Abstract
Acquired tracheoesophageal fistulas are rare but associated with significant morbidity
and mortality. The majority of cases are due to prolonged or complicated endotracheal
intubation, tracheostomy, or esophageal malignancy, or subsequent to radiation or
chemotherapy for treatment of the latter. Other etiologies include esophageal stenting
and complications secondary to endoscopic procedures. The pathophysiology involves
chronic inflammation of the esophagus or posterior wall of the trachea, ultimately
promoting fistulization between these two structures. Risk factors primarily depend
on the etiology; however, excessive balloon pressures and prolonged intubation are
among the strongest predictors of acquired tracheoesophageal fistula. In two reported
cases, intubation with persistent air leaks resulted in fistulization. Patients present
with refractory pneumonia, aspiration, hypoxemia, acute respiratory distress, enteral
feed in endotracheal aspirate, or gastric distention following extubation. It can
be difficult to distinguish normal functional deterioration from deterioration secondary
to intubation. Up to 51% of patients intubated for at least 48 hours may experience
dysphagia following extubation. Ultimately, the diagnostic algorithm includes an esophagogram,
followed by imaging with computed tomography (CT) scan, and, more recently, CT scan
with three-dimensional reconstructions, a bronchoscopy, and an esophagoscopy. Spontaneous
closure rarely occurs, and the primary treatment modalities include interventional
therapy with stenting via bronchoscopy, esophagoscopy, or surgical correction. Surgical
intervention is associated with higher risks due to surrounding vital anatomy and,
often, technical challenges requiring multispecialty care. Our case study presents
a novel and effective method of repairing a benign acquired tracheoesophageal fistula
utilizing the transverse cervical artery flap.
Keywords
tracheoesophageal fistula - transverse cervical artery flap - repair
