, Vaezy A, Postlethwait RW, Bridgman A. Surgical treatment of H-type tracheoesophageal fistula diagnosed in an adult Ann Thorac Surg 1986;41:453-454.[Abstract]
- Zacharias J, Genc O, Goldstraw P. Congenital tracheoesophageal fistulas presenting in adultspresentation of two cases and a synopsis of the literature. J Thorac Cardiovasc Surg 2004;128:316-318.[Free Full Text]
- Azoulay D, Regnard JF, Magdeleinat P, Diamond T, Rojas-Miranda A, Levasseur P. Congenital respiratory-esophageal fistula in the adult J Thorac Cardiovasc Surg 1992;104(2):381-384.[Abstract]
- Rothenberg S. Thoracoscopic repair of tracheoesophageal fistula in newborns J Pediatr Surg 2002;37(6):869-872.[Medline]
- Bax NMA, van Der Zee DC. Feasibility of thoracoscopic repair of esophageal atresia with distal fistula J Pediatr Surg 2002;37(2):192-196.[Medline]
- Hazelrigg SR, Boley TM, Naunheim KS, et al. Effect of bovine pericardial strips on air leak after stapled pulmonary resection Ann Thorac Surg 1997;63(6):1573-1575.[Abstract/Free Full Text]
Top
Abstract
Introduction
