title: Recurrent, nonmalignant tracheoesophageal fistulas and the need for surgical improvisation.
abstract: BACKGROUND
  Despite the many recent advances in thoracic surgery, the management of patients with recurrent, nonmalignant tracheoesophageal fistulas remains problematic, controversial, and challenging.
  
  
  METHODS
  Between 1998 and 2008, we treated 8 patients with RTEF. Closure of the original tracheoesophageal fistula had been attempted once in 5 patients, twice in 2 patients, and 4 times in 1 patient, all in different institutions. Four cases necessitated right posterolateral thoracotomy and cervical exposure, 2 cases cervical and abdominal incision, and 1 case right posterolateral thoracotomy, with abdominal and cervical exposure. With the exception of the 2 patients whose excluded esophagus was used to substitute for the trachea membranous wall, the damaged tracheal segment was removed. In general, a pedicled mediastinal pleural flap was pulled into the neck to increase the safety of the tracheal anastomosis formed with the trachea, and (or) to separate the suture lines of the two organs.
  
  
  RESULTS
  A single intervention was sufficient for all 8 patients: no reoperation was necessary, and there was no perioperative mortality. Transient reflux, abdominal distention, and dyspnea in response to forced physical exertion occurred in 1 case each. Only 1 patient subsequently takes medication regularly for reflux disease.
  
  
  CONCLUSIONS
  Separation initiated from the tracheal bifurcation, a pedicled mediastinal pleural flap pulled into the neck, a tracheal anastomosis sewn onto the cricoid cartilage with avoidance of its posterolateral elbow, a shaped Dumon stent (Novatech, Plan de Grasse, France) with an individually fenestrated tracheostomy cannula, and endoscopy-assisted, transhiatal vagal-preserving esophageal exclusion all served as successful elements of our surgical procedures.
authors.affiliation: Department of Surgery, Saint George University Teaching Hospital, Székesfehérvár, Hungary. altorjay@mail.fmkorhaz.hu
authors.forename: Aron
authors.initials: A
authors.lastname: Altorjay
authors.forename: Mihály
authors.initials: M
authors.lastname: Mucs
authors.forename: Miklós
authors.initials: M
authors.lastname: Rüll
authors.forename: Zoltán
authors.initials: Z
authors.lastname: Tihanyi
authors.forename: Balázs
authors.initials: B
authors.lastname: Hamvas
authors.forename: László
authors.initials: L
authors.lastname: Madácsy
authors.forename: Balázs
authors.initials: B
authors.lastname: Paál
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D012008:Recurrence; D012189:Retrospective Studies; D019616:Thoracic Surgical Procedures / Q000379:methods; D014138:Tracheoesophageal Fistula / Q000601:surgery*; D055815:Young Adult