Acquired Nonmalignant Tracheoesophageal Fistula: Changing Causes and Surgical Methods Over 40 Years

Objective: Our aim was to assess changes in causes, surgical treatments, and outcomes of Acquired non-malignant tracheoesophageal fistula (ANM-TEF) over 40 years of experience. Background: ANM-TEF are rare but life-threatening disease. Their management are not well established. Methods: We included the 90 consecutive patients who underwent surgical ANM-TEF repair at our institution between 1981 and 2022. We compared the 48 patients managed in 1981-2007 to the 42 patients managed in 2008-2022. Results: Intubation was the cause in 44/48 (91.7%) and 9/42 (21.4%) patients in the early and recent periods (P=10^-12). Emerging causes in the recent period were laryngeal cancer treatment (33.3%) and esophageal procedures (40.5%). In 1981-2007, the main surgical technique was direct esophageal suturing and tracheal repair (N=19), followed by tracheal resection-reconstruction (N=16); Pearson's technique was used for laryngotracheal fistulas (N=5). Fasciocutaneous perforator flaps were more often required after laryngeal or esophageal procedures, due to blood-supply compromise (1/48 [2.1%] and 23/42 [66.7%] in the early and recent periods, respectively; P=10^-9). In the recent period, 6 patients required cervical esophagostomy and delayed jejunal free-flap reconstruction. Overall, day-90 mortality was 13.3%, with no significant between-group difference; fistula closure was initially successful in 78 (86.6%) patients; and the main postoperative complications were recurrent nerve palsy (22%), recurrent fistula (18%), tracheal stenosis (10%), and dysphagia (7%). Conclusions: Laryngeal and esophageal surgery has superseded intubation as the main cause of ANM-TEF. Despite the worse local tissue damage, outcomes remain unchanged, thanks to new surgical techniques including fasciocutaneous flap reconstruction.