Rigid Bronchoscopy for Diagnosis and Treatment of Proximal Pouch Fistula in...

Proximal fistulas or type D atresia can be missed even when rigid bronchoscopy is performed routinely prior to repair of presumed esophageal atresia with distal tracheoesophageal fistula or type C.

Proximal fistulas are often subtle and look quite different from the distal fistula.

A term male with presumptive esophageal atresia and distal tracheoesophageal fistula underwent repair through a right thoracotomy on the second day of life.

A rigid bronchoscopy performed just prior to the repair was interpreted as showing a distal fistula 1.5 to 2 centimeters proximal to the carina with no other anomalies.

A routine esophagogram performed 6 days after repair showed a tracheoesophageal fistula, despite the absence of a leak or significant stenosis.

The patient underwent a rigid bronchoscopy a week later to minimize the chances of traumatizing the recently ligated fistula.

A subtle fold was seen approximately 1 centimeter proximal to the distal fistula site.

A glide wire was easily passed through the fold, confirming the presence of a proximal fistula.

The glide wire was used to stent the fistula open as the tract was cauterized with the bugby cautery until the tract and fistula wall were fully cauterized.

Following cauterization, extratronomer hyaluronic acid copolymer, or Deflux, was injected into the tract.

The endoscopic procedure was unsuccessful, and the proximal fistula was still patent on an esophagogram two weeks later.

The patient subsequently underwent successful repair through a right neck incision.

If any suspicion is seen on rigid bronchoscopy, insufflation of air through the esophageal pouch or installation of methylene blue may help confirm a proximal fistula.