Tracheoesophageal Fistula

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Tracheoesophageal Fistula

• R2???/VS???

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Epidemiology

• Incidence 1/4000
• 30-50 congenital anomalies (35 cardiac 30
  musculoskeletal)
• 20-30 premature, BWlt2000g
• VACTERAL and VATER syndrome
• Vertebral anomalies
• Anal imperforate anus
• Cardiac VSD, PDA, TOF, coarction of aorta, ASD
• Trachea TEF
• Esophageal EA
• Renal renal agenesis,ureteral abnormalities,
  hypospadias
• Limb polydactyly, wrist/knee anomalies

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Embryology

• Esophagus and tracheal originate from the median
  ventral diverticulum of the forgut, separated by
  esophagotracheal septum
• TEF esophageal and tracheal failure to separate
  during divison of the endoderm
• Esophageal atresia tracheal structure assume
  most of the endoderm

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Types of TEF
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Diagnosis

• During pregnancy maternal polyhydramnios and
  premature labor
• Newborn
• s/s cough, chocking, cynosis, excessive
  salivation, drooling,
• OG tube inability to pass down the esophagus
  into the stomach
• X-ray
• catheter curled up in the upper pouch of the
  esophagus
• air/gas bubbles in the stomach and intestine
• ultrasonography diagnosis of any associated
  cardiac, musculoskeletal, GI or GU abnormalities

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General management

• Primary repair of TEF is urgent
• Associated anomalies CV, GU, musculoskeletal
• Protect the lungs from aspiration pneumonia
• Avoidance of feeding
• Positioning of the infant slightly head up to
  minimize regurgitation of gastric contents
  through fistula
• Intermittent suction
• Antibiotic therapy and physiotherapy in babies
  with contaminated lung

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Surgical management

• One stage repair optimal surgical management
• Fistula is ligated, proximal and distal ends of
  the esophagus are anastomosed
• Right posterolateral extrapleural thoracotomy
• Left thoracotomy if the pt has right aortic arch
• Gastrostomy
• High risk infants unable to withstand a
  thoracotomy
• Decompress the stomach and prevent regurgitation
  via fistula into the lungs
• Local anesthesia
• general anesthesia protect the lungs from
  aspiration during surgical manipulation

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Surgical Managment

• Definitive repair
• 24-72 hours later, when infant can withstand both
  surgery and anesthesia
• Method right thoracotomy using a posterolateral
  extrapleural approach
• Fistula is ligated, esophageal segments are
  anastomosed
• If distal esophagus is too short
• Fistula is ligated
• exteriorization of the upper pouch through an
  esophagostomy is performed
• wait till weight of 9kg or 1 y/o to perform
  anastomosis

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Anesthetic Management

• Operating room set up
• keep warm warm room, blanket, overhead warmer
• Release NE vasoconstriction, increases
  metabolism, change degree of shunting
• Affect anesthetic agents likely overdosage,
  postop hypoventilation, apnea
• Coagulopathy, metabolic acidosis
• Standard monitoring EKG, pulse oximetry, end
  tidal CO2, BP monitoring (A line in high risk
  infants), U/O

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Anesthetic Management

• Induction establish airway without pulmonary
  aspiration or gastric distension
• Suction, pre-oxygenation
• Maintain spontaneous ventilation
• Avoid positive pressure ventilation
• Insufflation of the stomach via the fistula or
  loss of ventilation through the gastrostomy
• Gastric distention compromise ventilation,
  aspiration

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Anesthetic ManagementIntubation/Airway

• Awake intubation
• Safe
• Appropriate positiong of ETT w/o positive
  pressure ventilation
• Difficult and traumatic in vigorous infants
• Inhalation/IV anesthetic /- muscle relaxant
• Aware of positive pressure ventilation
• Avoid excessive insufflation of the stomach via
  fistula
• Maintain spontaneous ventilation
• With assistance ventilation until fistula is
  ligated
• Keep airway pressure low (10-15 cmH20)

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Anesthetic ManagementIntubation/Airway

• ETT position
• Below the fistula and above the carina
• Right mainstem intubation, then withdraw
• Proximal to carina, bevel facing anteriorly so
  that posterior wall can occlude the fistula
• Confirmation
• Fiberoptic bronchoscopy
• Gastrostomy to water seal

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Anesthetic Management

• Occlusion of fistula
• Fogarty catheter via bronchoscope or gastrostomy
• Intraop problems
• One lung ventilation hypoxia, CO2 retension
• ETT obstruction blood clot, secretion,
• kinking of trachea
• Vagal response tracheal manipulation, lead to
  bradycardia

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Anesthetic ManagementPostoperative problems

• Post op extubation is desired, better suture line
  healing
• 1) degree of pulmonary dysfunction
• 2) presence of associated anomalies
• Post op ventilation
• Conditions
• Defective tracheal wall at the site of fistula
• Contaminated lung
• Problems associated with prematurity or
  associated anomalies
• ETT positioned gt1cm away from site of fistula
  repair
• Distance btw lip and site of esophageal repair
  measured, avoid suction too deep

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References

• Smiths Anesthesia for Infants and Children, 6th
  edition, 1996 Mosby
• Clinical Cases in Anesthesia, 3rd edition, 2005
  Elsevier
• Pediatric AnesthsiaThe Requisites in
  Anesthesiology, 2004 Mosby Elsevier
• Yao Artusios Anesthesiology Problem Oriented
  Patient Management, 5th edition, 2003 Lippincott

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Questions

• What are preoperative concerns in a patient with
  TEF?
• How will you induce and maintain general
  anesthesia?
• During ligation of the fistula, the infants
  oxygen saturation decreases to 86, what will you
  do?
• Will you extubate at the end of the surgery? Why
  or why not?