Transcript of "Anesthetic management of Tracheo Esophageal fistula and Eosphageal Atresia"
ANESTHETIC MANAGEMENT OF
AND ESOPHAGEAL ATRESIA
Type A : Esophageal atresia + no fistula
Type B : Esophageal atresia + fistula between
the upper segment and the trachea.
Type C : Esophageal atresia + fistula between
the lower segment and the trachea
(The commenest 87%)
Incidence : 1 : 3500 live births
Gross and vogt classification
Type D : Esophageal atresia + 2 fistulas
between the upper and the lower
segment and the trachea.
Type E : No atresia but a fistula between the
oesophagus and the trachea.
Type H or N : are subtypes of E, where
tracheal opening is more cephalad
than esophageal opening
• Failure of passage of a catheter down to
the stomach is diagnostic (except in
• On feeding, chocking, cyanosis and
coughing occur → aspiration
• Prenatally, polyhydramnios is present.
Clinical Picture :
1- It is diagnosed as follows :
Respiratory acidosis due to :
3- Acid-base disorders :
Metabolic acidosis : due to severe
dehydration and shock
• Gastric distention with elevation of
diaphragm → impaired diaphragmatic
excursion, so the infant may need one lung
ventilation until gastric decompression
• if the newborn is mechanically
ventilated by mask, gastric distention
may occur, which may impair ventilation
and venous return resulting in
hypoxemia and cardiopulmonary arrest.
This needs gastrostomy under L.A and
one lung ventilation until gastrostomy is
4- During neonatal resuscitation :
• VATER :
5- Associated congenital anomalies :
V : Vascular or vertebral anomalies
A : Anal or GIT atresia
T.E : Tracheo-Esophageal fistula
R : Renal or radial anomalies
• VACTER : As VATER in addition to cardiac
anomaly and limb anomaly
• C.V congenital anomalies : VSD, ASD or
fallot tetralogy they need Echo
6- Investigations such as plain x-ray, CT
The infant’s general condition and the
anatomy of the defect govern the choice of
surgical management :
Preoperative Management :
Primary complete repair (ligation of fistula and
esophageal anastomosis) which is preferred.
Staged repair (gastrostomy followed by division of
the fistula, followed later by repair of the
esophagus). Often the operation is preceded by
bronchoscopy to define the site of the fistula and
exclude other tracheal defects.
1- Preoperative assessment and management
of TEF and complications :
Pulmonary infection with antibiotics.
Dehydration and acid base balance
disturbances should be managed
Frequent suction of the upper
esophageal pouch in the semi-sitting
position is required
(A) Risk classification according to
Waterston and colleagues.
Total repair immediatelyBody weight > 2500 g and
Staged repair (gastrostomy
Body weight 1800-2500 g
Body weight > 2500 g with
moderate pneumonia and
cong heart diseases
Surgeries should be post
Body weight <1800 gC1
Body weight 1800-2500 g
with severe pneumonia
2- Preoperative assessment of prognosis :
Group I : Birth weight >1500 g without cardiac diseases
survival rate is 97%.
Group II : Birth weight <1500 g or major cardia diseases
survival rate 59%
Group III : Birth weight <1500 g and major cardiac
disease the survival 22%
(B) The spitz classification :
High risk : Life threatening anomalies or a major
anomaly and ventilator dependence
Low risk : all other patients : It is recently used because
advances in neonatal intensive care have improved the
outcome so that birth weight is no longer an
independent risk factor for mortality.
(C) The montreal classification system :
It divides patients into two groups :
3- Gastrostomy : may be done in the pre-repair
period value :
Prevent gastric distention and rupture
so improve ventilation and venous
Prevents reflux of gastric content into
Allows proper nutrition of the baby in
pre- and post-repair periods.
It prevents elevation of the diaphragm
so avoiding respiratory distress.
4- Patient’s position : The neonate is placed in
a head-up position to decrease regurgitation
of gastric secretion through the fistula.
Atropine used to avoid bradycardia which
may be caused by :
• Traction on the hilum or mobilization of the
esophagus, which stimulates the vagal nerve.
Induction and intubation : Before intubation
suction the upper pouch is done by a
catheter, apply lidocaine 4% to the gums and
palate using a gauze sponge this lessens the
response to intubation.
Induction : Inhalational induction with
spontaneous ventilation, without muscle
relaxant is better.
It is performed by an extrapleural
approach for ligation of the defect and
primary anastomosis of the esophagus.
Size : large enough without a Murphy eye to allow
easy suction and allow blocking of the fistula.
Position : above the carina and below the opening of
the fistula. It is passed 1st into the Rt main bronchus
then withdrawn gradually until breath sounds are
heard bilaterally equal this position is confirmed by :
1. Auscultation of both lungs and stomach.
2. Fiberoptic bronchoscopy.
3. By placing the gastrostomy tube into a baker of
water and applying positive airway pressure,
absence of bubbling confirms good positioning
while presence of bubbling indicates bad
positioning requiring more advancement.
Other options that prevent gas from entering the
stomach include :
A snug abdominal binder that can compress
the stomach and prevent over-distention.
A Fogarty catheter that is placed across the
fistula to occlude it. This can be done via the
trachea with the aid of fiberoptic
bronchoscope. The disadvantage of this
technique is that if the catheter is disloged
into the trachea. It can occlude the airway.
If the fistula is connected to the carina or the
main stem bronchus, in this case it is
impossible to place the tube end distal to the
opening of the fistula, so, intermittent venting
of a gastrostomy tube that has been placed
preoperatively may allow P.P.V without
excessive gastric distention or alternatively
by using ECMO (Extracorporeal membrane
Endobronchial intubation can occur it should
be observed and managed.
Patient position :
The patient should be in :
• Semi-setting during gastrostomy
• Left lateral position during repair
O2 : air (+ N2O), sevoflurane or halothane and
spontaneous ventilation are used.
O2 : air (+ N2O) : maintain PaO2 50-70 mmHg or
SaO2 87-92% to avoid retinopathy of prematurity if
gastrostomy was done O2 can be diluted by N2O
according to patient status.
Spontaneous ventilation with sevoflurane or
halothane is used before doing the repair then
controlled ventilation with sevoflurane or
halothane and a muscle relaxant is used after
doing the repair because :
Mediastinal stability is essential for proper
No fear of gastric distension.
I.O fluid therapy.
I.O body temperature
Beside the standard monitors :
- Precordial stethoscope : placed in the dependent axilla to
monitor respiratory obstruction because traction on the upper
lung causes a kink of the main bronchus of the dependent lung
or obstruction of the ETT by blood or mucus, which must be
- Arterial blood gases.
- Invasive arterial blood pressure and CVP
Extubation and recovery :
- Before extubation adequate suctioning from ETT with 100% O2
and tracheo bronchial toilet are done.
- The criteria of extubation should be fulfilled such as :
Level of consciousness
1. The child with a clear chest who is awake and
moving vigorously should be extubated in the OR.
Some surgeons may prefer to keep the trachea
intubated and a gastroesophageal tube in place for
several days to avoid reintubation and damage to
the tracheal repair.
2. If there are pulmonary complications or inadequacy
of ventilation, continue controlled ventilation.
3. The pharynx is suctioned with a soft catheter that
has a suitable maximum length of insertion, it must
not reach the anastomotic site.
4. Prolonged intensive respiratory care.
5. Prognosis after the repair depends on the
maturity of infant, whether other congenital
anomalies are present, and whether pulmonary
complication develop. In absence of these
conditions, the prognosis is excellent.
6. Postoperative analgesia may be provided by a
caudal epidural catheter inserted intraoperatively
and threaded to the thoracic level, careful
management of local anesthetic doses is
If staged repair is planned, a preliminary
gastrostomy is performed under local or
general anesthesia. Management of the
second stage should follow the sequence
outlined for primary repair. Further surgery
to repair the atresia may be done when the
child’s condition is optimal.
Late complications :
Diverticulum of the trachea, at the site of the old
fistula is common in children who had
tracheoesophageal fistula repaired during infancy.
The tracheal cartilage structure is abnormal and
tracheomalacia may cause symptoms during infancy
after repair of a TEF. Episodes of stridor, dysnea, and
cyanois (dying spells) characteristically occur during
feeding. This is caused by compression of the soft
trachea between the dilated esophagus and arch of
the aorta. Severe symptoms require surgical
treatment by aortopexy or tracheoplasty with an
external splint. These children often have a deep
barking cough much like children with croup.
Stricture may develop at the site of the
esophageal anastomosis with episodes
of esophageal obstruction with food (the
hotdog of the esophagus) it may require
repeated dilatations and later, possibly
resection with replacement using the
colon or a gastric tube.
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