Tracheoesophageal Fistula Cervical Ligation

Tracheoesophageal fistula cervical ligation

Cervical ligation of tracheoesophageal fistula is the ligation of the aberrant tracheoesophageal communication through a neck incision (cervical approach) and without thoracotomy. 

This method is most widely applied in:

• Isolated (H-type) TEF
• Repeat or chronic TEF following surgery.
• Cases in which thoracotomy is more dangerous.

Indications

Indications are as follows when ligation of the cervix is required:

• Fistula is found in the high part of the neck.
• Aspiratory pneumonia is recurrent.
• During feeds, the child has choking, coughing or cyanosis.
• Past thoracic repair is unsuccessful.
• Thoracic access is dangerous due to associated anomalies.

Cervical TEF ligation

Cervical tracheoesophageal fistula (TEF) ligation is surgery that is conducted using an incision on the neck (cervical) in order to seal an abnormal opening between the trachea and esophagus. It does not involve the opening of the chest as compared to selected cases of TEF, the most common of which is H-type TEF.

Cervical Approach Strengths

• Avoids thoracotomy
• Minimal lung manipulation
• Reduced postoperative pain
• Faster recovery
• Reduced possibility of pleural complications.
• Increased access to high fistulas.

H-type TEF cervical repair

H-type tracheoesophageal fistula is a non-esophageal atresia, congenital anomalous attachment between the trachea and the esophagus. Both the trachea and esophagus are continuous and there is a small fistulous passage between them, which offers an oblique running between them, making it look like an H. It represents between 4-5 percent of all TEF cases.

Why Cervical Repair?

The majority of cases of H-type TEF use a cervical (neck) approach since:

• The fistula is normally high.
• It offers a direct access to the tract.
• It does not need a thoracotomy or manipulation of the lungs.
• It enables quick recovery and less pulmonary complications.

TEF ligation cervical procedure

The procedure of TEF ligation of the cervix is described in detail and line by line:

Preoperative Preparation

Pivotal preoperative measures involve:

• Flexible bronchoscopy (gold standard of localization of fistulas)
• Contrast esophagogram
• Assessment of related birth deformities.
• Improvement of lung condition.
• Nil per oral and antibiotic prophylaxis.

Surgical Procedure:

Positioning

• The patient is lying supine and with the neck straightened, the shoulder roll is applied.

Cervical Incision

• Cut across a natural crease on the neck, most commonly on the right.

Exposure

• Platysma parted; the strap muscles parted and the tracheoesophageal groove was exposed.

Structures Identification

• Detection and protection of the trachea, esophagus and the RLN. 

Fistula Identification

• Fistulous tract is identified with either preoperative bronchoscopy/guidance or intraoperative catheterization.

Ligation and Division

• The TEF is cleaved, clamped and removed.

Separate Closure

• Fine absorbable tracheal opening sutures.
• Esophageal opening was closed separately.

Tissue Interposition

• Placing a muscle or fascial flap between trachea and esophagus to prevent recurrence.

Wound Closure

• Neck incision is closed in layers.

Operative time: 1–2 hours

Postoperative Care

• Nil by mouth initially
• Feeding via nasogastric/gastrostomy tube.
• Analgesics and antibiotics. 

Monitor for:

• Hoarseness or weak cry
• Respiratory distress
• Neck wound infection

Cervical TEF ligation recovery

An obvious, practical analysis of the postoperative treatment of Cervical TEF Ligation is as follows:

Recovery (First 24 to 48 hours) 

• Tight monitoring in the NICU or pediatric surgical ward. 

Continuous observation of:

• Breathing and oxygen levels
• Heart rate and temperature
• Proper analgesia palliative management.
• Nil by mouth (NPO) to safeguard the repair.
• Feeding through nasogastric or gastrostomy tube.
• Prescribed IV antibiotics.

Hospital Recovery (Days 3–7)

• Levelling-off decrease in oxygen provision as necessary.

Careful monitoring for:

• Hoarseness or weak cry (recurrent laryngeal nerve function)
• Wound redness or swelling of neck.
• The patient has coughing or breathlessness.
• Indicated chest physiotherapy.
• Contrast swallow test typically performed in the postop day 5-7 to identify leakages.

Resumption of Feeding

• The oral feeds are commenced once there is no leakage as seen by imaging.
• Introduction of feeds is slow and gradual.
• There could be some initial coughing related to feeds, which tends to eliminate.
• There are infants who might require thick feeds in the meantime.

Discharge and Home Care

• Majority of children are released in 7-10 days.

At home:

• Watch the neck incision to be clean and dry.

Observe for:

• Fever
• Wound erythema or discharge.
• Continuous coughing at the time of feeding.
• Breathing difficulty
• Continue prescribed drug therapy.
• Obey feeding instructions.

H-type fistula cervical ligation complications

H-type TEF cervical ligation is considered to be safe and very successful, yet as in any other surgical procedure, there are certain possible risks involved. The majority of complications are unusual when used by advanced pediatric surgeons.

Complications in the Early Period

• Recurrent Laryngeal Nerve Injury
• Respiratory Complications 
• Anastomotic Leak
• Neck Wound Complications

Intermediate Complications

• Persistent Aspiration
• Esophageal or Tracheal Stricture (Rare)

Late Complications

• Recurrent TEF
• Tracheomalacia
• Feeding Difficulties

Best hospital for cervical TEF ligation India

• Artemis Hospital, Gurgaon
• Medanta-The Medicity, Gurgaon
• Fortis Memorial Research Institute, Gurgaon
• Max Hospital, Saket

Conclusion

H-type tracheoesophageal fistula can be successfully treated through cervical ligation which is safe, effective and well-established with great success rates. In cases where the fistula is carefully identified and neatly surgically bound with the cervical approach, the majority of children recover quickly, have few complications, and show desirable long-term feeding and respiratory results. Even though complications like transient hoarseness, aspersion, or fistula recurrence may be present, they are not common and are usually treatable, mostly in experienced centers. Close postoperative follow-ups and regular follow-ups will assist in the detection and management of any complications at an early stage. All in all, H-type TEF cervical ligation has a good prognosis with most of the patients able to grow well, feed well and lead a good life.

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FAQ

What is the rationale behind using the cervical (neck) approach when using H-type TEF?

• High-lying fistulas are found to be most prevalent in the H-type. Cervical approach is direct approach, does not involve opening of chest, minimizes complications in the lungs, and gives quicker recovery.

What is the age at which a cervical ligation is done?

• It may be done to children in newborn, infancy, or even among older children when they are diagnosed with it and they are also medically stable.

What is the method of diagnosing the fistula prior to surgery?

• The gold standard is the flexible bronchoscopy. Esophagoscopy and contrast esophagogram can also be applied.

Will there be scar?

• The cut is made on a natural crease of the neck and thus scarring is not very much.

Does fistula reoccur following cervical ligation?

• Recurrence is rare (about 2–5%). Interposition of the tissues during surgery aids in alleviating this risk.