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Respiratory failure due to retained esophagus: a complication of esophageal replacement
1Department of Surgery, Hospital for Sick Children, Toronto, Ontario, Canada.
Insights
Recurrent tracheoesophageal fistulas in infants can lead to complex complications. Post-esophageal replacement, a retained esophageal segment caused fatal tracheal compression and air embolism.
Area of Science:
- Pediatric Surgery
- Thoracic Surgery
- Gastroenterology
Background:
- Recurrent tracheoesophageal fistula (TEF) complicates approximately 10% of infant esophageal atresia repairs.
- Failed TEF repair may necessitate esophageal replacement, but complications are rare.
- This case highlights a rare, fatal complication following esophageal replacement for recurrent TEF.
Observation:
- A patient with recurrent TEF underwent esophageal replacement with a colonic interposition graft.
- Post-replacement, the patient experienced chronic aspiration, failure to thrive, and respiratory distress.
- Progressive respiratory compromise led to intubation, mechanical ventilation, and eventual cardiac arrest.
Findings:
- Autopsy revealed a dilated, blind segment of native esophagus compressing a malacic trachea.
- Massive air embolism, secondary to high ventilation pressures, was identified as the cause of death.
- Tracheal compression by residual native esophagus was directly linked to the fatal air embolism.
Implications:
- Esophageal remnant compression of the trachea is a critical, underrecognized complication after esophageal replacement.
- This diagnosis should be considered in patients with unexplained respiratory failure post-esophageal surgery.
- Careful surgical technique and postoperative monitoring are crucial to prevent such adverse outcomes.
Abstract:
Recurrent fistulas occur in about 10% of infants treated for esophageal atresia with distal tracheoesophageal fistula. Failed repair of a recurrent fistula rarely requires esophageal replacement and removal or diversion of the native esophagus. We present a patient who underwent multiple operations for recurrent tracheosophageal fistula whose native esophagus was eventually replaced with a colonic interposition graft. Over the subsequent 9 years he experienced failure to thrive, respiratory distress, and repeated pulmonary infections attributed to chronic aspiration. Eventually, he developed respiratory failure and required endotracheal intubation and mechanical ventilation. He became increasingly difficult to ventilate and, in spite of aggressive efforts, suffered a cardiac arrest from which he could not be resuscitated. At postmortem, a dilated blind segment of native esophagus, which was compressing and obstructing the malacic trachea, was found in the posterior mediastinum. Death was caused by massive air embolus, which was in turn attributed to the high airway pressures needed to ventilate the patient. Tracheal compression by a remnant of native esophagus should be considered in the differential diagnosis of respiratory failure after esophageal replacement.