Pediatric Surgery—Tracheoesophageal Fistula
Concept
Common cause of respiratory distress in the infant.
Several variants:
(A) esophageal atresia and distal TEF (most common) (B) atresia without fistula
(C) H-type TEF
(D) atresia with proximal and distal TEF
Approximately 50% of infants will have other congenital defects (VACTERL—vertebral, anorectal, cardiovascular, TEF, renal, limb) and you need to rule these in/out prior to operation.
Way Question May be Asked?
“Called to NICU to evaluate a newborn who is small for his gestational age that had an episode of choking and desaturation with his first two feedings. What do you want to do?” Should consider any newborn with respiratory dis- tress. Key is that problems are associated with feeding.
Most should be identified preterm by U/S.
How to Answer?
History
Maternal polyhydramnios
Respiratory distress with first feeding (choking, cough- ing, regurgitation)
Desaturation with eating
Physical Exam
Can’t place NGT
Small for gestational age infant
Scaphoid abdomen (if atresia without TEF)
Imperforate anus or limb abnormalities Cardiac exam
Diagnostic Tests
“Babygram”
air in GI tract rules out atresia without TEF r/o duodenal atresia, vertebral anomalies 0.5 cc barium down NGT (identify blunt pouch) Pre-op echo to r/o cardiac anomalies (affects anesthesia
management)
Renal U/S before or after repair
Surgical Treatment
(1) NGT in pouch (2) Elevate head of bed (3) abx if pneumonia
(4) OR in first 24 h for repair:
(a) extrapleural approach/right thoracotomy (b) divide fistula
(c) close trachea
(d) end to end esophageal anastomosis (e) gastrotomy for early post-op feeding (f) leave drain next to esophageal anastomosis (g) alternative is gastrotomy only and spit fistula
in neck and delay repair until one year old (colon interposition →usually in cases of atresia without TEF)
Common Curveballs
Post-op complication:
Leak Stricture
Recurrent fistula Reflux
94
Part 2.qxd 10/19/05 2:52 AM Page 94
Will enter pleura during extrapleural approach
Will be associated anomalies (Down syndrome, valvu- lar defect, etc.)
Won’t be able to perform primary end to end anasto- mosis because of long “gap”
Pt will present with H-type fistula (repeated episodes of pneumonia in infancy)
Scenario will switch to management of associated imperforate anus
Strikeouts
Not making the diagnosis
Not knowing most common type/how to repair most common type
Not ruling other associated anomalies pre-op (espe- cially cardiac!)
Not trying to place NGT (alternatively, continuing to try to advance when meet resistance)
Not placing G-tube at operation
Strikeouts 95
Part 2.qxd 10/19/05 2:52 AM Page 95
