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Button battery ingestions in children increased in recent years and may lead to life-threatening complications, especially if the battery is impacted in the esophagus. The pH close to the negative pole of the battery can rise in a very alkalotic range (pH 10) leading to severe tissue damage. Therefore, in this case series report, the clinical courses of four children with button battery ingestion leading to tracheoesophageal fistulas are presented. The diagnosis and removal of the button battery was delayed in all cases. The surgical reconstruction of the trachea was performed in intravenous anesthesia and with extended monitoring. The intraoperative oxygenation was maintained using a combination of extracorporeal membrane oxygenation (ECMO) and mechanical ventilation via an endobronchial tube. To prevent these life-threatening complications, the awareness of the parents and child care providers should be raised, and the manufacturers should redesign their products to secure the battery compartment. In children with suspected battery ingestions, the immediate localization and removal of the battery ( 2 h) is of highest importance. Local administration of honey or sucralfate can be considered in ingestions 12 h but should not delay an endoscopic removal.Fremdkörperingestionen bei Kindern nehmen stetig zu – dabei werden u. a. Knopfbatterien sehr häufig verschluckt. Das weitverbreitete Modell CR2032 führt bereits nach kurzer Zeit zu schweren Laugenverätzungen mit möglicher Perforation in benachbarte Organe. Dieser Fallserienbericht stellt 4 Kinder vor, die nach Ingestion von Knopfbatterien eine tracheoösophageale Fistel entwickelten und in unserer Kinderklinik interdisziplinär versorgt wurden.

Oesophageal atresia is a rare congenital malformation occurring in 1 : 3000/1 : 4000 neonates. Surgical correction is always required. Perioperative management concepts depend on the type of malformation. Postoperative results are closely related to postsurgical complications. Interdisciplinary management should extend from prenatal diagnosis, birth and perinatal care to neonatal intensive care and paediatric surgical therapy with specialised pediatric anaesthesia. Other areas that should be available are logopedia, paediatric gastroenterology and paediatric pulmonology. Long-term care should include systematic aftercare and transition programs to adult medicine.Die Ösophagusatresie (ÖA) ist mit einer Inzidenz von 1 : 3000 bis 1 : 4000 Neugeborenen eine seltene, angeborene Erkrankung. Die Therapie beinhaltet obligatorisch die operative Korrektur. Behandlungskonzepte sind abhängig von der Variabilität der ösophagotrachealen Fistelmöglichkeiten, der variablen Distanz der Ösophagussegmente und der prognostischen Relevanz assoziierter Fehlbildungen. Die postoperativen Resultate werden entscheidend durch krankheitsspezifische Symptome und Komplikationen beeinflusst. Ein interdisziplinäres Betreuungskonzept von der pränatalen Diagnostik über die Geburt, die neonatalogische Intensivpflege und kinderchirurgische Versorgung mit hochspezialisierter Kinderanästhesie bietet in einem spezialisierten Kinderzentrum mit Logopädie, Gastroenterologie und Pulmologie die besten Voraussetzungen für eine optimale Lebensqualität. Systematische Nachsorge- und Transitionsprogramme sind für betroffene Kinder essenziell.

Esophagobronchial and esophagotracheal fistulas are rare but complex diseases with a heterogeneous spectrum of underlying etiologies. Common causes are locally advanced tumors of the esophagus and larynx, traumatic perforation from the esophageal or tracheal side as well as postoperative fistulas. The management of esophagotracheal and esophagobronchial fistulas always involves different health care providers and in most cases patients require a multidisciplinary treatment on the intensive care unit. The therapeutic concept primarily depends on the underlying cause, localization and size of the fistula but decision making is also influenced by the severity of the course of sepsis and the extent of the respiratory dysfunction. Endoscopic management with esophageal and/or tracheobronchial stenting is the most common treatment. Surgical reconstructive procedures are predominantly reserved for patients with a treatment refractory fistula or a septic multiple organ failure. The prognosis is particularly influenced by the underlying disease.Ösophagotracheobronchiale (OETB-)Fisteln sind ein insgesamt komplexes Krankheitsbild mit niedriger Inzidenz und einem heterogenen ätiologischen Spektrum. Häufige Ursachen sind lokal fortgeschrittene Malignome des Ösophagus und Larynx, traumatische Perforationen von ösophagealer oder trachealer Seite sowie postoperative Fisteln. Das Management der OETB-Fisteln ist aufgrund der Komplexität immer interdisziplinär und in den meisten Fällen nur unter intensivmedizinischen Bedingungen möglich. Das therapeutische Konzept hängt primär von Ursache, Lokalisation und Größe der Fistel ab, wird aber auch durch die Schwere des septischen Verlaufes, insbesondere durch die respiratorische Insuffizienz, beeinflusst. Interventionelle Verfahren mit Platzierung ösophagealer und/oder tracheobronchialer Stents sind in der Therapie führend; operative rekonstruktive Verfahren bleiben therapierefraktären Fisteln und Patienten mit septischen Multiorganversagen vorbehalten. Die Prognose wird insbesondere durch die Grunderkrankung beeinflusst.

Esophageal atresia (EA) is a congenital anomaly that entails an interrupted esophagus with or without tracheoesophageal fistula (TEF). Depending on the distance of the two esophageal pouches a "short-gap" is distinguished from a "long-gap" variant. Up to 50% of newborns have additional anomalies. EA is prenatally diagnosed in 32-63% of cases. Recently, the interdisciplinary care in these children underwent substantial changes. Therefore, we summarize the current guideline of the German society of pediatric surgery for the treatment of patients with EA and distal TEF (Gross Type C). Controversies regarding the perioperative management include surgical-technical aspects, such as the thoracoscopic approach to EA, as well as general anesthesia (preoperative tracheobronchoscopy, intraoperative hypercapnia and acidosis). Moreover, postoperative complications and their management like anastomotic stricture are outlined. Despite significant improvements in the treatment of EA, there is still a relevant amount of long-term morbidity after surgical correction. This includes dysmotility of the esophagus, gastroesophageal reflux disease, recurrent respiratory infections, tracheomalacia, failure to thrive, and orthopedic complications following thoracotomy in the neonatal age. Therefore, close follow-up is mandatory to attain optimal quality of life.Die Ösophagusatresie (ÖA) ist eine angeborene Kontinuitätsunterbrechung der Speiseröhre mit oder ohne Fistel zur Trachea (Tracheoösophageale Fistel, TÖF). Je nach Abstand zwischen den beiden Ösophagusenden unterscheidet man eine „kurzstreckige“ von einer „langstreckigen“ Form. Bis zu 50% der Neugeborenen weisen weitere Anomalien auf. Eine pränatale Diagnose der ÖA gelingt in 32–63% der Fälle. Die interdisziplinäre Betreuung dieser Kinder hat sich in den letzten Jahren gewandelt. In der folgenden Arbeit wird die aktuelle S2K-Leitlinie der Deutschen Gesellschaft für Kinderchirurgie zur Behandlung der ÖA mit unterer TÖF, die etwa 90% aller Fälle ausmacht, zusammengefasst. Hierzu gehören das präoperative Management sowie operative und anästhesiologische Aspekte (u. a. Thorakoskopie vs. Thorakotomie, präoperative Tracheobronchoskopie, intraoperative Hyperkapnie und Azidose). Ferner wird das postoperative Management insbesondere von relevanten Komplikationen wie der Anastomosenstenose beschrieben. Trotz Fortschritten in der Behandlung der ÖA ist die Langzeitmorbidität mit Motilitätsstörungen des Ösophagus, gastroösophagealer Refluxkrankheit, rezidivierenden Infektionen der oberen und unteren Atemwege, Tracheomalazie, mangelhaftem Gedeihen sowie orthopädischen Problemen nach Thorakotomie weiterhin hoch. Zum Erreichen einer guten Lebensqualität ist daher eine gute interdisziplinäre Nachsorge wichtig.

A tracheoesophageal fistula is the formation of an abnormal communication between the airway and the esophagus. Acquired tracheoesophageal fistulas can be benign or malignant. The management is either surgical or endoscopic depending on the etiology, size and anatomy of the fistula as well as on the patient's performance status. The interventional treatment of choice is endoscopic stent implantation. In general, tracheoesophageal fistulas in patients with benign conditions are managed surgically. If the patient is unfit for surgery silicone stents should be used because they can be more easily removed after a longer indwelling time compared to metal stents. Malignant fistulas are associated with very limited life expectancy of only a few weeks or months. In this situation fully covered self-expandable metal stents (FC-SEMS) are recommended, whereas surgical treatment approaches can only be considered in individual cases. Depending on the location of the fistula and the presence of an airway stenosis, tracheal stenting, esophageal stenting or parallel stenting of the trachea and the esophagus is carried out. Successful stent placement leads to immediate palliation of symptoms, such as cough or aspiration and results in a higher quality of life. Potential complications are stent migration, bleeding of the upper gastrointestinal tract, arrosion of neighboring organs and vessels with esophageal stents as well as secretion retention and obstruction with displacement of the airway with tracheobronchial stents.

Oesophageal atresia causes a dysplasia of the oesophagus with or without a connection to the adjoining trachea. Prenatal ultrasound results are not specific enough to confirm a suspected diagnosis. In addition to polyhydramnios and a small or absent stomach, the so-called "pouch sign" reinforces the suspected diagnosis. An MRI increases the prenatal detection rate. Due to the lack of reliable sonografic markers, ultrasonic testing is advised during pregnancy. Particularly, further causes for the polyhydramnios should be categorically excluded. Postnatally, children present with classic symptoms. Surgical treatment results in a very high quality of life and a very good prognosis. Nevertheless lifelong monitoring and follow-up of the patient is required.Bei der Ösophagusatresie kommt es zu einer Hemmungsfehlbildung der Speiseröhre mit oder ohne Verbindung zur angrenzenden Trachea. Eine pränatale Diagnostik mittels Ultraschalluntersuchungen ist durch die indirekten Hinweiszeichen relativ unspezifisch und nur als eine Verdachtsdiagnose möglich. Neben dem gleichzeitigen Vorliegen eines Polyhydramnions sowie der wiederholt nicht möglichen Darstellung einer Magenblase, bzw. zu kleiner Magenblase, bestärkt das Vorliegen eines sog. „Pouch-sign“ die Verdachtsdiagnose. Eine MRT erhöht die pränatale Detektionsrate. Aufgrund der fehlenden sicheren sonografischen Marker, neben der möglichen direkten Darstellung des Ösophagus, sollten Ultraschallkontrollen in der Schwangerschaft durchgeführt werden. Insbesondere sollten kategorisch weitere mögliche Ursachen eine Polyhydramnions ausgeschlossen werden. Postnatal fallen die Kinder mit der klassischen Symptomatik auf. Die operative Versorgung ermöglicht den Betroffenen eine sehr gute Lebensqualität und Prognose. Eine lebenslange Observation und Begleitung ist notwendig.

The creation of a primary anastomosis in newborns with oesophageal atresia and distal oesophageotracheal fistula (EA-DF) is technically challenging, especially in small children. The goal is to approximate the fragile oesophageal ends without suture disruption and to minimize the mobilisation of the lower segment. We describe an alternative anastomosis technique aiming at reducing the tension on the first sutures at the posterior wall.EA-DF was corrected in 13 newborns either by open (n = 11) or thoracoscopic (n = 2) surgery using this technique.The anastomosis technique is based on creation of a dorsal flap of the upper oesophageal pouch and insertion in the spatulated lower oesophageal segment after the fistula has been separated. Subsequently, the first sutures of the posterior wall can be accomplished with reduced tension. Upon completion of the anastomosis, a diagonally shaped anastomotic plane results.The method is a helpful alternative to approximate the oesophageal stumps of newborns with EA and distal oesophagotracheal fistula. By this technique, the first stabilising sutures of the posterior wall can be accomplished with reduced tension. This results in reduced tensile stress on the individual sutures and simplifies the anastomisation in comparison to the conventional end-to-end anastomosis.Die Durchführung einer primären Anastomose bei Neugeborenen mit Ösophagusatresie und distaler ösophagotrachealer Fistel (EA-DF) ist insbesondere bei kleinen Kindern technisch anspruchsvoll. Ziel ist es, die fragilen Enden des Ösophagus ohne Ausreißen der Nähte anzunähern und den distalen Ösophagus hierbei möglichst wenig zu mobilisieren. Wir beschreiben eine alternative Anastomosentechnik, welche die Spannung der ersten Nähte der Hinterwand reduzieren soll.Die operative Korrektur einer EA-DF wurde bei 13 Neugeborenen mit dieser Anastomosentechnik entweder offen (n = 11) oder thorakoskopisch (n = 2) durchgeführt.Die Anastomosentechnik basiert auf der Bildung eines dosalen Lappens aus dem oberen Ösophagusstumpf, der in das spatulierte Ende des unteren Ösophagussegmentes eingeschlagen wird. Die ersten Hinterwandnähte können anschließend unter verminderter Spannung angelegt werden. Bei Komplettierung der Anastomose resultiert eine schräg verlaufende Anastomosenebene.Die Methode stellt eine hilfreiche Alternative dar, um die Ösophagusstümpfe von Neugeborenen mit Ösophagusatresie und distaler ösophagotrachealer Fistel anzunähern. Durch die Technik können die stabilisierenden ersten Hinterwandnähte unter verminderter Spannung angelegt werden, wodurch die Zugbelastung auf einzelne Nähte reduziert und die Anastomosierung im Vergleich zur herkömmlichen End-zu-End-Anastomose erleichtert wird.

We present a 54 year old female patient who had undergone a Ross procedure in 2009, and in 2013 again a replacement of the aortic root and arch with bioprothetic material and homograft replacement of the pulmonalis walve. Postoperatively the patient had experienced a functional compromising tracheal stenosis and a persistent esophago-tracheal fistula. Endoscopic attempts to close the fistula were not successful, and the fistula was "bridged" with an endoscopically positioned tracheal stent.We report the anaesthesiological management during the open surgical repair of the esophago-tracheal fistula and resection of 2 tracheal rings with high frequency jet ventilation over a period of 2.5 h. The Patient was discharged from hospital on the 17. postoperative day.

The treatment of newborns with esophageal atresia (EA) and tracheoesophageal fistula (TEF) is associated with a great logistic effort. The aim of the presented study was to analyse the possibility to influence the time of surgery.Data from 30 neonates with EA and TEF regarding the date and mode of birth, biometric data and preoperative acid-base and blood gas values were collected retrospectively. The newborns were divided into two subgroups: birth between Monday and Thursday ("week"), and birth from Friday to Sunday ("weekend").We observed a seasonal peak of births in November/December. The rate of prenatal ultrasound detection of polyhydramnions was 40%. In 14 of 16 cases with Caesarean section, maternal or foetal problems predicted the date and mode of delivery. In both groups, most newborns had an unimpaired postnatal adaptation. There were no significant differences regarding biometry. Delivery at the weekend was associated with later surgical repair (second vs. first day of life). Repeated estimations of acid-base and blood gas parameters over a median time span of 13 hours revealed a stable situation with a trend to normalisation.The time of birth is multifactorial and, in most cases, can neither be predicted nor influenced. Stable respiratory and metabolic parameters in the majority of patients allow a surgical intervention within a limited time frame during the first days of life.As it is hardly possible to plan the surgical procedure, an experienced team as well as neonatal intensive care facilities and operation room access must be available throughout the week.

During the past three decades, the use of voice prostheses has developed worldwide into the gold standard for voice rehabilitation after total laryngectomy. Insertion of a voice prosthesis is a simple and rapid surgical procedure, which is associated with a low rate of complications. The current article describes the cases of 2 patients showing a rapid development of granulation tissue around the voice fistula, leading to complete incarceration of the prosthesis and subtotal/total stenosis of the neopharynx.

Background: In the past decade, targeted therapy with antiangiogenic drugs has become standard of care for most types of metastatic, progressive thyroid cancer. While these drugs were thought initially to be less toxic than traditional chemotherapy, they can have rare but serious and fatal toxicities. Once such toxicity that has been reported in other tumor types is upper airway fistula formation, which can be life-threatening.

Esophageal malformations are rare and can occur sporadically or as a component of various syndromes. The variations and classifications are manifold. With the available modern operation techniques most malformations can be resolved with good results. However, esophageal malformations are often combined with further malformations which limit the prognosis. The separation of the trachea and esophagus after gastrulation is not yet completely researched. The results so far indicate that the localized expression of various homeodomain transcription factors is essential for normal development of the trachea and esophagus.

Osophageale Fehlbildungen sind selten. Sie kommen sowohl sporadisch als auch im Rahmen von Syndromen vor. Ihre Varianten und Klassifikationen sind vielfaltig. Mit den zur Verfugung stehenden modernen Operationsmethoden lassen sich die meisten mit guten Ergebnissen sanieren. Haufig sind osophageale Fehlbildungen allerdings mit weiteren Malformationen kombiniert, welche die Prognose limitieren. Die Separation von Trachea und Osophagus nach der Gastrulation ist noch nicht vollstandig erforscht. Die bisherigen Ergebnisse weisen darauf hin, dass die lokalisierte Expression verschiedener Homeodomain-Transkriptionsfaktoren essenziell fur die regelrechte Entwicklung von Trachea und Osophagus ist.

Congenital deformities, various forms of trauma, foreign bodies, granulomatous infection and tumors are the most common causes of tracheoesophageal fistulas. This is a rare but life-threatening complication with mortality rates up to 60% due to chronic aspiration and innominate artery arrosion and bleeding. Bronchoscopy should be done promptly if a fistula is suspected, followed by esophagoscopy. Radiologic examinations are only helpful for operational planning. Surgical treatment is mandatory for benign fistulas with excellent short-term and long-term results. However, for malignant fistulas the survival time is often only weeks to months and are best treated by palliative stenting, which offers a short-term improvement in the quality of life.

The use of extracorporeal membrane oxygenation (ECMO) was established in Germany 25 years ago in specialized centers as an approach for patients suffering from severe life-threatening lung failure. Apart from such indications the inclusion of ECMO as a planned intervention for safety purposes in the postoperative weaning from mechanical ventilation in a 22-year-old woman is described. Following a complex tracheal reconstruction due to oesophageal-tracheal fistula formation, conventional weaning procedures would have been accompanied by a very high risk as extubation failure might have caused an airway disaster. After elective use of veno-venous ECMO the young patient was extubated without risk and lung function was stabilized safely. Extracorporeal lung assist can be indicated apart from rescue management in elective situations for prevention of an airway catastrophe after careful calculation of the harm/benefit ratio.

Approximately 30% of all patients show periprosthetic leakage or severe fistula enlargement after laryngectomy and prosthetic voice restoration. In a prospective study, we investigated the role of aggressive anti-reflux therapy in fistula complications.A total of 48 patients were assigned to one of two groups. Group A consisted of 16 patients with recurrent periprosthetic leakage. Group B comprised 32 patients without periprosthetic leakage. The presence of reflux was objectively assessed using 24-h dual-probe pH monitoring. All patients with pathological reflux underwent proton pump inhibitor (PPI) therapy. After 6 months, patients were re-evaluated for fistula complications and objective reflux parameters.The mean absolute number of reflux events was 202.8 (+/-44) before and 74.5 (+/-22.9) after PPI therapy (p=0.025). The reflux area index decreased from 419.5 (+/-112.5) before treatment to 105.8 (+/-54.7) after treatment (p=0.0005). The mean DeMeester score was 104.4 (+/-21.3) without PPIs and 43.5 (+/-9.3) after 6 months with PPIs (p=0.028). A risk analysis for patients with both periprosthetic leakage and pathological reflux (15 patients at the beginning of the study, four patients after therapy) showed that the relative risk of periprosthetic leakage decreased to 0.3 (p=0.0054) with PPI therapy.Patients with recurrent periprosthetic leakage in the region of the fistula showed a significantly higher number of supra-oesophageal reflux episodes. Rigorous anti-reflux treatment can help manage or prevent leakage problems in a large proportion of patients.

Voice rehabilitation after laryngectomy by tracheo-esophageal puncture with insertion of voice prosthesis (provox, bloom singer) has proven a valuable tool for many years. However, in some patients major problems arise due to enlarged tracheo-esophageal fistulas causing troublesome aspiration. Many different approaches for closure of these fistulas have been suggested including major surgery like myocutaneous flaps. In the paper we describe our safe and reliable procedure of a three layered closure of tracheao-esophageal fistulas using a sliding trachea as the third layer.

Tracheoesophageal (TEF) and tracheopharyngeal fistulas (TPF) after laryngectomy can mainly be divided into five types: "high TEF with leakage through the voice prosthesis (VP)" (Type Ia), "high TEF with leakage around the VP" (Type Ib), "enlarged high TEF" (Type II), "deep TEF" (Type III), "TPF" (Type IV) and "TPF associated with pharynx stenosis" (Type V). Leakage of TEF in prosthetic voice restoration usually responds well to conservative measures. If these measures fail, as well as in all cases of TPF, surgical intervention is necessary for transtracheostomal or transcervical closure with multi-layer sutures of the esophagus and trachea. In persisting TEF/TPF after unsuccessful surgical attempts revision surgery remains challenging. Tracheostoma transposition for dissociation of the cranial end of the trachea and the hypopharynx and esophagus is essential for effective closure. In rare cases of TPF combined with pharyngoesophageal stricture formation a resection and immediate reconstruction of the stenotic pharyngoesophageal segment with a tube-shaped fasciocutaneous radial forearm flap must be considered.

Postradiotherapy or malignant esophagotracheal fistulas still represent a dilemma. In the absence of surgical options attempts are made to close the fistula endoscopically by means of esophageal and/or tracheal stents. Tracheal stent placement in laryngectomy patients with terminal stomas is particularly problematic due to the risk of stent dislocation during cannula replacementSix laryngectomy patients with high esophagotracheal fistulas were each fitted with a coated Ultraflex stent (Boston Scientific, Watertown/MA, US). Following skin undermining, the stents were fixed to the tracheostoma with interrupted sutures and the skin flaps attached to the stent with a second row of sutures.Fistulas could be completely closed in all patients and there were no cases of stent dislocation. Cannula replacement was unproblematic.Suture fixation of tracheal stents is a viable procedure even for patients with esophagotracheal fistulas and terminal tracheostomy following laryngectomy.

In a prospective study on patients who developed recurrent periprosthetic leakage in the region of the fistula after laryngectomy and prosthetic voice restoration, we investigated whether there was an increased incidence of supra-oesophageal reflux.A total of 48 patients included 16 patients with recurrent periprosthetic leakage (group A) and 32 patients without periprosthetic leakage (group B). The presence of reflux was objectively assessed using 24-hour dual-probe pH monitoring. The number of supra-oesophageal reflux events, the reflux area index (RAI 4) and the DeMeester score were determined as well as the relative risk of fistula enlargement in relation to the presence of reflux and postoperative radiotherapy.In group A pathological reflux events were detected in 100% of the cases. The mean number of supra-oesophageal reflux episodes was 414.8, the RAI was 419.5 (+/-212.45) and the DeMeester score was 104.4 (+/-21.3). In group B pathological reflux events were found in only 50% of the cases. The mean number of supra-oesophageal reflux episodes was 11.8, the RAI was 146.9 (+/-40.4) and the DeMeester score was 42.9 (+/-11.8). All reflux parameter results for group A patients were significantly higher than those obtained for group B patients. The relative risk of fistula enlargement was 1.8-2.3 times higher in the presence of reflux. Postoperative radiotherapy did not increase the risk of fistula enlargement (relative risk 0.75-0.93).A significantly higher number of supra-oesophageal reflux episodes occurred in patients with recurrent periprosthetic leakage in the region of the fistula. As reflux events may cause problems in the region of the fistula, prophylactic treatment with proton pump inhibitors is recommended.

Approximately a quarter of all patients who undergo prosthetic voice restoration develop periprosthetic leakage with aspiration symptoms within 1 to 4 years following surgery. Depending on the severity of fistula enlargement, treatment ranges from conservative approaches to surgical procedures. In some cases, however, these measures prove unsuccessful. The causes of treatment failure and fistula enlargement are not fully understood. There is growing evidence, however, that the presence of coexisting supraesophageal reflux can contribute to fistula complications. We report the case of two patients with voice prostheses and simultaneous severe reflux disease who underwent multiple failed attempts at fistula closure. After effective reflux therapy, the fistulas could eventually be closed successfully.

This report highlights the diagnostic and therapeutic challenges which occurred in a newborn with oesophageal atresia of the type Vogt III c in association with a tubular supracarinal tracheal stenosis.

Tracheal agenesis (TA), aplasia or total atresia of the trachea are congenital anomalies which are still incompatible with life. Despite the many attempts of different interventions, there are yet no promising, long-term methods of treatment. Only with sufficient proportion of the proximal or distal trachea available, it is possible to place a tracheostomy, which also opens up new vistas of life for the affected child. In most cases the seldom deformation, trachealagenesis, does not get recognised before the child is born. It may therefore be the immediate diagnosis postnatal that is decisive over the final prognosis of the child. The prepartal suspicion of a duodenal stenosis, an aphonic newborn as well as the frustrane attempts of intubation are possible guidelines of TA. In independence of peripartal and anamnestical factors, individual disciplinary decisions are necessary for further treatments. After the cancellation of intensive care the premature infant of the case report died as consequence of postnatal diagnosed tracheal aplasia. Under circumstances, medical treatments such as the ex utero intrapartum procedure (Exit), the temporary method of extracorporal membrane oxygenation (ECMO) or the use of cartilage tissue for the plastic trachea reconstruction can provide advanced medical opportunities.

The Staffieri technique is a method for surgical rehabilitation of the voice after laryngectomy. A fistula between trachea and esophagus is created to achieve a so-called "Neoglottis phonatoria". The assignment of the neoglottis is to protect the airways during ingestion and to give the patient a chance to phonate during expiration.The case of a 71-year-old man with aspiration via his Staffieri fistula is presented. The fistula was created in 1979 after laryngectomy because of a laryngeal carcinoma. He also suffered from a metastasized gastric carcinoma which was cured by a 2/3 resection of the stomach in 1970. He is free of recurrence with regard to his oncologic diseases. Until 2003 the patient had no problems with the fistula and was able to phonate well. In 2003 the patient had progressive aspiration via the fistula and the Staffieri fistula was therefore reduced in diameter by surgery. In 2005 the patient presented himself again because of a recurrence of the aspiration. Endoscopy of the upper aerodigestive tract showed healthy mucosa, contrast imaging of the esophagus showed a significant aspiration of the contrast medium into the trachea. Due to these findings a voice prosthesis was inserted into the fistula. This therapy cured the patient from aspiration. He is able to phonate well and has no further complaints.Aspiration via a Staffieri fistula is described in about 25 % of cases and therapy is sometimes difficult. Surgical narrowing of the diameter of the fistula is inadequate in most cases and many patients would lose their restored voice if the fistula was closed permanently. Through the insertion of a voice prosthesis aspiration could be stopped and voice was immediately restored.

Leakage around an indwelling voice prosthesis is detected during 13% up to 27% of all replacement procedures of voice prosthesis and causes serious complications in further voice restoration of the laryngectomee. Lots of therapeutic options to stop periprothetic leakage have been described (Injection of Bioplastique, autologous fat or collagen, suture techniques, spacer therapy) without convincing success rates.Custom-fit voice prostheses are ordinary indwelling voice prostheses (Blom-Singer low pressure Indwelling 20 fr) with enlarged flanges and reduced shaft length that are individually sized for the shunt of the laryngectomee. Especially enlarging the esophageal flange provides a tight sealing of leakage around the prosthesis.In a one year lasting clinical trial 692 voice prostheses were changed. In 77 cases periprothetic leakage was detected and fistulas were fitted with individually sized voice prostheses.In 76 cases total control of leakage was achieved without any specific complications taking place. Moreover two types of leaking tracheoesophageal fistulas were distinguished, a dilated-atrophic and an infected-necrotic type. 57% of the fistulas were dilated-atrophic type and 43% of the fistulas were classified infected-necrotic type. Infected-necrotic fistulas needed enlarged flanges tracheal an esophageal for tight sealing in 91% of the cases whereas dilated-atrophic fistulas needed double flanges only in 45%. 70% of infected-necrotic type fistulas needed only one singular history of a custom-fit prosthesis and could be changed back to ordinary indwelling prostheses after healing had taken place.As the insertion of a modified prosthesis is only slightly more effort than an ordinary voice prosthesis insertion, the success rate is high und complications are rare we recommend the custom-fit voice prosthesis for treatment of periprothetic leakage.

Acquired, benign esophago-respiratory fistula occurs as a rare complication of different disorders.Over a period of 30 years, 37 patients with acquired, benign esophago-respiratory fistulas were treated at the authors' institutions. 35 of the 37 patients were operated upon. Acute operation involved primary repair of the trachea and esophagus, or intubation of the gullet and/or gastrostomy. Elective operations were performed on 13 patients.Complications were observed in 14 patients. There were 4 cases with anastomotic leakage (all of them on the neck). Direct closure was carried out in 2 patients; the remaining 2 cases healed spontaneously. None of the 4 patients died. Seven of the 37 patients died (18.9%). This seems acceptable in view of the severity of the cases and the extension of the operations.1. The causes of a majority of the esophago-respiratory fistulas in this material are connected with the complications of corrosive injury and peptic stricture of the esophagus. 2. The well-known fact that most of these fistulas occur in the right chest is confirmed. 3. Gastrostomy and/or intubation of the gullet seems to be the best solution for this lesion in the acute cases and in severely ill patients. 4. In elective cases, reconstruction is suggested, if possible in one step.

Since the technique of vacuum assisted closure has been clinically introduced, the possibilities in reconstructive head and neck surgery have greatly increased. Preconditioning and prelaminating allows a pedicled or free flap plasty to be epithelialized on both sides before the flap gets transferred to its future location.We describe the technique of preconditioning and prelaminating of pedicled and free microvascular anastomised flap plasties and we report our experience with 5 cases. Our results are compared with data from the literature.The procedures concerned take only little time and the flap gets optimally prepared for its task in view of the postoperatively modified hemodynamics. By preconditioning, the flap to be lifted is prepared for the future centralised blood supply exclusively via the pedicle vessel without leaving the donor side. Thereby the skin island of such flaps can be increased in size over the natural angiosomes without an increased risk of necrotisation.By the technique of prelamination, skin or mucosa tissue may be applied onto both sides of the flap so that it can resist the biochemical and mechanical tasks which will be required after transposition. Especially for the reconstruction of defects in the upper aerodigestive tract this is a great advantage, since the inner side of the flap has to resist saliva which represents one of the most aggressive secretions in the human body.

The self-expanding nitinol stent is easy to handle and well tolerated. It offers an improved method in the treatment of perforations of the upper aerodigestive tract. It is easily implantable with rigid and flexible endoscopes. A 45-year-old female patient developed a tracheal necrosis after polytrauma and protracted intubation and ventilation. The permanent cuff pressure caused a 5-cm long fistula located at the posterior trachea 3 cm above the carina. After stabilization of the general condition and spontaneous reduction of the fistula length to 2 cm, we implanted the silicon-covered esophageal stent. Daily bronchoscopic examination was done before and after implantation of the stent. Two days after implantation, we were able to remove the blocked tracheostomy tube. Immediately oral nutrition was possible without complications. Because of its easy and fast application without any complications, the new type of nitinol stent is a promising alternative for ear, nose, and throat patients in bad general condition to provide fast and safe treatment in benign tracheoesophageal fistulas.

In association with perforating or blunt trauma, isolated injuries of the trachea and the bronchi are rarely seen. More frequently, however, they occur when adjacent organs or structures are involved, thus creating very complex syndromes. Symptoms such as dyspnea, coughing attacks, hemoptysis, soft tissue emphysema, cyanosis, and pneumothorax should point to severe tracheobronchial injuries. Diagnosis is confirmed through an emergency tracheobronchoscopy; early surgical repair is mandatory. Iatrogenic injuries--most often due to intubation maneuvers--are infrequent but potentially life-threatening and demanding immediate repair except in cases with superficial tears. Leading symptoms of transmural lacerations are dyspnea, soft tissue emphysema, and pneumothorax. Tracheoesophageal fistulas result from decubital necrosis caused by long-term intubation. With spontaneous healing never occurring, surgical repair is carried out ideally by closing both openings in chronic fistulas, while simultaneous tracheal stenosis is treated by segmental resection. Tracheoarterial fistulas, mostly associated with tracheostomy, become fatal if not detected immediately. Definitive repair requires the resection of the vascular segment involved.

Virtual bronchoscopy of the pediatric patient has been reported to be more difficult because of artifacts due to breathing or motion. We demonstrate the benefit of the accelerated examination based on multislice spiral CT (MSCT) in the pediatric patient which has not been reported so far.MSCT (tube voltage 120 kV, tube current 110 mA, 4 x 1 mm Slice thickness, 500 ms rotation time, Pitch 6) was performed on a CT scanner of the latest generation (Volume Zoom, Siemens Corp. Forchheim, Germany). In totally we examined 11 patients (median age 48 months, range 2-122 months) suspected of having tracheoesophageal fistula (n = 2), tracheobronchial narrowing (n = 8) due to intrinsic or extrinsic factors or injury of the bronchial system (n = 1).In all patients we obtained sufficient data for 3D reconstruction avoiding general anesthesia. 6/11 examinations were described to be without pathological finding. A definite diagnosis was obtained in 10 patients. Virtual bronchoscopy could avoid other invasive diagnostic examination in 8/11 patients (73%).Helical CT provides 3D-reconstruction and virtual bronchoscopy in the newborn as well as the infant. It avoids additional diagnostic bronchoscopy in a high percentage of all cases.

In this case report we discuss the anaesthetic management of newborns with esophageal atresia classified as Vogt III b. This type is characterised by an upper esophageal pouch which ends blindly and a distal tracheoesophageal fistula. Commonly associated diseases are cardiac, renal, vertebral and anal anomalies. The most important intraoperative anaesthesiological complications are acidosis, hypoxaemia, gastric distension, endotracheal tube obstruction, tracheal compression, cardiac arrhythmias and atelectasis. In the presented case an endotracheal tube obstruction with hypercapnia occurred which required a change of the airway. After changing the endotracheal tube the newborn could be ventilated sufficiently. Further postoperative course was uneventful.

Since the landmark report by Crohn, Ginzburg and Oppenheimer in 1932, the spectrum of involvement of Crohn's disease has expanded to include the entire digestive tract from mouth to anus. The involvement of the esophagus by Crohn's disease is very rare.We report a 41-year-old male patient with severe Crohn's disease of the distal esophagus with a fistula to the right bronchial system.After a long period of nutritional support we performed a transthoracic esophagectomy and a Nissen fundoplication. Postoperatively his course was complicated by pneumonia and withdrawal symptoms.Esophagectomy is indicated in Crohn's disease of the esophagus with severe stricture or fistula formations.

Esophagorespiratory fistulas were frequently caused by malignant tumors, bougienage, laser therapy or radiochemotherapy. We here report the case of a patient with inoperable bronchial cancer, who developed a symptomatic esophagorespiratory fistula during combined radiochemotherapy with Cisplatin. A sufficient occlusion of the fistula could not be achieved with conventional plastic tubes or novel self-expanding silicone-coated Gianturco Song stents. After extraction of two Gianturco Song stents we inserted a Montgomery Salivary Bypass Stent into the esophagus and Dynamic stent into the trachea. This resulted in a total occlusion of the fistula. This present case suggests that the Montgomery stent may have little tendency to migrate due to its characteristic configuration and fixation and further demonstrates that the novel self-expanding silicone-coated Gianturco Song stents can be removed, if necessary.

14 patients with central malignant airway obstructions (n = 10), poststenotic pneumonia (n = 2) and esophagotracheal fistulas (n = 2) were treated with self-expanding stents in the trachea (n = 9), right (n = 4) and left (n = 1) main bronchus. The results showed that stent implantation in the tracheobronchial system is a very effective palliative treatment in the above-mentioned indications which takes immediate effect and complements the already established palliative therapy modalities in central airway malignancies.

Congenital esophago-tracheal and esophago-bronchial fistulae are rare. Symptoms are recurrent pneumonia, cough, dysphagia and pain. The diagnosis is made by bronchoscopy or esophagoscopy. Every time the diagnosis is certain, the fistula has to be exstirpated by means of a thoracotomy and plastic reconstructive flap surgery.

Traumatic and iatrogenic injuries of the trachea are rare. In case of suspected rupture of the trachea a bronchoscopy remains the 'gold standard' of diagnostic procedures. The injuries should be repaired as soon as possible through a right thoracotomy or a collar incision using resorbable sutures. In case of small lesions a conservative treatment may be discussed. Overall the prognosis of tracheal injuries is good.

Cystic neck alterations are discussed. Practically important guidelines and possible pitfalls are outlined. The importance of a thorough preoperative evaluation is stressed, in order to obtain optimal surgical results.

Closure of oesophagotracheal fistulae in the cervicothoracic region using a cervical approach often fails. We report a patient with carcinoma of the larynx who underwent pharyngolaryngectomy, postoperative radiotherapy and several operations for reconstruction of the hypopharynx and cervical oesophagus elsewhere. Finally we were asked to close an oesophagotracheal fistula in the cervicothoracic region. We were successful using a pectoralis major muscle flap via a combined transcervical-transthoracal approach. This interdisciplinary procedure seems to be the method of choice in difficult cases of achieving safe closure of fistulae in this region.