Tracheoesophageal fistula repair

Sonali1*, Deepapriya.R2, Dhariniya3, Ruby Ravichandran4

1Staff Nurse, OT, Maa Kauvery, Trichy, Tamil Nadu

2Incharge, OT, Maa Kauvery, Trichy, Tamil Nadu

3Nursing Educator, Maa Kauvery, Trichy, Tamil Nadu

4Senior Deputy Nursing Superintendent, Maa Kauvery, Trichy, Tamil Nadu

*Correspondence

Abstract

Tracheoesophageal fistula (TEF) is a congenital anomaly involving abnormal communication between the trachea and esophagus, often associated with esophageal atresia, leading to significant respiratory and feeding difficulties. This case report describes a 2-year-old female child presenting with recurrent symptoms suggestive of TEF, including choking, cyanosis during feeding, and recurrent respiratory infections. Clinical evaluation, laboratory investigations, and surgical findings confirm recurrent tracheoesophageal fistula. The patient underwent successful surgical repair followed by intensive postoperative and nursing care. Early diagnosis, timely surgical intervention, and comprehensive postoperative management contributed to a favorable outcome. This case highlights the importance of prompt recognition and multidisciplinary care in improving prognosis in TEF patients.

Key words: Tracheoesophageal fistula (TEF); Trachea; Esophagus

Introduction

Tracheoesophageal fistula is a life-threatening congenital anomaly caused by failure of separation of the foregut into respiratory and digestive tracts during early embryonic development, typically between the 4th and 6th week of gestation. It commonly occurs with esophageal atresia and presents shortly after birth with feeding difficulties and respiratory distress. Infants often exhibit excessive salivation, choking, coughing, cyanosis during feeding, and recurrent aspiration leading to pneumonia. TEF is frequently associated with other congenital anomalies such as those seen in VACTERAL association. Advances in neonatal intensive care, anesthesia, and pediatric surgery have significantly improved survival rates, making early diagnosis and timely intervention crucial.

History

The patient, Baby Nandika B, a 2-year-old female child, presented with complaints of excessive salivation, frothing from the mouth and nose, choking, coughing, and cyanosis during feeding. There was also difficulty in feeding and swallowing along with respiratory distress. Past history revealed recurrent lower respiratory tract infections, although developmental milestones were normal. The recurrent nature of symptoms raised suspicion of a persistent or recurrent tracheoesophageal fistula.

Clinical findings

On clinical examination, the child showed regurgitation of feeds soon after feeding, excessive salivation, and frothing from the mouth and nose. Episodes of choking, coughing, and cyanosis were particularly noted during feeding. The child had poor feeding habits and signs of failure to thrive. Abdominal distension was present, and respiratory examination revealed bilateral crepitation’s and wheeze, indicating possible aspiration-related lung involvement.

Investigations and results

Laboratory and diagnostic investigations were performed to assess the condition. Microbiological examination of bronchial wash showed no significant growth. C-reactive protein was elevated to 74.715 mg/L, indicating inflammation. Screening for HIV, HBsAg, and HCV was non-reactive. Blood group was B positive. Hemoglobin was low at 8.2 g/dL, suggesting anemia, and platelet count was elevated at 6,03,000 cells/µL. Electrolyte levels were within normal limits, with sodium at 136 mmol/L and potassium at 4.3 mmol/L. INR was normal at 1.0. These findings supported the presence of inflammation and recurrent respiratory involvement without coagulopathy or major electrolyte imbalance.

Diagnosis

Based on clinical presentation, history of recurrent symptoms, and investigative findings like Endoscopy, Bronchoscopy, X-ray the diagnosis of recurrent tracheoesophageal fistula was established. The presence of feeding difficulties, aspiration symptoms, and recurrent respiratory infections strongly supported this diagnosis.

Fig (1): X – Ray

Management

The patient underwent surgical repair of the tracheoesophageal fistula on 25/08/2025 under general anesthesia. Intraoperative findings included doubtful recurrence of fistula and diffuse airway inflammation due to chronic aspiration. The child was positioned in the right lateral decubitus position. Surgical steps included identification of anatomical structures with preservation of the azygos vein, careful dissection of the fistula from the trachea, ligation and division of the fistulous tract, and closure of the tracheal defect using fine absorbable sutures.

The upper and lower esophageal segments were mobilized with preservation of blood supply, followed by end-to-end esophageal anastomosis. Hemostasis was ensured, a chest drain was placed, and the wound was closed in layers. Postoperative management in the NICU included airway maintenance, continuous monitoring of oxygen saturation, heart rate, and respiratory status, and positioning with head elevation to 30 degrees. Intravenous fluids were administered, and parameters such as electrolytes, urine output, and blood glucose were monitored. Analgesics like fentanyl and paracetamol were given. Enteral feeding via tube was initiated after confirming absence of anastomotic leak.

Outcome

The patient showed gradual improvement following surgery with stabilization of respiratory status and resolution of feeding difficulties. There were no immediate postoperative complications such as anastomotic leak or severe respiratory distress. The child responded well to supportive care and medications, indicating a successful surgical outcome.

Discharge

Prior to discharge, the child was stable with adequate feeding tolerance and improved respiratory function. Parents were educated regarding feeding techniques, importance of follow-up, and early recognition of complications such as recurrent fistula, anastomotic stricture, gastroesophageal reflux, and respiratory infections. Instructions were given on maintaining hygiene, ensuring proper nutrition, and adherence to medications.

Discussion

Tracheoesophageal fistula is a serious congenital anomaly that results in significant morbidity due to aspiration of saliva, milk, and gastric contents into the lungs. The most common type is esophageal atresia with distal TEF (Type C), accounting for approximately 85% of cases. Recurrent TEF, though less common, presents diagnostic and management challenges. Clinical features such as choking, coughing, cyanosis during feeding, and recurrent respiratory infections are key indicators.

Early diagnosis is critical to prevent complications like aspiration pneumonia and failure to thrive. Surgical repair remains the definitive treatment, and meticulous technique is essential to prevent recurrence. Postoperative care plays a vital role in recovery, with emphasis on airway management, nutrition, infection prevention, and monitoring for complications. Long-term follow-up is necessary to detect issues such as strictures, gastroesophageal reflux, and recurrent respiratory problems.

Conclusion

Tracheoesophageal fistula is a life-threatening congenital condition requiring early recognition and prompt surgical management. This case demonstrates that with timely intervention, appropriate surgical technique, and comprehensive preoperative and postoperative care, favorable outcomes can be achieved. Advances in neonatal and pediatric care have significantly improved survival rates; however, long-term follow-up remains essential to ensure optimal growth, development, and quality of life in affected children.

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