Cardiothoracic Surgery: Student/Resident Case Report Poster - Cardiac and Thoracic Surgery |

Congenital Tracheo-Esophageal Fistula Repaired 31 Years Later FREE TO VIEW

Simran Randhawa, MD; Alisan Fathalizadeh, MD; Nimisha Parikh; Doraid Jarrar, MD; Thomas Kennedy, MD
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Einstein Healthcare Network, Philadelphia, PA

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):54A. doi:10.1016/j.chest.2016.08.061
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SESSION TITLE: Student/Resident Case Report Poster - Cardiac and Thoracic Surgery

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM

INTRODUCTION: Congenital esophageal atresia and/or tracheoesophageal fistula occur in 1 in 4,500 births, and may cause multiple complications, even when repaired early in life. Delayed diagnosis is rare, especially in the adult, but usually presents with worsening pulmonary symptons such as recurrent pneumonia, aspiration, tracheomalacia and asthma.

CASE PRESENTATION: We present the case of a 31 year old adult who initially presented with fever and hemoptysis and only upon further questioning, reported a past history of congenital H-type TEF, with dysphagia, regurgitation and recurrent bouts of pneumonia. Due to lack of medical coverage in his native country, he was never evaluated for possible repair. He was working as a landscaper with no apparent limitations except occasional symptoms as mentioned before. Physical exam should clubbing with absent breath sounds on the left side. Diagnostic work up including upper endoscopic, esophageal manometry, bronchoscopy and computed tomography of the chest and abdomen was done to determine its anatomy. Patient’s left lung almost completely destroyed from chronic aspiration. He underwent TEF excision and repair via a right postero-lateral thoracotomy using intercostal muscle to buttress the repair. The fistula was about 2 by 2 mm and abut 24 cm from the incisors. Intra-operatively, he would not tolerated single left lung ventilation and surgery was performed with low tidal volumes of the right lung. Post-operative course uneventful with patient tolerating solid food and no aspiration on evaluation by the speech and swallow therapist. At 12 month follow up, patient denied any recurrence of symptoms and clubbing had improved.

DISCUSSION: Congenital TEF with delayed repair in adulthood is rare with less than 50 cases reported. Classic signs and symptoms include a triad of paroxysmal choking and cough, gastrointestinal distention and recurrent aspiration pneumonia. Delay in repair could be for multiple reasons and in our case, for lack of medical coverage. The patient had accomodated his eating habits and was a landscaper. Once identified, the approach should be primary repair with coverage with a muscle flap. There is no role for stenting in this benign condition. Point of contention is what to do with the destroyed left lung since it could serve as a persistent nidus for infection and possible contamination of the right lung.

CONCLUSIONS: Delayed repair of congenital fistulas is uncommon, but has been reported in the literature. Regardless, of the etiology, tenents of repair are the same with interposition of healthy tissue, i.e., a muscle flap being a fundamental principle. Because of the chronicity of aspiration, significant pulmonary damage is common and may need to be addressed after the repair.

Reference #1: Thomas Kovesi and Steven Rubin. Long-term Complications of Congenital Esophageal Atresia and /or Tracheoesophageal Fistula. CHEST 2004:126:915-925.

DISCLOSURE: The following authors have nothing to disclose: Simran Randhawa, Alisan Fathalizadeh, Nimisha Parikh, Doraid Jarrar, Thomas Kennedy

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