1. Tracheo esophageal fistula Dr. S. Parthasarathy MD., DA., DNB, MD (Acu), Dip. Diab. DCA, Dip. Software statistics, PhD(physiology) Mahatma Gandhi Medical College and Research Institute, Puducherry, India

2. What is it ?? There is a connection between trachea and esophagus Congenital Sometimes plain esophageal atresia is talked with fistula

3. GROSS classification

4. Why does it happen ?? The embryogenesis - not completely defined. The trachea and esophagus develop from a common site, the foregut, in the first 4 to 5 weeks of gestation. Both the esophagus and the trachea originate from the median ventral diverticulum of the primitive foregut. The TEF lesion results from failure of the two structures to separate during division of the endoderm.

6. 1 in 4000 --- C A E C A E

8. Diagnosis antenatal polyhydramnios Excessive salivation choking, coughing,aspiration pneumonia, cyanosis. Attempts at feeding - met with explosive vomiting passing an oral (nasal) gastric tube is impossible. A chest radiograph of a coiled oral gastric tube in the cervical esophageal pouch is diagnostic. No contrast please

10. VACTERL A common association is the VACTERL complex, consisting of vertebral, anorectal, cardiac, tracheoesophageal, renal, and limb defects VATER, VACTER and VACTERL 30 % may have !! But the ligation of a TEF is urgent.

11. Preoperative management --FUSA F eedings – NO U pright positioning S uctioning intermittent A ntibiotic administration Dehydration and acid base to be corrected Should we intubate preop ?? Does this prevent aspiration

12. Two ways of aspiration If significant aspiration pneumonia definitive corrective surgery ?? decompressing gastrostomy local or caudal anesthesia

13. Waterson prognostic criteria Weight - > 2.5, 1.8 – 2.5, <1.8 Associated anomalies Pneumonia A, B or C

14. Preoperative work up Echocardiography ( routine + right sided aortic arch) X ray chest Blood gases Lumbar ultrasound – Xray spines – caudal ?? USG abdomen Rigid bronchoscopy (airway + fogarty) Tracheoscopy flexible (Zurisch et al) 1 unit of packed red blood cells should be type and crossed matched

15. Surgery Repair primary repair involves isolation and ligation of the fistula followed by primary anastamosis of the esophagus. A staged repair is possible in sick neonates Posterior thoracotomy Thoracoscopic Bronchoscopic clipping of H Sometimes stabilizing and do it in 7 – 10 days FUSA remains

16. Gastrostomy

17. Sometimes During gastrostomy, they may clamp the fistula with esophagostomy and do the surgery after a few months also. Esophagostomy done from the neck to remove the secretions Described

18. Routine monitors Precordial steth in the left axilla Adequate IV access Radial artery cannulation (Lt) or umbilical 0.15 mg atropine IV Temperature, IV fluids Urine output – 1 ml/kg /hour

19. Anaesthetic management

20. Awake intubation Inhalation Induction Intubation in sitting posture Proper suctioning Circuits, scopes, cuffed ETT, Neonatal ventilators

21. Fish mouth fixation

22. Principle Intubate purposely Rt main bronchus Withdraw slightly to get bilateral air entry Reverse the curve of the tube Reverse the side of murphy eye Gas leak Ventilate lungs and not the fistula

23. Ventilation - adequate ?? Gastric distension Gastrostomy to water – to ETCO2 Tube kink Anomaly – different Even OLV

24. Ventilate to the stomach – fistula – no ventilation Tight bag with occlusion of the fistula

25. To prevent leak

26. Its easier to describe spontaneous – but open chest with surgeon pushing the right lung its difficult to maintain with spontaneous appropriate positioning of ETT is mandatory.

27. Spontaneous or controlled Are we sure – we are ventilating the lungs and not the fistula ?? Allow spontaneous & Give caudal 0.5–1 mL/ kg of 0.25% bupivacaine with epinephrine (5 μg/mL) Try threading far up.. But guarantee ?? USG Fentanyl Relaxants after clamping the fistula

28. No caudal ?? Avoidance of regional anesthesia with its corresponding decrease in systemic vascular resistance is warranted in patients with coexisting congenital heart disease such as hypoplastic left heart syndrome (HLHS). Cautious caudal in CVS diseases

29. Intra op problems left lateral decubitus position. During the surgical repair, the right lung is compressed and packed away, which may result in hypoxia. the trachea and/or endotracheal tube is compressed and occluded by the surgeon. Alternatively, the endotracheal tube can become obstructed by blood clots or may migrate into the fistula tract.

30. Intra op problems During localisation of the fistula, an anaesthesiologist can help the surgeon by applying traction to the wire loop. Some routinely use 100% oxygen during these anesthetics, even in premature infants who are at risk for developing the ROP. Class C -- bad lungs HFO used - reports !! Extubate in healthy infants -- class A Otherwise ??

31. Intra op problems The surgeon will get hold of the fistula and pull it. It will dislodge the position of ETT. The rt. Lung is collapsed by the surgeon. The tube becomes RT. endobronchial. ?? No ventilation – that’s why keep the steth Left axilla and watch for breath sounds..

32. Prognosis

33. Post op problems Surgical postoperative complications include anastomotic leak, stricture, gastro esophageal reflux, tracheomalacia, recurrent TEF. flush ligation is a must. Otherwise - Diverticulum –stasis, infection and giving way

34. Thoracoscopic approach The advantages Reduction of musculoskeletal sequelae that often develop following open thoracotomy in the newborn period. These have been well described as “winged” scapula, asymmetry of thoracic wall and thoracic scoliosis. superior visualization of fistula and surrounding structures including vagus nerve with the thoracoscopic approach.

35. Post op giving way Don’t extend Neck of neonate anastomosis will stretch and give way as there is always a gap between the two ends of oesophagus, which surgeon has mobilised to bring together

36. Post operative problems Need for ventilation arises secondary to  Compression of lung for several hours  Pre-existing aspiration pneumonia  Is always preferred in the backdrop of other coexistent congenital anomalies

37. Summary Incidence Types Commonest Clinical features FUSA Intubation and positioning, techniques Intra op hypoxemia Waterson, spitz, post op ventilation

38. Thank you all