|Year : 2018 | Volume
| Issue : 2 | Page : 39-44
Recent advances in anesthetic management in repair of tracheoesophageal fistula repair
Bhavna Gupta1, Munisha Agarwal1, Shandip Kumar Sinha2
1 Departments of Anaesthesia and Critical Care, MAMC and Lok Nayak Hospital, New Delhi, India
2 Department of Pediatric Surgery, Madhukar Rainbow Hospital, New Delhi, India
|Date of Submission||11-Aug-2018|
|Date of Acceptance||03-Sep-2018|
|Date of Web Publication||15-Nov-2018|
Dr. Bhavna Gupta
Department of Anaesthesia, MAMC and Lok Nayak Hospital, New Delhi
Source of Support: None, Conflict of Interest: None
Thoracosopic repair of tracheoesophageal fistula and esophageal atresia (TREAT) is an advanced endoscopic procedure which requires a skilled approach in minimally invasive surgeries. TREAT is considered as a superior technique in achieving cosmesis and avoiding complications when compared to open thoracotomy. It requires a team of surgeons, anesthesiologists, and assistants and neonatal intensivists to look after the neonate in the perioperative period. Recent meta-analysis has shown no significant difference in outcome and functional evaluation in open thoracotomy and thoracoscopic approach to TEF repair. Anesthesiologists should be well versed with knowledge and ability to anticipate challenges in managing neonates under thoracoscopic TEF repair which plays an important role in the management and survival of these kids. We searched PubMed and Google Scholar databases with the following keywords anesthetic management, tracheoesophageal repair, surgical repair, non-intubated video-assisted thoracoscopic surgery, video-assisted thoracoscopic surgery, video-assisted thoracoscopic surgery, pediatric one-lung ventilation, and pediatric regional anesthesia. The last search was made on July 31, 2018.
Keywords: Anesthetic management, nonintubated video-assisted thoracoscopic surgery, pediatric one-lung ventilation, pediatric regional anesthesia, surgical repair, tracheoesophageal repair, video-assisted thoracoscopic surgery
|How to cite this article:|
Gupta B, Agarwal M, Sinha SK. Recent advances in anesthetic management in repair of tracheoesophageal fistula repair. Indian Anaesth Forum 2018;19:39-44
|How to cite this URL:|
Gupta B, Agarwal M, Sinha SK. Recent advances in anesthetic management in repair of tracheoesophageal fistula repair. Indian Anaesth Forum [serial online] 2018 [cited 2019 Aug 25];19:39-44. Available from: http://www.theiaforum.org/text.asp?2018/19/2/39/245550
| Introduction|| |
Tracheoesophageal fistula and esophageal atresia (TEF and EA) presents after birth. Repair of TEF is classically performed through open thoracotomy, but there are various postoperative concerns which include pain because of major incision, splinting of diaphragm thereby delayed weaning, postoperative pulmonary complications, scoliosis, elevation or fixation of the shoulder, asymmetry of chest wall, large scar, and cosmetic concerns. Jacobaeus, in 1912, described the idea of thoracoscopy using a cystoscope to release adhesions of pleura. Rothenberg, in 1999, reported initially repair of EA using thoracoscope and later on for repair of TEF and EA. Avoidance of thoracotomy has a proven advantage in postoperative recovery period. It has also been proven that rate of leaks and anastomotic stricture is same. Advancement in neonatal intensive care, anesthetic, and surgical techniques has significantly reduced morbidity and survival rate is now 99% after successful repair of TEF.,, We searched PubMed and Google Scholar databases with the following keywords anesthetic management, tracheoesophageal repair, surgical repair, nonintubated video-assisted thoracoscopic surgery (NIVATS), video-assisted thoracoscopic surgery, video-assisted thoracoscopic surgery (VATS), pediatric one-lung ventilation, and pediatric regional anesthesia. The last search was made on July 31st, 2018.
| Epidemiology|| |
TEF occurs in 1 in 3000-1 in 4500 births and 85% infants; lesion includes EA with distal esophageal pouch and a tracheal fistula connection. Affected neonates develop progressive abdominal distension and present with spillover of pooled oral secretions, thereby tracheal aspirations of gastric contents. A common association with consisting of vertebral, anorectal, cardiac, TEF, renal and limb defects (VACTREL) is present. The morbidity and mortality rates have drastically reduced with greater advancement of the surgical techniques. Significant mortality is limited to low birth weight neonates with co-existing cardiac, respiratory, and congenital anomalies. Neonates with TEF and EA have associated anomalies in the acronym VACTREL. VACTREL includes vertebral 17%, anal 12%, cardiac 20%, TE and EA, renal 16%, limb 10%, and other midline defects (cleft lip, palate, sacral dysgenesis, and urogenital abnormalities). Several classifications of EA and TEF have been made based on the presence of atresia and relation of fistula to the atresia. Gross classification describes EA with or without TEF types A till F. Another classification describes TEF into five types: Type I, II, III A, III B, and III C. Most common type is EA with distal TEF.,
| Diagnosis|| |
Diagnosis is usually made shortly after birth by the inability to pass nasogastric (NG) tube beyond 8–10 cm. Ryle tube is secured and suctioned so as to aspirate contents, after which X-ray can be obtained for confirmation. Prenatal diagnosis can be made by polyhydramnios and absence of swallowing or stomach content. In neonates not diagnosed at birth, suspicion is made by bouts of coughing, cyanosis, or vomiting at onset of feeds. Association of VACTREL anomalies should also raise the suspicion of TEF with EA.
| Management|| |
Surgery is the definitive management, delay in surgical correction is usually associated with increased risk of aspiration from the upper esophageal pouch. Reflux of gastric contents from the lower pouch and TEF is responsible for causing pneumonitis. Early diagnosis and repair results in significant improvement in survival outcomes. Waterston classification, as shown in [Table 1], allows for risk stratification, predicting outcome, and surgical timing. There are three important factors which predict outcome and includes birth weight, associated anomalies, and pneumonia.
| Preoperative Assessment|| |
Preoperative evaluation is done to diagnose associated anomalies which include cardiac, musculoskeletal, and gastrointestinal defects which occur in 30%–50% patients. Prematurity, associated lung disease, and congenital anomalies constitute poorer prognosis. Routine hematological investigations are sought. Imaging includes chest and abdomen X-ray to see the level of upper pouch.
Patient selection depends on the following three factors:
- Weight of the kid
- Overall clinical condition of neonate and
- Upper pouch level.
| Monitoring|| |
Routine standard American Society of Anesthesiologists (ASA) monitoring including electrocardiogram, noninvasive blood pressure (BP), peripheral oxygen saturation, and end-tidal carbon dioxide is required. An arterial line can be inserted into the right radial artery for invasive BP monitoring and for arterial blood gas analysis. A urinary catheter is also desirable in anticipated prolonged surgeries. Monitoring has been summarized in [Table 2].
| Initial Optimisation and Management for Treat|| |
Low birth weight babies tend to be more sick, and tolerate the stressors such as hypoxia, hypercarbia poorly and are not able to sustain prolonged duration of surgery. The known cardiac abnormality is also considered a relative contraindication considering impaired oxygenation during thoracoscopic approach, right aortic arch is an anomaly where anatomy is distorted, and it is difficult to work in a small space during TREAT. Similarly, long gap atresia and gap more than vertebral length are difficult to handle at the time of anastomosis. If TEF presents in the immediate few hours of birth, initial management is the same as that of open approach. Similarly, if patients present late, they require preoperative stabilization and optimizing investigations.
An isotonic fluid should be used to correct dehydration, followed by maintenance fluids at the rate of 4 ml/kg/h. Preoperative antibiotics are administered to avoid the risk of perioperative respiratory complications.
| Positioning and Anesthetic Strategy|| |
Mask ventilation is avoided prior to surgery as it exacerbates gastric distension and may compromise respiration of the neonate. Whenever trachea is intubated an attempt is made to keep the endotracheal tube (ETT) just above carina and occluding the fistula orifice with tracheal tube. The tip of tracheal tube is positioned after auscultation of diminished breath sounds over left axilla as the tube is advanced into right mainstem bronchus after which tube is retracted until breath sounds are increased.
| Positioning|| |
Patient is placed in semi-prone position with placement of pad underneath right pectoral region so as to tilt chest by 15° to opposite side. Table is tilted by 15° reversed Trendelenburg position.
| Indications and Techniques of One Lung Ventilation in Tracheoesophageal Fistula Repair|| |
Initially, all thoracic surgeries were performed by thoracotomy. In majority of the cases, anesthesiologists ventilated both the lungs by ETT and retraction of lung was done by surgeons to gain exposure into surgical field. Lately, after 2000, the use of video-assisted thoracoscopic surgeries has dramatically increased in both adults and children. Recent advances in surgical techniques, technology, high resolution camera, and smaller endoscopic instruments have facilitated application of VATS in smaller patients. VATS has been extensively used in empyema, lung biopsy, and wedge resections, drainage of lung abscesses, mediastinal masses, and metabolic lesions. Even for complex lesions, such as congenital cystic adenomatoid malformation, closure of patent ductus arteriosus, repair of hiatus hernia, and tracheoesophageal repair. VATS can be performed while both lungs are ventilated and placement of retractor to displace lung tissues in operative field. One lung ventilation is desirable during VATS, as lung deflation improves visualization of thoracic contents and reduces lung injury caused by retractors. Various techniques for one-lung ventilation include:
- Single lumen ETT: The simplest technique is to intubate ipsilateral right mainstem bronchus intentionally with conventional ETT. When left bronchus has to be intubated, ETT is rotated by 180°, and head is turned to the right side, ETT is then advanced until breath sounds on the operative side disappear. A fiber optic bronchoscope may be passed through ETT to confirm its placement. Problems can occur in case of smaller uncuffed ETT as it may not provide an adequate seal of bronchus and there may be spillage from the operative side into healthy lung. Hypoxemia may also occur in cases of obstruction of upper lobe bronchus,
- Bronchial Blockers balloon-tipped: Fogarty Embolectomy catheter or an end hole balloon wedge catheter are used for bronchial blockade to provide one-lung ventilation A fiberscope (FOB) may be used to confirm its placement. The catheter balloon is positioned in proximal main stem bronchus under FOB visual guidance. With the help of inflated balloon blocker, airway is completely sealed and provides optimal lung collapse and better operating conditions to the surgeons. However, there is potential for dislodgement of BB into trachea. The balloons of most of BB are high pressure and low volume and overdistension of the same can damage airway. Furthermore, the operative lung cannot be suctioned and one cannot apply continuous positive airway pressure during surgery,
- Univent Tube: Univent tube is conventional ETT with a 2nd lumen that contains a small tube that can be advanced into a bronchus. A balloon located at the distal end of tube serves as a blocker. Univent tubes are available in size 3.5 and 4.5 mm ID for children above 6 years and require FOB for successful placement. Displacement of balloon of uninvent tube blockers is unlikely to be displaced as they are firmly attached to main ETT. The blocker tube has a small lumen allowing insufflation of oxygen, egress of gas, and suctioning the operative lung
- Double-Lumen Tubes (DLTs): All DLT consists of two tubes, D shaped, of unequal lengths which are molded together, shorter tube ends in trachea and longer one goes and resides in bronchus. There is bilumen tube for infants as described by Marraro which consists of two separate uncuffed tubes of different lengths attached longitudinally. Smallest available DLT is 26 F which may be used for children aged 8 years. Size 28 and 32 F are available for children 10 years and above. The inflated bronchial cuff allows ventilation to be diverted to either or both lungs and helps prevent lung contamination from contralateral side. Major advantage of DLT is its ease of insertion, ability to oxygenate with CPAP and suction the operative lung.
| Concerns during Conduct of Thoracoscopic Tracheoesophageal Fistula|| |
Intubation is done in a similar way as that of open technique such that ET tube bevel is placed away from fistula. Fogarty balloon occlusion method can be used for lung isolation. Left main stem bronchus intubation may be necessary in Large pericarinal fistulae, by techniques as described above. Most of the other times, pediatric surgeons do not request for one-lung ventilation as nondependent lung is compressed by CO2 insufflation. Neonatal insufflators are also used to overcome the problem of overdistension of chest cavity. A 10 or 12F catheter is inserted to the proximal esophageal pouch through the mouth, and is kept loosened so that anesthesiologist can push on it when required and an 8F catheter is inserted as a nasoesophageal tube. Surgery is started with insertion of 5 mm port at postaxillary line near the tip of scapula, ensuring proper position of first port in pleural space. Gas insufflation is started at 0.1–3 L/min flow, maintaining 5 mmHg intrapleural space. This is often not tolerated in sick neonates with compromised cardio-respiration. Transient hypoxemia and hypercarbia can occur at the beginning of procedure due to pressure effects on mediastinal contents and collapse of lung. Ventilator parameters are adjusted, maintaining minute ventilation, so as to maintain normal oxygenation and ventilation. Pneumothorax may also be diminished to achieve the same, increase in fractional of oxygen is also done to avoid desaturation at this time point. After few minutes, after the ipsilateral lung is collapsed no pneumothorax pressure is applied. High FiO2 may be required along with application of positive end-expiratory pressure may be required to maintain saturation above 85%. End-tidal carbon dioxide reading will be unreliable during this period. Arterial CO2 will be raised, and must be noted in the setting of congenital cardiac disease and pulmonary hypertension. Procedure is started after a stable condition is achieved.
A magnificent view of upper chest is obtained, and lung is collapsed by gentle pressure by instruments and intrathoracic pressure which is kept at 4–6 mm. Superior vena cava is seen anteriorly and phrenic nerve lies above it. Major Landmarks include azygous vein, and vagus nerve, subclavian forms the apex. The proximal pouch is identified after the anesthesiologist pushes the Ryle tube, it also helps surgeon decide the gap distance. The distal fistula is located at the level of azygous vein or above it. Its position is ascertained as the trachea expands posteriorly at this level.,
Control of Fistula-Lower pouch is identified by vagus nerve which lies just above it, and by expansible impulse of azygous vein which is synchronous with ventilation. The endothoracic fascia is incised to identify the lower pouch. The fistula is then grasped by a grasper and dissected preserving the vagus nerve. Once mobilization has been done, all around to gain length, the pouch is opened with an oblique cut and two ends are prepared for anastomosis. The first stitch should be meticulously placed as the two ends tend to fall apart. Once it is done, posterior raw sutures are done, making sure mucosa is included following which NG tube is passed through anastomosis by anesthesiologist, the anastomosis is completed after the same. The tube is pulled back to avoid traction onto the anastomosis. After the anastomosis is finished, operative field is irrigated and cannulae are removed. The anesthesiologists at this time point inflates the collapsed lung and skin of cannula holes are closed with adhesive tape.
A postoperative chest X-ray is made to evaluate lung expansion as well as the position of the endotracheal and NG tube. The child remains mechanically ventilated for a few days and is then weaned from the ventilator. Feeding is started through the NG tube on day 2. Oral feeding ad libitum is started when the child has been extubated, and salivation has stopped. No routine contrast studies of the esophagus are performed. The child is discharged when on full oral feeding and doing well. As after open surgery, children with an EA are regularly seen as an outpatient.
| Regional Anesthesia|| |
- Intercostal nerve block may be placed by surgeons or anesthesiologists at the completion of surgery, at levels two dermatomal segment above and below the surgical incision. It helps provide excellent postoperative analgesia and helps the child breathe with good respiratory efforts. Local anesthetic toxicity is, however, a concern as it is known to be absorbed most through intercostal spaces
- Port infiltration with local anesthetics may be provided in thoracoscopic approach to provide postoperative pain relief. Port site is considered most notorious for causing pain; hence, relief should be adequate
- Thoracic epidural anesthesia is usually not required in VATS repair of TEF unless the surgery is planned under non-intubated VATS repair, which however is tricky in neonates, and there are concerns for local anesthetic toxicity, hypoxia, hypercarbia, and inadequate analgesia. Local anesthetics such as 0.1% bupivacaine or ropivacaine with fentanyl 2–3 μg/ml or morphine may be used.
Postoperative care and management
Postoperative care and management are similar as in conventional TEF repair except that since thoracotomy is not done, so ventilator stay is less, and requirement for pain is reduced. A postoperative chest X-ray is done to evaluate lung expansion as well as certain the position of endotracheal and NG tube. The child remains mechanically ventilated for few days and weaned from ventilator. Feeding is started through NG tube at 48 h; oral feeds are commenced after the child is extubated and salivation has stopped. The child is discharged when on oral feeds and does well, and seen as outpatients. Mortality rate is <1.5% and is based on SPITZ classification [Table 3] of predicting mortality and morbidity.
Aspiration may manifest as recurrent respiratory infections. Following repair gastroesophageal reflex may remain because of inherent esophageal dysfunction in subsets of patients.
| Nonintubated Video-Assisted Thoracoscopic Surgery|| |
In recent years, the use of NIVATS instead of conventional general anesthesia VATS is increasing researched and reported. NIVATS is considered beneficial with respect to faster recovery, reduced morbidity and shorter stay in the hospital. It is considered superior and less costly and is considered good alternative in patients with low risk of general anesthesia and use of conventional one-lung ventilation. There is avoidance of untoward effects of hemodynamic changes occurring as a result of tracheal intubation, mechanical ventilation, and muscle relaxation. Systemic complications due to use of muscle relaxants and intubation leading to a sore throat, cough, increase in postoperative patient's discomfort are all responsible for the delay in patient's recovery in postoperative period. NIVATS can satisfactorily remove these issues., According to Liu et al., on comparison of NIVATS and VATS lobectomy, they found that the surgical duration and intraoperative bleeding was not significantly different in the two groups, some complications, however, were significantly decreased and had significantly better results in terms of postoperative rehabilitation indicators such as antibiotic use, feeding time, thoracic drainage volume, and postoperative hospital stay in NIVATS which demonstrated safety and feasibility of the NIVATS. The current contraindications for NIVATS are expected difficult airway management patients, obesity (body mass index >30 kg/m2), dense and extensive pleural adhesions, hemodynamically unstable patients and ASA >II. However, patient selection should be carefully done, and feasibility of the same depends on surgeon's experience and comfort of attending anesthesiologist. It is even more appropriate for high-risk patients to avoid postoperative pulmonary complication and prolonged ventilator stay. However, there are many limitations which include inadequate analgesia, respiratory excursions, hypoxia, hypercarbia, and conversion into general anesthesia. Aspiration and loss of airway risk are attributed to loss of airway reflexes during deep sedation. Refluxed gastric contents or secretions can result in laryngospasm, bronchospasm, and increasing further morbidity. For surgeries such as thoracoscopic video-assisted repair of TEF, requiring prolonged surgery, the risk and benefit of the same should be ascertained and discussed with surgeon.,
| Conclusion|| |
Thoracoscopic TEF repair has lesser musculoskeletal complications as compared to open TEF repair. The complications associated with open TEF repair include winging of scapula, thoracic scoliosis, and chest wall asymmetry. Thoracoscopic TEF repair is described as opioid sparing technique and has reduced pain in postoperative period. These patients have shorter extubation, and recovery times and also shorter intensive care unit stays and not to forget better cosmetics. The benefits of NIVATS including enhanced recovery, improved analgesia, early oral intake, and early ambulation and reduced stress responses to surgery cannot be refuted. However, there are still complexities and limitations as NIVATS is still in its nascent phase and its application is not widely accepted for all surgeries under VATS especially involving neonates and complex procedures and is governed by the comfort of the attending anesthesiologist and surgeon's experience.
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Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]