Download 2 MB - TRACHEOESOPHAGEAL FISTULA MGMC

Tracheo esophageal fistula
Dr. S. Parthasarathy
MD., DA., DNB, MD (Acu), Dip. Diab. DCA,
Dip. Software statistics, PhD(physiology)
Mahatma Gandhi Medical College and Research
Institute, Puducherry, India
What is it ??
• There is a connection between trachea and
esophagus
• Congenital
• Sometimes plain esophageal atresia is talked
with fistula
GROSS classification
Why does it happen ??
• The embryogenesis - not completely defined.
• The trachea and esophagus develop from a common site,
the foregut, in the first 4 to 5 weeks of gestation.
• Both the esophagus and the trachea originate from the
median ventral diverticulum of the primitive foregut.
• The TEF lesion results from failure of the two structures to
separate during division of the endoderm.
1 in 4000 --- C A E
C
A
E
Diagnosis
• antenatal polyhydramnios
• Excessive salivation
• choking, coughing,aspiration pneumonia,
cyanosis.
• Attempts at feeding - met with explosive vomiting
• passing an oral (nasal) gastric tube is impossible.
• A chest radiograph of a coiled oral gastric tube in
the cervical esophageal pouch is diagnostic.
• No contrast please
VACTERL
• A common association is the VACTERL
complex, consisting of vertebral, anorectal,
cardiac, tracheoesophageal, renal, and limb
defects
• VATER, VACTER and VACTERL
• 30 % may have !!
• But the ligation of a TEF is urgent.
Preoperative management --FUSA
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F eedings – NO
U pright positioning
S uctioning intermittent
A ntibiotic administration
• Dehydration and acid base to be corrected
• Should we intubate preop ?? Does this prevent
aspiration
Two ways of aspiration
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If significant aspiration pneumonia
definitive corrective surgery ??
decompressing gastrostomy
local or caudal anesthesia
Waterson prognostic criteria
• Weight - > 2.5 , 1.8 – 2.5 , <1.8
• Associated anomalies
• Pneumonia
• A, B or C
Preoperative work up
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Echocardiography ( routine + right sided aortic arch)
X ray chest
Blood gases
Lumbar ultrasound – Xray spines – caudal ??
USG abdomen
Rigid bronchoscopy (airway + fogarty)
Tracheoscopy flexible (Zurisch et al)
• 1 unit of packed red blood cells should be type
and crossed matched
• Repair
Surgery
• primary repair involves isolation and ligation of the fistula
followed by primary anastamosis of the esophagus.
• A staged repair is possible in sick neonates
• Posterior thoracotomy
• Thoracoscopic
• Bronchoscopic clipping of H
• Sometimes stabilizing and do it in 7 – 10 days
• FUSA remains
Gastrostomy
Sometimes
• During gastrostomy, they
may clamp the fistula
with esophagostomy and
do the surgery after a few
months also.
• Esophagostomy done
from the neck to remove
the secretions
• Described
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Routine monitors
Precordial steth in the left axilla
Adequate IV access
Radial artery cannulation (Lt) or umbilical
0.15 mg atropine IV
Temperature , IV fluids
Urine output – 1 ml/kg /hour
Anaesthetic management
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Awake intubation
Inhalation Induction
Intubation in sitting posture
Proper suctioning
• Circuits, scopes, cuffed ETT,
• Neonatal ventilators
Fish mouth fixation
Principle
• Intubate purposely Rt main bronchus
• Withdraw slightly to get bilateral air entry
Reverse the curve of the tube
Reverse the side of murphy eye
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Gas leak
Ventilate lungs
and not the
fistula
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Ventilation - adequate ??
Gastric distension
Gastrostomy to water – to ETCO2
Tube kink
Anomaly – different
• Even OLV
Ventilate to the stomach –
fistula – no ventilation
Tight bag with occlusion of the
fistula
To prevent leak
• Its easier to describe spontaneous –
• but open chest with surgeon pushing the right
lung its difficult to maintain with spontaneous
• appropriate positioning of ETT is mandatory.
Spontaneous or controlled
• Are we sure – we are ventilating the lungs and
not the fistula ??
• Allow spontaneous
& Give caudal
• 0.5–1 mL/ kg of 0.25% bupivacaine with
epinephrine (5 μg/mL)
• Try threading far up .. But guarantee ?? USG
• Fentanyl
• Relaxants after clamping the fistula
No caudal ??
• Avoidance of regional anesthesia with its
corresponding decrease in systemic vascular
resistance is warranted in patients with
coexisting congenital heart disease such as
hypoplastic left heart syndrome (HLHS).
• Cautious caudal in CVS diseases
Intra op problems
• left lateral decubitus position.
• During the surgical repair, the right lung is compressed and packed
away, which may result in hypoxia.
• the trachea and/or endotracheal tube is compressed and occluded
by the surgeon.
• Alternatively, the endotracheal tube can become obstructed by
blood clots or may migrate into the fistula tract.
Intra op problems
• During localisation of the fistula, an anaesthesiologist can
help the surgeon by applying traction to the wire loop.
• Some routinely use 100% oxygen during these anesthetics,
even in premature infants who are at risk for developing the
ROP.
• Class C -- bad lungs HFO used - reports !!
• Extubate in healthy infants -- class A
• Otherwise ??
Intra op problems
• The surgeon will get hold of the fistula and
pull it.
• It will dislodge the position of ETT.
• The rt. Lung is collapsed by the surgeon. The
tube becomes RT. endobronchial. ??
• No ventilation – that’s why keep the steth Left
axilla and watch for breath sounds ..
Prognosis
Post op problems
• Surgical postoperative complications include
anastomotic leak, stricture,
gastro esophageal reflux,
tracheomalacia, recurrent TEF.
flush ligation is a must. Otherwise
- Diverticulum –stasis, infection and
giving way
Thoracoscopic approach
• The advantages
• Reduction of musculoskeletal sequelae that often develop
following open thoracotomy in the newborn period. These
have been well described as “winged” scapula, asymmetry
of thoracic wall and thoracic scoliosis.
• superior visualization of fistula and surrounding structures
including vagus nerve with the thoracoscopic approach.
Post op giving way
• Don’t extend Neck of neonate
• anastomosis will stretch and give way as there
is always a gap between the two ends of
oesophagus, which surgeon has mobilised to
bring together
Post operative problems
• 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
Summary
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Incidence
Types
Commonest
Clinical features
FUSA
Intubation and positioning , techniques
Intra op hypoxemia
Waterson, spitz , post op ventilation
Thank you all