Key Points

• Acquired tracheoesophageal fistula (TEF) Is uncommon and requires a high index of suspicion for accurate and early diagnosis.
• Prevention of airway soilage and maintenance of nutrition are critical in management.
• Patients need to be weaned from mechanical ventilation before surgical intervention, if possible.
• Repair of the fistula entails positioning healthy tissue between the esophageal and tracheal repairs. Primary repair without tracheal resection may be possible for small fistulas.
• An anterior approach is most useful for high fistulas with circumferential tracheal injury. Resection of the involved trachea, repair of the esophagus, and reconstruction of the trachea is a safe and effective method for dealing with benign acquired TEF.
• Lower fistulas, or fistulas involving the esophagus and a major bronchus, are approached through the right chest, and tracheal resection may not be required.
• A creative, individualized approach is frequently necessary for optimal outcomes

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.