TrachoEsophagial fistula (TEF) f.ghaseminia

A tracheoesophageal fistula (TEF) is a congenital or acquired communication between the trachea and esophagus.

Pathophysiology of congenital Remember Embryology: The esophagus and trachea both develop from the primitive foregut. In a 4- to 6-week-old embryo, the caudal part of the foregut forms a ventral diverticulum that evolves into the trachea.

The longitudinal tracheoesophageal fold fuses to form a septum that divides the foregut into a ventral laryngotracheal tube and a dorsal esophagus. The posterior deviation of the tracheoesophageal septum causes incomplete separation of the esophagus from the laryngotracheal tube and results in a TEF.

5 main categories of congenital TEFs:

Clinical presentation: Depends on the type 1,2,4,5(with EA) copious, fine white frothy bubbles of mucus in the mouth and nose can’t be feeded 4,5first feeding may cause sudden arestsudden death 3 (without EA)rattling respiration and episodes of coughing and choking in association with cyanosis. abdominal distention may occur secondary to collection of air in the stomach(atelectasis  respiratory failure)

Diagnosis of EA .Insertion of a NG-tube(8-10F) or OG-tube (10-12F)may show coiling in the mediastinum of patients. .Contrast studies are seldom required to confirm the diagnosis. These studies have the risk of aspiration pneumonitis and pulmonary injury

Diagnosis of TEF .Presence of air in the gastrointestinal lumen with Percussion or abdominal radiography . Some clinicians prefer direct visualization by flexible esophagoscopy or bronchoscopy and assess its exact location prior to surgery.

Prenatal diagnosis Prenatal 3D ultrasounds after 24 weeks may reveal polyhydramnios, absence of fluid-filled stomach, small abdomen, and a distended esophageal pouch

…Diagnosis It’s very important to check other anomalies.

Main anomalies VACTERL including: Syndrome that can be associated with it  VACTERL including: Vertebral anomalies Anorectal anomalies Cardiovascular anomalies TrachoEsophagial fistula Renal anomalies Limb anomalies

treatment Goals of the initial treatment: 1)Attention to ventilation 2)↓ upper pouch pressure 3)Determine appropriate time for surgery So: For ↓ aspiration risk: 1)elevate neonate’s head at least 30º in infant warmer 2)Use “sump” catheter on13 continiouse suction IV AB and electrolyte.

In premature infants Use oscillatory ventilation with high frequency Gastrostomy may be neededplaced on the water seal,elevated or Intermittently be clamped

surgery 1)Thoracotomy 2)Thoracoscopy  w>2.5 kg, stable, without anomalies After surgery: 7,8 days NPO in ICU

So follow up is Necessary complication Recurrent TEF Stenosis pristaltism problem Gastroesophagial refluxantireflux drug/surgery So follow up is Necessary

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