Repair of a laryngotracheoesophageal cleft in an infant by means of extracorporeal membrane oxygenation

Endoscopic repair of laryngotracheoesophageal clefts

BACKGROUND/PURPOSE

In Japan, surgical repair of a laryngotracheoesophageal cleft (LTEC) typically consists of the anterior approach, with the lateral approach as an alternative. Endoscopic surgery to repair the tracheoesophageal septum has been reported, and this study reviewed our experience treating several cases of LTEC endoscopically.

METHODS

Endoscopic repair of LTEC was performed in 7 patients (3 boys, 4 girls; age range 4 months to 2 years 10 months; mean age 11 months; mean weight at surgery 7.23 kg; weight range 3.85-12.24 kg) between 2009 and 2014. LTEC was type I in 5 patients and types II and IV in 1 patient each. The patient with type IV was first operated on by the lateral approach, and the remaining cleft, which level was type III, was repaired endoscopically. Postoperative outcomes were retrospectively studied.

RESULTS

Endoscopic surgery was successful in all patients. All 6 patients with types I and II LTEC were extubated easily, while in the patient with type IV LTEC, it was difficult to remove the tracheostomy cannula because of tracheomalacia. Postoperatively, tracheostomy cannulation became more stable, and the patient is gradually being weaned off the ventilator. All patients could be fed orally without difficulty postoperatively.

CONCLUSIONS

Endoscopic surgery provides a view from the cephalic aspect permitting the surgeon to form a normal larynx with only minimal risk of complications.

Anesthetic challenges in managing a case of type III laryngo-tracheo-esophageal cleft

Laryngo-tracheo-esophageal cleft (LTEC) is a rare congenital anomaly characterized by failure of fusion of the cricoid cartilage posteriorly and incomplete development of the tracheo-esophageal septum. Securing the airway during anesthesia in patients with LTEC, especially in the severe forms is a challenge. We describe the anesthetic management and the airway challenges in a neonate with type III LTEC who underwent bronchoscopy and repair of LTEC.

Laryngo-tracheo-oesophageal clefts

A laryngo-tracheo-esophageal cleft (LC) is a congenital malformation characterized by an abnormal, posterior, sagittal communication between the larynx and the pharynx, possibly extending downward between the trachea and the esophagus. The estimated annual incidence of LC is 1/10,000 to 1/20,000 live births, accounting for 0.2% to 1.5% of congenital malformations of the larynx. These incidence rates may however be underestimated due to difficulty in diagnosing minor forms and a high mortality rate in severe forms. A slightly higher incidence has been reported in boys than in girls. No specific geographic distribution has been found. Depending on the severity of the malformation, patients may present with stridor, hoarse cry, swallowing difficulties, aspirations, cough, dyspnea and cyanosis through to early respiratory distress. Five types of laryngo-tracheo-esophageal cleft have been described based on the downward extension of the cleft, which typically correlates with the severity of symptoms: Type 0 laryngo-tracheo-esophageal cleft to Type 4 laryngo-tracheo-esophageal cleft. LC is often associated with other congenital abnormalities/anomalies (16% to 68%), mainly involving the gastro-intestinal tract, which include laryngomalacia, tracheo-bronchial dyskinesia, tracheo-bronchomalacia (mostly in types 3 and 4), and gastro-esophageal reflux disease (GERD). The syndromes most frequently associated with an LC are Opitz/BBB syndrome, Pallister Hall syndrome, VACTERL/VATER association, and CHARGE syndrome. Laryngeal clefts result from failure of fusion of the posterior cricoid lamina and abnormal development of the tracheo-esophageal septum. The causes of the embryological developmental anomalies leading to LC are not known but are thought to be multifactorial. LC appears to be mostly sporadic although some familial cases with suspected autosomal dominant transmission have been reported. The age of diagnosis depends mainly on the severity of the clinical symptoms and therefore on the extent of the LC. Diagnosis is made either based on clinical manifestations or on investigations, such as endoscopy, X-ray, CT scan, performed for other conditions. Differential diagnoses include tracheo-bronchial fistula, gastro-esophageal reflux disease and neurological swallowing disorders, as well as laryngomalacia and laryngeal palsy. Prenatal diagnosis of LC has never been reported, although associated anomalies may be detected on fetal ultrasonography. Once the cleft is diagnosed, it is essential to determine its length to orient the management and treatment approach. Management involves maintenance of satisfactory ventilation, prevention of secondary pulmonary complications as a result of repeated aspirations, and adequate feeding. Endotracheal intubation may be required for respiratory distress in severe cases. Treatment requires endoscopic or external surgery to close the cleft. Surgery should be performed as early as possible to avoid complications related to aspiration and gastric reflux, except in type 0 and type 1 cases in which conservative measures must first be attempted. The prognosis is variable depending on the severity of the LC and associated malformations. Early diagnosis and appropriate treatment and management help to reduce mortality and morbidity.

Type IV laryngotracheoesophageal cleft: report of long-term survivor successfully decannulated

Laryngotracheoesophageal cleft (LTEC) is a rare congenital anomaly that results from failed posterior fusion of the cricoid cartilage and incomplete development of the tracheoesophageal septum. LTEC presents with increased secretions, respiratory distress, aspiration and recurrent pulmonary infections. The severity of presenting symptoms is dependent on the type of cleft. LTEC is most commonly classified into four types (I, II, III and IV) based on the inferior extent of the cleft. Types III and IV LTEC are associated with high morbidity and mortality and require timely diagnosis and repair for survival. Most patients who survive repair of Type IV LTEC have long-term tracheotomy dependency with minimal chance of decannulation. We report on a case of a long-term survivor of Type IV who has been safely decannulated.

Emergency use of a size 1 laryngeal mask airway in a ventilated neonate with an undiagnosed type IV laryngotracheo-oesophageal cleft

The perioperative management of a neonate with a type IV laryngotracheo-oesophageal cleft and exomphalos major is described. Following an otherwise uncomplicated exomphalos repair, this baby became increasingly and inexplicably difficult to ventilate through an endotracheal tube. The emergency use of a laryngeal mask airway as a rescue maneuver allowed positive pressure ventilation, and subsequent diagnosis of the airway abnormality. The difficulties in management of the two co-existing conditions are discussed.

Strategies for managing Type IV laryngotracheoesophageal clefts at Great Ormond Street Hospital for Children

OBJECTIVE

To review our strategy for the treatment of patients with Type IV laryngotracheoesophageal cleft-a very rare congenital malformation.

METHODS

Retrospective review of nine cases of Type IV laryngotracheoesophageal cleft managed between October 1994 and January 2004 at Great Ormond Street Hospital for Children, London.

RESULTS

Three children were not operated upon (Group A) because of serious co-morbidity and parental decision not to opt for repair; they died at the ages of 2, 7 and 14 days, respectively. Six cases were repaired (Group B) at ages ranging from 2 to 53 days, all using an anterior cervico-thoracic approach. Two cases were operated upon using conventional ventilation, three using cardiopulmonary bypass and one using extracorporeal membrane oxygenation. There was no intra-operative mortality. The number of operative and diagnostic procedures varied from 4 to 37. Two operated cases expired at the ages of 11 days and 25 months; both were operated upon using cardiopulmonary bypass and had significant cardiac co-morbidity. Post-operative microlaryngoscopy and bronchoscopy showed dehiscence in the cleft repair ranging from 1mm to 2cm in five cases. This was observed at the distal end in three patients and just below the vocal cords in two cases. Three cases underwent further repair which was successful. The most recent case repaired using extracorporeal membrane oxygenation required less heparin when compared with those done on cardiopulmonary bypass and had the best post-operative result. Two patients were finally decannulated. The total duration of diagnostic and operative procedures ranged from 9 to 26h and 30min. The hospital stay in the operated cases varied from 9 days to 2 years 2 months 3 days, and their ICU stay ranged from 9 days to 10 months 7 days. All four of our patients with clefts which ended above the carina are alive after multiple repairs whereas all five cases with clefts extending all the way to the carina died (repair was attempted in two).

CONCLUSION

Early diagnosis and repair are essential for successful treatment of Type IV laryngotracheoesophageal clefts. We believe it is best to repair this defect via an anterior cervico-thoracic approach, with or without a median sternotomy, and extracorporeal membrane oxygenation is now our preferred method of gas exchange during such repair. The longest Type IV clefts extending all the way to the carina have the worst prognosis. The decision to operate or not should be based upon the associated co-morbidity and fully informed parental choice, since treatment entails significant morbidity and mortality.

Anaesthetic management in a case of a type IV laryngotracheo-oesophageal cleft

We report the case of a newborn baby with a type IV laryngotracheo-oesophageal cleft and the anaesthetic management during the rigid bronchoscopy that was performed at 5 days of age. After anaesthetic induction with sevoflurane and atropine, the child was maintained with sevoflurane 2-2.5% and remifentanil at an infusion rate of 0.5 microg.kg(-1).min(-1). Ventilation was managed through the lateral port of the bronchoscope. The patient breathed sevoflurane and oxygen/N2O spontaneously via a Jackson-Rees circuit. To prevent the stomach from filling up with anaesthetic gases, a Foley catheter was placed orally into the stomach. The Foley balloon was inflated and retracted until it sealed the gastro-oesophageal junction. Tracheal intubation was performed after bronchoscopy to allow suture of the stomach into two chambers. Oxygenation was adequate with no air leakage, with spontaneous ventilation. The Foley catheter was removed afterwards and the patient awakened. We review the literature on different ways of managing the airway in these cases and protecting it from gastric aspiration during ventilation.

Laryngotracheo-oesophageal cleft in an infant: airway management during bronchoscopy

A case of laryngotracheo-oesophageal cleft scheduled for bronchoscopy and repair is described. The authors highlight the difficulties of bronchoscopy in such a patient and suggest simple manoeuvres to negotiate the rigid bronchoscope into the trachea.

Congenital laryngotracheo-oesophageal cleft: successful ventilation with the Laryngeal Mask Airway

A congenital laryngotracheo-oesophageal cleft is a rare airway malformation which results from incomplete separation of the larynx and trachea from the hypopharynx and oesophagus. Patients usually present with stridor, aspiration and cyanosis associated with feeding. For early diagnosis, a high index of suspicion is needed. Unless an appropriate diagnostic approach is taken, the diagnosis can be missed. The successful ventilation of a neonate with the Laryngeal Mask Airway is described.

Repair of a type IV laryngotracheoesophageal cleft with cardiopulmonary bypass

Laryngotracheoesophageal clefts (LTECs) are rare congenital defects of variable severity depending on the extent of malformation. Management of a complete LTEC represents a major surgical and anesthetic challenge. The main problems are achieving adequate operative exposure and maintaining ventilatory support during and after the operation. We describe correction of a type IV LTEC extending down to the carina in an infant who had respiratory distress at birth. Surgical repair was achieved in a single stage by an anterior sternotomy approach on the 11th day of life. The procedure was facilitated by cardiopulmonary bypass. After the operation, the infant was intubated, mechanically ventilated, and sedated. Nissen fundoplication and gastrostomy were carried out on the 11th postoperative day. The child was extubated on the 12th postoperative day. The rationale for this method and its advantages in comparison with other surgical approaches are discussed.

Artificial lungs: a new inspiration

An estimated 16 million Americans are afflicted with some degree of chronic obstructive pulmonary disease (COPD), accounting for 100,000 deaths per year. The only current treatment for chronic irreversible pulmonary failure is lung transplantation. Since the widespread success of single and double lung transplantation in the early 1990s, demand for donor lungs has steadily outgrown the supply. Unlike dialysis, which functions as a bridge to renal transplantation, or a ventricular assist device (VAD), which serves as a bridge to cardiac transplantation, no suitable bridge to lung transplantation exists. The current methods for supporting patients with lung disease, however, are not adequate or efficient enough to act as a bridge to transplantation. Although occasionally successful as a bridge to transplant, ECMO requires multiple transfusions and is complex, labor-intensive, time-limited, costly, non-ambulatory and prone to infection. Intravenacaval devices, such as the intravascular oxygenator (IVOX) and the intravenous membrane oxygenator (IMO), are surface area limited and currently provide inadequate gas exchange to function as a bridge-to-recovery or transplant. A successful artificial lung could realize a substantial clinical impact as a bridge to lung transplantation, a support device immediately post-lung transplant, and as rescue and/or supplement to mechanical ventilation during the treatment of severe respiratory failure.

Extracorporeal membrane oxygenation for severe respiratory failure

The use of extracorporeal technology to accomplish gas exchange with or without cardiac support is based on the premise that "lung rest" facilitates repair and avoids the baso- or volutrauma of mechanical ventilator management. Extracorporeal membrane oxygenation (ECMO), a modified form of cardiopulmonary bypass, has been shown to decrease mortality of neonatal, pediatric and adult respiratory failure and is capable of total gas exchange. In neonates, over 20,638 patients have been treated with an overall survival of 77% in a population thought to have 78% mortality.

Type IV laryngotracheoesophageal clefts -- recent 5 year experience at Great Ormond Street Hospital for Children

This article summarises a 5 year experience of type IV laryngotracheoesophageal clefts from Great Ormond Street Hospital for Children, London. We present six infants who had type IV clefts, two of whom are long-term survivors, and we review the literature. The recognition of specific complicating issues may lead to a standardised approach, which can result in successful repair and long-term survival. Increased awareness of the condition and early diagnosis combined with aggressive, planned surgical intervention in centres of paediatric expertise should result in a significant reduction of current mortality.

Congenital laryngeal anomalies. Laryngeal atresia, stenosis, webs, and clefts

Congenital laryngeal anomalies may occur as a result of defects in normal prenatal development. They are associated with a broad spectrum of symptoms and require treatment ranging from observation alone to complex open airway surgery. The treating otolaryngologist must organize a management strategy focused on timely diagnosis, ensuring a safe airway, and maximum conservation of respiratory, phonatory, and swallowing ability.

Type IV laryngotracheo-oesophageal cleft--management of a difficult airway

Congenital laryngotracheo-oesophageal cleft is a rare anomaly which presents a challenge to the anaesthetists because of the potential problems of establishing and maintaining an airway. We report the anaesthetic management of a one-month old baby with complete or type IV laryngotracheo-oesophageal presenting for the repair of the defect. The management of the precarious airway is presented and the various techniques of managing the airway are reviewed.

Type III-IV laryngotracheoesophageal cleft: report of a successfully treated case

This report presents a case of Stage III laryngotracheoesophageal cleft (LTEC). It is, to our knowledge, the fourth case in which the patient is still alive twenty months after surgery. We herein describe an initial symptomatology dominated by a bubbling hypersalivation, our surgical technique using a pleural shred of interposition and an endoscopic check during the operation and, finally, the clinical development dominated by a food intake refusal which was progressively improved through psychiatric help.