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YOUR PATIENT

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A 38-week-gestation male child who was born with Apgars of 8 and 9 is unable to pass the nasogastric tube. The patient starts coughing and choking with pooling of secretions in the mouth. He is unable to swallow.

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Chest x-ray shows the nasogastric tube coiled up in the chest and a big gastric bubble.

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Physical examination shows bilateral equal breath sounds with a distended abdomen and systolic murmur.

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PREOPERATIVE CONSIDERATIONS

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The incidence of tracheoesophageal fistula (TEF) is 1 in 3000-4500 live births, and 35-65% of patients have associated congenital anomalies. This anomaly may be part of the VACTERL (vertebral anomalies, anorectal malformation, cardiac anomalies, tracheoesophageal fistula, esophageal atresia, renal anomalies, and limb anomalies) association. There are different types of TEF with varying incidence, with the commonest type being type C. Patients present with the “3Cs of esophageal atresia” (choking, coughing, and cyanosis) because of an inability to swallow and may develop aspiration pneumonia.

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Patients should have a chest x-ray, echocardiography to rule out any cardiac anomaly, and a complete blood cell count and serum electrolytes to rule out renal anomalies.

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Once diagnosed, the patient is given nothing by mouth, and a nasogastric tube is placed in the upper pouch with suction in the head up position. Antibiotics are started. Surgery is performed after 24-48 hours of stabilization.

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ANESTHETIC MANAGEMENT

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  • In premature patients with a cardiac lesion, consider staged repair, with placement of a gastrostomy tube under local or spinal anesthesia, subsequent ligation of the fistula, and esophageal repair when stable.

  • Use IV and/or inhalation induction until the airway is secure and adequate ventilation is assured.

  • The goal is to place the tip of the endotracheal tube beyond the origin of the fistula.

  • Avoid controlled ventilation; spontaneous and gently assisted ventilation is preferred until the fistula is ligated.

  • A good option is to maintain anesthesia with sevoflurane and remifentanil infusion.

  • Constant communication with the surgeon is crucial.

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POSTOPERATIVE CONSIDERATIONS

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The goal should be to return to spontaneous ventilation and extubation as soon as possible to avoid ventilation in a patient with a fresh tracheal anastomosis. These patients are at risk of developing tracheomalacia, mediastinitis, and sepsis due to leakage from the site of the esophageal anastomosis. Usually there is some residual esophageal dysfunction, decreased esophageal motility, and stricture formation.

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DOs and DON’Ts

  • ✓ Do IV and/or inhalation induction with spontaneous ventilation.

  • ⊗ Do not give positive pressure ventilation.

  • ⊗ Do not give muscle relaxant until the surgeon has control of the fistula.

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SURGICAL MANAGEMENT

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A retropleural approach via a right thoracotomy with the child in left lateral decubitis position is commonly used. The new trend is toward thoracoscopic repair of TEF, where thoracoscopy introduces significant physiologic changes: right-sided thoracoscopy ...

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