Anesthesia Practice: Review of Perioperative Management of H-Type Tracheoesophageal Fistula

Abstract

Tracheoesophageal fistula (TEF) is a rare congenital developmental anomaly, affecting 1 in 2500–3000 live births. The H-type TEF, consisting of a fistula between the trachea and a patent esophagus, is one of the rare anatomic subtypes, accounting for 4% of all TEFs. The presentation and perioperative management of neonates with H-type TEFs and all other TEFs are very similar to each other. Patients present with congenital heart disease and other defects and are prone to recurrent aspirations. A barium esophagogram or computed tomography of the chest is a common means to the diagnosis, and surgical repair is carried out through either a cervical approach or a right thoracotomy. During operation, anesthetic management is focused on preventing positive pressure ventilation through the fistula in an attempt to minimize gastric distension. For patients with H-type TEFs, because of the patent esophagus, symptoms are often less severe and nonspecific, resulting in subtle yet important differences in their diagnostic workup and management. This review will cover the finer details in the diagnosis and perioperative anesthetic management of TEF patients and clarify how H-type TEF distinguishes itself from the other anatomic subtypes.

Care Recommendations for the Respiratory Complications of Esophageal Atresia-Tracheoesophageal Fistula: The International Network of Esophageal Atresia, Respiratory Complications Working Group

“…Patients with severe (especially extensive) tracheomalacia (with or without bronchomalacia) may have severe, potentially life-threatening symptoms due to the almost complete tracheal collapse, and they are likely to require some type of ventilatory support [127][128][129][130] . Such support is usually needed immediately after extubation following the surgical repair of the EA-TEF, but may be needed for weeks or months afterwards.…”

Anesthetic management of tracheo-esophageal fistula

“…The better understanding of outcome and long-term complications following the surgical repair, which have not actually been clear yet, might lead perinatal counseling provide beneficence (1). However, antenatal ultrasonography might be helpful in the presence of EA, whereas, it is not as useful in an H-type TEF (TEF without EA), in which polyhydramnios is not likely (2). This congenital anomaly is often associated with the anomalies in the acronym VACTERL, which is constituted of vertebral anomalies, imperforated anus, congenital heart disease, tracheoesophageal atresia, renal anomalies and limb anomalies (radial atresia).…”

“…These neonates and the ones that cannot be diagnosed immediately after birth, often present with excessive secretions, regurgitation leading to respiratory problems during feeding and recurrent pneumonia due to pulmonary aspiration of the feedings (4). Recurrent pneumonia is often the presentation later in life in patients with H-type TEF, as well as, cyanotic spells and choking while feeding (2,4).…”

Diagnostic and management strategies for congenital H-type tracheoesophageal fistula: a systematic review

“…Fallon et al [3] presented a large multicentre case series, including 102 patients over a 10 year study period [3]. Three reviews were included in the cohort; 2 reviews evaluated open 'classical' cervical vs thoracoscopic and endoscopic approaches and critical report analysis of H-type fistulae from an anaesthetic perspective [4][5][6].…”