Endoscopic treatment of congenital H-Type and recurrent tracheoesophageal fistula with electrocautery and histoacryl glue.

OBJECTIVE: Congenital H-Type tracheoesophageal fistulae (H-Type TEF) and recurrent fistulae after primary repair of esophageal atresia represent a difficult problem in diagnosis and management. The treatment traditionally involved an open technique via a cervical or thoracic route, approaches with high morbidity and mortality rates of up to 50%. Endoscopic closure of fistulae has been reported with various techniques such as tissue adhesives, electrocautery, sclerosants and laser. However, the published case series contain a small number of patients with usually short-term follow-up. The aim of this paper is to present the experience of a decade at Toronto's Hospital for Sick Children, using diathermy and histoacryl tissue adhesive and discuss the indications and limitations of this technique. METHODS: Since 1995, 192 patients have been managed in this institution with tracheoesophageal fistulae of which 10 patients have been treated endoscopically. The fistulae were both of H-Type and recurrent tracheoesophageal fistulae following surgery for esophageal atresia and fistula division. One fistula occurred following trauma. The procedure was undertaken under general anesthesia in the image guided therapy suite under fluoroscopic control. Flexible ball electrocautery and injection of histoacryl glue were used either on their own or in combination. RESULTS: Fistula closure was achieved in 9 out of 10 fistulae. Four patients had a second endoscopic procedure. No major respiratory or other complications were encountered in association with the procedure. Follow-up has been between 3 months and 9 years. CONCLUSION: We conclude, endoscopic treatment of tracheoesophageal fistulae with electrocautery and histoacryl glue has been a safe and successful technique of managing H-Type and recurrent tracheoesophageal fistulae. In this paper, we discuss the indications and the surgical steps of the procedure. We highlight that diathermy should be carefully controlled and applied preferably in the small non-patulous fistulae. A fistula that has not closed after two endoscopic attempts is not suitable for further endoscopic treatment and therefore an external approach should be recommended.

Thoracic CT in the intensive care unit: assessment of clinical usefulness.

PURPOSE: To determine the clinical usefulness of thoracic computed tomography (CT) in patients in a general intensive care unit (ICU). MATERIALS AND METHODS: Images obtained in 108 consecutive thoracic CT examinations and the associated bedside chest radiographs and medical records in 85 patients (55 men, 30 women; age range, 19-92 years) in the ICU of an institution were retrospectively reviewed. CT findings were compared with concurrent bedside chest radiographic findings. The clinical importance of each CT finding was determined by reviewing the clinical record. RESULTS: Of the 232 chest radiographic findings, 199 (86%) were confirmed at CT; when disagreement about mild congestive heart failure was excluded, there was a 93% agreement (199 of 213 findings). However, only CT demonstrated 250 (52%) of the 482 total findings (232 + 250 findings). Although many of these new findings were not clinically important, 32 (30%) of the 108 CT examinations had at least one new clinically important finding. These important new findings most often were (a) abscesses or postoperative fluid collections in the mediastinum, chest wall, or retroperitoneum; (b) malignancies that were detected, staged, or evaluated; (c) unsuspected pneumonia; or (d) pleural effusions. The CT findings resulted in changes in clinical management in 24 (22%) of the 108 examinations. CONCLUSION: CT of the thorax is clinically useful in selected situation in patients in ICUs.