Thoracoscopic Division of H-Type Tracheoesophageal Fistula

Abstract

Introduction:

H-type tracheoesophageal fistula repairs have historically been approached from either a low cervical or a high thoracic incision, both of which are associated with attendant problems. Chief among these is adequate identification and isolation of the fistula; it is commonly located at the level of the thoracic inlet. The thoracoscopic approach provides a magnified improved view of the relevant anatomy and pulls the operative field to a site remote from the recurrent laryngeal nerve.

Methods:

A 3-day-old 2.2 kg baby girl was referred for repeated coughing with feeds and an esophagram, which demonstrated an H-type tracheoesophageal fistula. An echocardiogram identified an atrial septal defect. In the operating room, rigid bronchoscopy showed a normal airway with the exception of a fistula in the posterior wall of the trachea; a #3 Fogarty balloon catheter was inserted through the fistula and the balloon inflated. Traction on the catheter wedged it into the esophageal lumen at the position of the fistula. Flexible bronchoscopy was used to perform a left mainstem bronchus intubation. The child was positioned in an exaggerated left lateral decubitus position. A right thoracoscopic approach was used with 3-mm equipment. Dissection commenced cephalad to the azygos vein below the level of the fistula. The position of the Fogarty balloon in the esophagus was identified and followed to isolate the fistula. The fistula was isolated with a silicone vessel loop and then the Fogarty withdrawn. The tracheal side of the fistula was closed with two 5-mm Hem-o-lok clips, the esophageal side tied off with size 0 braided absorbable suture twice, and the fistula divided. At the completion of the operation, an 8F feeding tube was guided through the esophagus and a 12F chest tube placed into the right hemithorax.

Results:

The operative time for thoracoscopic division of the H-type tracheoesophageal fistula was 90 minutes. Nasogastric feeds were initiated with the return of bowel function. An esophagram on postoperative day 7 showed no leak and no stricture. Oral feeds were started and the thoracostomy tube removed. Repeat esophagram at 14 months showed no evidence of stricture.

Conclusion:

We demonstrate the thoracoscopic approach to repair of an H-type tracheoesophageal fistula. This approach utilizes the placement of an intraluminal balloon catheter to identify the location of the fistula. Caudal traction on the fistula down into the chest minimizes the risk of injury to the recurrent laryngeal nerve.

The authors have no relevant financial disclosures.

Runtime of video: 4 mins 54 secs