Publish in this journal
Journal Information
Vol. 51. Issue 1.
Pages 49-50 (January 2015)
Vol. 51. Issue 1.
Pages 49-50 (January 2015)
Letter to the Editor
DOI: 10.1016/j.arbr.2014.11.015
Full text access
Recurrent Tracheoesophageal Fistula in Children With Repaired Esophageal Atresia and the Usefulness of Flexible Bronchoscopy
Fístula traqueoesofágica recurrente en niños con atresia esofágica reparada y utilidad de la broncoscopia flexible
Visits
4515
Antonios Platnarisa, Dimitra Lianoub, Athanasios G. Kaditisa,
Corresponding author
kaditia@hotmail.com

Corresponding author.
a Pediatric Pulmonology Unit, First University Department of Pediatrics, University of Athens School of Medicine and Aghia Sophia Children's Hospital, Atenas, Greece
b First Department of Pediatrics, National Health System, Aghia Sophia Children's Hospital, Atenas, Greece
This item has received
4515
Visits
Article information
Full Text
Bibliography
Download PDF
Statistics
Figures (2)
Additional material (2)
Full Text
To the Editor:

Diagnosing recurrent tracheoesophageal fistula (TEF) in a child with congenital esophageal atresia repair during the neonatal period who has recurrent or persistent respiratory symptoms is a real challenge, since medium leakage in the gastrointestinal tract may be missed on standard contrast studies.1,2 We present a case that illustrates the importance of high-pressure administration of contrast medium in the esophagus via a catheter, for visualization of recurrent TEF, and the additional utility of flexible bronchoscopy for diagnosis.

A 3 ½-year-old boy was evaluated for recurrent lower respiratory tract infections. He had a history of congenital esophageal atresia with distal TEF repair in the neonatal period. At the age of 2 ½ years, the child was hospitalized for complicated pneumonia with pneumothorax and pneumomediastinum, requiring admission to the intensive care unit and chest tube placement. Chest CT showed diffuse ground glass opacities and areas of atelectasis in both lungs. In view of the seriousness of the clinical signs, recurrent TEP was considered in the differential diagnosis. The patient had a history of anastomotic leakage, a known risk factor for fistula recurrence,3 yet there were no signs of contrast medium leak or esophageal stenosis in the gastroduodenal tract.

Nonetheless, the patient was admitted on 4 occasions in the following year for fever, cough and shortness of breath. Evaluation by a pediatric pulmonologist was requested by the attending physician. Chest auscultation revealed crepitations and wheezing. Chest X-rays showed areas of atelectasis in both lungs and mild gastroesophageal reflux was detected on pH-metry. The most important finding on flexible bronchoscopy was a pouch in the posterior tracheal wall, with air bubbling during bag valve mask ventilation administered by the anesthesiologist, suggesting a communication between the esophagus and the pouch (Fig. 1 and Supplementary video 1). Lipid-laden macrophages were found in bronchoalveolar lavage (BAL) fluid and Pseudomonas aeruginosa was isolated from BAL culture. Both of these data suggest chronic aspiration and lower respiratory tract infection. Since no diagnostic procedures had been performed in the gastroduodenal tract, contrast medium was injected via a catheter into the esophagus, confirming concurrent TEF (Fig. 1 and Supplementary video 2).2

Fig. 1.

(A) A tracheal pouch in the posterior tracheal wall was observed using flexible bronchoscopy (white arrow), near the carina. (B) Air bubbling was then seen during bag valve mask ventilation administered by the anesthesiologist, suggesting a communication between the esophagus and the pouch.

(0.07MB).

Approximately 50% of children with history of esophageal atresia and TEF repair have recurrent or persistent respiratory symptoms due to bronchial hyperreactivity, tracheomalacia or aspiration due to esophageal dyskinesia, esophageal stenosis, gastroesophageal reflux or relapse of repaired TEF (in up to 10% of cases of esophageal atresia).3–5 Recurrence of the fistula in the gastrointestinal tract may be difficult to identify, so injection of contrast medium in the esophagus is the next diagnostic step.2 Under cinefluoroscopic guidance and with the patient prone, contrast medium is injected under pressure via a nasogastric tube placed in the stomach that is slowly withdrawn to the esophagus.

The identification of lipid-laden macrophages in the cytological examination of BAL fluid obtained by flexible bronchoscopy is a sign that aspiration may have occurred. Intubation of the fistula with the bronchoscope or injection of methylene blue with esophagoscopy are additional methods that can provide important information for the diagnosis of recurrent TEF.2

Conflict of Interest

None of the authors has any conflict of interests to declare.

Appendix A
Supplementary data

The following are the supplementary data to this article:

(24.82MB)
(0.81MB)

References
[1]
D.R. Lal, K.T. Oldham.
Recurrent tracheoesophageal fistula.
Eur J Pediatr Surg, 23 (2013), pp. 214-218
[2]
A.G. Coran.
Redo esophageal surgery: the diagnosis and management of recurrent tracheoesophageal fistula.
Pediatr Surg Int, 29 (2013), pp. 995-999
[3]
T. Kovesi, S. Rubin.
Long-term complications of congenital esophageal atresia and/or tracheoesophageal fistula.
Chest, 126 (2004), pp. 915-925
[4]
R.E. Delius, M.J. Wheatley, A.G. Coran.
Etiology and management of respiratory complications after repair of esophageal atresia with tracheoesophageal fistula.
Surgery, 112 (1992), pp. 527-532
[5]
K. Malmstrom, J. Lohi, H. Lindahl, A. Pelkonen, M. Kajosaari, S. Sarna, et al.
Longitudinal follow-up of bronchial inflammation, respiratory symptoms, and pulmonary function in adolescents after repair of esophageal atresia with tracheoesophageal fistula.
J Pediatr, 153 (2008), pp. 396-401

Please cite this article as: Platnaris A, Lianou D, Kaditis AG. Fístula traqueoesofágica recurrente en niños con atresia esofágica reparada y utilidad de la broncoscopia flexible. Arch Bronconeumol. 2015;51:49–50.

Copyright © 2013. SEPAR
Idiomas
Archivos de Bronconeumología (English Edition)

Subscribe to our newsletter

Article options
Tools
Supplemental materials
es en

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?

es en
Política de cookies Cookies policy
Utilizamos cookies propias y de terceros para mejorar nuestros servicios y mostrarle publicidad relacionada con sus preferencias mediante el análisis de sus hábitos de navegación. Si continua navegando, consideramos que acepta su uso. Puede cambiar la configuración u obtener más información aquí. To improve our services and products, we use "cookies" (own or third parties authorized) to show advertising related to client preferences through the analyses of navigation customer behavior. Continuing navigation will be considered as acceptance of this use. You can change the settings or obtain more information by clicking here.