2. A tracheoesophageal fistula is an abnormal connection
(fistula) between the esophagus and the trachea. 3. Acquired
nonmalignantTEFs Acquired malignantTEFs 4. Causes of non-malignant
acquired TOF Blunt or penetrating trauma Granulomatous infection
Previous surgery of trachea and oesophagus Corrosive fluid
ingestion Poisons and inhalation burns Small battery ingestion
Iatrogenic Oesophageal stenting Oesophageal or tracheal endoscopy
Transoesophageal echocardiography Tracheal tubes and intubation
Percutaneous tracheostom 5. Co-existing factors predisposing to the
development of an acquired TOF Poor general state Poor nutritional
status Airway infection Episodic hypotension Restless/awake
patients Diabetes Steroid therapy Posterior counter-pressure by
nasogastric tubes Long-term mechanical ventilation 6. Epidemiology
Frequency Acquired nonmalignantTEFs occur in approximately 0.5% of
patients undergoing tracheostomy. Incidence of malignantTEFs was
reported at 4.5% for primary malignant esophageal tumors, and 0.3%
for primary malignant lung tumors. Other investigators have
reported the incidence ofTEFs secondary to esophageal carcinoma to
be 4.3-8.1%. 7. Mortality/Morbidity Patients with acquiredTEFs have
high mortality and morbidity rates because of critical illnesses
and comorbidities. 8. Age AcquiredTEFs may occur in individuals of
any age, and elderly individuals are at increased risk if they
become ventilator dependent because of respiratory failure. 9.
Pathological sequelae As a result of laryngeal bypass, spillage of
oesophageal contents occurs into the trachea. Saliva, food and
gastric juice contaminate the airways. This leads to congestion,
infection, pneumonia, bronchial obstruction, atelectasis and
respiratory distress. The severity of contamination depends on the
width and length of the fistula as well as the posture of the
patient. Spontaneous closure of non-malignantTOFs is exceptional
10. Clinical presentation An acquiredTOF should be considered in
any ventilated patient who has unexplained weight loss, recurrent
chest infections and repeated failures to wean. Symptoms in the
non-ventilated patient are related to repeated tracheal
soiling.Ono's sign refers to the uncontrolled coughing after
swallowing, often worse with carbonated drinks. 11. Other features
which should raise suspicions of an acquired TOF are: history of
trauma, malignancy or ingestion of caustic substances; chest pain;
haemoptysis; shortness of breath; dysphagia; hoarseness; pyrexia of
unknown origin; repeated respiratory tract infections; and
pneumonia. 12. Time course for symptomatic presentation of acquired
TOF related to cause Cause Time (days) Surgical 15 Ischaemia and
traumatic iatrogenic 515 Local infection 1521 Tracheal cuff-related
injury 2130 13. Differential Diagnoses Esophageal Cancer Esophageal
Diverticula Esophageal Rupture Esophageal Stricture Esophagitis
Gastroesophageal Reflux Disease Pneumonia,Aspiration Respiratory
Failure TrachealTumors Tracheomalacia Zenker Diverticulum 14.
Investigations 15. Endoscopy 16. Contrast X-ray 17. Ultrasound 18.
CT 19. 3D CT 20. Preoperative management The principles of
preoperative management of an acquired TOF are to minimize further
aspiration, prevent and treat pulmonary infections, provide
supportive therapy until definitive surgery can be performed.
tracheostomy gastrostomy tube to reduce reflux acid suppression
therapy The bed head should be elevated to prevent further passive
regurgitation Antibacterial therapy 21. Operative management
Acquired nonmalignantTEFs The fistula can be simply resected and
closed or whether tracheal resection and reconstruction is
required. A right lateral thoracotomy is used in most cases. A
small fistula and normal trachea does not require tracheal
resection. A large defect with tracheal damage often requires
tracheal resection and reconstruction. 22. Acquired malignantTEFs
For patients with malignant tracheoesophageal fistulas, treatment
depends on whether the patient is resectable and/or medically fit
for surgical therapy. However, most patients with malignant
trach-eoesophageal fistulas have advanced disease and can only be
treated with palliative measures. The current standard of
palliative therapy for patients with malignant tracheoesophageal
fistulas is the endoscopic or radiologic placement of covered
self-expanding metallic stents (SEMS), which allow closure of the
fistula. 23. SEMS 24. Complications Congenital and acquiredTEFs are
associated with multiple complications, including recurrent
pneumonia, acute lung injury, acute respiratory distress syndrome,
lung abscess, bronchiectasis from recurrent aspiration, respiratory
failure, and death. Post-operative stenosis, recurrent fistula
