Acquired tracheoesophageal fistula in critically ill patients

Acquired benign tracheoesophageal fistula (TEF) is an infrequent complicati on of prolonged intubation and tracheostomy. Not infrequently, it is associ ated with severe circumferential malacia of the trachea and a need for conc omitant correction of both. Controversy exists as to whether this should be performed in a single-stage or a 2-stage procedure. Four patients with acq uired TEF underwent operation in a tertiary referral medical center between 1995 and 1997. The operations were performed through either an anterior (3 ) or a lateral (1) neck approach. Three patients underwent closure of the f istula with tracheal resection and anastomosis in a single stage and are do ing well. One patient with complete subglottic stenosis underwent closure o f the: TEF and was planned for tracheal reconstruction in a second stage. T his: patient died in the early postoperative period. The complications incl uded aspiration of blood leading to pneumonia (2), spontaneously resolving pneumomediastinum (1), subcutaneous emphysema (2), and cardiac arrhythmia ( 1). Residual fistula, noted in 1 patient, was treated conservatively and re solved spontaneously within several weeks. We conclude that acquired TEF is amenable to repair through a cervical approach. A single-stage correction of the TEF with reconstruction of the trachea is suitable and successful in most patients. Several stages seem justified when concurrent laryngotrache al reconstruction is needed.