The anaesthetic management of tracheo-oesophageal fistula: a review of ten years' experience

Tracheoesophageal fistula and associated congenital heart disease: implications for anesthetic management and survival

BACKGROUND

Infants with tracheoesophageal fistula (TEF) and/or esophageal atresia (EA) frequently have other associated congenital anomalies which can have a significant impact on their anesthetic care and survival to discharge.

METHODS

A medical record review and retrospective data analysis were performed in a university affiliated children's hospital of all infants undergoing TEF/EA repair between January 1998 and July 2004. The incidence of intraoperative complications during the TEF repair and overall survival to hospital discharge was compared in two groups of infants: 26 patients with TEF/EA and coexisting congenital heart disease (CHD), and 27 patients with TEF/EA and no CHD.

RESULTS

The overall incidence of intraoperative critical events during repair of TEF/EA was significantly higher in infants with associated cardiac pathology (P = 0.003). Six of 53 infants died during hospitalization (overall mortality, 11.3%) and all had associated cardiac pathology. In comparison with nonductal-dependent lesions, the presence of a ductal-dependent cardiac lesion appeared to significantly increase patient mortality (57% vs. 10%, P = 0.028).

CONCLUSIONS

Low birth weight (<1500 g) and associated cardiac pathology were found to be independent predictors of mortality in infants undergoing surgery for TEF/EA repair. The presence of a ductal-dependent cardiac lesion further increased the risk of morbidity and mortality, in addition to necessitating special anesthesia considerations.

Temporary transgastric fistula occlusion as salvage procedure in neonates with esophageal atresia with wide distal fistula and moderate to severe pneumonia

A method to achieve distal fistula occlusion by inflating the balloon of a catheter placed at the gastroesophageal junction via a transgastric route was tried in seven consecutive neonates with esophageal atresia and wide distal fistula. Due to associated moderate or severe pneumonia, these infants were at poor anesthetic risk for the definitive repair. The procedure was done under local anesthesia with mild sedation and took an average of half an hour for completion. Another feeding tube was negotiated through another gastrotomy across the pylorus to allow early enteral feeds. Temporary transgastric fistula occlusion (TTFO) allowed better ventilation of the hypocompliant lungs (by increasing resistance at the fistulous end), prevented lung injury due to aspiration of the refluxing gastric juices, and facilitated optimal ventilation by preventing epigastric distension. All study subjects survived this procedure except for one of our earlier study subjects who died of massive pneumothorax that was a procedure-related complication. None of the remaining subjects required mechanical ventilation either after TTFO or after the definitive esophageal repair that was carried out 5-7 days subsequent to TTFO, except for one other neonate with right lung aplasia who began deteriorating 48 h after thoracotomy and died of cardiac failure. There were no anastomosis-related problems among the survivors over a 12-month follow-up. The gratifying results of our study prompt us to suggest that this procedure deserves attention, and its role should be explored for salvaging neonates with type C esophageal atresia with wide fistula and pneumonia in developing countries with few neonatal intensive care services.

[Acute gastric distension necessitating gastrostomy after anesthetic induction for surgical correction of type III esophageal atresia]

IPPV during anaesthesia for management of oesophageal atresia with tracheo-oesophageal fistula (TOF) can cause gastric insufflation. We report such a complication in a one-day-old newborn, who developed, 15 min after induction, a distension of the abdomen, hypoxia and bracdycardia. An emergency gastrostomy was performed. His status improved rapidly and surgery could be completed. TOF was located at the carina and had a large calibre. To avoid gastric distension in such cases, the tip of the tube is located just proximal to the carina, but distal to the fistula to prevent intubation of the latter. Difficulties are due to position of the fistula (carina, main bronchi) or its large bore. Gastric distension carries a risk of regurgitation and inhalation of gastric contents, elevation of hemidiaphragm and lung compression, decreased tidal volume, decreased venous return, cardiovascular collapse and cardiac arrest. When insufflation peak pressures are low, gastrostomy is benefitful, as in our case, as the tidal volume loss through the stomach is acceptable. In case of high insufflation pressures because of co-existing lung disease, gastrostomy is better avoided, as most if not all the tidal volume may be lost through the stomach.

Tracheo-oesophageal fistula and pre-operative mechanical ventilation

Twelve patients with tracheo-oesophageal fistula (TOF) and restrictive lung disease necessitating pre-operative ventilation are reported. Eight patients had respiratory distress syndrome, four had aspiration pneumonia, and 11 had associated oesophageal atresia. Two patients in whom a preliminary gastrostomy was performed died. Emergency ligation of the fistula was performed in 10 patients, nine of whom survived. Following division of the fistula, respiratory function improved dramatically in three patients and primary oesophageal repair was performed. Three patients underwent delayed primary repair and the oesophagus was sacrificed, with a view to replacement at a later date, in the remaining three patients. We believe that the presence of a TOF in a neonate with poorly compliant lungs requiring mechanical ventilation represents a serious surgical challenge. Gastrostomy alone should never be performed. Ligation of the fistula with either immediate or delayed primary repair of the oesophagus are the treatments of choice.

Management of esophageal atresia and tracheoesophageal fistula in the neonate with severe respiratory distress syndrome

In a 10-year period, 22 neonates with esophageal atresia (EA) and tracheoesophageal fistula (TEF) required high pressure ventilatory support soon after birth because of respiratory distress syndrome (RDS). Eleven of the 22 or 50% survived overall, but if the 5 patients who died before definitive surgical repair could be attempted are excluded, 11 of 17 or 65% survived. More importantly, 4 of 7 (57%) patients who had gastrostomy performed first survived while 7 of 10 (70%) who had fistula ligation performed first survived. The difficulties with intraoperative management of those who had gastrostomy performed first were even more impressive. Our experience leads us to conclude that patients with EA and TEF with severe RDS who require high pressure ventilation preoperatively represent a group of patients who require special consideration. The danger to such patients with increased pulmonary resistance is not gastric distention but sudden loss of intragastric pressure. In the presence of poor lung compliance, the upper gastrointestinal tract functions in continuity with the tracheobronchial tree. A sudden loss of intragastric pressure, as with placement of a gastrostomy tube, results in an acute loss of effective ventilating pressure. Resuscitation of such a patient is not possible until leakage from the esophagus is controlled by ligation of the fistula or transabdominal occlusion of the distal esophagus. Placement of a Fogarty catheter into the fistula via a bronchoscope is effective but may not be feasible in every case. Early thoracotomy and ligation of the fistula in patients with progressive RDS provides immediate improvement in ventilatory efficiency and relief of gastric distention.

Esophageal atresia. Prognostic factors and contribution of preoperative telescopic endoscopy

In recent years, the surgical correction of esophageal atresia with distal tracheoesophageal fistula (TEF) has become increasingly successful. However, there remains a group of high-risk patients with specific anatomical abnormalities in whom the mortality remains appreciable. These associated disorders include cardiac, renal, and chromosomal anomalies as well as severe respiratory distress syndrome. These factors, rather than low birth weight or early gestational age, are primarily responsible for surgical mortality. Preoperative telescopic bronchoscopy has been a useful adjuvant confirming the diagnosis, identifying unusual variants, and permitting the proper anatomic placement of the endotracheal tube. A Fogarty balloon catheter can be passed bronchoscopically into the distal TEF in patients with severe respiratory distress syndrome to occlude the fistula and facilitate effective positive pressure ventilation. Thirty-two patients were treated for esophageal atresia among whom 28 had esophageal atresia with distal TEF, three had esophageal atresia alone, and one had esophageal atresia with proximal TEF. The higher-risk group comprised those with severe respiratory insufficiency as evidenced by a room air paO2 of less than 60 mmHg; this group accounted for nine of the ten deaths in the total series. There was one late death following surgical correction. In summary, in the absence of severe respiratory insufficiency or associated life-threatening congenital anomalies, the results of surgical correction for esophageal atresia are remarkably good and survival in this group approximates 100%.

The Fogarty balloon catheter as an aid to management of the infant with esophageal atresia and tracheoesophageal fistula complicated by severe RDS or pneumonia

Early ventilatory failure in an infant with EA/TEF may prove difficult to manage because of the low resistance "vent" provided by the TEF. In this Case Report Fogarty balloon occlusion of the vent was possible and aided management of the patient who was not a candidate for primary repair of the anomaly.

An epidemiologic study of tracheoesophageal fistula and esophageal atresia in North Carolina

Two hundred and eighty-five cases of TEF/EA occurring in North Carolina from 1952-1978 were reviewed. Except for a greater incidence of low-birth-weight infants and hydramnios during pregnancy, the cases appeared to be representative of the population. Clustering of cases over time was statistically confirmed. The cyclic variation suggested an association with an infectious agent. The variation of reported infectious hepatitis cases during the period of this study resembled the variation of TEF/EA cases that had no other documented congenital malformations.