T ageal fistulas result from complications of mechanical

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1 Management of Acquired Nonmalignant Tracheoesophageal Fistula Douglas J. Mathisen, MD, Hermes C. Grillo, MD, John C. Wain, MD, and Alan D. Hilgenberg, MD Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts Acquired, nonmalignant tracheoesophageal fistula is an uncommon and difficult problem to manage. The most common cause is a complication of endotracheal or tracheostomy tubes. Most are diagnosed while patients still require mechanical ventilation. We use a conservative approach until patients are weaned from ventilation. A tracheostomy tube is placed so that the balloon rests below the fistula, if possible, to prevent contamination of the tracheobronchial tree. A gastrostomy tube is placed for drainage and a separate jejunostomy tube for nutrition. Single-stage repair is done after the patient is weaned from mechanical ventilation. Esophageal diver- sion is rarely required. We have performed 41 operations on 38 patients. Simple division and closure of the fistula was done in 9 patients and tracheal resection and reconstruction in the remainder. The esophageal defect was closed in two layers and a viable strap muscle interposed between the two suture lines. There were four deaths (10.9%). There were three recurrent fistulas and one delayed tracheal stenosis. All were successfully managed. Of the 34 surviving patients, 33 aliment themselves orally and 32 breathe without the need for a tracheal appliance. (Ann Thorac Surg 1991;52:759-65) he majority of acquired nonmalignant tracheoesoph- T ageal fistulas result from complications of mechanical ventilation. Most are diagnosed while patients are still mechanically ventilated. Because mechanical ventilation after tracheal reconstruction is associated with a high incidence of anastomotic dehiscence or restenosis, we have used a conservative approach until the patient is weaned [l, 21. The devastating pulmonary complications from tracheoesophageal fistulas can be minimized by a few simple maneuvers. A new tracheostomp tube should be placed if possible, so that the balloon is below the fistula to minimize soiling of the tracheobronchial tree. If this is impossible, the sealing cuff must be inflated with minimal pressure. The head of the bed is elevated and patients are encouraged to suction oral secretions. A draining gastrostomy tube is placed to minimize gastroesophageal reflux. A separate jejunostomy tube is inserted for nutritional purposes. These measures usually obviate the need for esophageal diversion with ligation of the gastroesophageal junction. Esophageal diversion complicates and lengthens management of these patients. It should be reserved for cases where soilage of the tracheobronchial tree continues despite conservative measures or for supracarinal fistulas that cannot be controlled otherwise. Once the patient is weaned from mechanical ventilation, single-stage repair can then be undertaken without the risks of postoperative ventilation. Most tracheoesophageal fistulas require tracheal resection because Presented at the Twenty-seventh Annual Meeting of The Society of Thoracic Surgeons, San Francisco, CA, Feb 1S20, Address reprint requests to Dr Mathisen, Warren 1109, Massachusetts General Hospital, Boston, MA of circumferential injury to the trachea at the inciting cuff site or because of the size of the fistula. This approach has been employed in 38 patients over a 20-year period. The results of this experience are reported. Follow-up has been obtained by direct patient contact and office records. Material and Methods Diagnosis A sudden increase in tracheal secretions is often the first sign that a tracheoesophageal fistula is present. Aspiration of liquids or suctioning of gastric contents or tube feedings from the tracheobronchial tree occurs. Plain chest radiographs may demonstrate the esophagus dilated with air distal to the fistula. This finding, although often subtle, is pathognomonic for tracheoesophageal fistula. Barium contrast studies usually demonstrate the fistula. Complete radiographic examination of the trachea is also done. Bronchoscopy and esophagoscopy are helpful to demonstrate and identify its exact location. Instillation of methylene blue or air into the esophagus while observing the trachea through a bronchoscope may identify small fistulas. Rigid bronchoscopy is essential to determine the extent of airway injury and to determine whether resection and reconstruction of the trachea is required. Anesthesia Anesthetic technique is crucial to the success of any tracheal operation. We have employed the same technique in virtually all of our tracheal operations [3]. A deep Ethrane (Anaquest, Madison, WI) technique allows spontaneous ventilation during operation and extubation at by The Society of Thoracic Surgeons /91/$3.50

2 760 MATHISEN ET AL TRACHEOESOI HAGEAL FISTULAS Ann Thorac Surg 1991;52: Fig 1. Exposure for most tracheoesophageal fistulas is through a low collar incision. Occasionally, a partial upper sternotomy is required for more distal exposure of the trachea. the completion of the procedure. When tracheal resection is required, intraoperative management of the airway is accomplished by a sterile Tovell tube inserted into the distal trachea. Sterile connecting tubing is passed off to the anesthesiologist to control ventilation. Operative Technique The principles of patient management before definitive repair have been delineated. This approach allows pulmonary sepsis to be controlled, nutrition to be optimized, and, most importantly, mechanical ventilation to be ended. The principles of tracheal surgery need to be closely followed because many of the cases are reoperations or associated with more than the usual amount of inflammation [4, 51. The most important initial decision is to determine whether the fistula can be simply resected and closed or whether tracheal resection and reconstruction will be required. Most postintubation tracheoesophageal fistulas may be corrected through a low collar incision, oftentimes including the tracheostomy stoma if present. Partial division of the sternum to just below the angle of Louis gives exposure of the trachea to carinal level (Fig 1). A right lateral thoracotomy through the fourth interspace is preferable for fistulas at or just above the carina or if a previous operation was done transthoracically. Management of the Tracheal Defect SMALL FISTULA AND NORMAL TRACHEA. The small tracheoesophageal fistula that does not require tracheal resection poses unique technical problems. Exposure is gained by approaching the fistula from the side (Fig 2). Exposure through the neck is often limited, especially when the fistula is located distally. More importantly, the recurrent laryngeal nerve on the side of exposure is in jeopardy of being injured. Local inflammation may make identification of the nerve difficult. In these circumstances, it is best to identify the nerves at a location remote from the fistula. The nerve should be elevated with the trachea during exposure of the fistula (see Fig 2). Care should be taken to avoid retractor injuries to the recurrent nerve. The fistula is identified and divided. We prefer to close the tracheal defect with absorbable suture material (4-0 Vicryl [Ethicon, Somerville, NJ]). The esophageal defect is closed in two layers. The inner layer consists of esophageal mucosa. We prefer inverting, interrupted 4-0 silk sutures. The esophageal muscle is then closed over the mucosal layer. A strap muscle is pedicled to buttress and separate the tracheal and esophageal suture lines (Fig 3). This minimizes the risk of recurrent fistula. If concern exists about the degree of narrowing of the trachea, a small amount of esophageal mucosa can be left with the tracheal side of the fistula. This can then be used in the closure of the tracheal defect to minimize tracheal narrowing. LARGE DEFECT WITH CIRCUMFERENTIAL TRACHEAL DAMAGE. The fistula that requires tracheal resection, although technically more complicated, provides much better exposure. Circumferential dissection above and below the fistula should be very close to the trachea to avoid injury to the recurrent nerves. The nerves are allowed to fall laterally.

3 Ann Thorac Surg 1991;52: MATHISEN ET AL 761 Resection of the damaged portion of the trachea gives excellent exposure of the esophageal defect (Fig 4). The esophageal defect is closed longitudinally in two layers (Fig 5). It is essential to separate the esophageal suture line with a strap muscle to help prevent recurrent tracheoesophageal fistula (Fig 6). The esophagus is closed over a nasogastric tube. Narrowing of the esophagus to this degree is well tolerated. Esophageal dilation may be required postoperatively. Tracheal reconstruction is performed as detailed elsewhere [4, 51 (Fig 7). We prefer interrupted 4-0 Vicryl sutures. Lateral traction sutures of 2-0 Vicryl are used and left in place. Absorbable suture material has dramatically reduced the incidence of suture line granulomas. Anastomotic tension must be scrupulously avoided. Resection of excessive amounts of trachea must be avoided. A Montgomery suprahyoid laryngeal release may be needed if flexion of the neck is not sufficient to minimize anastomotic tension [6]. Prolonged mechanical ventilation after operation should be avoided. Tracheostomy rarely is needed, but if necessary it should A Small A tracheoesophageal fistula Recurrent laryngeal nerve Esophagus --- Fig 3. A strap muscle is used to cover the esophageal suture line and separate it from the tracheal suture line. be placed at least two rings below the anastomosis. The anastomosis should be covered by reapproximation of the thyroid isthmus or strap muscle to avoid contamination by the tracheostomy tube. In some instances the length of the posterior defect in the membranous wall and the length of the damaged trachea will exceed the amount of trachea that can be safely resected. It is possible to close longitudinally the posterior defect in the membranous tracheal wall, borrowing some adjacent esophageal wall if needed. This limits the amount of trachea to be resected and allows reconstruction that otherwise might not be possible. This presumes the cartilaginous tracheal wall is healthy. For those situations where the length of tracheal damage exceeds the limits of reconstruction, it is still worthwhile to repair the fistula and buttress the closure with strap muscle. The airway can be maintained by a tracheal T tube. Oral alimentation is then possible, thus avoiding the need for permanent feeding tubes. Fig 2. Small tracheoesophageal fistula treated by division and local repair. The recurrent nerve is elevated with the trachea. The esophagus is closed in two layers. Results We treated 17 male and 21 female patients. Their ages ranged from 15 years to 72 years. The average postoperative hospital stay was 17.5 days. Etiology The vast majority of the tracheoesophageal fistulas (27) in our series resulted from the combined effects of a nasogastric tube and the cuff on either an endotracheal tube or a tracheostomy tube. Laryngotracheal trauma accounted for 5 fistulas. Complications of radiation therapy and anterior spine fusion led to fistulas in 2 patients each. Both patients who had complications from radiation had prior laryngectomies for cancer. Foreign body and a presumed congenital fistula were responsible for fistulas in 1 patient each.

4 762 MATHISEN ET AL Ann Thorac Surg 1991;52:75945 Fig 5. The esophageal defect is closed in two layers using interrupted 4-0 silk sutures. (a) The first layer closes the esophagus. (b) The esophageal muscle is closed over the first layer. had a median sternotomy for a tracheoinnominate artery fistula and mediastinal sepsis. Because of dense adhesions, calcifications, and uncertainty of the location of the ends of the previously divided innominate artery, median sternotomy was performed for sufficient exposure. Lateral Fig 4. Circumferential dissection above and below the fistula is very near the trachea to avoid inju y to the recurrent nerves. Division of damaged trachea gives excellent exposure of the esophageal defect. Ventilation is maintained by a sterile Tovell tube in the distal trachea. Prior Treatment Eight patients had undergone attempted repair at other institutions. Many patients had more than one attempted repair. Reasons for failure included the need for postoperative mechanical ventilation and failure to interpose tissue between tracheal and esophageal suture lines. Seven patients from other institutions underwent esophageal diversion with cervical esophagostomy or pharyngostomy, and 3 had ligation or interruption of the gastroesophageal junction. Colon interposition was performed at another institution in an attempt to isolate a tracheoesophageal fistula. Surgical Approach Forty-one operations were performed in 38 patients (recurrent fistulas developed in 2 patients and delayed tracheal stenosis developed in 1). A low collar cervical incision was used in 26 patients. Partial sternotomy was performed for additional distal exposure in 10 patients (see Fig 1). Cervical collar incision and full median sternotomy was required in 1 patient for a complex problem. In addition to tracheoesophageal fistula, this patient had Fig 6. A local strap muscle is used to buttress the esophageal closure and separate it from the tracheal suture line.

5 Ann Thorac Surg 1991; MATHISEN ET AL 763, Management of Esophageal Defect Thirty-three patients had direct closure of the esophageal fistula using a two-layer closure as described (see Fig 5). Some narrowing of the esophageal lumen is inevitable in this situation but is well tolerated by most patients. Because of prior cervical esophagostomy, 5 patients underwent end-to-end esophageal anastomosis. Thirty-four patients had interposition of a local strap muscle between the esophageal and tracheal suture lines. Cervicomediastinal exenteration with creation of a mediastinal tracheostomy and a substernal colon bypass was required for a tracheoesophageal fistula after laryngectomy and irradiation. Fig 7. The tracheal repair is done with interrupted 4-0 Vicryl sutures. Not shown are four lateral traction sutures of 2-0 Vicryl. thoracotomy was used in 4 patients because of distal fistulas or failed previous repair done through lateral thoracotomy. Management of Tracheal Defect Tracheal resection and reconstruction was performed in 31 patients. This was done because of the presence of tracheal stenosis with full thickness circumferential damage at the level of the cuff or stoma or when the defect in the membranous tracheal wall was too large for direct closure. Two patients had tracheal resection for recurrent fistulas, and 1 patient had a tracheal resection for tracheal stenosis that developed at the stoma which was retained after repair of a tracheoesophageal fistula. Twenty-one patients had inclusion of the tracheal stoma in the resected specimen. Five patients had laryngotracheal resection because of stenosis involving the subglottic larynx. This required a slightly different technique described in detail elsewhere [7]. Six patients who had tracheal resection and reconstruction had longitudinal closure of the membranous wall of the trachea where the fistula had been located. The amount of injured trachea would have been too excessive to allow reconstruction otherwise. All of these patients did well despite some narrowing of the trachea. Laryngeal release was done for 2 patients because of excessive anastomotic tension. One of these patients died postoperatively of tracheal separation. The tracheal defect was managed by direct closure in 9 patients. Care was taken to avoid narrowing the tracheal lumen in these cases. Many had inclusion of some esophageal mucosa to allow easier closure of the defect to avoid compromise of the tracheal lumen. Tracheal damage was too extensive in 1 patient to allow tracheal resection, and therefore a T tube was placed after repair of the fistula. There has been no recurrence of the fistula in this patient and a good airway is maintained. I I Morbidity and Mortality Four patients died after repair of tracheoesophageal fistula (10.5%). Three of these patients died after attempted transthoracic repair of very distal tracheoesophageal fistulas. All patients had extensive mediastinal sepsis at the time of repair and required mechanical ventilation after operation. Two patients died of progressive pulmonary sepsis. The third patient ultimately was weaned from mechanical ventilation and required a long T tube for tracheal malacia. The patient died of an aortotracheal fistula 2 months later. The fourth death occurred in a young man who had extensive tracheal resection with laryngeal release. Tracheal separation occurred on the sixth postoperative day and the patient could not be resuscitated. Small recurrent tracheoesophageal fistulas requiring reoperation developed in 2 patients. Both patients had complicated fistulas with marked inflammation of the tissues at the time of their initial repair. Both patients had cervical esophagostomies and required end-to-end anastomosis. The recurrent fistulas were small and were successfully managed by short tracheal resection and closure of the esophageal defect. Strap muscles were used on both patients on both occasions. A small esophageal fistula developed postoperatively in 1 patient but healed spontaneously after simple drainage. Tracheal stenosis developed at the level of the retained stoma in 1 patient and was corrected by a second tracheal resection. Aspiration was noted transiently in 5 patients. The cause was multifactorial, being secondary to previously paralyzed vocal cords, laryngeal release, or extensive tracheal resection. All resolved in short periods of time. Pneumonia developed in 4 patients postoperatively. Osteomyelitis requiring prolonged antibiotics and debridement developed in 3 of the patients who had partial median sternotomy. Temporary tracheostomy was done in 2 patients due to inadequate airway after resection. Both patients were successfully decannulated. Two patients with prior paralyzed vocal cords required procedures to improve their glottic aperture after repair of their tracheoesophageal fistula. One patient had a Teflon injection to stiffen the vocal cord, and another had a partial laser resection of one vocal cord. Both have maintained a good airway and functional voice. Tracheal granulations occurred in 2 patients and required endoscopic removal.

6 764 MATHISEN ET AL Ann Thorac Surg 1991;52:75%65 Results of Treatment Thirty-three of the 34 surviving patients aliment themselves orally. Five patients required esophageal dilation for narrowing at the level of the repair of the esophageal fistula. None still require dilation. The 1 patient who does not aliment himself orally is also 1 of 2 patients requiring a tracheal appliance to provide an airway. This patient had sustained a serious head injury from which he has never fully recovered. A tracheostomy is required for pulmonary toilet and a gastrostomy for feeding. There has been no recurrence of the fistula, however. Another patient requires a T tube because of the extent of injury to her airway. The patient maintains an excellent airway and functional voice, and swallows normally. Four patients had a hoarse voice postoperatively. Three of these patients had paralyzed vocal cords preoperatively and remain hoarse; the other patient had transient bilaterial vocal cord paresis, which gradually resolved. Comment Acquired nonmalignant tracheoesophageal fistula is an uncommon problem occurring in only 0.5% of patients undergoing tracheostomy [8]. Certain high risks factors in intubated patients have been identified [9]. Among them, the most important are high cuff pressures, excessive motion of the tube, infections, hypotension, steroids, nasogastric tubes, and diabetes. For prevention, each intubated patient should be considered with these risk factors in mind. Endotracheal or tracheostomy tubes and large, firm nasogastric tubes for prolonged periods of time must be avoided. Patients who sustain laryngotracheal trauma and esophageal injuries should have careful repair of both injuries with interposition of a strap muscle. Diagnosis is readily made by history, simple x-ray studies, or endoscopy. When the diagnosis is made, we favor a conservative approach while the patient requires mechanical ventilation. More than 75% of the patients in our series required tracheal resection because of the presence of circumferential damage to the trachea or size of the fistula. It has long been our experience that mechanical ventilation after tracheal resection is contraindicated because of a high hazard of tracheal dehiscence. Therefore, when tracheoesophageal fistula is diagnosed in a patient on mechanical ventilation, the nasogastric tube should be removed, the tracheostomy tube positioned so that the balloon rests below the fistula, a gastrostomy tube placed to drain the stomach, and a jejunostomy tube placed for feeding purposes. Once the patient has been weaned from mechanical ventilation, definitive single-stage repair can be undertaken because spontaneous closure rarely if ever occurs [1&12]. We do not believe this approach prolongs mechanical ventilator dependence if the measures described are instituted promptly and effectively. We do not favor esophageal diversion. This should rarely if ever be required if the above measures are promptly instituted. Diversion might be useful for a patient with a very distal fistula who is not a candidate for thoracotomy and has persistant soilage of the tracheobronchial tree. In this extreme case, an end-cervical esophagostomy is preferable with the divided distal end being clearly identified and secured in the neck for future reconstruction. This will avoid the need for complicated future esophageal reconstructive measures. Ligation of the gastroesophageal junction should be avoided because it adds unnecessary complexities to a future reconstruction, and if the fistula cannot be occluded, it may lead to massive dilatation or rupture of the intrathoracic esophagus. Aggressive early measures must be taken to control distal fistulas before local and pulmonary sepsis become irreversible. A single-stage repair is preferable in most situations. Simple division and closure of the fistula in properly selected cases with a buttress of nearby healthy tissue is desirable and has been effective in 9 patients in our series. Unfortunately, this represents a minority of the patients in our experience (24%). Exposure is limited, and the recurrent laryngeal nerve on the side of the repair is at risk. Tracheal resection and reconstruction along with closure of the esophageal defect was required in most of our patients (27/38). Three patients required reoperation for either recurrent fistula (2) or tracheal stenosis (1). Overall functional results of the airway and esophagus were very good, in spite of many patients having marked inflammatory changes in the tracheal mucosa. Precise technique, avoidance of tension, and the interposition of a strap muscle are important to success. The timing of intervention in the management of tracheoesophageal fistulas is crucial. Others have suggested attempted repair through cervical incisions while patients are still ventilated [12]. The rationale is to limit continued pulmonary contamination and limit the length of time mechanical ventilation is required. Because most patients are on mechanical ventilation for other reasons and have pulmonary sepsis at the time of diagnosis, early intervention would seem to have little chance of altering the course in these patients. Early and effective measures to limit aspiration from the fistula with repositioning of the tracheostomy tube and a draining gastrostomy tube are just as effective in limiting contamination of the tracheobronchial tree. The fact that the majority of our patients were managed in just this manner, were eventually weaned from mechanical ventilation, and had their fistulas successfully repaired justifies this approach. In addition, at least 6 of our patients had undergone repairs elsewhere while on mechanical ventilation and had recurrent fistulas. Another problem with repair while on mechanical ventilation is that it may be difficult to determine the degree of tracheal damage. This may lead to inappropriate management of the tracheal problem. If the injury is underestimated and local repair attempted, tracheal stenosis from circumferential injury may develop at a later date. If the injury is overestimated and tracheal resection performed, this may be unnecessary and lead to dehiscence or restenosis. Because the majority of our patients required tracheal resection (76%), it is best done when the patients are weaned from mechanical ventilation. This has also been the experience of others [lo, 11, 131. Single-stage repair of tracheoesophageal fistula gives

7 Ann Thorac Surg 1991;52: MATHISEN ET AL 765 excellent results and a low incidence of recurrent fistulas. All but 1 of our patients (a patient with severe neurological injury) aliment themselves orally, and all but 2 (1 with severe neurological injury and 1 with extensive injury) breathe without the need for a tracheal appliance. Our results support the approach outlined for management of acquired nonmalignant tracheoesophageal fistulas. References Grillo HC, Moncure AC, McEnany MT. Repair of inflammatory tracheoesophageal fistula. Ann Thorac Surg 1976;22: Hilgenberg AD, Grillo HC. Acquired non-malignant tracheoesophageal fistula. J Thorac Cardivasc Surg 1983;85: Wilson RS. Tracheal resection. In: Marshall BE,'Longnecker DE, Fairly HB, eds. Anesthesia for thoracic procedures. Boston: Blackwell Scientific, 1988: Grillo HC. Surgery of the trachea. In: Keen G, ed. Operative surgery and management. 2nd ed. Bristol: Wright, Grillo HC. Surgery of the trachea. In: Ravitch M, Steichen F, eds. Atlas of general thoracic surgery. Philadelphia: W.B. Saunders, 1988:29> Montgomery WW. Suprahyoid release for tracheal anastomosis. Arch Otolaryngol 1974;99: Grillo HC. Primary reconstruction of airway after resection of subglottic and upper tracheal stenosis. Ann Thorac Surg 1982;33: Harley HR. Ulcerative tracheo-esophageal fistula during treatment by tracheostomy and intermittent positive pressure ventilation. Thorax 1972; Pavne DK, Anderson WM, Romero MD, Wissinp. - DR, Fowler M. Tracheoesophageal fistula formation in intubated patients: risk factors and treatment with high-frequency jet ventilation. Chest 1990;98: Marzelle J, Dartevelle P, Khalife J, Rojas-Miranda A, Chapelier A, Levasseur l'. Surgical management of acquired postintubation tracheo-oesophageal fistulas. Eur J Cardiothorac Surg 1989;3: Couraud L, Bercovici D, Zanotti L, Velly JF, Dubrez J. Treatment of oesophago-tracheal fistulae secondary to respiratory intensive care. Report of seventy cases. Ann Chir 1989;43: Thomas AN. The diagnosis and treatment of tracheoesophageal fistula caused by cuffed tracheal tube. J Thorac Cardiovasc Surg ;65: Bugge-Asperheim B, Birkeland S, Storen G. Tracheooesophageal fistula caused by cuffed tracheal tubes. Scand J Thorac Cardiovasc Surg 1981;15: DISCUSSION DR ROBERT J. GINSBERG (New York, NY): I think this is an elegant series, demonstrating the fact that these are not necessarily mortal injuries. It appears that an important precept is to wean patients off the ventilator and then use standard surgical principles to close the defects. As well, interposing some kind of buttress between the two suture lines seems to be efficacious. This report has few complications and mostly successes. I congratulate the authors. DR PETER C. PAIROLERO (Rochester, MN): How often have you had to divide the sternum for some injuries that may be more distal? DR MATHISEN: Ten patients had partial division of the upper sternum. The 1 patient who had a full median sternotomy had a very complicated condition including not only a tracheoesophageal fistula but a tracheoinnominate artery fistula that was repaired at another institution. Because of excessive calcifications and the fact that we did not really know where the ends of the innominate artery were, a full median sternotomy was done. That patient also had had division of the gastroesophageal junction, and that had to be reconstructed. So it was a much more complicated problem, and rarely is full median sternotomy required. DR THOMAS W. SHIELDS (Chicago, IL): As usual, this is an excellent technical discussion of how these fistulas should be closed, and the principles that they have described apply to all tracheoesophageal fistulas of nonmalignant etiology. But we have to remember that this series represent a very skewed population. I mean, many of these patients were sent to Massachusetts General Hospital because of the interest in these injuries due to intubation at that institution: Out in the hinterlands, you know, west of Cambridge, most surgeons will not see many of these specific injuries. The one instance that we really should be aware of is the patient who sustains severe chest trauma in deceleration injuries. Necrosis of the common wall of the esophagus and trachea just above the azygos vein area will occasionally develop in a few of these patients. This will lead to a fistula that will not really become evident until the patient is put back on alimentation. And so if a patient is alimented and starts to have the typical symptoms of aspiration on swallowing, one must keep this infrequent injury in mind. I think this is what most of the people will see rather than the high incidence in this series of tracheoesophageal fistulas from intubation; this is a unique experience that most surgeons will not really see. DR MATHISEN: I think Dr Shields brings out an important point about people who have had traumatic tracheoesophageal fistulas or traumatic laryngotracheal trauma that results in a tracheoesophageal fistula. I think the same principle applies to the management of these patients in terms of the technical problems when you are trying to repair an injured trachea and a concomitantly injured esophagus in that they both require meticulous repair and the interposition of a local strap muscle. It has been our experience that doing that will avoid the subsequent tracheoesophageal fistulas that we saw in 5 of our patients who had not had strap muscle interposed. It is not clear whether that was the only reason why a tracheoesophageal fistula developed after their injury, but certainly it was one contributing factor. DR PAIROLERO: Could I inquire what your special sutures are? DR MATHISEN: For the esophageal closure we generally use 4-0 silks. I think you could use Dexons or Vicryls in their place. For the airway closures, it is always with an absorbable suture, 4-0 Vicryl. That has minimized the subsequent granulations that were so common when permanent sutures were used.