TEF/EA: The less talked about issues

Report
Alyssa Brzenski MD
May 2, 2012
Overview
 Background
 Pre-repair bronchoscopy
 Thorascopic repair
 To extubate or not?
 Esophageal atresia – treatment of long-gap esophageal
atresia
 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.
Background
 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
Background
Co-morbidities
Waterson Classification
Spitz Classification
Pre-repair Bronchoscopy
The Evidence behind the pre-repair
Bronch
 May change the operative management (changed
operative approach in 57% with 31% being crucial
changes)
 Bronchoscopy can
 Define the fistula location
 Determine unusual characteristics of the fistula(double
fistula or trifurcation)
 Determine presence of tracheobronchitis (surgery
contraindicated)
 Locate the aortic arch
 Influence anesthetic management
Thorascopic vs. Open Repair
Thorascopic vs. Open Repair
 Reduces Musculocutaneous sequelae
 32% of patients have significant musculocutaeous
sequelae
 24% with winged scapula
 20% asymmetry of chest wall 2/2 atrophic serratus
anterior
 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
induction
 Classic teaching that paralysis can be given after fistula
ligated
 Balanced anesthetic +/- epidural for post-op pain
management
 May have difficulty with hypercapnia or difficulty
ventilating
Fistula Management
Extubate or Not?
 Must consider pre-op lung disease and other
comorbidities
 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
ends
 Ideal to use the patient’s own esophagus
 Excess tension on the esophageal anastamosis is
associated with increased complications and worse
outcome
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
anastamosis
 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
Pullthrough
 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
airway
 Bleeding– Need adequate IV access
Complications following TEF/EA
Repair
 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
De-epithelithalization
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
GERD
 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
therapy
 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
Tracheomalacia
 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
EA/TEF
Presents with brassy cough, stridor, and dyspnea with
feeds
Treatment usually medical
Bibliography
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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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