TEF/EA: The less talked about issues

Alyssa Brzenski MD
May 2, 2012
 Background
 Pre-repair bronchoscopy
 Thorascopic repair
 To extubate or not?
 Esophageal atresia – treatment of long-gap esophageal
 Complications following TEF/EA repair
Case 1
 Called to do a case in the NICU. The patient is a 2 day old
26 week neonate with a distended abdomen. He under
went an ex-lap yesterday for NEC with free-air and
resection of part of the small bowel and primary
anastamosis. Over the last few hours, progressive
abdominal distention with free air seen again on X-ray.
 The surgeon gains adequate exposure of the abdomen and
can not find any area of bowel perforation, but notes that
the stomach is enlarged and seems to be increasing in a
rhythmic cycle, perhaps with the ventilator.
Case 2
 5 month old term infant presenting for definitive
repair of EA. Initially, taken to the operating room at
an OSH on DOL 1 for repair of TEF. On exposure, the
gap was noted to be 4cm and thought to be too
lengthy for closure. Fistula was ligated, cervical
esophagoscopy was created and g-tube placed.
 Plan today to perform esophageal anastamosis with lap
assisted gastric pull-through via a cervical approach.
 TEF/EA associated with
 1:2,500-4,000 live births
 30% of which the neonate is premature
 Few cases diagnosed prenatally
 May present with inability to pass an OGT
Waterson Classification
Spitz Classification
Pre-repair Bronchoscopy
The Evidence behind the pre-repair
 May change the operative management (changed
operative approach in 57% with 31% being crucial
 Bronchoscopy can
 Define the fistula location
 Determine unusual characteristics of the fistula(double
fistula or trifurcation)
 Determine presence of tracheobronchitis (surgery
 Locate the aortic arch
 Influence anesthetic management
Thorascopic vs. Open Repair
Thorascopic vs. Open Repair
 Reduces Musculocutaneous sequelae
 32% of patients have significant musculocutaeous
 24% with winged scapula
 20% asymmetry of chest wall 2/2 atrophic serratus
 18% developed thoracic scoliosis
 Better visualization
 Reduced Pain Post-operatively
Patient Position
Anesthesia for Thorascopic
 Rarely need lung isolation as operative lung
compressed by CO2 insufflation (5mmHg)
 Can be associated with mild desaturation requiring
100% O2 or mild hand ventilation.
 Some centers using HFOV for these repairs to
minimize the movement of the operative side
(MAP 14-24, Hz=10-14, delta P=20-27, FiO2 adjusted to
Sat of 92%)
 EtCO2 will be falsely low due to compression of the
lung and CO2 insufflation.
Anesthetic Considerations
 Routine ASA monitors +/- A-line
 Maintence of spontaneous ventilation during
 Classic teaching that paralysis can be given after fistula
 Balanced anesthetic +/- epidural for post-op pain
 May have difficulty with hypercapnia or difficulty
Fistula Management
Extubate or Not?
 Must consider pre-op lung disease and other
 Spontaneous ventilation decreases the stress placed on
the suture line
 Risk of injury to the repaired fistula with re-intubation
Long-gap Esophageal Atresia
 Defined as Greater than 3cm between the esophageal
 Ideal to use the patient’s own esophagus
 Excess tension on the esophageal anastamosis is
associated with increased complications and worse
Surgical Options
 Primary anastamosis at time of initial repair
 Serial staged dilation with bougie followed by
esophageal anastamosis
 External tension with sutures, magnets, etc to
lengthen esophagus following by esophageal
 Esophageal replacement with gastric pullthrough,
colonic graft or jejunal graft
Gastric Pullthrough
Gastric Pullthrough
 Free up the stomach via laparoscopy
 Cervical approach to bring down the cervical
esophagoscopy (spit fistula), followed by creating a
track in the mediastinum to approach the two ends of
the esophagus
Anesthetic Concerns of Gastric
 Lengthy procedure
 Capnothorax or Capnomediastinum when surgeon
taking down the stomach
 Can have difficulty ventilating during the
esophagoscopy take down and esophageal
mediastinum due to large dilators compressing a small
 Bleeding– Need adequate IV access
Complications following TEF/EA
 Anastomotic leak
 Recurrent esophageal fistula
 Esophageal strictures
 GERD/Esophageal dismotility
 Tracheomalacia/ Pulmonary Issues
 Musculocutaneous disturbances
Anastomotic leak
 Early complication occurring in 17% of patients
 Typically will resolve spontaneously without oral feeds or
with pleural drainage
 Case reports of glycopyrolate and atropine used to
minimize secretions
 Major leaks may require cervical esophagostomy and
gastrostomy with delayed definitive repair
 Esophageal strictures and recurrent fistula are more likely
to follow
Recurrent TEF
Recurrent Esophageal Fistula
 Serious complication affecting 5-20% of patients
 Open thoracotomy associated with morbidity and
mortality rates of 10-22%
 Endoscopic Closure preferred
 Presents with cough, choking, or cyanosis with
feeding, or recurrent pneumonia
Endoscopic Closure of RTEF
 Closure can be obtained with de-epitheliazation of the
fistula, application of tissue adhesives
 De-epitheliazation of the fistula
 Application of tissue adhesives(Tissel, dermabond, etc)
 Combination of both
 Highest overall and first time success with
combination treatment(93.3 and 66.7% respectively)
 Likely will need repeat procedures– first time success
28.6% with tissue adhesives and 50% for deepitheliazation
Fibrin Glue
Endoscopic Closure of RTEF
 Performed with Rigid Bronch
 Possibility of inability to ventilate if
 aspiration of a Fibrin Plug
 Occlusion of the trachea with the glue
Esophageal Strictures
 Occurs in 6-40% of patients
 More common with
 Gap >2.5cm
 EA/TEF type A, C, D
 Non-absorbable sutures
 Presents with dysphagia, poor feeding, and emesis
 Treated with Esophageal dilation
 Improves with time
Esophageal Dysmotility
 Esophageal peristalsis is abnormal in 75-100% of
patients with EA/TEF
 Small discoordinate contractions lead to increased risk
for esophageal obstructions
 Improves with time as 65% of kids will be admitted
with GI sx in the first 10 years of their life, but only 3%
of patients will be admitted after 18 years of age
 Occurs in 35-58% of TEF/EA children
 Due to intrinsic motor dysfunction of the esophagus as
well as possible anastomotic tension
 56% of patients with GERD respond to medical
 13-25% of patients will require a Nissen fundoplication
 However, attempts are made to avoid fundoplication
due to risk of severe dysphagia following given
dyskinetic esophagus
Respiratory Complications
 Present in 46% of patients following EA/TEF repair
 74% GERD
 13% with tracheomalacia
 13% with recurrent TEF
 Present in 75% of pathologic specimens in patients
with EA/TEF
Clinically significant in 10-20%
Usually found at or just above the level of the original
Presents with brassy cough, stridor, and dyspnea with
Treatment usually medical
Broemling N, Campbell F. Anesthetic Management of Congenital Tracheoesophageal Fistula. Peds
Anesth 21(2011): 1092-99.
Holcomb GW et al. Thorascopic Repair of Esophageal Atresia and Tracheoesophageal Fistula: A
Multi-Institutional Analysis. Ann Surg 2005;242: 422–430.
Briganti V et al. Usefulness of dextranamer/hyaluronic acid copolymer in bronchoscopic treatment of
recurrent tracheoesophageal fistula in children. International Journal of Pediatric Otolaryngology.
75(2011): 1191-94.
Atzori P et al. Preoperative tracheobroncoscopy in newborns with esophageal atresia. Journal of Peds
Sugery. 41(2006): 1054-57.
Meier J et al. Endoscopic Management of Recurrent Congenital Tracheoesophageal Fistula: A Review
of Techniques and Results. International Journal of Pediatric Otolaryngology. 71(2007): 691-97.
Tovar JA, Fragoso AC. Current Controversies in the Surgical Treatment of Esophageal Atresia.
Scandanavian Journal of Surgery. 100(2011): 273-8.
Sung M et al. Endoscopic Management of Recurrent Tracheoesophageal Fistula with trichloroacetic
Acid Chemocauterization: A Preliminary Report. Journal of Pediatric Surgery. 43(2008): 2124-7.
Knottenbelt G et al. Tracheo-esophageal fistula and oesophageal atresia. Best practice and Research
Clinical Anesthesiology. 24 (2010): 387-401.
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