tracheo esophageal fistula and anesthesia

TRACHEO-ESOPHAGEAL FISTULA

Speaker: Dr Bhagirath.S.N

Moderator: Dr Sarika

Tracheo-esophageal fistula

First noticed in 1697Incidence: 1 in 3000 live births

Embryology: • division of foregut happens at 4th & 5th week of intrauterine life

• imperfect division results in a communication –fistula

• associated with other congenital anomalies-Vertebral anomalies-hemi-vertebra, hypoplastic vertebraAnal defectsCardiac defects-atrial septal defect, ventricular septal defect, tetralogy of fallot (>15%)Tracheo-Esophageal, esophageal atresiaRenal defectsLimb defects-hypoplastic thumb, polydactyl, syndactyl, radial aplasia.


• Five types

Type IIIB represents 90% of cases


• Gross’ classification


IIIBI IIIA IIIC II

Tracheo-esophageal fistula-Clinical presentation

• Early indicators

Polyhydramnios

Coiling of the nasogastric tube high up in the esophagus

choking, cyanosis and coughing on oral feeding. (3 Cs)

Breathing leading to abdominal distension

• Clinical presentation depends on

1. Dehydration-proximal esophagus does not communicate with stomach

2. Aspiration pneumonia-reflux of stomach contents through the distal esophagus into the trachea.


Gross’ Classification

Gastric distension

requires prompt

relief

Blind ending of the esophagus


1. Dehydration-hydrate adequately, correct electrolyte imbalance

2. Aspiration pneumonia-if degree of reflex is high, then a gastrostomy is planned to protect the pulmonary system

3. Fistula repair is taken up if neonate is in good health. It consists of ligation of fistula and approximation of two ends of esophagus at 24-48 hours.


anesthetic considerations

1. Copious pharyngeal secretions warrant frequent suctioning

2. PPV-to be avoided-gastric distension

3. Awake intubation is safest

4. Avoiding PPV minimizes the risk of gastric distension from inspired gases flowing through the fistula.

5. Alternatively, inhalational anesthetic may be used with gentle PPV

6. Once ET tube is in place, end-tidal CO2 and Oxygen saturation are monitored.

7. Stomach should be auscultated from time to time to see if there is distension.

Tracheo-esophageal fistula-Clinical presentationanesthetic considerations

8. Placement of ET tube near or into

the fistula is to be avoided

9. Gastrostomy tube can be

submerged under water to see air

bubbles as confirmation that the

fistula has been intubated

10.Operative positions, patient’s

anatomy and surgical manipulation

can all disturb the ET tube position

11.After the fistula is ligated,

anesthetist passes a catheter from

the nose into the esophagus which

meets the one from the stomach

Tracheo-esophageal fistula-Repair

1. Conventional open method

2. Thoracoscopic method

Note: if a gastrostomy is done, then it can be left open to air at the head end of the table


Conventional open Tracheo-esophageal closure

1. Tracheal intubation can be done in three ways

Using an inhalation induction with topical spray of lidocaine. Intubating

while the infant is breathing spontaneously.

Intravenous or inhalational induction agents are employed and muscle

paralysis is additionally achieved using relaxants before intubation is

attempted.—associated complication might be in the form of a fistula

distending secondary to excessive PPV. The same sort of dilatation is

seen in the stomach. All attempts therefore must aim at minimising

distension of stomach and potential for reflux during controlled

ventilation.

Awake intubation with mild sedation. Advantage being airway is

protected from aspiration.


Conventional open Tracheo-esophageal closure…continued

First attempted in 1943

Involves surgical division of fistula and esophageal anastamoses via right extra pleural thoracotomy with patient in left lateral

position.

Precordial + axillary stethoscopes (main bronchus may get blocked)


Associated risks

1. ET tube placement just distal to the fistula is beneficial and can be

achieved by initially Intubating one lung and then slowly withdrawing

the ET tube until bilateral chest expansion is witnessed.

2. However, the ET tube might inadvertently enter the fistula during

repositioning of the infant or during surgical manipulation.

3. Difficult ventilation, decreasing levels of oxygen saturation and end

tidal carbon-di-oxide are indicators towards fistula intubation.

4. Immediate steps include stopping the surgery and requesting the

surgeon to feel for the tip of the ET tube.


Associated risks

5. The handling of the H type fistula is particularly difficult and calls for

the use of direct laryngoscopy and bronchoscopy.

6. Following this a guide wire is introduced into the trachea and then

threaded through the fistula into the Oesophagus (distal). Then ET

tube is intubated into the trachea taking care not to dislodge the

guide wire. Now an endoscopy is performed and guide wire pulled out

through the mouth. Fluoroscopy helps the surgeon to decide between

a cervical or a thoracic approach.

7. During localisation of the fistula, an anaesthesiologist can aid the

surgeon by applying traction to the wire loop.


Endoscopic Tracheo-esophageal repair

• The infant is kept spontaneously breathing until the fistula is ligated.

• Spontaneous ventilation is particularly difficult in neonates as their

tolerance to volatile agents is limited.


Post operative care

• 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

Care is taken to avoid neck extension and instrumentation of

esophagus which might disrupt the surgical repair. Prognosis

• Is guarded. It is not just a anatomical aberration.

Recurrent fistulas are a major concern

Esophageal stricture, reflux disease are seen years down the line.

High incidence of restrictive & obstructive lung disease has been

recorded.

tracheo esophageal fistula and anesthesia

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