Left Cervical Approach for Unrecognized Proximal Tracheoesophageal Fistula in an Adolescent following Neonatal...

Esophageal atresia with both proximal and distal tracheoesophageal fistulas (TEF) is rare, and a proximal TEF may be overlooked during the initial neonatal surgery. However, reports describing the surgical management of residual proximal TEF beyond infancy are limited. Herein, we report a case of a residual proximal TEF that was unrecognized during neonatal repair of esophageal atresia, remained undiagnosed until adolescence, and was successfully resected using a left cervical approach.

A 14-year-old boy with recurrent aspiration pneumonia was diagnosed with a residual proximal TEF and referred to our department for further management. He had a history of primary esophageal anastomosis for esophageal atresia during the neonatal period and was diagnosed with Gross type C esophageal atresia based on intraoperative bronchoscopy. He subsequently experienced recurrent aspiration pneumonia for many years. At 14 years of age, videofluoroscopic swallowing study, chest CT, and esophagogastroduodenoscopy revealed a residual proximal TEF at the level of the third thoracic vertebra (Th3). Under endoscopic guidance, a guidewire was introduced through the esophagus into the fistula and positioned within the trachea in a U-shaped configuration. Intraoperative fluoroscopy demonstrated that the fistula location corresponded to the left supraclavicular cervical region, and surgery via a left cervical approach was done. The guidewire was used to localize the proximal TEF intraoperatively by palpation and fluoroscopic guidance, and the fistula was successfully resected.

Even in adolescent patients with a larger body habitus, a guidewire-assisted left cervical approach is an effective surgical option for residual proximal TEF located at the Th3 level.