Repair Of Tracheo-oesophageal Fistula Research Articles

Monitored epidural catheter placement-ultrasound-guided neurostimulation-aided thoracic catheter placement via caudal route for perioperative analgesia in neonatal thoracotomies: A technical feasibility study.

In this case series, we investigated the feasibility of combining ultrasound and neurostimulation for inserting a stimulating epidural catheter in the thoracic epidural space through the caudal route in neonates. Twelve neonates undergoing tracheo-oesophageal fistula repair under general anaesthesia were studied. The catheter was visible on ultrasound as a hyperechoic dot in the epidural space. Inadvertent high placement was identified in two neonates with neurostimulation, in whom the catheter was withdrawn to the thoracic epidural space, and the position was confirmed on ultrasound. A 0.5 ml/kg bolus dose of 0.125% bupivacaine injected through the epidural catheter was imaged in real-time in the epidural space. Block was effective in 10 neonates; two needed an additional local anaesthetic (LA) bolus. To conclude, ultrasound with neurostimulation facilitates accurate positioning of the caudally placed epidural catheter to the mid-thoracic level in neonates.

Perioperative management and outcomes of neonates undergoing anaesthesia for congenital tracheo-oesophageal fistula repair at Charlotte Maxeke Johannesburg academic hospital.

Congenital tracheo-oesophageal fistula (TOF) occurs in 1 in 3000 births. Perioperative management for TOF repair requires co-ordination with a multi-disciplinary team, support from critical care units, and expertise in neonatal and cardiothoracic anaesthesia. Charlotte Maxeke Johannesburg academic hospital (CMJAH) is a quaternary referral centre that serves the regional community of Johannesburg, in Gauteng, South Africa. The aim of this research was to describe the perioperative outcomes of neonates undergoing surgical TOF repair at CMJAH. Factors in the preoperative, intra-operative, and postoperative management were considered to find relationships with the perioperative outcomes. A retrospective single institution study was conducted with a population of 38 neonates who underwent congenital TOF repair from 1 January 2015 to 31 March 2020 at CMJAH. Descriptive statistics were used to describe the biodata using percentages, median, and inter-quartile ranges. An in-depth description of neonates that died was performed. A total of 38 neonates diagnosed with TOF/OA were operated on during the study period. The mortality rate was 15.8%. No deaths occurred intraoperatively. In addition, 52.6% of the neonates had a prolonged stay in ICU, 44% had a delay in the initiation of feeds, 65% developed sepsis, and 36.8% had surgical related complications. CPR was required in 1 neonate, hypoxia leading to bradycardia in 10, and hyperlactataemia in 9 neonates. Inotropic support was required in 6 neonates, and vasopressor support in 4. Blood product transfusion were necessary for 9 neonates. The in-hospital mortality of TOF repair was better than that reported in other African countries and worse than international findings. In-hospital morbidity was burdened by respiratory illness and sepsis. Areas where management could be improved include widespread foetal anomaly scanning, incorporation of bronchoscopy, and preoperative respiratory optimisation.

Development and validation of a novel 3D-printed simulation model for open oesophageal atresia and tracheo-oesophageal fistula repair

BackgroundThe role of simulation training in paediatric surgery is expanding as more simulation devices are designed and validated. We aimed to conduct a training needs assessment of UK paediatric surgical trainees to prioritise procedures for simulation, and to validate a novel 3D-printed simulation model for oesophageal atresia and tracheo-oesophageal fistula (OA-TOF) repair.MethodsA questionnaire was sent to UK trainee paediatric surgeons surveying the availability and utility of simulation. The operation ranked as most useful to simulate was OA-TOF repair. 3D-printing techniques were used to build an OA-TOF model. Content, face and construct validity was assessed by 40 paediatric surgeons of varying experience.ResultsThirty-four paediatric surgeons completed the survey; 79% had access to surgical simulation at least monthly, and 47% had access to paediatric-specific resources. Perceived utility of simulation was 4.1/5. Validation of open OA-TOF repair was conducted by 40 surgeons. Participants rated the model as useful 4.9/5. Anatomical realism was scored 4.2/5 and surgical realism 3.9/5. The model was able to discriminate between experienced and inexperienced surgeons.ConclusionUK paediatric surgeons voted OA-TOF repair as the most useful procedure to simulate. In response we have developed and validated an affordable 3D-printed simulation model for open OA-TOF repair.

Airway manoeuvres during anaesthetic management of adult acquired tracheo-oesophageal fistula

Regardless of aetiology, acquired tracheo-oesophageal fistula (TEF) is a life-threatening condition due to the risk of pulmonary soiling and sepsis. Distorted airway anatomy below the glottis makes airway management challenging. We present the anaesthetic management for TEF repair in an adult male who developed fistula following organophosphorus poisoning. Maintaining optimum position of the endotracheal tube (ETT) during cross-field ventilation and ETT repositioning is crucial. For better understanding of the anaesthetic management for this relatively rare surgery, we have described airway management sequentially to coincide with different phases of surgical interventions.

Endotracheal tube blockage during tracheo-oesophageal fistula surgery: A case report

The multifarious anaesthetic challenges associated with tracheo-oesophageal fistula surgery are difficult tracheal intubation, continuous air leakage during positive pressure ventilation, gastric distension, sharing of the airway with surgeons, intraoperative desaturation due to surgical retractors and maintaining anesthetic depth. These challenges are managed properly only when pathophysiology of the fistula is well understood. In this case report we present an anaesthetic management with a near miss situation during repair of tracheo-oesophageal fistula in a neonate. Intraoperatively, the patient’s oxygen saturation decreased which did not improve despite correcting all possible reasons. Before the worst could have occurred, we identified endotracheal tube blockage as the cause and changing the tube on time saved the neonate.

Criticality in tailoring the treatment for tracheoesophageal fistulas in children.

Tracheo-oesophageal fistula (TOF) is a rare pathology. It can be congenital and concurrent with other congenital anomalies such as oesophageal atresia, laryngeal and tracheal agenesis, or it can be acquired. The purpose of this study was to analyse various management strategies and their outcomes in infants and children with TOF and identify potential areas for standardisation of the fistula repair procedures. At a single institution, a retrospective analysis of infants and children with congenital or acquired TOF between 2013 and 2019 was performed. Thirteen patients were identified. Data collection included: patient demography, associated congenital anomalies, details of fistula at the time of endoscopy, surgical approach and intra-operative findings, need for additional intervention(s), and outcomes. Thirteen patients underwent endoscopic or open surgeries for correction of TOF. The TOF was congenital in ten patients and acquired in three patients. Eight patients had associated aero-digestive comorbidities, and six patients had systemic comorbidities. Three patients underwent endoscopic procedures and nine patients underwent an open TOF repair. One patient had tracheal agenesis and was not offered any treatment. Two patients required multiple endoscopic interventions for recurrent TOFs. Among four patients with prior tracheostomy, three were decannulated and one awaits decannulation. Conclusıon Appropriate case selection and surgical ergonomics are essential for patients with TOF to avoid recurrences. Preoperative endoscopy to obtain precise details regarding associated laryngotracheal lesions and demographics of the fistula is crucial.

Aortopexy for the treatment of tracheobronchomalacia in 100 children: a 10-year single-centre experience.

Our study describes and analyses the results from aortopexy for the treatment of airway malacia in children. Demographic data, characteristics and preoperative, operative and outcome details, including the need for reintervention, were collected for children undergoing aortopexy between 2006 and 2016. One hundred patients [median age 8.2 months, interquartile range (IQR) 3.3-26.0 months] underwent aortopexy. Sixty-four (64%) patients had tracheomalacia (TM) only, 24 (24%) patients had TM extending into their bronchus (tracheobronchomalacia) and 11 (11%) patients had bronchomalacia. Forty-one (41%) children had gastro-oesophageal reflux disease, of which 17 (41%) children underwent a Nissen fundoplication. Twenty-eight (28%) children underwent a tracheo-oesophageal fistula repair prior to aortopexy (median 5.7 months, IQR 2.9-17.6 months). The median duration of follow-up was 5.3 years (IQR 2.9-7.5 years). Thirty-five (35%) patients were on mechanical ventilatory support before aortopexy. Twenty-seven (77%) patients could be safely weaned from ventilator support during the same admission after aortopexy (median 2 days, IQR 0-3 days). Fourteen patients required reintervention. Overall mortality was 16%. Multivariable analysis revealed preoperative ventilation (P = 0.004) and bronchial involvement (P = 0.004) to be adverse predictors of survival. Only bronchial involvement was a predictor for reintervention (P = 0.012). Aortopexy appears to be an effective procedure in the treatment of children with severe airway malacia. Bronchial involvement is associated with adverse outcome, and other procedures could be more suitable. For the treatment of severe airway malacia with isolated airway compression, we currently recommend aortopexy to be considered.

Management of Low Tidal Volume and ETCO2 during Thoracoscopy in the Treatment of Tracheo-Esophageal Fistula: A Case Report

Esophageal atresia with tracheo-oesophageal fistula (TEF) occurs in 1 in 2500-3000 live births. Management of airway and ventilation in TEF repair is challenging. Nowadays, advances in minimally invasive surgical techniques and neonatal intensive care for neonates have allowed endoscopically repair of TEF, which lends another level of complexity to airway management. Usually, a sudden increase in ETCO2 should alert the anesthesiologist to possible surgical trauma and entrainment of thoracoscopic gas. However, low ETCO2 emerging with low tidal volume can also alerts the anesthesiologist to possible surgical trauma. We had an uncommon situation, where a sudden low ETCO2 emerged with low tidal volume when doing the complete anastomosis. After communicating with surgeons, they stopped and tried to find the possible causes. Finally, it appeared to be a surgical injury on the right lung. Continuous communication between the surgeon and the anesthesiologist is imperative when performing these operations.

Repair of tracheo-oesophageal fistula.

Acquired non-malignant tracheo-oesophageal fistula (TOF) most commonly develops after prolonged intubation or tracheostomy. It may also develop after trauma, oesophagectomy, laryngectomy and other disparate conditions. TOF leads to respiratory compromise secondary to chronic aspiration and pulmonary sepsis. Difficulty with oral intake usually leads to nutritional compromise. After diagnosis, the goals are to eliminate or reduce ongoing pulmonary contamination and to restore proper nutrition. Operative repair of benign TOF is generally performed through a cervical approach. The majority of patients require tracheal resection and reconstruction to address concomitant tracheal or laryngotracheal stenosis. Muscle flap interposition between tracheal and oesophageal repairs reduces the risk of fistula recurrence. Operative repair of the fistula is associated with generally good outcomes with a minimal risk of mortality.

Unexpected presentation of a type IV laryngo-tracheo-oesophageal cleft: Anaesthetic implications of a rare case.

Laryngo-tracheo-oesophageal cleft (LTEC) is a congenital midline defect of the posterior larynx and trachea and the anterior wall of the oesophagus. Existence of these clefts may not be apparent during pre-operative evaluation. We present a rare case of a neonate initially scheduled for tracheo-oesophageal fistula repair. Unexplained air leak in spite of placement of size 4.0 mm endotracheal tube in a 2.5 kg neonate triggered extensive intra-operative evaluation of the airway anatomy via flexible and rigid bronchoscope. A type IV LTEC with an unusual anatomy was identified that was considered surgically irreparable. This case also highlights the need for a team approach and preparedness of anaesthesiologists for a difficult airway while managing such cases. Maintenance of high degree suspicion is warranted.

Management of associated anomalies of oesophageal atresia and tracheo-oesophageal fistula.

Tracheo-oesophageal fistula (TEF)/oesophageal atresia is one of the most common and serious congenital malformation. Despite progresses made in the field of early diagnosis, surgical techniques, ventilatory support and control of chest infections; morbidity and mortality still remains quite high and differs a lot from one to another centre particularly in the developing countries; as the availability and the level of neonatal care facilities are different. Associated anomalies play a significant role in dictating the outcome, timing of intervention and even the approach to management. The objectives of this review article is to outline the spectrum of associated anomalies, emphasise need of standardised system of documentation of anomalies, prognosis and management issues that would influence timing and approach of TEF repair.

Thoracotomy in a spontaneously breathing neonate undergoing tracheo-oesophageal fistula repair

Tracheo-oesophageal fistulae present a unique ventilator problem in the neonatal population. We describe the use of a caudal epidural catheter in a neonate who had to undergo carinal tracheo-oesophageal fistula repair. The epidural administration of a local anaesthetic enabled the provision of optimal analgesia, while simultaneously allowing maintenance of comfortable spontaneous ventilation during the thoracotomy.

Acquired tracheal diverticulum following repair of tracheo-oesophageal fistula: Endoscopic management

Remnant tracheal diverticulum following the repair of a tracheo-oesophageal fistula (TOF) is an uncommon complication. The majority of lesions are discovered and repaired at the time of primary oesophageal repair. Respiratory complications are reported to be a major cause for morbidity after surgical repair of a TOF. They include anastomotic stricture, oesophageal dysmotility and tracheomalacia. These case reports highlight the need to be wary of tracheal diverticulum as a complication following the repair of a TOF, which may cause difficulty in intubation, airway compromise or an inability to provide effective ventilation. An effective endoscopic surgical technique has been described.

Epidural analgesia for tracheo‐oesophageal fistula repair

Introduction: Traditionally neonates undergoing surgical repair of tracheo‐oesophageal fistula (TOF) would receive opioid analgesia and be returned ventilated to a neonatal intensive care unit (ICU). It has been shown that the use of epidural analgesia can reduce the need for postoperative ventilation (1). In recent years it has been the practice in our institution to use epidural analgesia for these neonates where possible. This is an audit of our recent experience.Methods: We retrospectively identified cases of TOF repair at our institution from January 2002 to September 2005. The notes of these neonates were reviewed for the following information: birth weight, gestational age, co‐existing congenital anomalies, preoperative respiratory function, operation duration, postoperative analgesia, ICU admission and duration of stay in ICU.Results: Thirty‐five TOF repairs were identified. One neonate was excluded as he had concomitant abdominal surgery. Of the 34 remaining, 30 sets of notes were reviewed. The outcome for these neonates is shown in the diagram. Of the 10 neonates who did not receive an epidural, a reason was found in eight cases: three were already ventilated, two had abnormal coagulation, two had coexisting congenital heart disease and one had recurrent apnoeas. Only three of the 20 neonates with an epidural required postoperative ventilation, one for metabolic acidosis, one for lung collapse and one for inadequate respiratory effort. All three remained on ICU for <24 h. The median PICU stay for those neonates who did not receive an epidural was 4 days (range 2–11 days). The group who received epidural analgesia was more mature (38.7 weeks c.f. 35.3 weeks gestational age) and heavier (2.9 kg c.f. 2.3 kg) than the group who did not. The mean operative time (including bronchoscopy and surgery) was 2.8 h in the epidural group and 3.3 h in the nonepidural group. Conclusion: Mature neonates presenting for TOF repair can be managed with epidural analgesia, usually removing the need for postoperative ventilation and an ICU bed. There is a group of smaller, less mature neonates that did not receive epidural analgesia, we cannot determine from this audit whether any of these would have benefited from epidural analgesia.Reference 1 Bosenberg AT, Wiersma R, Hadley GP. Esophageal atresia: caudo‐thoracic epidural anesthesia reduces the need for post‐operative ventilatory support. Pediatr Surg Int 1992; 7: 289–291.

Dysphagia due to tuberculosis

Dysphagia due to tuberculosis is rare in both the developing countries with high prevalence rates and the western population following the recent upsurge linked to the AIDS and immigration. To study tuberculosis as an aetiological factor in the causation of dysphagia and to evaluate the outcome of anti-tubercular treatment and surgical results in these patients. Retrospective review of experience with 14 cases of dysphagia due to tuberculosis encountered between 1996 and 2003. The duration of symptoms ranged between 3 and 18 months. All of them underwent oesophagogastroscopy, barium swallow, fiberoptic bronchoscopy and CT scan of the chest. The aetiology was subcarinal node enlargement in seven, tracheo-oesophageal fistula in four, oesophageal ulcer in two and cervical node suppuration in one. Tuberculous involvement was confirmed by pathological examination in all patients. All of them received anti-tuberculous therapy. Seven patients required surgery, transthoracic repair of tracheo-oesophageal fistula in four patients, one patient required subcarinal node excision and two needed abscess drainage. There were no mortalities and there was complete relief of dysphagia in all of them. Tuberculosis as a causative factor for dysphagia should be considered in regions with high incidences of tuberculosis and in immunocompromised patients. Treatment with anti-tuberculous therapy is effective. Surgery is required only for complications of tuberculosis.

Chronic cough and wheeze in children: do they all have asthma?

In the experience of both authors, children referred for investigation of a chronic productive cough often do not fit conventional diagnostic categories. The aim of this study was to answer two questions: 1) do such diagnostic orphans exist? and, 2) if so, can they be classified in a clinically useful manner? Eighty one previously undiagnosed children referred with a history of more than 3 months productive or rattly cough were studied prospectively. Investigations consisted of a detailed history, physical examination, and an extensive set of clinical investigations. Sixty randomly selected asthmatic children served as demographic controls. Children fell into three groups: 23 had newly diagnosed conditions, such as cystic fibrosis, or were indistinguishable from asthma; 24 had a history of major medical interventions (cardiac surgery, chemotherapy, tracheo-oesophageal fistula repair); 34 had a history of significant early respiratory tract infections, usually combined with poor social conditions. The latter group differed significantly from asthmatic controls in a wide range of demographic and clinical comparisons. Native American children were overrepresented. The results of this study suggest that early respiratory insults (whether viral or medical) can induce self-perpetuating inflammation, manifesting as a chronic productive cough and intermittent wheeze. The associations between poverty and infant chest infections or early invasive medical treatment with subsequent chronic respiratory disease are clearly definable and probably justify diagnostic terms distinct from asthma, particularly for use in epidemiological studies.

Nissen fundoplication for gastro-esophageal reflux in repaired tracheo-esophageal fistula.

One hundred and fifty three patients had repair of tracheo-oesophageal fistula in a 15 year period of observation. Of these 55 had associated gastro-oesophageal reflux and of these 12 (8%) underwent a Nissen fundoplication. All patients manifested significant failure to thrive but weight-gain was documented in all patients following their fundoplication. Twenty five percent of patients demonstrated recurrent reflux in this study and emphasises the difficulty of treating gastro-oesophageal reflux in repaired tracheo-oesophageal fistula patients. Careful selection is important.

Anaesthetic management during repair of tracheo-oesophageal fistula

INTERNATIONAL ABSTRACTS OF PLASTIC AND RECONSTRUCTIVE SURGERY: NECK: Larynx, Pharynx, Trachea, and Esophagus: PDF Only

Inhalation (aspiration) pneumonia following experimentally induced disordered motility of the oesophagus.

SYNOPSIS Neuromuscular inco-ordination of the oesophagus in infants following repair of tracheo-oesophageal fistula (T.O.F.) is responsible for inhalation of oesophageal content into the airways resulting in pneumonia. In an experimental study disordered motility of the oesophagus was induced surgically in piglets, to see if this premise was valid. Gross disturbance of peristalsis was confirmed both radiographically and by electromanometry. Prolonged retention of barium was seen in the upper oesophagus after a swallow with later reflux into the pharynx but no aspiration was demonstrated during screening. The tracheal contents of these piglets and a control group were therefore studied after the piglets had been fed regularly on milk and other food for weeks following recovery from the operation. The high incidence of fat filled macrophages in tracheal aspirates obtained from the piglets with surgically induced disordered motility of the oesophagus was significant (P < 0.004) compared with the low incidence in the control group, confirming that disordered motility is responsible for inhalation.

The management of infants with tracheo-oesophageal fistula.

Our technique of dealing with the problelms associated with repair of tracheooesophageal fistula has been described as we have developed it over the years, This method employs basic principles of paediatric anaesthesia and takes cognizance of the many additional factors which present themselves in this condirtion. These are due primarily to involvement of the respiratory tree in the disease, and the frequent coexistence of prematurity and other life-threatening congenital anomalies. With an incidence variously reported as 1:1,300 to 1:4,500 of live births, it is obvious that the condition is relatively infrequently encountered in the average general hospital. In an operation beset with so many problems and pitfalls, in which meticulous attention to even the most minor detail is essential and which is seen at most six times a year in any but the largest general hospitals or in children’s hospitals, it is essential that for best results the management should be limited to one team, so that avoidable mistakes are not repeated by combinations of different individuals. When one thinks in terms of a team, this must, in addition to surgeon and anaesthetist, include the nurses in the intensive treatment area upon whose skill and acute appraisal of abnormal situations the survival of these infants depends to a large measure in the postoperative period. The paediatricians contribute by their advice on fluid replacement therapy and other non-surgical problems and they regulate the oral feeding regimen until such time as the infants are returned to their primary care during convalescence. Until then, all treatment orders are written by one person only (usually by the surgeon or by his resident under his direct orders), after due consultation with other members of the team. This avoids the confusion arising out of contradictory orders or the omission of others, and ensures that at least one person is completely in the picture at all times of every phase of treatment.