Tracheoesophageal fistula after esophageal atresia repair: recurrent, missed or acquired

Esophageal atresia (EA) is a common congenital anomaly of pediatric surgical practice. Tracheoesophageal fistula (TEF) is defined as congenital fistulous connection between esophagus and airway. All newborns with EA need immediate surgical repair of this anomaly. As the survival has reached to 95%, the long-term consequences of TEF have become the focus of interest. The main complications of EA repair are classified as early complications including anastomotic leak, stricture, recurrent TEF (recTEF) and late complications including gastroesophageal reflux, esophageal dysmotility, tracheomalacia and respiratory disorders. TEFs seen after EA repair are the most challenging complication for both patient and the surgeon. These fistulas can occur after EA repair because of the recanalization of ligated original TEF called recTEF, a de novo fistula with different location called acquired TEF (acqTEF) or a second congenital fistula missed at the primary surgery called missed TEF (mTEF). Overall, incidence of fistula recurrence is between 5-10%. The well-described risk factors for TEF recurrences are inadequate ligation of original TEF, anastomotic complications including leak, stricture and ischemia, tracheal injuries at the primary repair, and juxtapositioning of esophageal and tracheal suture lines. The clinical presentation of all types of fistulas is similar. Thus, the diagnosis of all these fistulas is challenging. Even, all patients having coughing, chocking or recurrent respiratory tract infections after EA repair should be investigated for the presence of TEF recurrence. In addition, the management of each type of fistula requires different approaches and can be technically demanding for most cases. Although surgical management is mostly inevitable in the management of recTEF, medical observation may be a choice for the management of acqTEFs since there is a possibility of spontaneous healing. Despite the advanced surgical technique, the risk for secondary recurrences, increased morbidity and even mortality are still exists. Therefore, this review will focus on all of the aspects of TEFs seen after EA repair.