Surgical management of tracheosophageal fistula complicating caustic ingestion.

This report outlines principles of management for extensive corrosive esophageal burns in children complicated by formation of a tracheoesophageal fistula (TEF). Direct operative attack on the fistula usually is unsuccessful, since the tracheal tissues are so damaged that they will not hold sutures. On the basis of experiences with six children, we suggest the following plan of management: (1) early investigation of suspected TEF with thin barium or Dionosil; (2) early tracheostomy using a short, plastic tube; (3) end cervical esophagostomy with closure of the distal stump of the cervical esophagus; (4) gastrotomy; (5) complete disconnection of the intra-abdominal esophagus from the stomach. This can be completed in a single operation and leaves the thoracic esophagus containing the fistula completely isolated so that the trachea is protected from contamination by saliva and gastric juice. The esophageal mucosa in all cases has been destroyed so extensively by the corrosive material that the esophagus heals as a band of muscle and scar. If protected from continuous contamination by saliva, the trachea heals itself with little long-term defect. The esophagus is replaced with colon or a gastric tube 6 to 12 months later when the child is in good health. All four children treated by this regimen have survived and are able to eat normally.