Advancing Education, Research, and Quality of Care for the Head and Neck oncology patient.
Introduction: Tracheoesophageal fistulas (TEFs) are devastating, life threatening conditions that are challenging to manage. Amongst the most challenging are those related to malignancy or the treatment thereof. When surgery is indicated, adjunctive procedures including laryngectomy, sternotomy, or extracorporeal membrane oxygenation (ECMO) may facilitate repair. Herein, we report our multidisciplinary surgical approach.
Methods: An institutional review of adult, open surgical tracheoesophageal repairs performed between 2000 – 2024 was conducted. Cases without adequate documentation were excluded.
Results: We identified 9 cases of acquired TEF. The average age at diagnosis was 56.3 years old and 55% (5/9) were female. All patients experienced symptoms of coughing and dysphagia, with 88% (8/9) of patients experiencing at least one episode of aspiration pneumonia. All patients required enteral tube placement for nutrition prior to reconstruction. 88% (8/9) of patients had a history of malignancy, with esophageal cancer being the most common (50%; 4/8) followed by one case of larynx, hypopharynx, thyroid cancer and Hodgkin’s lymphoma respectively. 66% (6/9) of patients underwent radiation as part of their treatment and 66% (6/9) of patients had definitive airway surgery, either tracheostomy or laryngectomy, prior to TEF repair. Pre-operative cross-sectional imaging of the TEF identified a mean craniocaudal dimension of 24.8mm (range 7-44mm). The primary reconstructive techniques employed included 22% (2/9) primary tracheal/esophageal anastomosis, 22% primary tracheal/esophageal anastomosis with regional flap interposition, and 55% (5/9) free flap reconstructions. Out of these cases, 44% (4/9) required extracorporeal membrane oxygenation (ECMO), 22% (2/9) required a sternotomy and 22% (2/9) required a laryngectomy as part of their initial TEF repair. After reconstruction, 44% (4/9) of patients required repeat operations due to complications (median 3 operations; range 1-4) and 33% (3/9) of patients required esophageal diversion with pharyngostoma creation. With that said, 66% (6/9) of patients had persistent closure of TEF on most recent follow up appointments and 55% (5/9) returned to oral feeding. Overall, 77% (7/9) of patients are still living and 22% (2/9) are dead with a median survival of 20.6 and 50.1 months respectively.
Conclusions: In our case series and literature review we present 9 cases of TEFs repaired with advanced surgical techniques. Our study highlights that in the most challenging cases, adjunctive procedures including ECMO, sternotomy, or laryngectomy may be required for successful repair. Despite this, this remains a very high-risk patient population with patients requiring multiple procedures and some with persistent TEFs, or death.