P1.045: Repair of Complex Acquired Tracheoesophageal Fistula guided by 3D Printing

Introduction: Foreign body ingestion of button batteries (BB) in pediatric populations is increasingly common and can cause severe complications like an acquired tracheoesophageal fistula (TEF). TEFs require urgent airway management and surgical correction through a technically challenging procedure often unique to each patient’s condition. Increased access to 3D printing (3DP) technology has made (3DP) models more common for complex surgical planning: including, recently, for congenital TEF repairs. Here, a custom 3D printed model from a pediatric patient’s computed tomography (CT) scan guided the repair of an acquired TEF secondary to BB ingestion.

Case Description: A 10-month-old otherwise healthy female infant presented to the Emergency Department with one day of cough, fever, and congestion. She was discharged home with the diagnosis of an upper respiratory infection but two days later represented with persistent fevers and worsening respiratory distress. A chest x-ray demonstrated a 2cm BB in the proximal esophagus (Figure 1) that was urgently removed by rigid endoscopy though she remained intubated to monitor a plaque-like tracheal lesion. Although the lesion initially appeared to be healing, an extubation attempt on post-operative day #7 resulted in immediate respiratory failure with subsequent emergent rigid bronchoscopy revealing a 2x1.5cm TEF. An endotracheal tube (ETT) was placed distal to the TEF and a gastrostomy tube was placed for gastric decompression.
Given the complexity of the surgical repair, our Center for Advanced 3D+ Technologies was consulted and used a CT scan to construct a 3DP model, which was a 1:1 anatomical replica of the of the patient’s anatomy (Figure 2). This model helped the surgical team gain greater spatial 3D understanding of the patient’s anatomy and perform surgical simulation prior to the planned TEF repair. On hospital day 30, the TEF was repaired with a partial circumference esophageal anastomosis and end-to-end tracheal anastomosis. Her post-operative course was complicated by pseudomonal mediastinitis treated with additional antibiotics and post-extubation left vocal cord hypomobility treated with an injection laryngoplasty to minimize aspiration risks. She was discharged home in stable condition.

Discussion: 3DP models have been used across specialties to train and prepare surgeons for complex surgical procedures and/or abnormal anatomy. This case represents the first use, to our knowledge, of a patient-specific 3DP model for planning complex acquired TEF repair. Acquired TEFs secondary to BB ingestion can be challenging, multidisciplinary repairs with unique anatomies. 3DP models enhance interdisciplinary, collaborative surgical planning. When surveyed postoperatively, our surgical team rated the model as highly accurate compared to intraoperative findings, and instrumental in improving surgical precision and coordination.

Conclusion: Patient-specific 3DP models can significantly enhance interdisciplinary surgical planning of complex anatomy like the repair of this acquired TEF secondary to BB ingestion.