Pericardial flap interposition for the definitive management of recurrent tracheoesophageal fistula.

From 1974 to 1988, six children with fistula recurrence following primary tracheoesophageal fistula (TEF) repair have been managed at our hospital. Reclosure of the fistula with pleural flap interposition was used as the initial corrective procedure in five patients, with an 80% incidence of second TEF recurrences. Due to these discouraging results, we have abandoned this technique and instead favor fistula reclosure with interposition of a pedicle of vascularized pericardium between the esophageal and tracheal suture lines. The pericardial pedicle is easy to mobilize, effectively isolates the tracheal and esophageal suture lines, and eliminates the often difficult task of finding sufficient pleural tissue for fistula interposition in small infants. Furthermore, the vascularized pedicle serves as a template for the ingrowth of neomucosa from the existing esophageal mucosa should an anastomotic leak occur. Since adopting this approach, we have used this technique on four children, three of whom had second recurrences after pleural interposition, and have had no evidence of recurrent fistula formation at follow-up ranging from 2 to 6 years. With at least a 20% incidence of second recurrences reported following conventional management with fistula closure and pleural interposition, we believe use of a pericardial flap in the management of the recurrent TEF is the most appropriate surgical procedure.