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Tracheoesophageal Fistula R2 趙怡芳 /VS 范守仁 R2 趙怡芳 /VS 范守仁.

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Presentation on theme: "Tracheoesophageal Fistula R2 趙怡芳 /VS 范守仁 R2 趙怡芳 /VS 范守仁."— Presentation transcript:

1 Tracheoesophageal Fistula R2 趙怡芳 /VS 范守仁 R2 趙怡芳 /VS 范守仁

2 Epidemiology Incidence: 1/4000 Incidence: 1/ %: congenital anomalies (35% cardiac; 30% musculoskeletal) 30-50%: congenital anomalies (35% cardiac; 30% musculoskeletal) 20-30%: premature, BW<2000g 20-30%: premature, BW<2000g VACTERAL and VATER syndrome: VACTERAL and VATER syndrome: Vertebral anomalies: Vertebral anomalies: Anal: imperforate anus Anal: imperforate anus Cardiac: VSD, PDA, TOF, coarction of aorta, ASD Cardiac: VSD, PDA, TOF, coarction of aorta, ASD Trachea: TEF Trachea: TEF Esophageal: EA Esophageal: EA Renal: renal agenesis,ureteral abnormalities, hypospadias Renal: renal agenesis,ureteral abnormalities, hypospadias Limb: polydactyly, wrist/knee anomalies Limb: polydactyly, wrist/knee anomalies

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

4 Types of TEF

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

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

8 Surgical management One stage repair: optimal surgical management One stage repair: optimal surgical management Fistula is ligated, proximal and distal ends of the esophagus are anastomosed Fistula is ligated, proximal and distal ends of the esophagus are anastomosed Right posterolateral extrapleural thoracotomy Right posterolateral extrapleural thoracotomy Left thoracotomy if the p ’ t has right aortic arch Left thoracotomy if the p ’ t has right aortic arch Gastrostomy: Gastrostomy: High risk infants unable to withstand a thoracotomy High risk infants unable to withstand a thoracotomy Decompress the stomach and prevent regurgitation via fistula into the lungs Decompress the stomach and prevent regurgitation via fistula into the lungs Local anesthesia: Local anesthesia: general anesthesia: protect the lungs from aspiration during surgical manipulation general anesthesia: protect the lungs from aspiration during surgical manipulation

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

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

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

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

13 Anesthetic Management: Intubation/Airway ETT position ETT position Below the fistula and above the carina Below the fistula and above the carina Right mainstem intubation, then withdraw Right mainstem intubation, then withdraw Proximal to carina, bevel facing anteriorly so that posterior wall can occlude the fistula Proximal to carina, bevel facing anteriorly so that posterior wall can occlude the fistula Confirmation Confirmation Fiberoptic bronchoscopy Fiberoptic bronchoscopy Gastrostomy to water seal Gastrostomy to water seal

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

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

16 References Smith ’ s Anesthesia for Infants and Children, 6th edition, 1996 Mosby Smith ’ s Anesthesia for Infants and Children, 6th edition, 1996 Mosby Clinical Cases in Anesthesia, 3rd edition, 2005 Elsevier Clinical Cases in Anesthesia, 3rd edition, 2005 Elsevier Pediatric Anesthsia:The Requisites in Anesthesiology, 2004 Mosby Elsevier Pediatric Anesthsia:The Requisites in Anesthesiology, 2004 Mosby Elsevier Yao & Artusio ’ s Anesthesiology; Problem Oriented Patient Management, 5th edition, 2003 Lippincott Yao & Artusio ’ s Anesthesiology; Problem Oriented Patient Management, 5th edition, 2003 Lippincott

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


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