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Table of Contents
Year : 2021  |  Volume : 5  |  Issue : 4  |  Page : 267-270

Anesthetic management of patients undergoing one-step surgical tracheoesophageal fistula: Case series

Department of Anesthesiology and Intensive Care, Faculty of Medicine, Udayana University, Bali, Indonesia

Date of Submission28-Jul-2021
Date of Decision28-Sep-2021
Date of Acceptance01-Oct-2021
Date of Web Publication24-Nov-2021

Correspondence Address:
Dr. Desy Permatasari
Department of Anesthesiology and Intensive Care, Faculty of Medicine, Udayana University, Jl. PB Sudirman, Denpasar 80232 Bali.
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/bjoa.BJOA_84_21

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The anesthetic management of newborns with tracheoesophageal fistula (TEF) and esophageal atresia (EA) can be challenging due to fistula between the airway and esophagus leading to difficulty in perioperative airway management. Maintaining the endotracheal tube (ETT) position during surgical manipulation and adequate ventilation without gastric distention complications is crucial. This study presents two cases of full-term and normal-birthweight newborns with Type C TEF/EA. Both of the patients underwent one-step surgical repair without gastrostomy insertion. Instead of using gastrostomy, correct placement of ETT might be checked by physical examination. Induction of anesthesia was done using volatile inhalational agents and fentanyl as analgetic. For intubation facilitation, spontaneous breath and ventilation were maintained to prevent gastric distention. This report showed that good intubation conditions could be achieved with deep volatile agents and without muscle relaxants. Patients were ventilated with an assisted-controlled technique following their spontaneous breath until the defect was ligated. Hemodynamic was maintained stably in both patients during the operation. Full-term babies with normal birthweight and no other congenital anomalies are generally associated with a better prognosis.

Keywords: Anesthesia, esophageal atresia, infant, newborn, tracheoesophageal fistula

How to cite this article:
Permatasari D, Kurniyanta P, Senapathi TG. Anesthetic management of patients undergoing one-step surgical tracheoesophageal fistula: Case series. Bali J Anaesthesiol 2021;5:267-70

How to cite this URL:
Permatasari D, Kurniyanta P, Senapathi TG. Anesthetic management of patients undergoing one-step surgical tracheoesophageal fistula: Case series. Bali J Anaesthesiol [serial online] 2021 [cited 2021 Nov 28];5:267-70. Available from: https://www.bjoaonline.com/text.asp?2021/5/4/267/330960

  Introduction Top

Tracheoesophageal fistula (TEF) and esophageal atresia (EA) are parts of the VACTERL syndrome (vertebral defects, anal atresia, cardiac defects, TEF, renal anomalies, and limb anomalies), which is a congenital developmental anomaly that manifests within the first few hours of life and affects approximately 1 in 3000–4500 live births. It is one of the most common congenital anomalies found in pediatric surgical centers.[1] It results from a defect in the lateral septation of the foregut into the trachea and esophagus.[2]

TEF is often accompanied by congenital heart disease in 32.1% of patients.[3] TEF is a surgically correctable anomaly with a high rate of survival (90%) even in infants with low birthweight.[4] Some challenges faced by anesthesiologists during TEF repair are perioperative airway management, especially correct insertion of endotracheal tube (ETT) tip to prevent gastric dilatation and maintain the position of ETT during surgical manipulation. Several proposed methods to secure the airway are the conservative approach without gastrostomy and the current technique with gastrostomy installation. Conservative approach without gastrostomy has the possibility of increased intracranial pressure and intraventricular hemorrhage complications.[5] Another method with gastrostomy allows gas to be vented out. However, gastrostomies may cause gas from the trachea to bypass the lungs and exit through the stomach, thus losing adequate ventilation.[6] In this study, we reported two cases of vigorous and normal birthweight neonates born with TEF/EA managed with one-step surgical technique without gastrostomy insertion.

  Case Report Top

Case 1

A 3-day-old term baby girl, weighing 2780 g, was referred from a district hospital due to respiratory distress and suspected of TEF/EA. The patient was born vigorous with an APGAR score of 7–8–9. Upon breastfeeding, the baby was coughing, choking, and appeared cyanotic. Orogastric tube (OGT) insertion was unsuccessful on the first attempt. The patient was then transferred to our institution for further evaluation and management. On physical examination, the patient’s respiratory rate was 50x/minute. The primary respiratory sound was bronchovesicular with minimal ronchi in both lungs without wheezing. Oxygen saturation was maintained at 95%–97% with non-invasive ventilation (NIV) with oxygen fraction (FiO2) 35%, inspiratory pressure (Pinsp) 16, and positive-end expiratory pressure (PEEP) 7 mm Hg. Complete blood count showed normal leukocyte count (8.58 x 103/µL), average hemoglobin level (16.3 g/dL), and hematocrit level (47.5%). Evaluation of hemostatic profile revealed prolonged prothrombin time (16.1 s), activated partial thromboplastin time (37.7 s), and international normalized ratio (1.46). Blood chemistry and electrolyte examination were within the normal limits. Radiographic examination showed dilated gaster and OGT did not reach the gaster, suggesting TEF type C/D and features of pneumonia [Figure 1]. Echocardiography examination did not show any cardiac anomalies. The patient was managed surgically on the fourth day.
Figure 1: Babygram of Case 1

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Case 2

A 1-day-old term baby girl, weighing 3300 g, was admitted to our institution due to atresia ani, neonatal vomiting, and excessive salivation. The baby was born with an APGAR score of 6–7–8. After administration of breast milk, the baby suddenly coughed, choked, and appeared cyanotic. Initial management with OGT was done but unsuccessful. Physical examination revealed a respiratory rate of 50x/minute, with minimal rhales upon auscultation. Oxygen saturation was maintained at 95%–97% with NIV, FiO2 35%, Pinsp 16, and PEEP 5 mm Hg. Complete blood count result showed increased leukocyte count (21.68 × 103/μL), normal hemoglobin count (21.6 g/dL), and normal hematocrit count (65.9%). Hemostatic analysis revealed prolonged prothrombin time (26.3s), activated partial thromboplastin time (45.4s), and international normalized ratio (1.9). Blood chemistry and electrolyte level were within normal limits. We placed intravenous cannulation for parenteral feeding. A babygram showed that OGT did not reach the gaster, recoiled gastric tube forming a loop at C4-Th2, gastric dilatation, suggesting TEF type C/D with aspiration pneumonia and dilatation of the transverse and descending colon with absent pelvic air supports the appearance of atresia ani [Figure 2]. No cardiac anomalies were found from echocardiography. The patient was scheduled for TEF repair and anoplasty.
Figure 2: Babygram of Case 2

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  Discussion Top

TEF is one of the congenital anomalies that can be corrected surgically. Surgical repair of TEF can be performed during the first days of life. However, it is also common for operative repair to be delayed from 3 days to 2 weeks after birth. During this period, the patient is managed conservatively. A more extended period of conservative treatment is more frequently associated with aspiration pneumonia and sepsis.[7] The anesthetic management of newborns with TEF is often challenging due to fistula between the airway and esophagus leading to difficulty in lung ventilation. General anesthesia is frequently planned for patients with TEF. Anesthetic induction can be administered intravenously, through inhalation, or by a combination of techniques. Inhalational anesthetic induction is preferred to secure the airway during intubation and maintain spontaneous ventilation.[8] During anesthetic induction, spontaneous ventilation should be preserved to minimize gastric insufflation. Previously, it was recommended that positive pressure ventilation should be avoided until the fistula is ligated. Nevertheless, this technique may restrict ventilation and increase the risk of gastric perforation. Recent studies showed that controlled ventilation with positive pressure is relatively safe and can be done in patients with fistulas ≤3 mm.[1]

The initial key to successful anesthetic management is to secure the airway and correct the placement of ETTs. The correct placement of ETT is by positioning the ETT with its end lying distal to the fistula to avoid gastric distension. The tube is initially placed through the carina into the right main bronchus. The tube is pulled back if unilateral breath sounds are confirmed through auscultation until breath sounds become bilateral. For more precise placement, a fiberoptic bronchoscope can be used for guidance or by placing the end of the gastrostomy tube under a water seal and observing any bubbling presence.[5]

In patients with type C TEF, special attention should be paid to the intubation technique because the fistula is just above the carina, and the tip of the tube may easily enter into the fistula. In this study, induction with sevoflurane and fentanyl provided a good intubation condition to facilitate ETT insertion. Other reports also stated anesthesia induction with volatile agents, whereas maintaining spontaneous ventilation facilitated the intubation process well.[9],[10],[11] Another approach is awake intubation to avoid positive pressure mask ventilation, thus gastric distention. However, this approach poses several adverse complications, including increased intracranial pressure and intraventricular hemorrhage in the premature infant.

Gastrostomy was not performed in both of our patients. Gastrostomy is usually performed in the staged repair of TEF and to prevent the air inflow through the fistula in a positive pressure ventilation procedure that may cause excessive stomach distension, interfering with diaphragmatic movement. Gastrostomy is not mandatory because, though gastrostomy obviates complications such as gastric rupture, it may cause a low-pressure leak via broncho-cutaneous fistula with resultant ineffective ventilation.[12] Because gastrostomy was not done in both of our patients, the correct placement of ETT was checked by physical examination until breath sounds can be heard in both lungs and through continuous monitoring of oxygen saturation perioperatively.

Patients in our study were full-term with normal birthweight with no association to other congenital anomalies. Survival rate prognostic classification of EA/TEF by Waterstone based on three determinants: pneumonia, birthweight, and related congenital anomaly. In a cohort study by Xu et al.,[13] the result indicated that patients with low birthweight face more risks, and the accompanying heart malformations were relatively common. Although mortality has significantly declined in this group due to the establishment of advanced surgical expertise and neonatal care, the postoperative complications are still high. Several studies postulated that staged repair of EA/TEF in premature infants with low birthweights might result in a lower rate of complications. It can be concluded that normal birthweight infants with TEF/EA that are successfully repaired associated with higher survival rate, which nearly reached more than 90%.[14]

  Conclusion Top

Conservative approach in TEF patients without gastrostomy can be safely done with the risk of increase intracranial pressure and intraventricular hemorrhage. The anesthesia key is to maintain spontaneous breathing to minimize gastric dilatation.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Edelman B, Selvaraj BJ, Joshi M, Patil U, Yarmush J. Anesthesia practice: Review of perioperative management of H-type tracheoesophageal fistula. Anesthesiol Res Pract 2019;2019:8621801.  Back to cited text no. 1
Susanti PT, Kardana IM, Ariyanta KD. Tracheoesophageal fistula newborn presentation and outcome: Case series. Am J Pediatr 2020;6:259-67.  Back to cited text no. 2
Maroszyńska I, Piestrzeniewicz KF, Niedźwiecka M, Szaniawska AZ. Isolated esophageal atresia in both premature twins. Pediatr Pol 2015;90:91-3.  Back to cited text no. 3
Lal DR, Gadepalli SK, Downard CD, Ostlie DJ, Minneci PC, Swedler RM, et al; Midwest Pediatric Surgery Consortium. Perioperative management and outcomes of esophageal atresia and tracheoesophageal fistula. J Pediatr Surg 2017;52:1245-51.  Back to cited text no. 4
Choumanova I, Sanusi A, Evans F. Anaesthetic management of trachea-oesophageal fistula/oesophageal atresia; 2017. Available from: https://resources.wfsahq.org/wp-content/uploads/364_english.pdf. [Last accessed on 2021 Jul 26].  Back to cited text no. 5
Uzumcugil F. Anesthetic management of tracheo-esophageal fistula. Curr Chall Thorac Surg2021:2-7. DOI 10.21037/ccts-20–183  Back to cited text no. 6
Uluba M, Dayi S. Images in clinical medicine: Tracheoesophageal fistula in a newborn. N Engl J Med 2014;371:e23.  Back to cited text no. 7
Broemling N, Campbell F. Anesthetic management of congenital tracheoesophageal fistula. Paediatr Anaesth 2011;21:1092-9.  Back to cited text no. 8
Ni Y, Yao Y, Liang P. Simple strategy of anesthesia for the neonate with tracheoesophageal fistula: A case report. Int J Clin Exp Med 2014;7:327-8.  Back to cited text no. 9
Kurniyanta P, Putra KH, Senapathi TGA, Suryadi I. Airway and ventilatory management in a premature neonate with congenital tracheoesophageal fistula. Bali J Anesthesiol 2021;5:108-11.  Back to cited text no. 10
Hanggorowati AD, Wiryana M, Sinardja K, Kurniyanta P. Penatalaksaanaan anestesi pada koreksi atresia esofagus (article in Indonesian). Medicina 2018;49:71-5.  Back to cited text no. 11
Gupta B, Agarwal M, Sinha S. Recent advances in anesthetic management in repair of tracheoesophageal fistula repair. Indian Anasth Forum 2018;19:39-44.  Back to cited text no. 12
Xu X, Zhang N, Li B, Huang L. Prognostic factors on low-birth-weight infants of Atresia and / or tracheoesophageal Fistula: A cohort study. Res Sq 2019;14:1-14.  Back to cited text no. 13
Dingemann C, Brendel J, Wenskus J, Pirr S, Schukfeh N, Ure B, et al. Low gestational age is associated with less anastomotic complications after open primary repair of esophageal atresia with tracheoesophageal fistula. BMC Pediatr 2020;3:267.  Back to cited text no. 14


  [Figure 1], [Figure 2]


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