Tracheo Esophageal Fistula - Physiology involved and Anesthesia administration

1. TRACHEO-ESOPHAGEAL FISTULA
Speaker: Dr Bhagirath.S.N
Moderator: Dr Sarika

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. Tracheo-esophageal fistula
• Five types
Type IIIB represents 90% of cases

4. Tracheo-esophageal fistula
• Gross’ classification

5. Tracheo-esophageal fistula
IIIBI IIIA IIIC II

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. Tracheo-esophageal fistula-Clinical presentation
Gross’ Classification
Gastric
distension
requires
prompt
relief
Blind
ending of
the
esophagus

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. 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. 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. 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. 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. 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. 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. 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. 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. 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.