Congenital tracheo-oesophageal fistula

A.Prof Frank Gaillard et al.

Congenital tracheo-oesophageal fistula is a congenital pathological communication between the trachea and oesophagus.  

Tracheo-oesophageal fistula and oesophageal atresia have a combined incidence of approximately 1 in 3500 live births 1-3,5. There is only a minimal hereditary/genetic component with an incidence in twins and those with family history being only approximately 1% 5. There is no convincing gender or racial predilection 5.

Clinical presentation is similar for all types except for type E (H-type).

Antenatally polyhydramnios may be present due to inability to adequately swallow fluid, and it is found in up to 90% of cases 1, but is, unfortunately, a non-specific sign.

The diagnosis is usually made in the neonate, as they experience feeding difficulties and respiratory compromise due to repeated aspiration. In cases where oesophageal atresia is present (i.e. again, all but H-type), then attempted the passage of a nasogastric tube will not be successful. Only with H-type fistulae, which can be very small, and typically slant down from the trachea toward the oesophagus, may presentation be delayed, sometimes for many years 2.

In just over half of cases, there are other associated congenital abnormalities, including1-2,5:

The trachea is an out-budding from the ventral foregut, and tracheo-oesophageal fistulae represent incomplete/abnormal division. They are very closely related to oesophageal atresia, and represent a spectrum of disease. As such, the types of oesophageal atresia/tracheo-oesophageal fistula can be divided into 1-2:

  • proximal atresia with distal fistula: 85%
  • isolated oesophageal atresia: 8%
  • isolated fistula (H-type): 4%
  • double fistula with intervening atresia: 1%
  • proximal fistula with distal atresia: 1%

See: oesophageal atresia classification.

Demonstration of the nasogastric tube curled in the proximal oesophagus in a child where the passage of the tube has been unsuccessful is usually sufficient for diagnosis. The proximal oesophageal stump may be distended with air (types A and C).

The presence of air in the stomach and bowel in the setting of oesophageal atresia implies that there is a distal fistula.

Often the lungs demonstrate areas of consolidation/atelectasis due to recurrent aspiration. 

H-type fistulas can be difficult to diagnose and may require contrast swallow studies, looking for contrast passing into the tracheobronchial tree.

Barium is usually the contrast medium of choice, a non-ionic iodinated contrast medium can be used alternatively. Ionic iodinated contrast medium should not be used as they can cause chemical pneumonitis 6.  

Antenatal ultrasound may demonstrate polyhydramnios or even in some cases a distended proximal blind ending oesophagus 1.

In some instances, CT and virtual bronchoscopy may be of benefit in preoperative planning 4. This is especially the case in patients with long segment atresia who may require a staged operation.

Prior to surgical correction, bronchoscopy is frequently performed. In infants who are deemed unable to tolerate emergency repair, then a gastrostomy and sump drainage catheter may be performed to allow feeding and weight gain. Another reason for a delay is in patients who have a 'long-gap' atresia precluding primary anastomosis repair. In most cases, however, the defect is corrected immediately. 

Prognosis is often most affected by the presence of associated congenital anomalies. For example in one study (albeit from 1979) the mortality for infants with just oesophageal atresia / tracheo-oesophageal fistula was 23% vs 79% in those with associated cardiac anomalies 3.

In an older patient consider an 

 

Oesophageal pathology
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Article information

rID: 8292
Section: Pathology
Synonyms or Alternate Spellings:
  • Congenital tracheoesophageal fistula
  • Congenital tracheo-esophageal fistula
  • Congenital tracheo-oesophageal fistula

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Cases and figures

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    Tracheo-oesophage...
    Figure 1: diargram : commonest type
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    Case 1 : H-type
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    Tracheo-oesophage...
    Figure 2: diagram : relatively common type
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    TEF
    Case 2
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    Tracheo-oesophage...
    Figure 3: diagram : rare type
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    Tracheo-oesophage...
    Figure 4: diagram : rare type
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