Tracheo esophageal fistula Dr. S. Parthasarathy MD., DA., DNB, MD (Acu), Dip. Diab. DCA, Dip. Software statistics, PhD(physiology) Mahatma Gandhi Medical College and Research Institute, Puducherry, India

What is it ?? There is a connection between trachea and esophagus Congenital Sometimes plain esophageal atresia is talked with fistula

GROSS classification

Why does it happen ?? The embryogenesis - not completely defined. The trachea and esophagus develop from a common site, the foregut, in the first 4 to 5 weeks of gestation. Both the esophagus and the trachea originate from the median ventral diverticulum of the primitive foregut. The TEF lesion results from failure of the two structures to separate during division of the endoderm.

1 in C A E C A E

Diagnosis antenatal polyhydramnios Excessive salivation choking, coughing,aspiration pneumonia, cyanosis. Attempts at feeding - met with explosive vomiting passing an oral (nasal) gastric tube is impossible. A chest radiograph of a coiled oral gastric tube in the cervical esophageal pouch is diagnostic. No contrast please

VACTERL A common association is the VACTERL complex, consisting of vertebral, anorectal, cardiac, tracheoesophageal, renal, and limb defects VATER, VACTER and VACTERL 30 % may have !! But the ligation of a TEF is urgent.

Preoperative management --FUSA F eedings – NO U pright positioning S uctioning intermittent A ntibiotic administration Dehydration and acid base to be corrected Should we intubate preop ?? Does this prevent aspiration

Two ways of aspiration If significant aspiration pneumonia definitive corrective surgery ?? decompressing gastrostomy local or caudal anesthesia

Waterson prognostic criteria Weight - > 2.5, 1.8 – 2.5, <1.8 Associated anomalies Pneumonia A, B or C

Preoperative work up Echocardiography ( routine + right sided aortic arch) X ray chest Blood gases Lumbar ultrasound – Xray spines – caudal ?? USG abdomen Rigid bronchoscopy (airway + fogarty) Tracheoscopy flexible (Zurisch et al) 1 unit of packed red blood cells should be type and crossed matched

Surgery Repair primary repair involves isolation and ligation of the fistula followed by primary anastamosis of the esophagus. A staged repair is possible in sick neonates Posterior thoracotomy Thoracoscopic Bronchoscopic clipping of H Sometimes stabilizing and do it in 7 – 10 days FUSA remains

Gastrostomy

Sometimes During gastrostomy, they may clamp the fistula with esophagostomy and do the surgery after a few months also. Esophagostomy done from the neck to remove the secretions Described

Routine monitors Precordial steth in the left axilla Adequate IV access Radial artery cannulation (Lt) or umbilical 0.15 mg atropine IV Temperature, IV fluids Urine output – 1 ml/kg /hour

Anaesthetic management

Awake intubation Inhalation Induction Intubation in sitting posture Proper suctioning Circuits, scopes, cuffed ETT, Neonatal ventilators

Fish mouth fixation

Principle Intubate purposely Rt main bronchus Withdraw slightly to get bilateral air entry Reverse the curve of the tube Reverse the side of murphy eye Gas leak Ventilate lungs and not the fistula

Ventilation - adequate ?? Gastric distension Gastrostomy to water – to ETCO2 Tube kink Anomaly – different Even OLV

Ventilate to the stomach – fistula – no ventilation Tight bag with occlusion of the fistula

To prevent leak

Its easier to describe spontaneous – but open chest with surgeon pushing the right lung its difficult to maintain with spontaneous appropriate positioning of ETT is mandatory.

Spontaneous or controlled Are we sure – we are ventilating the lungs and not the fistula ?? Allow spontaneous & Give caudal 0.5–1 mL/ kg of 0.25% bupivacaine with epinephrine (5 μg/mL) Try threading far up.. But guarantee ?? USG Fentanyl Relaxants after clamping the fistula

No caudal ?? Avoidance of regional anesthesia with its corresponding decrease in systemic vascular resistance is warranted in patients with coexisting congenital heart disease such as hypoplastic left heart syndrome (HLHS). Cautious caudal in CVS diseases

Intra op problems left lateral decubitus position. During the surgical repair, the right lung is compressed and packed away, which may result in hypoxia. the trachea and/or endotracheal tube is compressed and occluded by the surgeon. Alternatively, the endotracheal tube can become obstructed by blood clots or may migrate into the fistula tract.

Intra op problems During localisation of the fistula, an anaesthesiologist can help the surgeon by applying traction to the wire loop. Some routinely use 100% oxygen during these anesthetics, even in premature infants who are at risk for developing the ROP. Class C -- bad lungs HFO used - reports !! Extubate in healthy infants -- class A Otherwise ??

Intra op problems The surgeon will get hold of the fistula and pull it. It will dislodge the position of ETT. The rt. Lung is collapsed by the surgeon. The tube becomes RT. endobronchial. ?? No ventilation – that’s why keep the steth Left axilla and watch for breath sounds..

Prognosis

Post op problems Surgical postoperative complications include anastomotic leak, stricture, gastro esophageal reflux, tracheomalacia, recurrent TEF. flush ligation is a must. Otherwise - Diverticulum –stasis, infection and giving way

Thoracoscopic approach The advantages Reduction of musculoskeletal sequelae that often develop following open thoracotomy in the newborn period. These have been well described as “winged” scapula, asymmetry of thoracic wall and thoracic scoliosis. superior visualization of fistula and surrounding structures including vagus nerve with the thoracoscopic approach.

Post op giving way Don’t extend Neck of neonate anastomosis will stretch and give way as there is always a gap between the two ends of oesophagus, which surgeon has mobilised to bring together

Post operative problems Need for ventilation arises secondary to  Compression of lung for several hours  Pre-existing aspiration pneumonia  Is always preferred in the backdrop of other coexistent congenital anomalies

Summary Incidence Types Commonest Clinical features FUSA Intubation and positioning, techniques Intra op hypoxemia Waterson, spitz, post op ventilation

Thank you all