tracheo esophageal and broncho-esopageal fistula by dr asogwa innocent kingsley
DESCRIPTION
Tracheo esophageal and broncho-esopageal fistula by dr asogwa innocent kingsleyTRANSCRIPT
TRACHEO-ESOPHAGEAL
AND
BRONCHO-ESOPHAGEAL
FISTULA
BY
DR. ASOGWA INNOCENT KINGSLEY
ML- 608
Tracheo-esophageal and broncho-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.
Tracheo-esophageal fistula
• Five types
Type IIIB represents 90% of cases
Tracheo-esophageal fistula
• Gross’ classification
Tracheo-esophageal fistula
IIIBI IIIA IIIC II
PATHOPHYSIOLOGY
The upper part of oesophagus is developed
from the retropharyngeal segment and lower
part from the pregastric segment of foregut. At
about 4 weeks of gestation, a laryngo-tracheal
groove is formed which divides the foregut into
two longitudinal tubes, which further develop
into the respiratory tract and the digestive tract.
Defective separation due to deviated or
incomplete septum or incomplete fusion of
tracheal fold results in malformation of trachea
and oesophagus.
Tracheo-esophageal fistula-Clinical presentation
• Early indicators
Polyhydramnios
Coiling of the nasogastric tube high up in the esophagus
Violent response occurs on feeding:
- choking, cyanosis and coughing on oral feeding. (3 Cs)
- Fluid returns through nose and mouth
-The infant struggles
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.
DIAGNOSTIC EVLUATION
The BEF/TEF may be suspected prenatally if
Ultrasound examination reveals polyhydramnios,
absence of a fluid-filled stomach, a small abdomen,
lower-than-expected fetal weight, and a distended
esophageal pouch.
Fetal MRI may be used to confirm the presence of
BEF/TEF
TEF/BEF may be detected postnatally by
X-ray taken with radiopaque catheter placed in esophagus to
check for obstruction; standard chest X- ray shows a dilated air-
filled upper esophageal pouch and can demonstrate
pneumonia.
Inability to pass a NG tube into stomach because it meets
resistance:;
Bronchoscopy visualizes fistula between trachea and
esophagus;
Abdominal ultrasound and echocardiogram to check for
cardiac abnormalities.
Tracheo-esophageal fistula-Clinical presentation
Gross’ Classification
Gastric
distension
requires
prompt
relief
Blind
ending of
the
esophagus
TREATMENT
The management of trachea-
oesophageal fistula is mainly
surgical. Surgical intervention
depends on the distance between
proximal and distal pouch of
oesophagus, type of defect,
condition of neonate and his
weight.
Tracheo-esophageal fistula-Symptomatic treatment
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.
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.
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
Tracheo-esophageal fistula/Broncho-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
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.
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)
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.
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.
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.
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.
COMPLICATION
Tracheomalacia (weakness of
tracheal wall)
Anastomotic leak (tension)
Strictures (narrowing, esophageal
dilation)
Dysphagia (esophageal motility
disorder)
Respiratory distress
Gastro-esophageal reflux.