The Laryngoscope C 2015 The American Laryngological, V
Rhinological and Otological Society, Inc.
How I Do It
Minimally Invasive Management of Tracheoesophageal Fistula with T-Tube Christopher Tran, MD; Daniel S. Fink, MD; Melda Kunduk, CCC SLP, PhD; Andrew J. McWhorter, MD
INTRODUCTION Tracheoesophageal fistula (TEF), a defect in the party wall between the trachea and esophagus, provides a pathway for the aspiration of orogastric contents and increased risk of severe pulmonary sequelae. Due to their intrinsic pathophysiologic nature, nonmalignant TEFs have traditionally been difficult to manage. Most literature on this discusses open repair with tracheal and esophageal resection and reconstruction, often with flap reinforcement. These procedures have been shown to be effective, but with a potential for leakage, fistula recurrence, and even death.1–6 Esophageal stenting has gained popularity as a less invasive approach, but difficulty has been encountered with stent migration and fistula enlargement.7,8 There is little in the literature supporting other methods of management. We describe our institution’s experience with the management of nonmalignant-acquired TEF using a Montgomery T-tube (MTT) (Boston Medical Products, Inc., Westborough, MA) in a minimally invasive approach in two patients. Specifically, we will describe the procedure, analyze its advantages and disadvantages, discuss patient factors and complications, and evaluate patient outcomes.
MATERIALS AND METHODS This study was approved by the institutional review board of both the Louisiana State University Health Sciences Center and Our Lady of the Lake Regional Medical Center, New Orleans, Louisiana. We examined the medical records of two patients, 61 and 19-year-old
From the Department of Otolaryngology–Head and Neck Surgery, Louisiana State University Health Sciences Center (C.T., D.S.F., M.K., A.J.M.), New Orleans; Our Lady of the Lake Voice Center (D.S.F., M.K., A.J.M.); and Department of Communication Sciences and Disorders, Louisiana State University (M.K.), Baton Rouge, Louisiana, U.S.A. Editor’s Note: This Manuscript was accepted for publication January 26, 2015. The authors have no funding, financial relationships, or conflicts of interest to disclose. Send correspondence to Daniel S. Fink, MD, Department of Otorhinolaryngology, 533 Bolivar St, Ste 566, Louisiana State University– Health Science Center, New Orleans, LA 70112. E-mail: daniel.fink@ ololrmc.com DOI: 10.1002/lary.25215
Laryngoscope 125: August 2015
females, who were treated for nonmalignant tracheoesophageal fistula at a tertiary care laryngology center between 2007 and 2014. The study assessed personal details, etiology, treatment, complications, and outcomes. Placement of the MTT (Boston Medical Products, Inc.) in both patients was performed in the operating room. In both patients, flexible esophagoscopy was performed to visualize the MTT (Boston Medical Products, Inc.) from the esophageal side of the fistula (Fig. 1). Direct laryngoscopy was then performed, and 0- and 70degree Hopkins rod telescopes were used to visualize the TEF from its tracheal aspect. Measurements of the length of the fistula and the distance from the superior surface of the true vocal folds to the proximal aspect of the fistula and its relation to the tracheostoma were made using the Hopkins rod telescope (Fig. 1). Tracheal granulation tissues were ablated as necessary using a CO2 laser, typically set at 10 W with a digital-pattern generator. Triamcinolone (40 mg/ml) was injected into the granulation site, and mitomycin C (0.5 mg/ml) was applied topically to the resection site. The size of the MTT (Boston Medical Products, Inc.) was judged by the senior author (AJM) based on clinical experience. The MTT (Boston Medical Products, Inc.) limbs were then trimmed, leaving sufficient length superiorly and inferiorly from the tracheostoma to pass both proximally and distally to the stoma. This was based on the measurements taken with the Hopkins rod telescope. At this point, the distal limb of the MTT (Boston Medical Products, Inc.) was placed through the stoma and passed into the distal trachea, allowing for placement of the proximal limb. The Hopkins rod telescope was used to confirm placement. Finally, balloon dilatation was used to dilate the MTT (Boston Medical Products, Inc.) limbs, and positioning was checked from the tracheal and esophageal aspects to ensure that the fistula was completely covered (Fig. 2). Prior to termination of the procedure, bronchoscopy with suction of mucus and operative hemorrhagic debris was indicated. Both patients went to the operating room for Ttube replacement and reexamination of fistula site. At that time, the fistula were measured as described above and continued to be managed successfully with the Ttubes. Tran et al.: T-Tube for Tracheoesophageal Fistula
1911
Fig. 1. Fistula visualized from tracheal aspect.
RESULTS Two patients with nonmalignant TEF development during treatment for tracheal stenosis were treated over the period studied. Both patients were female and presented at 15 and 61 years of age, respectively. Each patient was treated as an outpatient, with overnight observation after MTT (Boston Medical Products, Inc.) placement or replacement. TEF size at presentation was 8 mm and 20 mm, respectively. No serious long-term complications have been observed to date. Treatment of TEF, from time of diagnosis to optimal maintenance of symptom control, ranged from 1 and 5 years, respectively (Table I).
Patient A A 61-year-old female was diagnosed with undifferentiated carcinoma of the party wall and treated with primary chemoradiation therapy approximately 3 years prior to presentation. Posttreatment sequelae included left true vocal fold paralysis and severe tracheal stenosis. The patient underwent three repeat tracheal stenting procedures, followed by placement of a nitinol wire
stent. The patient then developed severe tracheal granulation tissue, which required placement of a tracheotomy through the stent. Upon presentation to our institution, the patient was aphonic with aspiration, chronic tracheitis, and long-segment tracheal stenosis. The patient subsequently underwent removal of the nitinol wire stent from the tracheal wall. This was a complicated laborintensive process that required multiple trips to the operating room over the next year. The wires cut from placement of the tracheostomy, embedded in the midst of granulation tissue, were removed in a piecemeal fashion and would intermittently migrate into the airway. The patient was discovered to have a tracheoesophageal fistula posterior to the tracheostomy tube cuff, for which she underwent a transcervical strap-muscle interposition flap repair that ultimately failed. However, with modifications, the MTT (Boston Medical Products, Inc.) that was placed at the time was successful with regard to both controlling the leakage of esophageal contents into the airway and maintenance of the voice. The TEF was measured to be 20 mm in length at the time of the initial stent replacement and 11 mm at the time of the stent replacement.
Patient B A 15-year-old female suffered a partial transection and avulsion injury to her trachea secondary to motor vehicle accident 1 year prior to presentation. Her trachea was primarily reconstructed with tracheostomy tube in place. She presented with aphonia, 100% proximal tracheal stenosis, and suprastomal granulation tissue. A small tracheoesophageal fistula was found, for which the patient underwent primary endoscopic suture repair and transoral multilayered repair that ultimately failed. A MTT (Boston Medical Products, Inc.) was used to stent the airway during these procedures, and continued use after their failure allowed for maintenance of oral intake with minimal aspiration and improved voicing. The TEF was measured to be 8 mm at the time of the initial stent placement and 4 mm at the time of the stent replacement. Traditional resection repair was not performed secondary to the long-segment stenosis with bilateral TVF paresis, as well as patient and family wishes.
DISCUSSION
Fig. 2. Fistula stented by T-Tube as visualized from esophageal aspect.
Laryngoscope 125: August 2015
1912
Surgical management of tracheoesophageal fistula may consist of many approaches, as discussed in a recent retrospective review by Muniappan et al.1 One can attempt tracheal closure, including resection and reconstruction, laryngotracheal resection, membranous tracheal repair, or repair over tracheal MTT. Esophageal closure may be attempted via two-layered closure, onelayered closure, esophagostomy, end-to-end esophageal anastomosis, and full-thickness skin graft reconstruction. Each of these methods may be buttressed by interposing pedicled muscle or omental flaps. Traditionally, these methods have been successful, with a reported fistula closure rate of 94%; resumed oral intake of 83%; and 71% of patients breathing without a tracheal Tran et al.: T-Tube for Tracheoesophageal Fistula
TABLE I. Patient Characteristics and Outcomes. Patient
A
B
Age (years)/Sex
61/female
15/female
Etiology Prior surgery
Postradiation tracheal stenosis Tracheal stents 33 plus tracheostomy through stent
Penetrating neck trauma Tracheal reconstruction plus tracheostomy
Time from insult to TEF
53 months
45 months
TEF size (initial/final) Other airway interventions Recovery of voice
20 mm/11 mm Transcervical repair (strap muscle interposition flap) Maintained
8 mm/4 mm Endoscopic transoral suture repair 32
Recovery of full per oral intake
Maintained
Maintained
Complications related to MTT
Mucus plug, proximal and distal stenosis, fungal colonization, leakage around MTT
Crusting, proximal stenosis, cricoid mucosal erosion, local tracheal irritation, bacterial colonization, leakage around MTT
Confounding issues
Nitinol stent sequelae, left TVC paralysis, tracheal breakdown after open repair, lung/bone metastases
TVC paresis, occasional laryngospasm, smoking (8-month duration)
Maintained
MTT 5 Montgomery T-tube (Boston Medical Products, Inc., MA); TEF 5 tracheoesophageal fistula; TVC 5 true vocal cord.
appliance, with an 11% post-operative fistula recurrence rate, and 3% mortality rate.1 Mathisen et al. reported a series of 41 operations on 38 patients in whom simple division and closure of the fistula was performed in nine patients and tracheal resection and reconstruction in the remainder.2 The authors noted a 10.9% mortality rate, 33% recurrence rate, and 9% delayed tracheal stenosis rate. Each of these surgical methods requires one or more major open procedures and inherently acquires the risks of such. Some patients are considered poor candidates for open surgical repair, including those with longsegment tracheal stenosis, those with poor tissue integrity, those who have failed open repair, or those who are not medically stable for major procedures. The alternative treatment paradigm employs endoluminal stents to seal the fistula without attempting to close the tissue defect. Blackmon et al. described the placement of covered self-expanding metal esophageal stents as a primary treatment option with a 50% success rate, to be followed by definitive surgical management.7 However, despite their novel technique for securing the esophageal stents, migration remained a problem occurring in 43% of patients. To our knowledge, there is no literature regarding the use of the MTT (Boston Medical Products, Inc.) in the management of tracheoesophageal fistula. The advantages of MTT placement are multiple. Craniocaudal and rotational migration is minimized by the horizontal limb of the tube. Microadjustments of MTT position were easily performed in a minimally invasive and safe manner in the operating room. In-office monitoring of position and endoscopic evaluation of airway soilage with per oral challenge is easily evaluated with flexible endoscopy through the horizontal limb. Use of the MTT does not preclude open surgical management for tracheoesophageal fistula. The Laryngoscope 125: August 2015
versatility of the MTT is further demonstrated by the ability to adjust the vertical limbs to provide maximal fistula coverage and minimize local mucosal irritation. Compared to the cuffed tracheostomy tube, the MTT provides minimized external and airway soilage by secretions, with the added benefit of voice preservation and improved oral intake—all factors contributing to improved patient quality of life. No fistula enlargement was noted in either patient. However, it should be noted that fistula placement did not cause healing of the fistula, but rather management of the condition in a minimally invasive fashion and with a comparatively improved quality of life. Complications relating to the MTT are those pertinent to any indwelling intratracheal tubes. Such complications include mucus crusting, local mucosal irritation leading to proximal or distal granulation, bacterial or fungal colonization, or leakage around the tube. Thus, thorough patient education regarding MTT care is paramount to minimizing possible complications.
CONCLUSION In summary, Montgomery T-tube placement appears to be a safe, efficacious, and minimally invasive option for the management of tracheoesophageal fistula that results in maintenance of the voice and better oralintake outcomes without migration and minimal aspiration. This option is particularly attractive for patients who are poor surgical candidates.
BIBLIOGRAPHY 1. Muniappan A, Wain JC, Wright CD, et al. Surgical treatment of nonmalignant tracheoesophageal fistula: a thirty-five year experience. Ann Thorac Surg 2013;95:1141–1146.
Tran et al.: T-Tube for Tracheoesophageal Fistula
1913
2. Mathisen DJ, Grillo HC, Wain JC, Hilgenberg AD. Management of acquired nonmalignant tracheoesophageal fistula. Ann Thorac Surg 1991;52:759–765. 3. Shen KR, Allen MS, Cassivi SD, et al. Surgical management of acquired nonmalignant tracheoesophageal and bronchoesophageal fistulae. Ann Thorac Surg 2010;90:914–918. 4. Baisi A, Bonavina L, Narne S, Peracchia A. Benign tracheoesophageal fistulas: results of surgical therapy. Dis Esophagus 1999;12: 209–211. 5. Camargo JJ, Machuca TN, Camargo SM, Lobato VF, Medina CR. Surgical treatment of benign tracheoesophageal fistulas with tracheal resection
Laryngoscope 125: August 2015
1914
and oesophageal primary closure: is the muscle flap really necessary? Eur J Cardiothoracic Surgery 2010;37:576–580. 6. Altorjay A, Mucs M, Rull M, et al. Recurrent, nonmalignant tracheoesophageal fistulas and the need for surgical improvisation. Ann Thorac Surg 2010;89:1789–1796. 7. Blackmon SH, Santora R, Schwarz P, Barroso A, Dunkin BJ. Utility of removable esophageal covered self-expanding metal stents for leak and fistula management. Ann Thorac Surg 2010;89:931–936. 8. Eleftheriadis E, Kotzampassi K. Temporary stenting of acquired benign tracheoesophageal fistulas in critically ill ventilated patients. Surg Endosc 2005;19:811–815.
Tran et al.: T-Tube for Tracheoesophageal Fistula
Rhinological and Otological Society, Inc.
How I Do It
Minimally Invasive Management of Tracheoesophageal Fistula with T-Tube Christopher Tran, MD; Daniel S. Fink, MD; Melda Kunduk, CCC SLP, PhD; Andrew J. McWhorter, MD
INTRODUCTION Tracheoesophageal fistula (TEF), a defect in the party wall between the trachea and esophagus, provides a pathway for the aspiration of orogastric contents and increased risk of severe pulmonary sequelae. Due to their intrinsic pathophysiologic nature, nonmalignant TEFs have traditionally been difficult to manage. Most literature on this discusses open repair with tracheal and esophageal resection and reconstruction, often with flap reinforcement. These procedures have been shown to be effective, but with a potential for leakage, fistula recurrence, and even death.1–6 Esophageal stenting has gained popularity as a less invasive approach, but difficulty has been encountered with stent migration and fistula enlargement.7,8 There is little in the literature supporting other methods of management. We describe our institution’s experience with the management of nonmalignant-acquired TEF using a Montgomery T-tube (MTT) (Boston Medical Products, Inc., Westborough, MA) in a minimally invasive approach in two patients. Specifically, we will describe the procedure, analyze its advantages and disadvantages, discuss patient factors and complications, and evaluate patient outcomes.
MATERIALS AND METHODS This study was approved by the institutional review board of both the Louisiana State University Health Sciences Center and Our Lady of the Lake Regional Medical Center, New Orleans, Louisiana. We examined the medical records of two patients, 61 and 19-year-old
From the Department of Otolaryngology–Head and Neck Surgery, Louisiana State University Health Sciences Center (C.T., D.S.F., M.K., A.J.M.), New Orleans; Our Lady of the Lake Voice Center (D.S.F., M.K., A.J.M.); and Department of Communication Sciences and Disorders, Louisiana State University (M.K.), Baton Rouge, Louisiana, U.S.A. Editor’s Note: This Manuscript was accepted for publication January 26, 2015. The authors have no funding, financial relationships, or conflicts of interest to disclose. Send correspondence to Daniel S. Fink, MD, Department of Otorhinolaryngology, 533 Bolivar St, Ste 566, Louisiana State University– Health Science Center, New Orleans, LA 70112. E-mail: daniel.fink@ ololrmc.com DOI: 10.1002/lary.25215
Laryngoscope 125: August 2015
females, who were treated for nonmalignant tracheoesophageal fistula at a tertiary care laryngology center between 2007 and 2014. The study assessed personal details, etiology, treatment, complications, and outcomes. Placement of the MTT (Boston Medical Products, Inc.) in both patients was performed in the operating room. In both patients, flexible esophagoscopy was performed to visualize the MTT (Boston Medical Products, Inc.) from the esophageal side of the fistula (Fig. 1). Direct laryngoscopy was then performed, and 0- and 70degree Hopkins rod telescopes were used to visualize the TEF from its tracheal aspect. Measurements of the length of the fistula and the distance from the superior surface of the true vocal folds to the proximal aspect of the fistula and its relation to the tracheostoma were made using the Hopkins rod telescope (Fig. 1). Tracheal granulation tissues were ablated as necessary using a CO2 laser, typically set at 10 W with a digital-pattern generator. Triamcinolone (40 mg/ml) was injected into the granulation site, and mitomycin C (0.5 mg/ml) was applied topically to the resection site. The size of the MTT (Boston Medical Products, Inc.) was judged by the senior author (AJM) based on clinical experience. The MTT (Boston Medical Products, Inc.) limbs were then trimmed, leaving sufficient length superiorly and inferiorly from the tracheostoma to pass both proximally and distally to the stoma. This was based on the measurements taken with the Hopkins rod telescope. At this point, the distal limb of the MTT (Boston Medical Products, Inc.) was placed through the stoma and passed into the distal trachea, allowing for placement of the proximal limb. The Hopkins rod telescope was used to confirm placement. Finally, balloon dilatation was used to dilate the MTT (Boston Medical Products, Inc.) limbs, and positioning was checked from the tracheal and esophageal aspects to ensure that the fistula was completely covered (Fig. 2). Prior to termination of the procedure, bronchoscopy with suction of mucus and operative hemorrhagic debris was indicated. Both patients went to the operating room for Ttube replacement and reexamination of fistula site. At that time, the fistula were measured as described above and continued to be managed successfully with the Ttubes. Tran et al.: T-Tube for Tracheoesophageal Fistula
1911
Fig. 1. Fistula visualized from tracheal aspect.
RESULTS Two patients with nonmalignant TEF development during treatment for tracheal stenosis were treated over the period studied. Both patients were female and presented at 15 and 61 years of age, respectively. Each patient was treated as an outpatient, with overnight observation after MTT (Boston Medical Products, Inc.) placement or replacement. TEF size at presentation was 8 mm and 20 mm, respectively. No serious long-term complications have been observed to date. Treatment of TEF, from time of diagnosis to optimal maintenance of symptom control, ranged from 1 and 5 years, respectively (Table I).
Patient A A 61-year-old female was diagnosed with undifferentiated carcinoma of the party wall and treated with primary chemoradiation therapy approximately 3 years prior to presentation. Posttreatment sequelae included left true vocal fold paralysis and severe tracheal stenosis. The patient underwent three repeat tracheal stenting procedures, followed by placement of a nitinol wire
stent. The patient then developed severe tracheal granulation tissue, which required placement of a tracheotomy through the stent. Upon presentation to our institution, the patient was aphonic with aspiration, chronic tracheitis, and long-segment tracheal stenosis. The patient subsequently underwent removal of the nitinol wire stent from the tracheal wall. This was a complicated laborintensive process that required multiple trips to the operating room over the next year. The wires cut from placement of the tracheostomy, embedded in the midst of granulation tissue, were removed in a piecemeal fashion and would intermittently migrate into the airway. The patient was discovered to have a tracheoesophageal fistula posterior to the tracheostomy tube cuff, for which she underwent a transcervical strap-muscle interposition flap repair that ultimately failed. However, with modifications, the MTT (Boston Medical Products, Inc.) that was placed at the time was successful with regard to both controlling the leakage of esophageal contents into the airway and maintenance of the voice. The TEF was measured to be 20 mm in length at the time of the initial stent replacement and 11 mm at the time of the stent replacement.
Patient B A 15-year-old female suffered a partial transection and avulsion injury to her trachea secondary to motor vehicle accident 1 year prior to presentation. Her trachea was primarily reconstructed with tracheostomy tube in place. She presented with aphonia, 100% proximal tracheal stenosis, and suprastomal granulation tissue. A small tracheoesophageal fistula was found, for which the patient underwent primary endoscopic suture repair and transoral multilayered repair that ultimately failed. A MTT (Boston Medical Products, Inc.) was used to stent the airway during these procedures, and continued use after their failure allowed for maintenance of oral intake with minimal aspiration and improved voicing. The TEF was measured to be 8 mm at the time of the initial stent placement and 4 mm at the time of the stent replacement. Traditional resection repair was not performed secondary to the long-segment stenosis with bilateral TVF paresis, as well as patient and family wishes.
DISCUSSION
Fig. 2. Fistula stented by T-Tube as visualized from esophageal aspect.
Laryngoscope 125: August 2015
1912
Surgical management of tracheoesophageal fistula may consist of many approaches, as discussed in a recent retrospective review by Muniappan et al.1 One can attempt tracheal closure, including resection and reconstruction, laryngotracheal resection, membranous tracheal repair, or repair over tracheal MTT. Esophageal closure may be attempted via two-layered closure, onelayered closure, esophagostomy, end-to-end esophageal anastomosis, and full-thickness skin graft reconstruction. Each of these methods may be buttressed by interposing pedicled muscle or omental flaps. Traditionally, these methods have been successful, with a reported fistula closure rate of 94%; resumed oral intake of 83%; and 71% of patients breathing without a tracheal Tran et al.: T-Tube for Tracheoesophageal Fistula
TABLE I. Patient Characteristics and Outcomes. Patient
A
B
Age (years)/Sex
61/female
15/female
Etiology Prior surgery
Postradiation tracheal stenosis Tracheal stents 33 plus tracheostomy through stent
Penetrating neck trauma Tracheal reconstruction plus tracheostomy
Time from insult to TEF
53 months
45 months
TEF size (initial/final) Other airway interventions Recovery of voice
20 mm/11 mm Transcervical repair (strap muscle interposition flap) Maintained
8 mm/4 mm Endoscopic transoral suture repair 32
Recovery of full per oral intake
Maintained
Maintained
Complications related to MTT
Mucus plug, proximal and distal stenosis, fungal colonization, leakage around MTT
Crusting, proximal stenosis, cricoid mucosal erosion, local tracheal irritation, bacterial colonization, leakage around MTT
Confounding issues
Nitinol stent sequelae, left TVC paralysis, tracheal breakdown after open repair, lung/bone metastases
TVC paresis, occasional laryngospasm, smoking (8-month duration)
Maintained
MTT 5 Montgomery T-tube (Boston Medical Products, Inc., MA); TEF 5 tracheoesophageal fistula; TVC 5 true vocal cord.
appliance, with an 11% post-operative fistula recurrence rate, and 3% mortality rate.1 Mathisen et al. reported a series of 41 operations on 38 patients in whom simple division and closure of the fistula was performed in nine patients and tracheal resection and reconstruction in the remainder.2 The authors noted a 10.9% mortality rate, 33% recurrence rate, and 9% delayed tracheal stenosis rate. Each of these surgical methods requires one or more major open procedures and inherently acquires the risks of such. Some patients are considered poor candidates for open surgical repair, including those with longsegment tracheal stenosis, those with poor tissue integrity, those who have failed open repair, or those who are not medically stable for major procedures. The alternative treatment paradigm employs endoluminal stents to seal the fistula without attempting to close the tissue defect. Blackmon et al. described the placement of covered self-expanding metal esophageal stents as a primary treatment option with a 50% success rate, to be followed by definitive surgical management.7 However, despite their novel technique for securing the esophageal stents, migration remained a problem occurring in 43% of patients. To our knowledge, there is no literature regarding the use of the MTT (Boston Medical Products, Inc.) in the management of tracheoesophageal fistula. The advantages of MTT placement are multiple. Craniocaudal and rotational migration is minimized by the horizontal limb of the tube. Microadjustments of MTT position were easily performed in a minimally invasive and safe manner in the operating room. In-office monitoring of position and endoscopic evaluation of airway soilage with per oral challenge is easily evaluated with flexible endoscopy through the horizontal limb. Use of the MTT does not preclude open surgical management for tracheoesophageal fistula. The Laryngoscope 125: August 2015
versatility of the MTT is further demonstrated by the ability to adjust the vertical limbs to provide maximal fistula coverage and minimize local mucosal irritation. Compared to the cuffed tracheostomy tube, the MTT provides minimized external and airway soilage by secretions, with the added benefit of voice preservation and improved oral intake—all factors contributing to improved patient quality of life. No fistula enlargement was noted in either patient. However, it should be noted that fistula placement did not cause healing of the fistula, but rather management of the condition in a minimally invasive fashion and with a comparatively improved quality of life. Complications relating to the MTT are those pertinent to any indwelling intratracheal tubes. Such complications include mucus crusting, local mucosal irritation leading to proximal or distal granulation, bacterial or fungal colonization, or leakage around the tube. Thus, thorough patient education regarding MTT care is paramount to minimizing possible complications.
CONCLUSION In summary, Montgomery T-tube placement appears to be a safe, efficacious, and minimally invasive option for the management of tracheoesophageal fistula that results in maintenance of the voice and better oralintake outcomes without migration and minimal aspiration. This option is particularly attractive for patients who are poor surgical candidates.
BIBLIOGRAPHY 1. Muniappan A, Wain JC, Wright CD, et al. Surgical treatment of nonmalignant tracheoesophageal fistula: a thirty-five year experience. Ann Thorac Surg 2013;95:1141–1146.
Tran et al.: T-Tube for Tracheoesophageal Fistula
1913
2. Mathisen DJ, Grillo HC, Wain JC, Hilgenberg AD. Management of acquired nonmalignant tracheoesophageal fistula. Ann Thorac Surg 1991;52:759–765. 3. Shen KR, Allen MS, Cassivi SD, et al. Surgical management of acquired nonmalignant tracheoesophageal and bronchoesophageal fistulae. Ann Thorac Surg 2010;90:914–918. 4. Baisi A, Bonavina L, Narne S, Peracchia A. Benign tracheoesophageal fistulas: results of surgical therapy. Dis Esophagus 1999;12: 209–211. 5. Camargo JJ, Machuca TN, Camargo SM, Lobato VF, Medina CR. Surgical treatment of benign tracheoesophageal fistulas with tracheal resection
Laryngoscope 125: August 2015
1914
and oesophageal primary closure: is the muscle flap really necessary? Eur J Cardiothoracic Surgery 2010;37:576–580. 6. Altorjay A, Mucs M, Rull M, et al. Recurrent, nonmalignant tracheoesophageal fistulas and the need for surgical improvisation. Ann Thorac Surg 2010;89:1789–1796. 7. Blackmon SH, Santora R, Schwarz P, Barroso A, Dunkin BJ. Utility of removable esophageal covered self-expanding metal stents for leak and fistula management. Ann Thorac Surg 2010;89:931–936. 8. Eleftheriadis E, Kotzampassi K. Temporary stenting of acquired benign tracheoesophageal fistulas in critically ill ventilated patients. Surg Endosc 2005;19:811–815.
Tran et al.: T-Tube for Tracheoesophageal Fistula
