A tracheoesophageal fistula (TEF) is an unusual entity and may be either congenital or acquired in origin. As a congenital lesion, it occurs in approximately 1 of every 3000 to 4000 live births and is discussed elsewhere in this text.
Acquired TEF are classified as either benign or malignant. Roughly 50% to 70% of acquired TEF arise from tumors; these are primarily esophageal or pulmonary in origin, but mediastinal tumors such as lymphoma may also result in this lesion. Benign acquired TEF may arise from a variety of causes, including trauma and infection, but as a general rule have a much better prognosis than those arising from malignancy. Most TEF seen today are a result of prolonged tracheal intubation and occur in the middle to upper trachea. In either malignant or benign TEF, the initial management is prevention of pulmonary soilage and maintenance of nutrition. The former may require esophageal diversion if the fistula is low. Nutrition is supported with the aid of a jejunostomy tube. Surgical repair is best undertaken after the patient has been weaned from mechanical ventilation because postoperative extubation and avoidance of positive-pressure ventilation provide the best chance of healing for the tracheal repair.
Surgical intervention for benign TEF involves resection of the fistulous tract, and possibly a section of trachea, and repair of the esophagus. Interposition of healthy tissue, such as a muscle flap or omentum, between the esophagus and the trachea reduces the incidence of recurrence. Various interventions aimed at palliation, such as luminal stenting, are employed for cases of malignancy, although occasionally surgical resection is indicated.
There's more to see -- the rest of this topic is available only to subscribers.