The pitfalls of endotracheal intubation beyond the fistula in babies with type C esophageal atresia

A unique presentation of a standard type C esophageal atresia in a very low-birth-weight neonate

“…Even in an intraoperative setting, it is often challenging to pass a catheter through the fistula and successfully achieve an airtight closure [3]. Interestingly, although many other cases in the literature have reported significant morbidity and even mortality related to blind intubation of the fistula [6,7], the aberrant placement of the NG within the trachea did not cause a dramatic worsening of the patient's respiratory status. The lack of respiratory symptoms in our case could be accounted for by only a partial occlusion of the trachea by the NG with the resultant increased airway resistance readily compensated for by present CPAP already in place.…”

Anaesthesia for oesophageal atresia with or without tracheo-oesophageal atresia

“…A case report by Alabbad et al highlights the pitfalls of this type of manoeuvre, where the tube migrated into the fistula after positioning with fatal consequences. 36 In another case report by Llewellyn and Reed, another complication was reported, with suturing in of the tube while ligating the fistula because of the proximity of the tube to the fistula. 37 The blind occlusion of the fistula, as shown in a report by Hack and Raj, might miss a second undiagnosed fistula with untoward complications.…”

“…Failure of isolation could have devastating consequences, including hypoxaemia, and even death. 36 Traditionally, the method of inserting the endotracheal tube (ETT) as deeply towards the carina as possible, with gentle manual ventilation and pulling of the tube back to a point where both lungs are ventilated, is the one commonly used. 8,36,37 The difficulty with this method is that the tube could migrate during positioning and ventilation of the fistula re-initiated.…”

Thoracoabdominal and General Surgery

“…One popular technique is to deliberately intubate the right main bronchus after general anesthesia is induced and then withdraw the tube until bilateral air entry is confi rmed. This ensures the tracheal tube is below the fi stula but does not prevent intubation of a large fi stula at the carina [ 96 ]. Alternatively, rigid bronchoscopy (or fl exible bronchoscopy after intubation) may be used to demonstrate the precise level of the fi stula (or exclude multiple fi stulae) and then plan the intubation strategy.…”

“…This may lead to gastric distension, deteriorating cardiorespiratory status, and possible gastric rupture. Inadvertent intubation of the fi stula must be excluded in cases of severe gastric distention with cardiorespiratory instability [ 96 ]. To prevent gastric distention from ventilation via the fi stula, some have recommended clamping the distal esophagus as soon as the chest is opened [ 97 ].…”