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TEF/EA: The less talked about issues. 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.

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tef ea the less talked about issues

TEF/EA: The less talked about issues

Alyssa Brzenski MD

May 2, 2012

overview
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
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
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
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
the evidence behind the pre repair bronch
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 repair1
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
anesthesia for thorascopic
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
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
extubate or not
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
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
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 pullthrough1
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
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
Complications following TEF/EA Repair
  • Anastomotic leak
  • Recurrent esophageal fistula
  • Esophageal strictures
  • GERD/Esophageal dismotility
  • Tracheomalacia/ Pulmonary Issues
  • Musculocutaneous disturbances
anastomotic leak
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 esophageal fistula
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
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 de-epitheliazation
endoscopic closure of rtef1
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
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 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
slide35
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
Respiratory Complications
  • Present in 46% of patients following EA/TEF repair
    • 74% GERD
    • 13% with tracheomalacia
    • 13% with recurrent TEF
tracheomalacia
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
Bibliography
  • 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.