TRACHEOESOPHAGEAL FISTULA

Successive stages in the development of the tracheoesophageal septum during embryologic development. (A) The laryngotracheal diverticulum forms as a ventral outpouching from the caudal part of the primitive pharynx. (B) Longitudinal tracheoesophageal folds begin to fuse toward the midline to eventually form the tracheoesophageal septum. (C) The

tracheoesophageal septum has completely formed. (D) If the tracheoesophageal septum deviates posteriorly, esophageal atresia with a tracheoesophageal fistula develops incidence of 1 in 3,000 to 4,000 live births. 10% cases may be associated with VACTREL polyhydramnios earliest,+/_ stomach bubble / neck pouch? Antenatal associated anomalies the neonate with esophageal atresia presents with copious, fine, white, frothy bubbles of mucus in the mouth and, sometimes, the nose. rattling respirations and episodes of coughing, choking and cyanosis.may be exaggerated by feeding abdominal distention develops as air builds up in the stomach i/c/o distal fistula Radiopaque 8 French (in preterm infants) or 10 French (in term infants) nasogastric or feeding tube should be passed through the nose to the stomach. In patients with atresia,

the tube typically stops at 10 to 12 cm. The normal distance to an infant's gastric cardia is approximately 17 cm. radiographs (posteroanterior and lateral views) should be obtained to confirm the position of the tube. The radiograph should include the entire abdomen. Contrast studies are seldom necessary to confirm the diagnosis. Such studies increase the risk of aspiration pneumonitis.

Waterson and Montreal classifications have been used to predict mortalit in patients with TOF. As per Watersons classification; Group A = bw >2500, no anomalies Group B = bw > 1800 moderate anomalies, moderate pneumoniis Group C = bw <1800 with svere anomalies / pneumoniis

As per Montreal class: Group I = No ventilator dependence with minor / major anomalies + ventilator dependence wih minor anomalies.

 Group II = Ventilator dependence wih major anomalies/ life threatening anomalies regardless of pulmonary status. Unstable neonate with/without sepsis = stabilize, Gastrostomy with distal esophageal pouch foleys balloon occlusion of TOF done to minimize the air leak following ventilation therapy. Stable / mild pulmonary symptoms /minimal infiltrates taken for thoracotomy. Occasionally, urgent thoracotomy with ligation and division of the TEF, followed by delayed esophageal repair, may be necessary when respiratory support is required, and inspired air is lost via the fistula. Definitive esophageal repair is attempted when the infant's condition stabilizes. Before surgical correction, the infant must be evaluated thoroughly for other congenital anomalies with chest radiograph,renal ultrasound and echocardiogram. The goal of airway management in a patient with EA/TEF is to maintain adequate ventilation of the lungs without ventilating the fistula. The patient is positioned left side down for a right posterior lateral thoracotomy. If a previous gastrostomy was performed, it is opened and placed on straight drainage to avoid gastric distention during the procedure. A short posterolateral incision is made below the level of the tip of the scapula (Fig. 4), and hemostasis is obtained with electrocoagulation. The latissimus dorsi muscle is identified and retracted posteriorly, but occasionally is divided (Fig. 5). The auscultatory space of Korotkoff is identified, and the scapula is retracted superiorly and the serratus anterior muscle medially. It is usually unnecessary to divide the serratus muscle, thus avoiding the risk of developing a winged scapula. The fourth intercostal space is identified and entered. The intercostal muscles are carefully divided to avoid entering the pleura. An extrapleural dissection is carried out

 The intact pleura and underlying lung are retracted medially with moistened sponges under a soft malleable retractor. The dissection continues with the use of a moist peanut sponge until the azygos is fully mobilized and the mediastinal pleura over the vein is opened. The azygos vein is divided between two 4-0 suture ties. This vein is often the marker for the site of the TEF as it enters the trachea. A branch of the vagus nerve usually passes over the area as well. the TEF is identified and carefully dissected free near the trachea preserving the small vessels to the midesophagus that arise directly from the aorta. A.The tracheoesophageal fistula site is mobilized circumferentially distal to the fistula, and the area is encircled with a vessel loop. B: Traction sutures are placed, with great care taken not to encroach on the lumen of the trachea, which can result in narrowing with closure. Division of the fistula is then performed using a tenotomy scissors. C: The tracheal end is closed with a 5-0 continuous or interrupted suture. The closure is tested with positive-pressure ventilation to rule out a leak. The tracheal suture line is covered with mediastinal pleura to reduce the risk of recurrent tracheoesophageal fistula should an anastomotic leak occur. While the proximal esophageal pouch is mobilized, a proximal fistula should be excluded. The proximal esophagus is mobilized to the thoracic inlet within the neck. When opening the proximal esophagus, care should be taken to ensure that the opening is at the lowermost point recognized with the feeding tube tip. The distal esophagus is freed only as much as necessary to approximate the ends of the esophagus. A single-layer anastomosis is performed with full-thickness, interrupted 4-0 sutures, involving mucosa and muscularis. The posterior sutures are placed with the suture knots on the outside. B: After the posterior suture line is completed, a feeding tube is advanced into the distal esophagus and stomach. The anterior sutures are inserted to complete the single-layer anastomosis.

Circular myotomy of the proximal esophageal pouch is useful to gain 1.0 cm of esophageal length for a tension-free anastomosis.

No. 12 French chest tube is placed, entering the posterior mediastinal space below the incision, being careful to avoid injury to the intact pleura during insertion. The tip of the tube is situated superiorly, near, but not on, the anastomosis, and is kept in place with a 4-0 PDS or Vicryl suture Post op & complications: The nasogastric tube that was placed in the stomach at the time of the procedure should be fixed and not moved. If it slips out, replacement should not be attempted. Head of bed elevation and enteral drip feedings are often initiated through the nasogastric tube on postoperative day 3 in an effort to minimize GERD. The chest tube is left in place and usually on water seal until postoperative day 6, when a contrast barium swallow confirms that no anastomotic leak is present. Oral feedings may be initiated after a negative contrast study. Care should be exercised during oral feedings

because of the high incidence of esophageal dysmotility problems (>30%) and the risk of GERD, which is observed in 50% of cases. When GERD is noted, the patient should be placed on reflux precautions, along with the administration of H2-blockers and prokinetic agents (metoclopramide). If an anastomotic leak is noted, it is usually minimal and closes spontaneously over the course of the next week. Rarely, a major anastomotic disruption may require reoperation. Most anastomotic strictures respond to esophageal dilatation using either a balloon dilator or a more traditional dilator of the Tucker, Maloney type with fluoroscopic guidance or Savory dilators passed over a guidewire when needed. Failure of an anastomotic stricture to respond to dilatation is often caused by GERD; which can be treated wih floppy nissens or toupets fundoplication. Recurrent TEF is an uncommon complication.; requiring surgical repair. In c/o type A TOF; gap between the two ends of the esophagus can be measured by placing a radiopaque dilator in the proximal esophagus, refluxing contrast material into the lower esophagus through the gastrostomy, and obtaining a radiograph (Fig. 18). When the gap is less than 2.0 cm a thoracotomy and primary repair can be attempted. Delayed anastomosis is possible in the majority of cases (4 to 5 months); however, a proximal esophageal myotomy to bridge the gap frequently may be necessary. Staged stretching of the proximal esophagus by formation of an esophagostomy that is periodically advanced inferiorly onto the anterior chest wall, as described by Kimura and Soper, is an alternative method of achieving additional length A reversed gastric tube is fashioned along the greater curvature of the stomach, incising both anterior and posterior walls to conform to the size of No. 18 to 24 French catheter.alternatively gastric pullup may be done/ colon interposition may be done.