Thoracoscopic management of recurrent tracheoesophageal fistula: a single-center outcome analysis

Feng et al. BMC Surgery (2025) 25:548 https://doi.org/10.1186/s12893-025-03292-y BMC Surgery Open Access RESEARCH Thoracoscopic management of recurrent tracheoesophageal fistula: a single-center outcome analysis Cuizhu Feng1,2*, Long Li1,2, Xiang Li2, Yanxia Zhang2, Haibin Yu3, Mao Ye2 and Zhen Chen2 Abstract Background Although thoracoscopic treatment of congenital esophageal atresia is widely accepted among pediatric surgeons, its application in recurrent tracheoesophageal fistula (RTEF) remains rare because of its technical difficulty. This study retrospectively analyzed thoracoscopic RTEF repairs at a single center to evaluate the safety, feasibility, and outcomes of this approach, providing a clinical reference. Methods We retrospectively reviewed 22 patients with RTEF who underwent thoracoscopic repair at the Capital Center for Children's Health between October 2020 and July 2024. All patients had a history of type III esophageal atresia repair, including 13 cases of type IIIa and 9 cases of type IIIb (Gross classification). The cohort included 8 male and 14 female patients, with an admission age of 2 to 30 months (mean: 8.0 ± 7.2) and weight of 2.3 to 11.0 kg (mean: 5.5 ± 2.4). There were 16 first recurrences, 5 s recurrences, and 1 fourth recurrence. Five patients had failed previous endoscopic fistula ligation, and 9 had a history of open thoracotomy. All 22 underwent thoracoscopic repair. Results Thoracoscopic RTEF repair was successfully completed in all 22 patients (100%). The operation time ranged from 136 to 420 min (mean: 288.5 ± 93.1), hospitalization ranged from 15 to 124 days (median: 24), and postoperative invasive ventilator support lasted 0 to 480 h (median: 20). Esophageal leakage occurred in 6 patients (27.3%), all of whom recovered with 1 to 8 weeks of conservative treatment. Esophageal stenosis developed in 8 patients (36.4%), including 6 pre-existing and 2 new-onset cases; all improved after 1 to 6 sessions of endoscopic balloon dilation. During follow-up (0.5–4 years), only 1 patient (4.5%) experienced re-recurrence; the remaining patients showed good growth and development. Conclusion Thoracoscopic treatment of RTEF following esophageal atresia is safe, feasible, and yields satisfactory clinical outcomes. Keywords Recurrent tracheoesophageal fistula, Esophageal atresia, Thoracoscopic treatment *Correspondence: Cuizhu Feng 1 Department of General Surgery, Capital Institute of Pediatrics, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, People’s Republic of China 2 Department of General Surgery, Capital Center for Children’s Health, Capital Medical University, Beijing, People’s Republic of China 3 Department of Pediatric Surgery, Inner Mongolia Maternal and Child Health Care Hospital, Inner Mongolia, People’s Republic of China © The Author(s) 2025. Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creati vecommons.org/licenses/by-nc-nd/4.0/. Feng et al. BMC Surgery (2025) 25:548 Background Recurrent tracheoesophageal fistula (RTEF) is a serious complication following congenital esophageal atresia repair and often requires reoperation. Although endoscopic techniques—such as fistula ligation, drug injection, and covered stent placement—have been reported in the literature [1–4], their use remains limited because of small case numbers, high recurrence rates, and the need for multiple interventions. As such, these methods are still considered exploratory. Surgical repair remains the most definitive treatment [5–8]. Reoperations are typically performed via thoracotomy because of severe thoracic adhesions and unclear anatomical structures, with only a few pediatric surgical centers adopting thoracoscopic techniques for RTEF repair. Since 2020, the Capital Institute of Pediatrics has routinely employed thoracoscopy for RTEF treatment, achieving satisfactory outcomes. This study retrospectively analyzed 22 patients with RTEF treated thoracoscopically at our institute to evaluate the safety, feasibility, and outcomes of this approach, aiming to provide a reference for thoracoscopic management of RTEF. Materials and methods Patients We retrospectively analyzed 22 patients with RTEF who underwent thoracoscopic repair at the Capital Institute of Pediatrics between October 2020 and July 2024. Among them, 13 were classified as type IIIa and 9 as type IIIb (Gross classification). The cohort included 8 male and 14 female patients, with a mean age at admission of 8.0 ± 7.2 months (range: 2–30 months) and a mean weight of 5.5 ± 2.4 kg (range: 2.3–11.0 kg). Recurrence details included 16 first recurrences, 5 s recurrences, and 1 fourth recurrence. Five patients had previously failed endoscopic fistula ligation, and 9 had a history of open thoracotomy. Among the children included, two were from our center; the remaining were referred from other institutions. This study did not include cases of missed proximal tracheoesophageal fistula. All 22 patients underwent thoracoscopic tracheoesophageal fistula repair. Diagnostic methods Diagnostic methods included gastroenterography (using a water-soluble contrast medium), bronchoscopy, gastroscopy, and chest computed tomography (CT). These preoperative examinations were used to comprehensively evaluate the esophagus, trachea, and lungs to aid surgical planning. In this study, all 22 patients underwent gastroenterography; 19 underwent bronchoscopy, 18 underwent gastroscopy, and 19 underwent chest CT. Surgical methods The patients were positioned in the left lateral decubitus position with the right arm elevated. A 5-mm trocar was Page 2 of 5 inserted at the subscapular angle as the thoracoscopic port. Two 3-mm trocars were placed at the third and sixth intercostal spaces along the mid-axillary line as the main operating ports, and a 5-mm trocar was inserted at the seventh intercostal space near the spine as an assistant port. After successful trocar placement, pleural adhesions were dissected using an electric hook to expose the posterior mediastinum. Esophageal dissec (...truncated)