What is the management of esophageal stricture with tracheoesophageal fistula?

Management of Esophageal Stricture with Tracheoesophageal Fistula

The management of esophageal stricture with tracheoesophageal fistula requires a multistep approach with temporary stent placement as the primary intervention for most patients, followed by surgical repair once the patient is weaned from mechanical ventilation. 1, 2

Initial Assessment and Stabilization

• Diagnostic evaluation:

  • Perform upper endoscopy with biopsy to confirm diagnosis and exclude malignancy 3
  • Use barium esophagram to assess stricture length, diameter, and complexity 3
  • Perform bronchoscopy to evaluate the fistula location and size 2

• Immediate interventions:

  • Place a tracheostomy tube with the cuff positioned distal to the fistula to minimize tracheobronchial soilage 2
  • Insert a gastrostomy tube to diminish reflux of gastric contents 2
  • Place a jejunostomy tube to ensure adequate nutrition 2

Management Algorithm

For Non-Malignant TEF (Post-intubation, Traumatic, or Congenital):

1. Initial management:

   • Postpone definitive surgical correction until the patient is weaned from mechanical ventilation 2
   • Maximize PPI therapy with twice-daily dosing to reduce inflammation 3

2. Surgical approach:

   • Use an anterior cervical collar incision for most post-intubation TEFs 2
   • Close the esophagus in two layers over a nasogastric tube 2
   • Buttress the repair with a pedicled strap muscle flap 2
   • For small tracheal defects, perform primary repair 2
   • For larger defects, perform tracheal resection and reconstruction 2
   • Aim for extubation at the completion of surgery 2

3. For anastomotic strictures following repair:

   • Consider using the "+" shaped incision technique for the proximal end of the atretic esophagus during primary repair to minimize stricture formation 4
   • Address gastroesophageal reflux aggressively, as it increases the risk of stricture formation (relative risk 2.29) 5

For Malignant TEF:

1. Palliative interventions:

   • Offer esophageal stenting as first-line therapy, particularly for patients with poor physiological condition 2
   • Consider expansile metallic stents which may be advantageous compared to standard plastic stents 6
   • The optimum duration of stent placement is usually between 4 and 8 weeks 1

2. Alternative approaches:

   • Consider esophageal bypass for patients who can tolerate a major operation 2
   • Consider radiation therapy and chemotherapy as adjunctive treatments 2

Management of Refractory Strictures

• Define a stricture as refractory when unable to maintain a luminal diameter ≥14 mm after five sequential dilatation sessions 1-2 weeks apart 1, 3

• Use fluoroscopic guidance during dilatation of refractory esophageal strictures 1

• Choose either bougie or balloon dilators based on the nature of the stricture (length, location, cause) 1

• Therapeutic options for refractory strictures:

  1. Intralesional steroid therapy:

     • Inject 0.5 mL aliquots of triamcinolone 40 mg/mL to all four quadrants of the stricture 1
     • Most effective for peptic strictures, less effective for anastomotic and caustic strictures 1

  2. Incisional therapy:

     • Consider for refractory Schatzki's rings and anastomotic strictures 1
     • Most effective for short strictures (<1.5 cm) 3

  3. Temporary stent placement:

     • Offer when previous methods have been unsuccessful 1, 3
     • Consider biodegradable stent placement to reduce the frequency of dilatation 1

  4. Self-bougienage:

     • Consider teaching selected, self-motivated patients with short proximal strictures 1, 3

  5. Surgical intervention:

     • Offer to patients who do not respond or are intolerant to other measures 1, 3

Complications and Prevention

• Perforation risk:

  • Higher in caustic strictures (0.4% to 32%) compared to standard benign esophageal stricture dilatation 1
  • Risk is lower when performed by experienced operators (approximately 4.5%) 1
  • Monitor for signs of perforation: persistent chest pain, fever, breathlessness, or tachycardia 3

• Prevention of stricture formation:

  • For endoscopic resection of extensive esophageal lesions, consider prophylactic steroid therapy 7
  • Oral and injectable steroid therapy can significantly reduce the number of required endoscopic balloon dilations 7

Follow-up

• Monitor patients for at least 2 hours post-procedure 3
• Perform regular endoscopic follow-up due to increased risk of esophageal carcinoma in certain stricture types 3
• For patients with caustic strictures, psychiatric evaluation is mandatory prior to hospital discharge 3

Remember that the management approach should prioritize minimizing tracheobronchial contamination and ensuring adequate nutrition while planning for definitive repair of the fistula.