Esophageal atresia and TEF: Where’s the fistula?
Myron Yaster MD
I think all of us have favorite surgical procedures, for some it’s posterior spinal fusion surgery, or craniotomies/neurosurgery, for others its ENT or aerodigestive procedures…you get the picture. For me, one of my favorites was the management of neonates with esophageal atresia and trachea-esophageal fistula. As a fellow and young faculty member during the “dark ages” (before pulse oximetry and capnography), the classic teaching was to deliberately intubate the right main stem bronchus and with the PRECORIDAL stethoscope in the left axilla, slowly pull back the endotracheal tube until the first breath sounds could be heard on the LEFT side. In theory the endotracheal tube would be BELOW the fistula and ABOVE the carina. Sounds simple enough but most of the time we still were above the fistula and with positive pressure ventilation would insufflate the stomach with potentially catastrophic results. And then a miracle occurred! In a landmark paper, Dr. Adrian Bosenberg one of the giants in pediatric anesthesia, published a paper on placing a thoracic epidural from a caudal approach.1 This changed everything! The trachea could be routinely intubated and the patient allowed to breathe spontaneously. Positive pressure and Identifying the fistula’s location became unnecessary.
In today’s PAAD Koo et al.2 using fiberopitc bronchoscopy after intubation looked at where the fistulas most commonly arose. After reading it, it was clear to me why the classic technique often failed. Myron Yaster MD
Original article
Koo DC, Scalise PN, Izadi SN, Kamran A, Mohammed S, Zendejas B, Demehri FR. Bronchoscopic Localization of Tracheoesophageal Fistula in Newborns with Esophageal Atresia: Intubate Above or Below the Fistula? J Pediatr Surg. 2024 Mar;59(3):363-367. doi: 10.1016/j.jpedsurg.2023.10.044. Epub 2023 Oct 25. PMID: 37957098.
“Esophageal atresia (EA) is a rare congenital anomaly characterized by discontinuity of the upper gastrointestinal tract, often accompanied by a tracheoesophageal fistula (TEF). At a reported incidence of 1 in 3000 to 1 in 4500 live births, EA/TEF is one of the most common gastrointestinal birth defects worldwide and one of the most difficult conditions pediatric surgeons manage in the modern era.”2 “In neonates with suspected type C EA/TEF, endotracheal intubation and positive pressure ventilation should be avoided, if possible, prior to surgical correction of the fistula due to the risk of accidental intubation of the fistula and difficulty with ventilation secondary to preferential airflow into the stomach via the TEF with resulting gastric distension.”2
Patients underwent bronchoscopy following induction of general anesthesia looking for the location of the esophageal fistula and then divided into categories: fistulas at the carina, fistula <1.5 cm above the carina, > 1.5 cm above the carina, and fistulas > 2 cm above the carina. (figure)
What did they find? 74 % of patients were found to have fistulas located < 1.5 cm from the carina and only 17 patients (26 %) had fistulas >1.5 cm above carina. Thus, most neonates with suspected type C esophageal atresia and tracheoesophageal fistula have distal tracheal and carinal fistulas and are not amenable to blind deep intubation.
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References
1. Bosenberg AT, Bland BA, Schulte-Steinberg O, Downing JW. Thoracic epidural anesthesia via caudal route in infants. Anesthesiology 1988;69(2):265-269.
2. Koo DC, Scalise PN, Izadi SN, et al. Bronchoscopic Localization of Tracheoesophageal Fistula in Newborns with Esophageal Atresia: Intubate Above or Below the Fistula? J Pediatr Surg 2024;59(3):363-367. (In eng). DOI: 10.1016/j.jpedsurg.2023.10.044.