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TRACHEO-ESOPHAGEAL AND BRONCHO-ESOPHAGEAL FISTULA BY DR. ASOGWA INNOCENT KINGSLEY ML- 608

Tracheo esophageal and broncho-esopageal fistula by dr asogwa innocent kingsley

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Page 1: Tracheo esophageal and broncho-esopageal fistula by dr asogwa innocent kingsley

TRACHEO-ESOPHAGEAL

AND

BRONCHO-ESOPHAGEAL

FISTULA

BY

DR. ASOGWA INNOCENT KINGSLEY

ML- 608

Page 2: Tracheo esophageal and broncho-esopageal fistula by dr asogwa innocent kingsley

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.

Page 3: Tracheo esophageal and broncho-esopageal fistula by dr asogwa innocent kingsley

Tracheo-esophageal fistula

• Five types

Type IIIB represents 90% of cases

Page 4: Tracheo esophageal and broncho-esopageal fistula by dr asogwa innocent kingsley

Tracheo-esophageal fistula

• Gross’ classification

Page 5: Tracheo esophageal and broncho-esopageal fistula by dr asogwa innocent kingsley

Tracheo-esophageal fistula

IIIBI IIIA IIIC II

Page 6: Tracheo esophageal and broncho-esopageal fistula by dr asogwa innocent kingsley

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.

Page 7: Tracheo esophageal and broncho-esopageal fistula by dr asogwa innocent kingsley

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.

Page 8: Tracheo esophageal and broncho-esopageal fistula by dr asogwa innocent kingsley

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

Page 9: Tracheo esophageal and broncho-esopageal fistula by dr asogwa innocent kingsley

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.

Page 10: Tracheo esophageal and broncho-esopageal fistula by dr asogwa innocent kingsley

Tracheo-esophageal fistula-Clinical presentation

Gross’ Classification

Gastric

distension

requires

prompt

relief

Blind

ending of

the

esophagus

Page 11: Tracheo esophageal and broncho-esopageal fistula by dr asogwa innocent kingsley

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.

Page 12: Tracheo esophageal and broncho-esopageal fistula by dr asogwa innocent kingsley

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.

Page 13: Tracheo esophageal and broncho-esopageal fistula by dr asogwa innocent kingsley

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.

Page 14: Tracheo esophageal and broncho-esopageal fistula by dr asogwa innocent kingsley

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

Page 15: Tracheo esophageal and broncho-esopageal fistula by dr asogwa innocent kingsley

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

Page 16: Tracheo esophageal and broncho-esopageal fistula by dr asogwa innocent kingsley

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.

Page 17: Tracheo esophageal and broncho-esopageal fistula by dr asogwa innocent kingsley

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)

Page 18: Tracheo esophageal and broncho-esopageal fistula by dr asogwa innocent kingsley

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.

Page 19: Tracheo esophageal and broncho-esopageal fistula by dr asogwa innocent kingsley

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.

Page 20: Tracheo esophageal and broncho-esopageal fistula by dr asogwa innocent kingsley

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.

Page 21: Tracheo esophageal and broncho-esopageal fistula by dr asogwa innocent kingsley

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.

Page 22: Tracheo esophageal and broncho-esopageal fistula by dr asogwa innocent kingsley

COMPLICATION

Tracheomalacia (weakness of

tracheal wall)

Anastomotic leak (tension)

Strictures (narrowing, esophageal

dilation)

Dysphagia (esophageal motility

disorder)

Respiratory distress

Gastro-esophageal reflux.