Tracheoesophageal fistula is a congenital or acquired pathological condition in which a connection of the lumen of the esophagus tube and trachea is formed. Such a defect is characterized by a number of specific symptoms and requires mandatory surgical intervention, regardless of the form of the lesion and its severity.
Description of defeat
The channel formed in this condition includes the epithelium and granulation tissue. The lesion is diagnosed by radiography, as well as endoscopic examination. The ICD code of the tracheoesophageal fistula is a congenital tracheal-esophageal fistula without atresia Q39.2.
The disease can be of two forms: congenital and acquired. Congenital tracheoesophageal fistula is detected in 1 out of 3,000 children immediately after they are born. Of all the varieties of the anomaly, in most cases they are diagnosed with an isolated fistula at the level of the 7th thoracic and first cervical vertebrae. The disease in infants most often passes against a background of atresia.
The acquired disease is a rather rare phenomenon, and in almost all cases it passes against the background of stenosis of the lumen of the esophagus with additional scarring.
Causes of the disease
The congenital form of the tracheoesophageal fistula in newborns develops even at the stage of separation of the esophageal tube and trachea, which at the first stage are formed from a single germ. The named process begins from 4 to 12 weeks of embryo development in a woman’s uterus. Such an anomaly can be suspected during an ultrasound scan - poor visualization of the stomach or the underdevelopment of the embryo itself.
The cause of the tracheoesophageal fistula of the acquired form is most often the development of an oncological formation. The tumor actively develops from the tissues of the esophagus, which leads to a pathological narrowing of its lumen. In this case, risk factors are esophagoscopy with organ damage, esophageal vasodilation or stenting of the esophagus tube followed by perforation.
Common reasons
An esophageal-tracheal fistula can also develop due to a chemical or thermal burn that was obtained during surgery or damage to the chest and neck. Other less common causes of the appearance of pathology include:
- damage to the diverticulum of the esophagus;
- bacterial infection;
- lung abscess
- mediastinitis;
- lymph node tuberculosis;
- the formation of pressure sores;
- various actively developing inflammations in the body;
- mediastinitis.
The main varieties of fistulas
Doctors divide the tracheoesophageal fistula in newborns and older people into the following types:
- Type I - the proximal section of the esophageal tube is connected to the trachea, immediately the two ends of the organ are blind.
- Type II - the formation of a fistula between the posterior wall of the trachea and the anterior segment of the esophagus of the tube.
- Type III A - both ends of the organ are blind, a fistula is formed between the lower part of the trachea and the proximal end of the esophagus.
- Type III B - a fistula is formed between the distal part of the esophagus and the lower part of the trachea, atresia of the esophagus occurs.
- Type III C is the combination of the distal and proximal segment of the esophagus tube with the trachea at different levels with atresia.
Also, experts distinguish acquired fistulas of a traumatic and tumor nature, formed during a specific or nonspecific inflammatory process.
Possible complications
With the development of the tracheoesophageal fistula, in addition, the patient begins a serious purulent-inflammatory process, as a result of which the following diseases develop:
- tracheobronchitis;
- bacterial pneumonia;
- gangrene;
- pleurisy;
- mediastinitis.
When removing the tracheoesophageal fistula, the operation does not exclude a relapse of the disease. And in this case, the patient will be prescribed a second surgical intervention. The risk of death exists during the operation against the background of a complicated condition of the patient due to the severe form of the disease. Also, a fatal outcome may result in the patient's refusal to conduct radical excision of the fistula. Moreover, in most cases, purulent complication develops, which is simply incompatible with human life.
Clinical picture
Symptoms with a tracheoesophageal fistula will depend on its location, type and associated pathologies. As a rule, in all patients with this condition, a strong coughing attack begins with the release of small particles of food, there are problems with respiratory activity and other signs of the onset of the spread of inflammation. Tracheo-esophageal fistula passes against the background of the following symptoms:
- paroxysmal cough during eating;
- a hoarse voice;
- a feeling of suffocation due to a lack of oxygen entering the body;
- a feeling of having a foreign body in the throat.
With an exacerbated form of the disease, the patient additionally has symptoms of intoxication with an increase in body temperature, a feeling of malaise, as well as a complete or partial lack of appetite. Often the anomaly is complicated by aspiration or purulent pneumonia, which adds typical signs of pneumonia to existing symptomatic manifestations.
The child begins severe suffocation and coughing attacks when feeding, the color of his skin becomes cyanotic or becomes pale. In addition, the baby has a large amount of excess saliva and problems with swallowing.
Diagnostics
When diagnosing a tracheoesophageal fistula, the doctor prescribes the patient a contrast radiography or esophatography by introducing a catheter through the patient’s oral cavity.
With an external fistula, the patient is offered to drink a contrast agent, and in this case, the diagnosis will be confirmed by the release of a different color fluid from the fistula or during a coughing fit. With a strong prevalence of the disorder, diagnostic measures will also be carried out using a contrast medium, which, at the first sip, will help determine the violation.
If the doctor has established all the clinical signs of a fistula, the radiography is replaced by an endoscopic examination with the introduction of a contrast agent. This helps to track the progress of the fistula, determine the site of the connection, and based on the information received draw up an optimal treatment tactic and an operation plan.
If endoscopy does not give the expected results, then radiography with contrast is performed, which helps to accurately view the defect and even describe the disease in detail. This gives doctors the opportunity to make an effective and comprehensive treatment. Additionally, the patient is sampled for tracheobronchoscopy.
Fistula of the esophagus is a dangerous condition, it is important to deal with it immediately in the first stages of its development.
Treatment
The main treatment for a tracheoesophageal fistula is surgery. The doctor prescribes medications only for patients with concomitant diseases - such treatment helps maintain the patient's condition and alleviate symptoms.
Before the operation, the specialist can prescribe a set of medications that help reduce the severity of the inflammatory process and get rid of a purulent infection. Such exposure will significantly reduce the risk of early postoperative complications.
Surgical intervention will consist in the separation of the fistula and its excision. Access will be selected depending on the location of the formation - through the chest, neck or stomach. After excision of the fistula, damage to the walls of each organ is stitched in turn. Seams are additionally strengthened by adjacent tissues: omentum, diaphragm, pleura or pericardium.
Other forms of lesion
If strictures are found in addition to the patient with fistula, then the patient is prescribed plastic surgery of the esophagus using colon tissue. In case of abnormalities with concomitant hernia, AML is prescribed Nissen fundoplasty.
After surgery, the patient is prescribed medication to quickly recover and prevent the development of an inflammatory or infectious process. In severe purulent complications, the lungs will have to excise segments or completely remove the organ (pulmonectomy).
Postoperative Recovery
After surgery, the patient is fed with a probe, which is most often left for 10 days. On the first day after surgery, feeding is carried out exclusively by intravenous infusion.
Such surgical intervention is usually referred to as a complex surgical procedure, but correct and comprehensive diagnosis, as well as good preparation, will help prevent complications after surgery. The prognosis for a tracheoesophageal fistula with timely excision and plastic surgery is generally favorable among doctors.
After surgical intervention, the patient requires constant monitoring by the doctor, this will help identify complications in the early stages of their development and also make up a comprehensive treatment.
Detailed treatment description
Unfortunately, many unfortunately can only get rid of such an anomaly through surgical intervention. Taking medications and other physiotherapy only for a while help to alleviate the condition and get rid of complications. During surgery, the fistula is divided and bandaged. In the event that the move is too long, it is pulled by several ligatures, after they cross each other. With a wide and short course, the esophagus and trachea are dissected, as well as the stapling of the resulting hole. If an operation to excise a fistula is not performed in time, then the patient's condition will soon deteriorate significantly and even death can occur. Surgical intervention for a newborn child is carried out in the first day after birth.
After the operation, the patient is prescribed a course of treatment for pneumonia. A complication after surgery can be a relapse of the fistula, in which the operation will have to be carried out again. It is impossible to refuse it, since such an attitude can provoke the death of the patient.
When combining a tracheoesophageal fistula with atresia of the esophagus or with stenosis of the trachea, the doctor dissociates the formation with simultaneous circular resection, organ plasty or simultaneous plasty of the esophagus. If there is a large diastasis between the distal and proximal segments of the esophagus, which prevents the end-to-end anastomosis, then the upper section of the esophagus is brought to the neck, the fistula is disconnected and the operation is stopped.
If the tracheoesophageal fistula has arisen due to the decay of the tumor, the specialist creates a special artificial entrance to the cavity of the stomach through the front abdominal wall to feed the patient when he alone cannot take food through the mouth.
Is prevention possible?
The problem of prevention of tracheoesophageal fistula remains relevant for many doctors. Lethal outcomes during surgery for tracheoesophageal fistula account for 10-15 percent of all cases, which is associated in most cases with a severe initial condition of the patient. To avoid dangerous consequences, it is important to carefully consider the state of your health and, in which case, immediately seek medical help.