International Journal of Pediatric Otorhinolaryngology 74 (2010) 326–327
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Case report
KTP laser: An important tool in refractory recurrent tracheo-esophageal fistula in children George Rakoczy a,*, Bazil Brown a, Dave Barman b, Tanya Howell b, A. Shabani c, Basem Khalil a, Z. Sheehan d a
Department of Paediatric Surgery, Royal Manchester Children’s Hospital, Manchester, UK Department of Anaesthesia, Royal Manchester Children’s Hospital, Manchester, UK Department of Radiology, Royal Manchester Children’s Hospital, Manchester, UK d Department of Otorhinolaryngology, Royal Manchester Children’s Hospital, Manchester, UK b c
A R T I C L E I N F O
A B S T R A C T
Article history: Received 1 November 2009 Received in revised form 14 December 2009 Accepted 15 December 2009 Available online 8 January 2010
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. ß 2010 Elsevier Ireland Ltd. All rights reserved.
Keywords: Oesophageal atresia Laryngotracheobronchoscopy TOF KTP laser
1. Introduction Several methods exist in the treatment of recurrent tracheoesophageal 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. 2. 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
* Corresponding author. E-mail address:
[email protected] (G. Rakoczy). 0165-5876/$ – see front matter ß 2010 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijporl.2009.12.009
oesophageal atresia was confirmed. The neonate was initially anaesthetised with a technique involving spontaneous ventilation via a nasopharyngeal airway, which facilitated examination of the entire trachea. On DLTB the presence of a distal TOF opening just proximal to the bifurcation of the trachea in the midline was confirmed. Through an extra-pleural thoracotomy, the distal TOF was ligated with 4/0 Prolene and divided. The upper oesophageal pouch was located in the neck rather than in the mediastinum. No attempts were made to mobilise it as it was very short, underdeveloped, fragile and quite oedematous. Although the distal oesophageal segment seemed of an appropriate length for primary anastomosis it was deemed inappropriate to proceed because of the poor state of the upper pouch. The lower pouch was therefore closed and attached to the lateral chest wall at the level of the fourth intercostal space, away from the tracheal stump. There was no tracheal injury during the procedure and the tracheal stump was watertight on testing. A Stamm gastrostomy was inserted for feeding. Postoperatively, the baby was commenced on gastrostomy feeds and he received continuous low suction of his upper oesophageal pouch via a Replogle tube. A repeat thoracotomy and a delayed primary repair of his oesophagus were performed at three months of age. DLTB was not performed prior to this procedure. The upper pouch was still short and the final anastomosis was under tension. There was definite fibrosis of the distal end of the upper pouch and it was only partially mobilised in
G. Rakoczy et al. / International Journal of Pediatric Otorhinolaryngology 74 (2010) 326–327
order to reduce the risk of further damage. On the seventh postoperative day an oral contrast swallow was performed which demonstrated narrowing at the anastomosis and significant gastroesophageal reflux. Antireflux measures were initiated and the infant was gradually started on oral feeds. However, 2 weeks later he could no longer tolerate any feeds without demonstrating obvious signs of respiratory distress. An oral contrast study revealed significant narrowing of the anastomosis and a fistula between the upper oesophagus extending superiorly to midtrachea. This fistula was thin, 10–12 mm long and ran proximally from the level of the anastomosis to mid-trachea. DLTB confirmed the presence of this fistula as well as the closed distal fistula stump. Initially the oesophageal stricture was treated with balloon dilatation on three separate occasions. During this time he was kept nil by mouth with continuous Replogle tube suction to his pharynx and proximal oesophagus. The first dilatation improved his situation appreciably as initially he was unable to swallow his own saliva. When the oesophageal stricture had been satisfactorily dilated, the fistula was closed endoscopically using carefully controlled electrocautery to the fistula with injection of fibrin glue into its tract. Unfortunately the fistula recurred and a repeat attempt using electrocautery and fibrin glue was performed. However, these procedures were only temporarily effective as the fistula reopened 3 weeks after the second attempt. At the third attempt, the KTP laser was employed. Excellent access to the airway was provided by an anaesthetic technique involving spontaneous ventilation and a nasopharyngeal airway. The fistula was successfully closed. Postoperatively, the infant was gradually re-introduced to oral feeding. No signs of respiratory distress or aspiration pneumonitis occurred and the infant was finally discharged. A repeat contrast study 1 year later showed no recurrence of the fistula. He is 2 years old now, developing properly, eating solid food, and free from any respiratory symptoms. 3. 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 and healing process involving both the oesophagus and trachea. If a child has respiratory symptoms following repair of a TOF then a diagnostic modality for recurrent or missed fistula is essential. DLTB, oesophagoscopy three-dimensional CT scanning [5] have all been documented as useful. The incidence of recurrent fistulae is 5–14% [6] and it is usually the first differential diagnosis when a patient has respiratory symptoms following repair of a TOF. The techniques of endoscopic fistula mucosal diathermy with glue
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application have had good success and have been reported by several authors [7–9]. A case series from Toronto published in 2006 by Tzifa et al. showed that 9 out of 10 fistulae (90%) could be closed with diathermy and glue application [10]. Four patients needed a second endoscopic procedure. The authors concluded that if two endoscopic procedures using diathermy and glue were unsuccessful, then the fistula is not amenable to this technique. They recommended an external approach in these cases. In our case, the fistula recurred after two attempts with diathermy and glue application. We then used the KTP laser. However limited experience with the KTP laser in these cases has been reported. In 2006, Ishman et al. [11] reported the use of the KTP laser in one case of recurrent TOF. This was the first case report using the KTP laser in this situation. Our case report shows the KTP laser used successfully after 2 attempts using traditional techniques. It is unclear on whether the KTP laser is superior to other methods as the numbers are very small. Certainly the use of diathermy and glue is cheaper when effective. However in refractory cases, the KTP laser could be employed. 4. 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 [1] L. Spitz, Oesophageal atresia, Orphanet J. Rare Dis. 2 (2007) 24. [2] K. Fuzesi, I. Altorjay, Oesophageal perforation as a complication of handling of the newborn infant in the delivery room, Orv. Hetil. 120 (1979) 283–285. [3] V.M. Wright, H.R. Noblett, A complication of continuous upper pouch suction in oesophageal atresia, J. Pediatric Surg. 13 (1978) 369–370. [4] C. Seefelder, S. Elango, K.W. Rosbe, R.W. Jennings, Oesophageal perforation presenting as oesophageal atresia in a premature neonate following difficult intubation, Paediatr. Anaesth. 11 (2001) 112–118. [5] J. Soye, J. Yarr, A. Dick, A. Paterson, Multidetector-row computerised tomography three dimension volume reformatted ‘‘transparency’’ images to define an upper pouch fistula in oesophageal atresia, Paediatr. Radiol. 35 (June (6)) (2005) 624– 626. [6] K. Ghandour, L. Spitz, R. Brereton, E. Kiely, Recurrent tracheo-oesophageal fistula: experience with 24 patients, J. Paediatr. Child Health 26 (1990) 89–91. [7] C. Gutierrez San Roman, J.E. Barrios, J. Lluna, V. Ibanez, E. Hernandez, L. Ayuso, et al., Long-term assessment of the treatment of recurrent tracheoesophageal fistula with fibrin glue associated with diathermy, J. Pediatr. Surg. 41 (2006) 1870–1873. [8] S. Khurana, W.D.A. Ford, Long-term results of endoscopic diathermy coagulation of recurrent tracheoesophageal fistula, Pediatr. Endosurg. Innovative Tech. 8 (2004) 31–34. [9] N.E. Wiseman, Endoscopic closure of recurrent tracheoesophageal fistula using Tisseel, J. Pediatr. Surg. 30 (1995) 1236–1237. [10] K.T. Tzifa, E.L. Maxwell, P. Chait, A.L. James, V. Forte, S.H. Ein, et al., Endoscopic treatment of congenital H-Type and recurrent tracheoesophageal fistula with electrocautery and histoacryl glue, Int. J. Pediatr. Otorhinolaryngol. 70 (May (5)) (2006) 925–930. [11] S.L. Ishman, J.E. Kerschner, C.D. Rudolph, The KTP laser: an emerging tool in pediatric otolaryngology, Int. J. Pediatr. Otorhinolaryngol. 70 (April (4)) (2006) 677–682 (Epub 2005 November 8).
