KTP laser: An important tool in refractory recurrent tracheo-esophageal fistula in children

doi:10.1016/j.ijporl.2009.12.009

International Journal of Pediatric Otorhinolaryngology

Volume 74, Issue 3, March 2010, Pages 326-327

https://doi.org/10.1016/j.ijporl.2009.12.009 Get rights and content

Abstract

Secondary tracheo-oesophageal fistula in delayed primary repair of oesophageal atresia is rare. This paper reports the successful use of the KTP laser in the treatment of this condition in a refractory case. It also recommends the use of direct laryngotracheobronchoscopy (DLTB) in the diagnosis. We recommend the use of this laser in cases of recurrent tracheo-esophageal fistula especially when other means have failed.

Introduction

Several methods exist in the treatment of recurrent tracheo-esophageal fistula following repair of oesophageal atresia. These range from electrocautery and application of glue to the use of carbon dioxide and Nd.YAG lasers. The potassium titanyl phosphate (KTP) laser has recently been added to the armamentarium of the pediatric otorhinolaryngologist. The experience of KTP laser in this condition is very limited with only one case report so far in the literature. In this paper, we show that the KTP laser was successful in the management of recurrent tracheo-esophageal fistula where other traditional methods failed. It thus adds to the growing experience in the use of this technique.

Section snippets

Case report

A 3490 g term male neonate with antenatal diagnosis of oesophageal atresia was born by emergency caesarean section for foetal distress and transferred to our institution. An X-ray film demonstrated a feeding tube coiled in the upper oesophageal pouch and air was present in the stomach. The diagnosis of oesophageal atresia was confirmed. The neonate was initially anaesthetised with a technique involving spontaneous ventilation via a nasopharyngeal airway, which facilitated examination of the

Discussion

DLTB is the method of choice for identifying TOF and any other tracheal anomalies prior to attempts at repair of TOF [1]. Upper pouch injuries are not uncommon and can be due to oesophageal tube passage [2], [3], operative dissection or even attempts at endotracheal intubation [4]. The fibrosis seen around the upper pouch may have been indicative of healing of the oesophageal injury seen at the first operation. The subsequent new fistula was likely as a consequence of the inflammatory reaction

Conclusion

The KTP laser is a useful and safe tool in pediatric otorhinolarngology practice and can be used either primarily or when other traditional methods have failed.

References (11)

V.M. Wright et al.
A complication of continuous upper pouch suction in oesophageal atresia
J. Pediatric Surg.
(1978)
C. Gutierrez San Roman et al.
Long-term assessment of the treatment of recurrent tracheoesophageal fistula with fibrin glue associated with diathermy
J. Pediatr. Surg.
(2006)
N.E. Wiseman
Endoscopic closure of recurrent tracheoesophageal fistula using Tisseel
J. Pediatr. Surg.
(1995)
K.T. Tzifa et al.
Endoscopic treatment of congenital H-Type and recurrent tracheoesophageal fistula with electrocautery and histoacryl glue
Int. J. Pediatr. Otorhinolaryngol.
(2006)
S.L. Ishman et al.
The KTP laser: an emerging tool in pediatric otolaryngology
Int. J. Pediatr. Otorhinolaryngol.
(2006)

There are more references available in the full text version of this article.

Cited by (16)

Endoscopic closure of recurrent tracheoesophageal fistula using argon plasma coagulation: A case report
2023, Journal of Pediatric Surgery Case Reports
Recurrent tracheoesophageal fistula (RTEF) after surgical repair of esophageal atresia remains a serious complication. Open surgical repair for RTEF is associated with high levels of postoperative morbidity, mortality and repeat recurrence. Although endoscopic management has been expected to be an alternative to re-surgery, the optimal endoscopic management of RTEF remains to be determined. This report describes a successful experience of argon plasma coagulation (APC) for the closure of an intractable RTEF.
A newborn male diagnosed as having esophageal atresia with tracheoesophageal fistula (TEF) underwent a primary surgical repair. At 17 months of age, an oral contrast study showed the recurrence of the TEF, and subsequently he underwent a second open surgery. However, a postoperative esophagogram revealed a second recurrence of the TEF. Then, endoscopic treatment options were considered and APC was employed to coagulate the fistula epithelium. At 31 months of age, APC followed by fibrin glue application was performed. By this procedure the RTEF could be occluded safely and successfully without any complications.
APC is a simple, safe and effective procedure, and is therefore worth trying as a first attempt for the treatment of RTEF.
Endoscopic treatment in pediatric patients with recurrent and H-type tracheoesophageal fistulas – A systematic review and meta-analysis
2023, International Journal of Pediatric Otorhinolaryngology
Endoscopic treatments for managing recurrent tracheoesophageal fistula (rTEF) and H-type TEF are being utilized lately; however, the preferred technique is yet to be determined. We aimed to systematically review existing publications on endoscopic treatment of rTEF and H-type TEF to analyze their success and complication rates.
PRISMA guidelines were followed. MEDLINE, EMBASE, CINAHL and the Cochrane Central Register of Controlled Trials were comprehensively searched in accordance to a priori developed protocol, from 1975 until 2020. English, Spanish and German papers were included. Studies were independently screened and analyzed by two reviewers.
84 full texts were assessed for eligibility out of 581 screened studies, of these, 39 studies with 127 patients were eligible for inclusion (115 rTEF and 12 H-type TEF). All included studies were cases reports or case series. Overall success rate was 45% with sealant injection, 87% with de-epithelialization and 80% with sealant injection and de-epithelialization combined. The mean number of required treatments for success was 1.9 (range 1–6). Mixed effect model meta-analysis of case series with n > 1 showed that sealant injection had a significantly lower success rate of 50% (95% CI 1–99%, I² 72%) compared to de-epithelialization 90% (95% CI 72–99%, I² 27%), p = 0.007 and the combination of both techniques 87% (95% CI 68–99%, I² 11%), p = 0.02. Nine patients (7%) had transient respiratory distress. No mortalities reported.
Endoscopic treatment for rTEF and H-type fistula is a minimally invasive technique with favorable outcome and considerably less morbidity compared to open surgery, suggesting it as a safe and effective first line treatment option. Repeated endoscopic treatment attempts can be expected to obtain complete closure. De-epithelization techniques with or without combined tissue adhesive injection had significantly better results than sealant injection techniques alone.
Thulium LASER for endoscopic closure of tracheoesophageal fistula in esophageal atresia's spectrum: An appropriate tool?
2021, Journal of Pediatric Surgery
Citation Excerpt :
In a systematic review, Aworanti et al. also reported three cases of significant morbidity after endoscopic procedure (respiratory distress) [2]. Operative and anesthetic risks and a poor success rate associated with repeated procedures raises the question of the maximum number of endoscopic procedures that could reasonably be performed before open surgery is decided [8,10]. Especially since we had a major complication, we were reluctant to perform multiples procedures.
To report our experience with endoscopic Thulium LASER for treatment of recurrent TEF after EA surgery, and for H-Type fistulas.
A retrospective chart review of consecutive patients undergoing standardized endoscopic closure as first line therapy of recurrent tracheoesophageal fistula (RTEF) and H-type fistula using Thulium LASER, from 2013 to 2019, in a pediatric tertiary care center. Control endoscopic procedure was systematically performed. If persistence of the TEF was noted an external approach was performed. Patient demographics, medical history, symptoms, TEF type, treatment modalities, complications and outcomes were collected.
Eleven patients with tracheoesophageal fistula were included: six RTEF after primary repair of esophageal atresia and five H-type fistulas. The average age at endoscopic treatment was 19 months (SD 23 months, range 13 days–63 months). Closure of the fistula after single endoscopic procedure with Thulium LASER was obtained in 3 RTEF (50%) and 1 H-type fistula (20%). Six patients with failure of endoscopic treatment were cured after a single external procedure without any complications. One child, treated for H-type fistula, presented a severe complication of Thulium LASER treatment. Median follow-up after last repair was 24 months (range: 14–72 months). All fistulas were successfully treated.
In H-Type fistula, success rate of Thulium LASER is only 20% and thus should not be used. In contrast, in RTEF, success rate of 50% is achieved, avoiding as many open procedures, and Thulium LASER could be considered as first line treatment. In any case, open surgery is safe and efficient and can be considered as a first-line treatment for H-type fistulas, and as a salvage treatment for endoscopic treatment failures.
Level IV.
Pediatric Interventional Pulmonology
2018, Clinics in Chest Medicine
Citation Excerpt :
Infrequently, the laser is useful for dislodging foreign bodies deeply seated into large and vascular granulomas.49,56,66 Other potential indications include tracheal pouches and cysts,67 recurrent tracheoesophageal fistula,68,69 airway angiomas,70–72 tracheal papillomatosis (Fig. 9),57,59,73,74 endobronchial tuberculosis,36,56 and various types of tumors.75–80 Cartilage resection is also possible and has been described in CTS37,38,81 and tracheostomy-induced cartilage prolapse.57,65
Endoscopic esophageal and tracheal cauterization for closure of recurrent tracheoesophageal fistula: A case report and review of the literature
2017, International Journal of Pediatric Otorhinolaryngology
Recurrent tracheoesophageal fistula (TEF) can be a diagnostic and therapeutic challenge. Traditional treatment is thoracotomy, which carries significant morbidity and technical difficulty especially in a previously operated field. Recently, endoscopic techniques have been advocated as a primary approach for treatment of recurrent TEF prior to open repair. This case report describes the endoscopic technique used to address a recurrent TEF. The existing literature of all reported endoscopic cauterization methods is reviewed.
An 8 month old with proximal esophageal atresia and distal TEF underwent endoscopic closure of a recurrent TEF. The fistula was approached endotracheally utilizing Bugbee electrocautery (EC) and endoluminally through the esophagus using argon plasma coagulator and placement of porcine submucosa graft into the tract. Current literature review is presented with a synthesis of data on cases utilizing endoscopically applied EC and the combined results of this closure technique.
Our patient has maintained successful closure after a single treatment confirmed on follow up endoscopy 6 months post repair. Including this patient, there have been 30 patients with recurrent TEF treated utilizing endoscopic EC reported in the literature. The overall success rate is 78.8% with a mean of 1.88 procedures per successful closure. Comparing EC alone to EC combined with tissue glues or laser, success rates are 67% and 86% respectively.
Endoscopic repair of recurrent TEF has proven to be safe and effective in the literature as an alternative to a second thoracotomy/open surgical repair. EC combined with tissue glues or laser is more effective than EC alone based on available data.
Recurrent tracheoesophageal fistula in type III esophageal atresia: Diagnosis and treatment are not easy
2014, Archives de Pediatrie
La reperméation de fistule œso-trachéale (FOT) est une complication secondaire possible de l’atrésie de l’œsophage (AO) opérée observée dans environ 10 % des cas. À partir d’une cohorte de 67 enfants opérés d’une AO de type III entre 1998 et 2009, nous avons voulu préciser le nombre d’enfants ayant présenté une reperméation de FOT, les facteurs de risque de reperméation et les traitements entrepris. Le sex-ratio était de 1,7. La cure chirurgicale initiale avait eu lieu entre 4 et 36 heures de vie. Cinq enfants (7,5 %) avaient présenté une récidive fistulaire, la plupart dans les 3 premiers mois de vie, se révélant par des symptômes respiratoires rythmés ou non par l’alimentation. Cette reperméation était plus fréquente en cas de fuite anastomotique (p = 0,09) ou de pneumothorax (p < 0,01) postopératoire. Le diagnostic avait été posé 4 fois sur 5 par endoscopie trachéo-bronchique avec test au bleu de méthylène. Le traitement avait été chirurgical pour 4 enfants, avec 3 complications postopératoires. Un enfant avait bénéficié de la pose endoscopique d’un clip sur le versant œsophagien. Avec un recul médian de 52 mois après traitement, aucune FOT ne s’était de nouveau reperméabilisée. La reperméation de FOT semble liée à certaines caractéristiques postopératoires. Son diagnostic n’est pas aisé et son traitement mal codifié. Il faut évaluer les alternatives à une reprise chirurgicale qui pourraient peut-être diminuer à l’avenir la morbidité.
Recurrent tracheoesophageal fistula (TEF) is possible after repair of congenital esophageal atresia. The frequency of recurrent TEF is observed in about 10% of the cases. Within a cohort of 67 children with type III esophageal atresia repaired between 1998 and 2009, we aimed to identify the number of children with recurrent TEF, the risk factors for this condition, and the treatment proposed. The sex ratio was 1.7. Surgery was performed between 4 and 36 hours of life. Five children (7.5%) had a recurrent TEF, usually during the first 3 months, revealed by respiratory symptoms related to feeding in some cases. We noted that recurrent TEF was more frequent with anastomotic leakage (P = 0.09) or postsurgical pneumothorax (P < 0.01). The diagnosis was made in four cases out of five by a methylene blue test performed during a tracheobronchial endoscopy. Surgical treatment was noted in four children, with three postsurgical secondary effects. One child was treated by endoscopy and an esophageal clip. With a median follow-up of 52 months, no recurrence was noted. The recurrence of TEF may be linked to postsurgical events. Diagnosis is not easy and treatment is not clearly codified. Endoscopic treatment may be an advantageous option to surgery, likely with less morbidity.

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Case reportKTP laser: An important tool in refractory recurrent tracheo-esophageal fistula in children

Abstract

Introduction

Section snippets

Case report

Discussion

Conclusion

J. Pediatric Surg.

J. Pediatr. Surg.

J. Pediatr. Surg.

Int. J. Pediatr. Otorhinolaryngol.

Int. J. Pediatr. Otorhinolaryngol.

Case report
KTP laser: An important tool in refractory recurrent tracheo-esophageal fistula in children