Recurrent tracheoesophageal fistula (rTEF) is a severe complication following EA anastomosis that often does not heal spontaneously and requires interventional or surgical treatment. Our previous article reported a large number of cases of thoracoscopic surgery for rTEF, demonstrating that it can fully replicate the process of traditional thoracotomy with no difference in prognosis. Approximately 10% of children will experience repeated occurrences of TEF even after surgical repair of rTEF. There are few reports on the clinical characteristics of such patients. This article retrospectively collects the clinical data of multiple recurrences of rTEF after EA surgery, analyzes the clinical characteristics, and discusses the feasibility, efficacy, and experience of thoracoscopic surgery for this rare condition.

We retrospectively evaluated the clinical data of rTEF cases that underwent thoracoscopic repair at our hospital from September 2017 to December 2024. 

The group of 106 patients included 68 male children, constituting 64.2% of the cohort. The average birth weight was 2,757 ± 527g, with a median gestational age was 38 (37, 38) weeks. According to the Gross classification, there were 103 cases of type III, two cases of type IV, and one case of type V. Open thoracotomy was performed for initial esophageal anastomosis in 28 patients, while thoracoscopic surgery was utilized in 78 patients. Following the initial esophageal anastomosis, anastomotic leakage occurred in 36 cases (33.9%), and 68 children (64.2%) developed anastomotic strictures, necessitating esophageal dilation treatment.

The median preoperative weight for the 113 surgeries was 6.5 (5.5, 9.5) kg, and the median age at surgery was 8.9 (6.0, 21.2) months. There were 89 cases of TEF, 19 cases of EPF, 3 cases of EBF, and 2 cases of EPF combined with TEF. Ninety-two cases were the first-time repair of rTEF, 18 cases were the second-time repair, and three cases were the third-time repair. The median operation time for the 113 surgeries was 2.5 (2.0, 3.5) hours. The median postoperative duration of mechanical ventilation was 115 (89.4, 144.0) hours, the median postoperative ICU stay was 6 (5.0, 8.5) days, and the median duration of total hospitalization after surgery was 16 (13, 23) days. 

Postoperatively, 20 patients experienced pneumothorax, 29 had esophageal leakage, and 34 developed severe pneumonia and pyothorax. After a mean follow-up of 38.2 ± 22.4 months, 64 children required dilation for esophageal stricture, and 16 experienced a recurrence of tracheoesophageal fistula. There were six deaths in this group: four patients succumbed to severe pneumonia and respiratory failure following rTEF recurrence, one patient died from esophageal perforation due to esophageal dilation, and one patient died from severe pneumonia in ICU.

The 113 thoracoscopic surgeries were divided into a multiple recurrence group with 21 cases (18.6%) and a first recurrence group with 92 cases (81.4%). In the multiple recurrence group, there were 18 second-recurrence and three third-recurrence. This group included 16 male patients (76.2%), with a median birth weight of 2660 (2300, 3065) g and a median gestational age of 38 (36.5, 38) weeks. Twelve patients (57.1%) underwent thoracoscopic initial EA anastomosis. Following this, 9 patients (42.9%) experienced esophageal anastomotic leakage, and 14 patients (66.7%) developed anastomotic strictures requiring esophageal dilation. 

The median weight at the time of thoracoscopic repair surgery of multiple recurrence group was 10.5 (8.2, 11.8) Kg, and the median age was 24.3 (17.4, 34.5) months. During surgery, 2 cases were confirmed as EPF combined with TEF, 3 cases as EBF, 7 cases as EPF. Overall 12 patients (57.1%) were classified as EPF, while the remaining 9 patients (42.9%) were classified as TEF. Twelve patients (7.1%) used localization techniques during surgery, with a median surgery time of 3.5 (2.5, 4.0) hours. 

Postoperatively, the median duration of mechanical ventilation was 115.0 (50.0, 134.0) hours, the median ICU stay was 6.0 (5.0, 8.5) days, and the median postoperative hospital stay was 18 (14, 35) days. Complications included pneumothorax in one child, esophageal leaks in seven children, severe pneumonia or pyothorax in ten children, esophageal strictures requiring esophageal dilation in fourteen children, and re-recurrence of tracheoesophageal fistula in four children. One child died from severe pneumonia caused by re-recurrence of tracheoesophageal fistula. 

Comparing the above parameters with the first recurrence group, it was found that the age and weight at the time of thoracoscopic repair of rTEF were significantly higher in the multiple recurrence group. Additionally, the proportion of EPF were significantly higher in the multiple recurrence, and the surgery time was also significantly longer. No significant statistical differences were found in other variables.

Patients with multiple recurrence of rTEF after EA repair are more likely to have EPF, and the operation time is significantly longer compared to the first recurrence group. Thoracoscopic repair of multiple rTEF is safe and feasible.