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
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