Anesthetic Management of Acquired Tracheoesophageal Fistula: A Brief Report

Acquired tracheoesophageal fistula (TEF) is uncommon, especially in the pediatric population. Presentation may range from subclinical to severe respiratory distress. We report the case of a toddler who presented with complete left lung collapse. He was initially brought to the operating room (OR) with a diagnosis of bronchial foreign body. At bronchoscopy he was found to have a large perforation of both his trachea and esophagus with a distal TEF at the level of the proximal left mainstem bronchus. Definitive repair of the lesion occurred 4 days later. We report an unusual approach to intraoperative anesthetic and postoperative analgesia management of acquired TEF. Case Report A previously well, 15-mo-old, 9.2-kg boy was recovering from a recent episode of otitis media. He developed acute onset of shortness of breath for which the emergency medical system was activated. He was taken to a local hospital, where he had a normal chest radiograph, and was treated with albuterol and prednisone for presumed bronchiolitis. After initial improvement, he had a waxing and waning course with cough, lethargy, and increased work of breathing and decreased oral intake. He had a second acute episode of shortness of breath, and again the emergency medical system was activated. He was admitted to a local hospital, where he was treated with antibiotics, steroids and bronchodilators. The second radiograph was also reportedly normal. After a coughing spell associated with desaturations, a third radiograph showed total collapse of the left lung. He was transferred to our hospital with a presumed diagnosis of bronchial foreign body. His mother had seen her son eating rocks several weeks earlier. Preoperative examination of the chest radiograph by the otolaryngologist was noted as being “odd,” with air in the esophagus. The boy was brought directly to the pediatric intensive care unit. The initial assessment revealed a small-for-age toddler sitting up and drooling. His oxygen saturation was 100% while receiving oxygen 4 L/min via nasal canula. His airway appeared normal. Auscultation of the chest revealed breath sounds present on the right but absent on the left. A peripheral IV catheter was in place. He was transported to the OR where glycopyrrolate and dexamethasone were administered. A mask induction was performed with sevoflurane in oxygen. Spontaneous ventilation was maintained. Rigid bronchoscopy was performed by the pediatric otolaryngologist with assisted ventilation via the rigid bronchoscope. No rocks were seen but food debris was removed from the left mainstem bronchus. At that time, a rent in the left mainstem bronchus was noted from 4 mm distal to the carina up into the distal trachea for a total length of 3–4 cm (Fig. 1). The nasogastric tube, which had been placed after induction, was visible in the esophagus through the rigid bronchoscope in the trachea. The surgeon noted granulomatous tissue along both the tracheal and esophageal edges. The defects of both the trachea and esophagus were considerably larger than in the congenital type of TEF.Figure 1: Endoscopic view of distal trachea, just above carina. Left (L) and right (R) mainstem bronchi are visible, as is the tracheoesophageal fistula (arrow).Intraoperative consultation with a pediatric surgeon was obtained. The rigid bronchoscopy was repeated by the pediatric surgeon. The patient’s trachea was then intubated for rigid esophagoscopy. Spontaneous ventilation was preserved. Because of the location of the lesion, it was apparent that surgical repair would include both the distal trachea and left mainstem bronchus. Definitive repair was delayed, as cardiopulmonary bypass (CPB) might be required if oxygenation could not be maintained during surgical repair of such a large defect in the trachea. The patient was extubated awake in the OR. Oxygenation and ventilation were adequate in the postanesthetic care unit and pediatric intensive care unit. The patient remained NPO and antibiotics and ranitidine were administered IV. The patient returned to the OR 4 days later. His Spo2 was 97% while receiving 6 L/min of oxygen via face mask. After the administration of IV glycopyrrolate and midazolam, a mask induction with sevoflurane in oxygen was performed. Spontaneous ventilation was preserved, and anesthesia was deepened with incremental doses of IV ketamine to a total of 4 mg/kg. After topical application of oxymetazoline, nasal intubation with a 3.5 endotracheal tube (ETT) was performed. The ETT was passed into the right mainstem bronchus without the aid of neuromuscular blockade. Position was confirmed with a pediatric fiberoptic bronchoscope to ensure that the orifice of the right upper lobe bronchus was not obstructed. The ETT was too short, and the procedure was repeated with a 4.0 ETT. Bronchoscopy revealed no obstruction of the right upper lobe orifice. A second peripheral IV catheter, a radial arterial line and a femoral central venous catheter were subsequently placed. The patient was positioned in the right lateral decubitus position. ETT position was again confirmed with a fiberoptic bronchoscope. Surgical approach was via a left thoracotomy, with primary repair of both the trachea and esophagus. CPB was available but not required. Spontaneous ventilation was maintained initially, and arterial blood gas analysis revealed adequate oxygenation with mild carbon dioxide retention. Bronchoscopy demonstrated that the ETT remained in an excellent position, and gentle positive pressure ventilation of the right lung was begun. After tracheal and esophageal repair, the right lung was suctioned, and the ETT withdrawn into the trachea under fiberoptic guidance. Flexible bronchoscopy was performed by the surgeons before closure of the left chest. This revealed excellent surgical results, with no diminution in caliber of the airway. Positive pressure ventilation of both lungs was maintained with the endotracheal tube in the midtrachea as the chest was closed. A midthoracic epidural was placed for postoperative analgesia at the conclusion of the surgery. Epidural bupivacaine (0.25% with 1/200,000 epinephrine) was administered incrementally to a total of 6 mL. The patient was then tracheally extubated awake in the OR, with excellent analgesia. His immediate postoperative course was uneventful. He had excellent analgesia with bupivacaine (0.1%) and hydromorphone (2 μg/mL) via the epidural catheter at rates from 3.0–4.0 mL/h. The epidural catheter was removed on postoperative day 4, when a leak developed at the entry site. He had no respiratory depression, and was able to tolerate aggressive chest physical therapy. He remained NPO until a barium swallow demonstrated absence of extravasation, and he was discharged home on postoperative day 8. Discussion Acquired TEF is rare and is mainly described in the adult population as a result of trauma, corrosive ingestion, foreign bodies, inflammatory process (e.g., tuberculosis), or malignancy (1,2). In the pediatric population (3,4), it is most often a result of battery ingestion. The anesthetic management for repair of TEF, whether congenital or acquired, is a significant challenge for the pediatric anesthesiologist (5). Common problems include difficulties with oxygenation and/or ventilation resulting from placement of the ETT in or above the fistula with subsequent gastric dilation, atelectasis, or pulmonary changes related to recurrent aspiration. Standard anesthetic management includes awake tracheal intubation and avoidance of muscle relaxants and positive pressure ventilation until the fistula is controlled (5,6) to prevent ventilation of the TEF. Bronchial blockers may be placed under fiberoptic guidance into the TEF to prevent ventilation of the esophagus and stomach as well as to facilitate surgical identification of the fistula. There are few reported cases of pediatric acquired TEF (4). They differ from congenital TEF in the age of the patient, the lack of esophageal atresia, and location of the lesion. Ours was an unusual case of acquired TEF in a 15-month-old patient, presumably from rock ingestion. Ventilatory management during the procedure was the crucial intraoperative issue, although similar in principle to that for congenital TEF (5,6). However, the location of our patient’s TEF was more problematic. The 3–4 cm rent extended from the distal posterolateral trachea into the left mainstem bronchus, preventing placement of the ETT proximal or distal to the fistula. Placement of the ETT above the fistula would have resulted in ineffective ventilation unless the entire defect in both the trachea and left mainstem bronchus could be excluded. This was not feasible because of the large size of the defect. The rent extended into the left mainstem bronchus, making placement of an ETT distal to the lesion (as traditionally done for congenital TEF repair) not possible. Thus we felt the only viable option was selective intubation of the right mainstem bronchus. If that failed, we were prepared to place the patient on CPB to ensure adequate oxygenation. We encountered no difficulty with oxygenation, suggesting that our ETT was placed just past the carina in the right mainstem bronchus, without interfering with ventilation of the right upper lobe. Indeed, the orifice of the right upper lobe was visible on each endoscopic examination. A review (7) detailed options for single-lung ventilation of pediatric patients. Our patient was too small for a double-lumen ETT. Neither a Univent® tube (Fuji Systems Corporation; Tokyo, Japan) nor a traditional bronchial blocker were options, as both would have interfered with surgical repair and resulted in inadequate ventilation. The length (3–4 cm) and location (from the distal trachea into the left mainstem bronchus) of our patient’s lesion made management different from the other reported cases as well as standard management of congenital TEF. Neuromuscular blockade and opioids were both avoided during the procedure so that spontaneous ventilation could be preserved. After the trachea and esophagus were isolated, gentle positive pressure ventilation of the right lung was used. This was done to prevent atelectasis of the right lung, which might have occurred as a result of hypoventilation during spontaneous ventilation. After repair of the tracheal injury, the ETT was withdrawn into a midtracheal position, and positive pressure ventilation resulted in bilateral lung inflation without evidence of air leak. An epidural catheter was placed at the midthoracic level at the conclusion of the procedure. Thoracic placement of epidural catheters is common at our institution for children over 6 months of age undergoing thoracic surgery. Epidural catheters placed at dermatomes corresponding to surgical site are generally acknowledged to provide the best analgesia. The epidural catheter could have been placed via the caudal space, but successful threading to a midthoracic level is not assured. The epidural had not been placed before the procedure in the event that CPB with systemic heparinization was required. Had placement of the epidural catheter resulted in blood from an epidural vein, the risk of epidural hematoma with full anticoagulation would have been unacceptable. It was important to activate the epidural before emergence because the patient had received no intraoperative opioids. The patient was tracheally extubated in the OR with excellent analgesia. The epidural infusion was started on arrival in the postanesthesia care unit. Repair of acquired TEF may present multiple difficulties to both the anesthesiologist and surgeon. We report an approach that provided adequate oxygenation, ventilation, surgical exposure, and postoperative analgesia with an excellent outcome.