By

Kamelia Abaza

ANESTHETIC MANAGEMENT OF

TRACHEO-ESOPHAGEAL FISTULA

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

Types :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

type E).

• On feeding, chocking, cyanosis and

coughing occur → aspiration

pneumonia.

• Prenatally, polyhydramnios is present.

Clinical Picture :

1- It is diagnosed as follows :

2- Dehydration.

Respiratory acidosis due to :

3- Acid-base disorders :

Metabolic acidosis : due to severe

dehydration and shock

• Pneumonia

• Shunting

• Hypoxia

• Hypercarbia

• Atelectasis

• Gastric distention with elevation of

diaphragm → impaired diaphragmatic

excursion, so the infant may need one lung

ventilation until gastric decompression

occur.

• 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

done.

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

scan

The infant’s general condition and the

anatomy of the defect govern the choice of

surgical management :

ANESTHETIC 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.

ManagementCriteriaGroup

Total repair immediatelyBody weight > 2500 g and

well

A

Staged repair (gastrostomy

1st)

Body weight 1800-2500 g

and well

B1

Body weight > 2500 g with

moderate pneumonia and

cong heart diseases

B2

Surgeries should be post

poned

Body weight <1800 gC1

Body weight 1800-2500 g

with severe pneumonia

and CHD

C2

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

return.

Prevents reflux of gastric content into

lungs.

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.

Premedications :

Sedatives avoided.

Atropine used to avoid bradycardia which

may be caused by :

• Traction on the hilum or mobilization of the

esophagus, which stimulates the vagal nerve.

• Halothane.

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.

INTRAOPERATIVE MANAGEMENT

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.

ETT :

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

oxygenator).

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

Maintenance :

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

repair.

No fear of gastric distension.

I.O fluid therapy.

I.O body temperature

Monitoring :

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

sucked.

- 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

Muscle power

POSTOPERATIVE MANAGEMENT

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

required.

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.

ANESTHESIA MANAGEMENT-

STAGED REPAIR

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.