DOZ047.110: Recurrent tracheoesophageal fistula tracheoscopic chemocauterization with trichloroacetic acid

Abstract

Objective The aim of this study was to report the experience of two centers in the treatment of recurrent tracheoesophageal fistula (RTEF), by tracheoscopic chemocauterization with trichloroacetic acid (TCA). A surgical approach to RTEF has high morbidity and mortality. Some endoscopic techniques have been developed but nevertheless, optimal treatment is still not determined because of the low number of patients, short term of follow-up, and different techniques. Materials and Methods From January 2016 to March 2019, 12 patients with RTEF were selected for endoscopic management in two centers. Eleven had RTEF after primary repair of esophageal atresia/TEF and one had a second fistula with misdiagnosis, all of them by a thoracotomy approach. In all cases the diagnosis was confirmed by clinical evaluation, esophagram, and bronchoscopy. Under general anesthesia, a rigid pediatric bronchoscope with a 0° rod lens telescope telemonitoring was used to localize and refresh the fistula with a small endoscopy brush of 2–3 mm. Cotton soaked with 50% TCA was applied on the fistula for 30 seconds. The procedure had to be repeated two times. Results Fistulae were closed in 10 patients. The closure was confirmed by esophagram or bronchoscopy after 2 months of the procedure. It remains completely obliterated and the patients are asymptomatic. There were only two patients with progressive decrease in the diameter of the fistula; one patient died for some other medical reason and another patient is being treated. The mean number of procedures in each patient was 1.3, and the follow-up was 12 months on average (2–36). Two patients had bronchospasms as postoperative complication. Conclusion The tracheoscopic chemocauterization of RTEF with the use of 50% TCA is a minimally invasive, safe, and effective technique. It has fewer complications and avoids the morbidity of open surgery.

Endoscopic management of recurrent tracheoesophageal fistula with trichloroacetic acid in pediatric patients

“…We believe the optimal mean time between procedures should be one month, which is enough for healing and fibrosis formation at the chemically cauterized site, consistent with Sung's findings. Our results report greater effectiveness than Sung and Lara's (6,12) . It should also be mentioned that none of our patients had complications, and all procedures were managed on an outpatient basis, contrarily to what the aforementioned authors had previously described.…”

“…However, the endoscopic techniques combined have higher success rates (13) . Case publications by Sung in 2008 (11) , Lelonge in 2015 (6) , and Lara in 2019 (12) have reported better results with the endoscopic application of 50% topical trichloroacetic acid. Trichloroacetic acid is a strong acid used in chemical skin exfoliation.…”

“…In the last decade, various endoscopic techniques have been regarded as safe, but still with low success rates. Trichloroacetic acid application was described by Sung in 2008 (11) , Lelonge in 2015 (6) , and Lara in 2019 (12) . Even though it showed good results with 50% topical trichloroacetic acid for recurrent tracheoesophageal fistula closure, use and postoperative follow-up have not been standardized yet.…”

Endoscopic treatment of tracheoesophageal fistula

“…It provides de-epithelialization and fibrosis and leads to closure of the fistula (Figure 2A,B). Singhal et al reported successful chemocauterization with TCA in management of tracheoesophageal fistula for the (33) reported 100% success rate in three patients, 100% success rate in 14 patients (12 recurrent TEF and 2 H type TEF) and 83.3% success rate in 12 patients using TCA alone, respectively. Another point is that minimal morbidity is reported in these small series.…”

Manejo endoscópico de la fístula traqueoesofágica recurrente con la aplicación de ácido tricloroacético en el paciente pediátrico

“…Gdanietz y Krause describieron con éxito el primer tratamiento de la fístula traqueoesofágica recurrente, con adhesivos plásticos mediante abordaje endoscópico en 1975 (10) ; en la última década, existe una variedad de técnicas endoscópicas que pueden ser empleadas de manera segura pero aun con bajo porcentaje de éxito. La aplicación de ácido tricloroacético ha sido descrita por Sung en 2008 (11) , Lelonge en 2015 (6) y Lara en 2019 (12) , donde reportan buenos resultados mediante la aplicación de ácido tricloroacético al 50% en forma tópica para cierre de fístula traqueoesofágica recurrente; sin embargo, su uso y seguimiento postoperatorio aún no se encuentra estandarizado. Hasta la fecha, ningún procedimiento endoscópico ha sido aceptado como el estándar de oro debido a los resultados variables y al pequeño número de casos reportados.…”