Tracheo-oesophageal Fistula

Sunita Goel
Lecturer in Anaesthesiology, BJ Wadia Children's hospital, Mumbai, India
First Created: 02/23/2001 

Tracheo-Oesophageal Fistula - History

Its incidence is about 1/4000. It was first described in 1670. Surgical correction was started only in the 1920s. The first survivors were reported in 1939. The extrapleural approach was reported in 1941.

Tracheo-Oesophageal Fistula - Embryology

  • It occurs between the 21st and 34th days of fetal development.
  • From the Ventral diverticulum of foregut, masses of endodermal cells divide foregut into trachea and oesophagus. It begins at carina and its imperfect division results in TOF.
  • Explanation of Esophageal Atresia is less clear.
  • Growth of trachea in caudal direction is so rapid that dorsal wall of oesophagus becomes incorporated into trachea.
  • Other etiologies: "Vascular deficiency" Genetic basis.

Tracheo-Oesophageal Fistula - Classification

Gross divided this in to five groups:

  • A: Esophageal atresia without fistula
  • B: Atresia with upper segment communication
  • C: Atresia with lower segment communication
  • D: Atresia with both segments communicating
  • E: Fistula with no disruption in continuity
  • F: Esophageal stenosis

Presentation

ANTENATAL: Polyhydramnios

POST-NATAL: drooling, respiratory distress, choking, coughing, cyanosis

Associated Anomalies

Overall incidence of associated anomalies is 50-70%

  • Cardiac (30%): PDA, VSD, ASD
  • Gastrointestinal (12%): Imperforate anus, duodenal atresia, annular pancreas, pyloric stenosis
  • VACTERL (25%)

Waterson Risk Groups and Current Survival Figures


Group Survival(%) Waterson classification
A 100 Birth Weight > 2500 g, well child
B1 85 Birth Weight 1800-2500 g, well child
B2   Higher weight with moderate associated anomalies
C1 65 Birth Weight < 1800 g
C2   Birth Weight < 1800 g, severe anomalies

Tracheo-Oesophageal Fistula - Diagnosis

  • Failure to pass NG tube
  • Radiographic: Plain, Thin Barium Contrast
  • Bronchoscopy

Pre-operative Management

Oral feeds should be discontinued. Baby should be kept in a semi-upright position to minimize regurgitation. The proximal segment should be suctioned continuously to prevent aspiration. The severity of pulmonary disease should be evaluated. Hypothermia should be avoided.

General Management

  • Antibiotics
  • Sump catheter in upper pouch
  • Upright positioning
  • Screening for any congenital anomalies
  • Correction of fluid electrolyte status
  • Gastrostomy, uncommon, usually in isolated EA

Surgical Management

Aim for one-stage repair

  • Bronchoscopy
  • Extrapleural approach

    * Right thoracotomy

    * Division of fistula

    * Mobilisation and anastomosis

  • KIV Gastrostomy if anastomosis under tension

Problems with Tracheo-esophageal Fistula

General:

  • Management of neonate
  • Possible prematurity and low birth weight

Specific:

  • Aspiration
  • Chemical pneumonitis, pneumonia
  • Gastric distention with diaphragmatic splinting

Intra-operative Problems

Lung retraction

Secretions and blood clots

Kinking of trachea

Post-operative Problems

  • Tracheomalacia may result in life threatening cyanotic and apneic spells.
  • Tracheostomy may be necessary to maintain patent airway without ETT.
  • Leak
  • Stricture
  • Recurrent fistula
  • Problems with dysphagia and recurrent respiratory infections
  • Esophageal strictures might require dilatations
  • Abnormalities in esophageal motility leading to repeated aspirations.


Tracheo-Oesophageal Fistula Tracheo-Oesophageal Fistula Tracheo-Oesophageal Fistula 02/23/2001
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