Esophageal Atresia, Distal Tracheoesophageal Shunt That Compromised Mechanical By Wayne
E. Richenbacher Hershey,
and Thomas
the basis of prematurity, respiratory distress syndrome, aspiration of saliva, and reflux of gastric contents into the tracheobronchial tree. Thoracotomy and primary repair may be delayed to allow time for complete evaluation of the infant and respiratory stabilization. Poorly compliant lungs and a large distal fistula can result in selective passage of ventilatory gases into the gastrointestinal tract with resultant hypercarbia. Fogarty balloon occlusion of the distal
INDEX WORDS: Esophageal fistula; hypercarbia.
atresia:
and facilitates
tracheoesophageal
A
TTEMPTS at primary repair of esophageal atresia (EA) and tracheoesophageal fistula (TEF) in neonates classified as Waterston Group C’ have resulted in mortality rates of 42% to 64%.2*3 These high-risk infants are presently managed by performing immediate gastrostomy and delayed thoracotomy. Early gastrostomy permits gastric decompression and drainage of gastric contents, preventing reflux through the fistula into the lungs. The interval between gastrostomy and thoracotomy allows time for appropriate respiratory care, investigation for associated anomalies involving other systems, the administration of antibiotics, and parenteral hyperalimentation. Survival using this staged approach averages 71% to 85%.4*5 Prior to gastrostomy, patients with severe respiratory distress syndrome (RDS) who require highpressure ventilatory support are at risk of developing massive gastric distension6 gastric perforation7 a reduction in diaphragmatic excursion with compromised ventilation, and cardiac arrest.* Following gastrostomy, poor pulmonary compliance can result in a selective passage of ventilatory gases through the low-resistance distal TEF. Acute ventilatory deteriora-
From the Division of Pediatric Surgery, Department of Surgery, College of Medicine. The Milton S. Hershey Medical Center, The Pennsylvania State University, Hershey, PA. Address reprint requests to Thomas V.N. Ballantine, MD. Department of Surgery, College of Medicine, The Pennsylvania State University, The Milton S. Hershey Medical Center, PO Box 850. Hershey, PA 17033. o 1990 by W.B. Saunders Company. 0022-3468/90/2512-0003.$03.00/0
1216
Ballantine
Pennsylvania
l Infants with esophageal atresia and a distal tracheoesophageal fistula are predisposed to respiratory failure on
esophageal segment halts this air shunt effective mechanical ventilation. o 1990 by W.B. Saunders Company.
V.N.
Fistula, and an Air Ventilation
Journal
tion at the time of gastrotomy is a significant source of intraoperative mortality.’ CASE
REPORT
A 1,270-g, 30 weeks’ gestation, boy infant was born by spontane-
ous vaginal delivery following the premature onset of labor. Apgar scores were 2 at 1 minute and 3 at 5 minutes. Respiratory arrest, at 3 minutes of age, necessitated intubation with a 2.5mm oral endotracheal tube. A chest roentgenogram demonstrated the ground glass appearance characteristic of severe RDS. An arterial blood gas (ABG) documented a pH of 7.18, a PCO, of 62 mm Hg, and a PO, of 141 mm Hg on an F,O, of 1.O, rate of 60 breaths per minute and ventilatory pressures of 25/4 mm Hg. Ventilator pressures were increased to 36/4 mm Hg; however, the repeat ABG showed a persistent respiratory acidosis with a pH of 7.25, a PCO, of 57 mm Hg, and a PO, of 62 mm Hg. The infant’s abdomen became more noticeably distended and profuse, frothy oral secretions persisted. All attempts to pass a nasogastric tube failed and a chest film showed the tip to lie within the cervical esophagus. The diagnosis of EA with a distal tracheoesophageal communication was made. The patient’s deteriorating respiratory status precluded primary repair; thus, gastrostomy tube placement was planned. The infant was maintained on an air/ oxygen mixture with the F,O, varying from 0.8 to 1.O.At laparotomy a no. 14 mushroom catheter was inserted into the stomach, at which time a tremendous air leak was detected. The transcutaneous oxygen content (TcPO,) immediately decreased from 95 to 45 mm Hg. Placement of some device to obstruct the flow of air through the fistula seemed indicated, otherwise emergency thoracotomy and fistula ligation would have been necessary. Under C-arm fluoroscopy a 4F Fogarty catheter was inserted into the gastrostomy tube and carefully advanced into the distal esophagus. The balloon was inflated with 0.8 mL of renograffin and there was an immediate increase in TcPO, and a decrease in the amount of pressure necessary to ventilate the infant (Fig 1). An ABG following distal esophageal occlusion showed marked improvement in the respiratory acidosis with a pH of 7.39, a PCOz of 33 mm Hg, and a PO, of 177 mm Hg. Over the next 48 hours the patient was maintained on mechanical ventilation with a gradual reduction in F,O, to 0.21. Pressure necrosis of the esophagus was avoided by intermittently deflating the balloon. The balloon was reinflated with Renograffin (Squib, Princeton, NJ) in order to keep the TcPO, in excess of 90 mm Hg. A daily chest film confirmed the position of the balloon in the distal fistula (Fig 2). At 53 hours of age, the infant underwent right thoracotomy and transpleural division of both a proximal and distal TEF with primary esophagoesophagostomy. He required 3 weeks of mechanical ventilation. Postoperative esophageal dilation was performed prior to initiating oral feedings. The infant was taking two thirds of his feedings orally at the time of discharge, 45 days after surgery. DISCUSSION Management of the high-risk neonate with EA, distal TEF, and decreased pulmonary compliance remains a challenge. Templeton et al proposed early
of PediatricSurgery,
Vol 25, No 12 (December), 1990: pp 1216-1218
HYPERCARBIA
DUE TO EA AND DISTAL TEF
Fig 1. The Fogarty catheter is advanced, under fluoroscopic guidance, into the distal esophageal segment. Inflation with Renograffin permits radiological confirmation of catheter position. Once the balloon is inflated, ventiletory gases can no longer pass through the distal fistula and gastric reflux is eliminated.
retropleural fistula ligation with delayed esophageal repair.’ These infants have marked pulmonary insufficiency that often precludes thoracotomy. Hays et al described gastric division with double gastrostomy to reduce gastric reflux and avoid early thoracotomy.” The proximal pouch would still function as a lowresistance vent in the patient with decreased pulmonary compliance; the divided stomach would make the subsequent gastrointestinal reconstruction quite complex. More recently, Ogita et al recommended Nissen fundoplication and gastrostomy followed by delayed thoracotomy.” Reflux of gastric contents into the lungs is eliminated and leakage of air into the stomach prevented, provided peak pulmonary pressures do not exceed 30 cm H,O. This procedure prolongs the initial operation and can complicate subsequent esophageal reconstruction. Silastic banding of the esophagus at the time of gastrostomy as described by Leininger,” and modified by Fagalman and Boyarsky,13 stops the air leak from the trachea and prevents reflux of gastric contents into the tracheobronchial tree. However, esophageal banding can cause significant esophageal injury.14 Blocking the fistula’s opening with the tip of an endotracheal tube was first described by Salem et al.” This technique requires an endotracheal tube with no side hole and the bevel aimed anteriorly. The proximity of the fistula to the carina, and difficulty in securing an endotracheal tube, makes this procedure suitable for intraoperative use but unacceptable for long-term application. Baraka et al have used one-lung ventilation with the side wall of the tube occluding the fistula and one major bronchus.16 The deflated, motionless right lung facilitates esophagoesophagostomy, yet the
1217
potential for hypoxemia, in an infant with minimal pulmonary reserve, restricts the use of this technique to the operating room. Filston et al occluded a distal TEF with a Fogarty balloon catheter placed via bronchoscopy at the time of gastrostomy. ” When inflated, the Fogarty balloon successfully occludes the fistula, preventing leakage of ventilatory gases. This solution is simple and reversible at the time of thoracotomy. However, bronchoscopy significantly lengthens the initial surgical procedure and results in unnecessary manipulation of the tracheobronchial tree in an infant who has borderline pulmonary function. Furthermore, balloon dislodgement necessitates repeat bronchoscopy. This case report documents Fogarty catheter occlusion of a distal TEF in an infant with EA who was not a candidate for primary repair. Advancement of the catheter through the gastrostomy tube permits rapid occlusion of the TEF, avoids manipulation of the tracheobronchial tree, and permits respiratory stabilization prior to thoracotomy. Accidental catheter displacement does not require operative intervention because the catheter can be repositioned under Auoroscopic guidance.
Fig 2. Anteroposterior chest x-ray obtained following Fogarty catheter occlusion of the distal TEF. The catheter passes through the gastrostomy into the distal esophageal segment. A nasogastric tube is located in the proximal esophageal pouch. The umbilical artery line lies to the left of the midline.
1218
RICHENBACHER AND BALLANTINE
REFERENCES 1. Waterston DJ, Bonham Carter RE, Aberdeen E: Oesophageal atresia: Trachea-oesophageal fistula. A study of survival in 218 infants. Lancet 1:8 19-822, 1962 2. Louhimo I, Lindahl H: Esophageal atresia: Primary results of 500 consecutively treated patients. J Pediatr Surg 18:217-229, 1983 3. Brereton RJ, Zachary RB, Spitz L: Preventable death in oesophageal atresia. Arch Dis Child 53:276-283,1978 4. Randolph JG, Altman RP, Anderson KD: Selective surgical management based upon clinical status in infants with esophageal atresia. J Thorac Cardiovasc Surg 74:335-342, 1977 5. Grosfeld JL, Ballantine TVN: Esophageal atresia and tracheoesophageal fistula: Effect of delayed thoracotomy on survival. Surgery 84:394-402, 1978 6. Dryden GE: Gastric distension during tracheoesophageal fistula repair. J IN Med Assoc 62:46-47, 1969 7. Jones TB, Kirchner SG, Lee FA, et al: Stomach rupture associated with esophageal atresia, tracheoesophageal fistula and ventilatory assistance. AJR 134:675-677,198O 8. Baraka A, Slim M: Cardiac arrest during IPPV in a newborn with tracheoesophageal fistula. Anesthesiology 32:564-565, 1970 9. Templeton JM, Templeton JJ, Schnaufer L, et al: Management of esophageal atresia and tracheoesophageal fistula in the neonate with severe respiratory distress syndrome. J Pediatr Surg 20:394-397,1985 10. Hays DM, Woolley MM, Snyder WH: Changing techniques
in the management of esophageal atresia. Arch Surg 92:61 l-616, 1966 11. Ogita S, Tokiwa K, Takahashi T: Transabdominal closure of tracheoesophageal fistula: A new procedure for the management of poor-risk esophageal atresia with tracheoesophageal fistula. J Pediatr Surg 21:812-814, 1986 12. Leininger BJ: Silastic banding of esophagus with subsequent repair of esophageal atresia and tracheoesophageal fistula. J Pediatr Surg 7:404-407,1972 13. Fagelman KM, Boyarsky A: Temporary banding of the gastroesophageal junction in the critically ill neonate with esophageal atresia and tracheoesophageal fistula. Surgery 98:594-597, 1985 14. Harasawa N, Akiyama H, Saeki M, et al: Banding of distal esophagus for tracheoesophageal fistula C type. J Jpn Sot Pediatr Surg 18:823-828,1982 15. Salem MR, Wong AY, Lin YH, et al: Prevention of gastric distention during anesthesia for newborns with tracheoesophageal tistulas. Anesthesiology 38:82-83, 1973 16. Baraka A, Akel S, Haroun S, et al: One-lung ventilation of the newborn with tracheoesophageal fistula. Anesth Analg 67:189191,1988 17. Filston HC, Chitwood WR Jr, Schkolne B, et al: The Fogarty balloon catheter as an aid to management of the infant with esophageal atresia and tracheoesophageal fistula complicated by severe RDS or pneumonia. J Pediatr Surg 17:149-151, 1982
E. Richenbacher Hershey,
and Thomas
the basis of prematurity, respiratory distress syndrome, aspiration of saliva, and reflux of gastric contents into the tracheobronchial tree. Thoracotomy and primary repair may be delayed to allow time for complete evaluation of the infant and respiratory stabilization. Poorly compliant lungs and a large distal fistula can result in selective passage of ventilatory gases into the gastrointestinal tract with resultant hypercarbia. Fogarty balloon occlusion of the distal
INDEX WORDS: Esophageal fistula; hypercarbia.
atresia:
and facilitates
tracheoesophageal
A
TTEMPTS at primary repair of esophageal atresia (EA) and tracheoesophageal fistula (TEF) in neonates classified as Waterston Group C’ have resulted in mortality rates of 42% to 64%.2*3 These high-risk infants are presently managed by performing immediate gastrostomy and delayed thoracotomy. Early gastrostomy permits gastric decompression and drainage of gastric contents, preventing reflux through the fistula into the lungs. The interval between gastrostomy and thoracotomy allows time for appropriate respiratory care, investigation for associated anomalies involving other systems, the administration of antibiotics, and parenteral hyperalimentation. Survival using this staged approach averages 71% to 85%.4*5 Prior to gastrostomy, patients with severe respiratory distress syndrome (RDS) who require highpressure ventilatory support are at risk of developing massive gastric distension6 gastric perforation7 a reduction in diaphragmatic excursion with compromised ventilation, and cardiac arrest.* Following gastrostomy, poor pulmonary compliance can result in a selective passage of ventilatory gases through the low-resistance distal TEF. Acute ventilatory deteriora-
From the Division of Pediatric Surgery, Department of Surgery, College of Medicine. The Milton S. Hershey Medical Center, The Pennsylvania State University, Hershey, PA. Address reprint requests to Thomas V.N. Ballantine, MD. Department of Surgery, College of Medicine, The Pennsylvania State University, The Milton S. Hershey Medical Center, PO Box 850. Hershey, PA 17033. o 1990 by W.B. Saunders Company. 0022-3468/90/2512-0003.$03.00/0
1216
Ballantine
Pennsylvania
l Infants with esophageal atresia and a distal tracheoesophageal fistula are predisposed to respiratory failure on
esophageal segment halts this air shunt effective mechanical ventilation. o 1990 by W.B. Saunders Company.
V.N.
Fistula, and an Air Ventilation
Journal
tion at the time of gastrotomy is a significant source of intraoperative mortality.’ CASE
REPORT
A 1,270-g, 30 weeks’ gestation, boy infant was born by spontane-
ous vaginal delivery following the premature onset of labor. Apgar scores were 2 at 1 minute and 3 at 5 minutes. Respiratory arrest, at 3 minutes of age, necessitated intubation with a 2.5mm oral endotracheal tube. A chest roentgenogram demonstrated the ground glass appearance characteristic of severe RDS. An arterial blood gas (ABG) documented a pH of 7.18, a PCO, of 62 mm Hg, and a PO, of 141 mm Hg on an F,O, of 1.O, rate of 60 breaths per minute and ventilatory pressures of 25/4 mm Hg. Ventilator pressures were increased to 36/4 mm Hg; however, the repeat ABG showed a persistent respiratory acidosis with a pH of 7.25, a PCO, of 57 mm Hg, and a PO, of 62 mm Hg. The infant’s abdomen became more noticeably distended and profuse, frothy oral secretions persisted. All attempts to pass a nasogastric tube failed and a chest film showed the tip to lie within the cervical esophagus. The diagnosis of EA with a distal tracheoesophageal communication was made. The patient’s deteriorating respiratory status precluded primary repair; thus, gastrostomy tube placement was planned. The infant was maintained on an air/ oxygen mixture with the F,O, varying from 0.8 to 1.O.At laparotomy a no. 14 mushroom catheter was inserted into the stomach, at which time a tremendous air leak was detected. The transcutaneous oxygen content (TcPO,) immediately decreased from 95 to 45 mm Hg. Placement of some device to obstruct the flow of air through the fistula seemed indicated, otherwise emergency thoracotomy and fistula ligation would have been necessary. Under C-arm fluoroscopy a 4F Fogarty catheter was inserted into the gastrostomy tube and carefully advanced into the distal esophagus. The balloon was inflated with 0.8 mL of renograffin and there was an immediate increase in TcPO, and a decrease in the amount of pressure necessary to ventilate the infant (Fig 1). An ABG following distal esophageal occlusion showed marked improvement in the respiratory acidosis with a pH of 7.39, a PCOz of 33 mm Hg, and a PO, of 177 mm Hg. Over the next 48 hours the patient was maintained on mechanical ventilation with a gradual reduction in F,O, to 0.21. Pressure necrosis of the esophagus was avoided by intermittently deflating the balloon. The balloon was reinflated with Renograffin (Squib, Princeton, NJ) in order to keep the TcPO, in excess of 90 mm Hg. A daily chest film confirmed the position of the balloon in the distal fistula (Fig 2). At 53 hours of age, the infant underwent right thoracotomy and transpleural division of both a proximal and distal TEF with primary esophagoesophagostomy. He required 3 weeks of mechanical ventilation. Postoperative esophageal dilation was performed prior to initiating oral feedings. The infant was taking two thirds of his feedings orally at the time of discharge, 45 days after surgery. DISCUSSION Management of the high-risk neonate with EA, distal TEF, and decreased pulmonary compliance remains a challenge. Templeton et al proposed early
of PediatricSurgery,
Vol 25, No 12 (December), 1990: pp 1216-1218
HYPERCARBIA
DUE TO EA AND DISTAL TEF
Fig 1. The Fogarty catheter is advanced, under fluoroscopic guidance, into the distal esophageal segment. Inflation with Renograffin permits radiological confirmation of catheter position. Once the balloon is inflated, ventiletory gases can no longer pass through the distal fistula and gastric reflux is eliminated.
retropleural fistula ligation with delayed esophageal repair.’ These infants have marked pulmonary insufficiency that often precludes thoracotomy. Hays et al described gastric division with double gastrostomy to reduce gastric reflux and avoid early thoracotomy.” The proximal pouch would still function as a lowresistance vent in the patient with decreased pulmonary compliance; the divided stomach would make the subsequent gastrointestinal reconstruction quite complex. More recently, Ogita et al recommended Nissen fundoplication and gastrostomy followed by delayed thoracotomy.” Reflux of gastric contents into the lungs is eliminated and leakage of air into the stomach prevented, provided peak pulmonary pressures do not exceed 30 cm H,O. This procedure prolongs the initial operation and can complicate subsequent esophageal reconstruction. Silastic banding of the esophagus at the time of gastrostomy as described by Leininger,” and modified by Fagalman and Boyarsky,13 stops the air leak from the trachea and prevents reflux of gastric contents into the tracheobronchial tree. However, esophageal banding can cause significant esophageal injury.14 Blocking the fistula’s opening with the tip of an endotracheal tube was first described by Salem et al.” This technique requires an endotracheal tube with no side hole and the bevel aimed anteriorly. The proximity of the fistula to the carina, and difficulty in securing an endotracheal tube, makes this procedure suitable for intraoperative use but unacceptable for long-term application. Baraka et al have used one-lung ventilation with the side wall of the tube occluding the fistula and one major bronchus.16 The deflated, motionless right lung facilitates esophagoesophagostomy, yet the
1217
potential for hypoxemia, in an infant with minimal pulmonary reserve, restricts the use of this technique to the operating room. Filston et al occluded a distal TEF with a Fogarty balloon catheter placed via bronchoscopy at the time of gastrostomy. ” When inflated, the Fogarty balloon successfully occludes the fistula, preventing leakage of ventilatory gases. This solution is simple and reversible at the time of thoracotomy. However, bronchoscopy significantly lengthens the initial surgical procedure and results in unnecessary manipulation of the tracheobronchial tree in an infant who has borderline pulmonary function. Furthermore, balloon dislodgement necessitates repeat bronchoscopy. This case report documents Fogarty catheter occlusion of a distal TEF in an infant with EA who was not a candidate for primary repair. Advancement of the catheter through the gastrostomy tube permits rapid occlusion of the TEF, avoids manipulation of the tracheobronchial tree, and permits respiratory stabilization prior to thoracotomy. Accidental catheter displacement does not require operative intervention because the catheter can be repositioned under Auoroscopic guidance.
Fig 2. Anteroposterior chest x-ray obtained following Fogarty catheter occlusion of the distal TEF. The catheter passes through the gastrostomy into the distal esophageal segment. A nasogastric tube is located in the proximal esophageal pouch. The umbilical artery line lies to the left of the midline.
1218
RICHENBACHER AND BALLANTINE
REFERENCES 1. Waterston DJ, Bonham Carter RE, Aberdeen E: Oesophageal atresia: Trachea-oesophageal fistula. A study of survival in 218 infants. Lancet 1:8 19-822, 1962 2. Louhimo I, Lindahl H: Esophageal atresia: Primary results of 500 consecutively treated patients. J Pediatr Surg 18:217-229, 1983 3. Brereton RJ, Zachary RB, Spitz L: Preventable death in oesophageal atresia. Arch Dis Child 53:276-283,1978 4. Randolph JG, Altman RP, Anderson KD: Selective surgical management based upon clinical status in infants with esophageal atresia. J Thorac Cardiovasc Surg 74:335-342, 1977 5. Grosfeld JL, Ballantine TVN: Esophageal atresia and tracheoesophageal fistula: Effect of delayed thoracotomy on survival. Surgery 84:394-402, 1978 6. Dryden GE: Gastric distension during tracheoesophageal fistula repair. J IN Med Assoc 62:46-47, 1969 7. Jones TB, Kirchner SG, Lee FA, et al: Stomach rupture associated with esophageal atresia, tracheoesophageal fistula and ventilatory assistance. AJR 134:675-677,198O 8. Baraka A, Slim M: Cardiac arrest during IPPV in a newborn with tracheoesophageal fistula. Anesthesiology 32:564-565, 1970 9. Templeton JM, Templeton JJ, Schnaufer L, et al: Management of esophageal atresia and tracheoesophageal fistula in the neonate with severe respiratory distress syndrome. J Pediatr Surg 20:394-397,1985 10. Hays DM, Woolley MM, Snyder WH: Changing techniques
in the management of esophageal atresia. Arch Surg 92:61 l-616, 1966 11. Ogita S, Tokiwa K, Takahashi T: Transabdominal closure of tracheoesophageal fistula: A new procedure for the management of poor-risk esophageal atresia with tracheoesophageal fistula. J Pediatr Surg 21:812-814, 1986 12. Leininger BJ: Silastic banding of esophagus with subsequent repair of esophageal atresia and tracheoesophageal fistula. J Pediatr Surg 7:404-407,1972 13. Fagelman KM, Boyarsky A: Temporary banding of the gastroesophageal junction in the critically ill neonate with esophageal atresia and tracheoesophageal fistula. Surgery 98:594-597, 1985 14. Harasawa N, Akiyama H, Saeki M, et al: Banding of distal esophagus for tracheoesophageal fistula C type. J Jpn Sot Pediatr Surg 18:823-828,1982 15. Salem MR, Wong AY, Lin YH, et al: Prevention of gastric distention during anesthesia for newborns with tracheoesophageal tistulas. Anesthesiology 38:82-83, 1973 16. Baraka A, Akel S, Haroun S, et al: One-lung ventilation of the newborn with tracheoesophageal fistula. Anesth Analg 67:189191,1988 17. Filston HC, Chitwood WR Jr, Schkolne B, et al: The Fogarty balloon catheter as an aid to management of the infant with esophageal atresia and tracheoesophageal fistula complicated by severe RDS or pneumonia. J Pediatr Surg 17:149-151, 1982
