Tracheo esophageal fistula - PowerPoint Presentation

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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

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What is it ??

There is a connection between trachea and esophagus

Congenital

Sometimes plain esophageal

atresia

is talked with fistula

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GROSS classification

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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.

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1 in 4000 --- C A E

C

A

E

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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

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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.

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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

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Two ways of aspiration

If significant aspiration pneumoniadefinitive corrective surgery ??decompressing gastrostomy local or caudal anesthesia

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Waterson prognostic criteria

Weight - > 2.5 , 1.8 – 2.5 , <1.8

Associated anomalies

Pneumonia

A, B or C

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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

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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 HSometimes stabilizing and do it in 7 – 10 daysFUSA remains

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Gastrostomy

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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 secretionsDescribed

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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

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Anaesthetic

management

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Awake intubation

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

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Fish mouth fixation

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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

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Ventilation - adequate ??

Gastric distension

Gastrostomy

to water – to ETCO2

Tube kink

Anomaly – different

Even OLV

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Ventilate to the stomach – fistula – no ventilation

Tight bag with occlusion of the fistula

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To prevent leak

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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.

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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 μ

g/

mL

)

Try threading far up .. But guarantee ?? USG

Fentanyl

Relaxants after clamping the fistula

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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

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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.

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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 ??

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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 ..

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Prognosis

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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

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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

.

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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

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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

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Summary

Incidence

Types

Commonest

Clinical features

FUSA

Intubation and positioning , techniques

Intra op hypoxemia

Waterson

,

spitz

, post op ventilation

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Thank you all