1 / 38

TEF/EA: The less talked about issues

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.

perrin
Download Presentation

TEF/EA: The less talked about issues

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. TEF/EA: The less talked about issues Alyssa Brzenski MD May 2, 2012

  2. Overview • Background • Pre-repair bronchoscopy • Thorascopic repair • To extubate or not? • Esophageal atresia – treatment of long-gap esophageal atresia • Complications following TEF/EA repair

  3. 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.

  4. 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.

  5. 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

  6. Background

  7. Co-morbidities

  8. Waterson Classification

  9. Spitz Classification

  10. Pre-repair Bronchoscopy

  11. 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

  12. Thorascopic vs. Open Repair

  13. 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

  14. Patient Position

  15. 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.

  16. 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

  17. Fistula Management

  18. 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

  19. 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

  20. 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

  21. Gastric Pullthrough

  22. 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

  23. 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

  24. Complications following TEF/EA Repair • Anastomotic leak • Recurrent esophageal fistula • Esophageal strictures • GERD/Esophageal dismotility • Tracheomalacia/ Pulmonary Issues • Musculocutaneous disturbances

  25. 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

  26. Recurrent TEF

  27. 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

  28. 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

  29. De-epithelithalization

  30. Fibrin Glue

  31. 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

  32. 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

  33. 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

  34. 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

  35. Respiratory Complications • Present in 46% of patients following EA/TEF repair • 74% GERD • 13% with tracheomalacia • 13% with recurrent TEF

  36. 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

  37. 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.

More Related