Tracheo Esophageal Fistula and Anesthesia


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Tracheo Esophageal Fistula - Physiology involved and Anesthesia administration

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Tracheo Esophageal Fistula and Anesthesia

  1. 1. TRACHEO-ESOPHAGEAL FISTULA Speaker: Dr Bhagirath.S.N Moderator: Dr Sarika
  2. 2. Tracheo-esophageal fistula First noticed in 1697 Incidence: 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 vertebra Anal defects Cardiac defects-atrial septal defect, ventricular septal defect, tetralogy of fallot (>15%) Tracheo-Esophageal, esophageal atresia Renal defects Limb defects-hypoplastic thumb, polydactyl, syndactyl, radial aplasia.
  3. 3. Tracheo-esophageal fistula • Five types Type IIIB represents 90% of cases
  4. 4. Tracheo-esophageal fistula • Gross’ classification
  5. 5. Tracheo-esophageal fistula IIIBI IIIA IIIC II
  6. 6. 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.
  7. 7. Tracheo-esophageal fistula-Clinical presentation Gross’ Classification Gastric distension requires prompt relief Blind ending of the esophagus
  8. 8. Tracheo-esophageal fistula-Clinical presentation 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.
  9. 9. Tracheo-esophageal fistula-Clinical presentation 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.
  10. 10. Tracheo-esophageal fistula-Clinical presentation anesthetic 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
  11. 11. 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
  12. 12. Tracheo-esophageal fistula-Repair 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.
  13. 13. Tracheo-esophageal fistula-Repair 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)
  14. 14. Tracheo-esophageal fistula-Repair 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.
  15. 15. Tracheo-esophageal fistula-Repair 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.
  16. 16. Tracheo-esophageal fistula-Repair 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.
  17. 17. Tracheo-esophageal fistula-Repair 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.