Bronchoscopy and Occlusion of Tracheoesophageal Fistula

Abstract

To the Editor: The recent case report, "Is It Time to Reevaluate the Airway Management of Tracheoesophageal Fistula?" by Reeves et al. [1] raises some interesting management decisions that go beyond the scope a report of two cases. It may be that all newborns with tracheoesophageal fistula should have bronchoscopy and insertion of an embolectomy catheter in the fistula as part of their anesthetic management, but outcome data need to be developed before this change in therapy is recommended. As the authors point out, the survival rate in these patients, except in those with low birth weights in conjunction with severe congenital anomalies, approaches 100% [2]. Frequently, desaturation in a newborn that occurs intraoperatively can easily be "cured" by repositioning the endotracheal tube. The potential difficulty posed by inadvertent inflation of the stomach can easily be recognized by oximetry and observation of the patient. Preemptive procedures with a small yield haven't yet been proven advisable. From the discussion, it is obvious that the authors are recommending that a select group of patients with tracheoesophageal fistula be considered for routine bronchoscopy and catheter placement. From the title of the case report, it appears that this procedure should be considered for all patients. Complications can occur from any instrumentation, and, in this fragile group of patients, bronchoscopy and catheter placement could be more of a problem in skilled or unskilled hands than simple intubation and doesn't always take just 5 minutes. The real possibility of the catheter being dislodged and obstructing the trachea or a main stem bronchus must be considered. Also, the authors do not state when the Fogarty catheter should be removed. In summary, in a select group of low birth weight patients with severe respiratory dysfunction and serious congenital anomalies, if the fistula is near the carina or main stem bronchial takeoff, bronchoscopy and the insertion of a baloon can be of value as in Case 2. However, to make recommendations from a single case is hazardous. The discussion in this report is meritorious, but the title and conclusions can be misleading. Nishan G. Goudsouzian, MD John F. Ryan, MD Massachusetts General Hospital Boston, MA 02114