Tracheal diverticula after tracheoesophageal fistula repair: case series and review of the literature

Background: Tracheoesophageal fistula (TEF) is the most common congenital tracheal abnormality, frequently associated with esophageal atresia. Respiratory symptoms are associated with all types of TEF, even after surgical repair of the fistula. Gastroesophageal reflux (GER) with aspiration of gastric contents, structural instability of the airways (tracheomalacia), abnormal respiratory epithelium, abnormal esophageal motility, recurrent TEF, and esophageal stenosis contribute to postsurgical complications. Methods: We review 7 patients between 4 and 14 years of age with a history of TEF repair and persistent or worsening respiratory symptoms despite conventional airway clearance techniques and treatment of GER. Results: Bronchoscopic evaluation in all 7 patients revealed tracheomalacia and a diverticulum on the posterior wall of the trachea at the fistula repair site. Conclusion: We hypothesize that the diverticula impaired airway clearance and contributed to persistent respiratory symptoms. Possible mechanisms for the diverticulum contributing to poor airway clearance include facilitating the pooling of secretions and acting as a "barrier" to the lower airway clearance mechanism. The diagnosis of a diverticulum should be considered early in patients with persistent respiratory symptoms after management of GER and tracheomalacia. Early obliteration of tracheal diverticula might improve respiratory status in some patients. (C) 2009 Elsevier Inc. All rights reserved.