Left Cervical Approach for Unrecognized Proximal Tracheoesophageal Fistula in an Adolescent following Neonatal Esophageal Atresia Repair: A Case Report.

INTRODUCTION: Esophageal atresia with both proximal and distal tracheoesophageal fistulas (TEF) is rare, and a proximal TEF may be overlooked during the initial neonatal surgery. However, reports describing the surgical management of residual proximal TEF beyond infancy are limited. Herein, we report a case of a residual proximal TEF that was unrecognized during neonatal repair of esophageal atresia, remained undiagnosed until adolescence, and was successfully resected using a left cervical approach.

CASE PRESENTATION: A 14-year-old boy with recurrent aspiration pneumonia was diagnosed with a residual proximal TEF and referred to our department for further management. He had a history of primary esophageal anastomosis for esophageal atresia during the neonatal period and was diagnosed with Gross type C esophageal atresia based on intraoperative bronchoscopy. He subsequently experienced recurrent aspiration pneumonia for many years. At 14 years of age, videofluoroscopic swallowing study, chest CT, and esophagogastroduodenoscopy revealed a residual proximal TEF at the level of the third thoracic vertebra (Th3). Under endoscopic guidance, a guidewire was introduced through the esophagus into the fistula and positioned within the trachea in a U-shaped configuration. Intraoperative fluoroscopy demonstrated that the fistula location corresponded to the left supraclavicular cervical region, and surgery via a left cervical approach was done. The guidewire was used to localize the proximal TEF intraoperatively by palpation and fluoroscopic guidance, and the fistula was successfully resected.

CONCLUSIONS: Even in adolescent patients with a larger body habitus, a guidewire-assisted left cervical approach is an effective surgical option for residual proximal TEF located at the Th3 level.