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„H‟type
Tracheo-esophageal Fistula

SPEAKER- DR. VIJAYLAXMI SHRIVASTAVA
         DR. ASHWIN.A.JAISWAL

MODERATOR- DR.M.K.MOHANTY

DEPARTMENT OF PAEDIATRIC SURGERY
      J.L.N.H & R.C, BHILAI




                 Dnbpaediatrics.blogspot.in
 SIMMY
 3 MONTHS/FEMALE
 NONCONSANGUINOUS
MARRIAGE



              Dnbpaediatrics.blogspot.in
 NASAL REGURGITATION OF
  FEEDS SINCE DAY 15 OF LIFE
 RECURRENT PNEUMONIA
  SINCE BIRTH
 CHOKING ON FEEDING


                Dnbpaediatrics.blogspot.in
 HOSPITAL DELIVERY
 LSCS-MSAF
 VIGOROUS AT BIRTH
 BREAST FEEDING
 PHYSIOLOGICAL JAUNDICE

               Dnbpaediatrics.blogspot.in
 NASAL & ORAL
REGURGITATION OF FEEDS
ON LYING SUPINE EVEN
AFTER BURPING



                 Dnbpaediatrics.blogspot.in
 RECURRENT PNEUMONIA
 TREATED ON OPD BASIS FOR
  10 DAYS
 ADMITTED FOR PNEUMONIA
  FOR 15 DAYS THRICE IN 3
  DIFFERENT HOSPITALS
               Dnbpaediatrics.blogspot.in
 REFERRED TO OUR HOSPITAL FOR
 NONRESOLUTION OF SYMPTOMS

 PEDIATRICIANS TREATED
 PNEUMONIA WITH ANTIBIOTICS


                Dnbpaediatrics.blogspot.in
Xray




   Dnbpaediatrics.blogspot.in
“DUE TO RECURRENCE OF
 PNEUMONIA POSSIBILITY OF
 GERD OR
 TRACHEOESOPHAGEAL
 FISTULA WAS SUSPECTED”


              Dnbpaediatrics.blogspot.in
 CASE WAS DISCUSSED WITH
  PEDIATRIC SURGEON
 BARIUM MEAL DONE –GERD
  RULED OUT



              Dnbpaediatrics.blogspot.in
 BRONCHOSCOPY DONE
 H-TYPE TRACHEOESOPHAGEAL
FISTULA WAS CONFIRMED




              Dnbpaediatrics.blogspot.in
PREOPERATIVE MANAGEMENT

 PROPPED UP POSITION
 MINIMAL HANDLING
 PROKINETIC AGENTS
 THICK SMALL FEEDS
 PNEUMONIA WAS TREATED


               Dnbpaediatrics.blogspot.in
 PLANNED FOR SURGERY
 PRIOR TO SURGERY PATIENT
  HAD PNEUMONIA TWICE
 EFFICIENTLY TREATED




               Dnbpaediatrics.blogspot.in
ESOPHAGEAL ATRESIA &
       TRACHEOESOPHAGEAL FISTULA




       COMMON LIFE-THREATENING MALFORMATIONS

       INCIDENCE OF 1 IN 3500 TO 1 IN 4500 BIRTH

EQUAL SEX DISTRIBUTION / SLIGHT MALE PREPONDERANCE

       ASSOCIATED WITH CONGENITAL ANOMALIES
                    (40-55%)




                             Dnbpaediatrics.blogspot.in
Embryology




      Dnbpaediatrics.blogspot.in
Normal development of the
 Oesophagus and Trachea




              Dnbpaediatrics.blogspot.in
Gross-Vogt Classification




              Dnbpaediatrics.blogspot.in
Type A - EA without fistula / Pure EA(10%)




                      Dnbpaediatrics.blogspot.in
Type B - EA with proximal TEF(<1%)




                 Dnbpaediatrics.blogspot.in
Type C - EA with distal TEF (85%)
Type D -EA with proximal & distal TEF‟s(<1%)




                       Dnbpaediatrics.blogspot.in
Type E - TEF without EA/ H-type fistula (4%)




                       Dnbpaediatrics.blogspot.in
„H‟ TYPE TEF


 lamb ( 1873)


 Rare, isolated type of tef,4-5%


 m>f


 Level of fistula-2nd thoracic vertebra

                        Dnbpaediatrics.blogspot.in
„H‟ TYPE TEF

 70% occurs at /above the level of 2nd thoracic
 vertebra ( high as C7 and as low as T4)

 Types – „N‟ type & „H‟ type


 Oblique course –tracheal end cranially while
 esophagus caudally

 „N‟ type > „H‟ type

                                Dnbpaediatrics.blogspot.in
„H‟ TYPE TEF

 Classical triad of symptoms

    Coughing & choking precipitated
    by feeds with or without
    cyanosis

     Recurrent lower respiratory
     tract infections

     Gaseous abdominal distension


                           Dnbpaediatrics.blogspot.in
„H‟ TYPE TEF


 Excessive tracheal secretions with bubbly
 respirations



 Improvement of symptoms with gastric tube
 feedings




                           Dnbpaediatrics.blogspot.in
„H‟ TYPE TEF

 Delayed diagnosis


 Least associated with congenital anomalies (25-
 30%)

 Incidence of polyhydramnios is rare & lbw is less
 common

 Better prognosis


                           Dnbpaediatrics.blogspot.in
DIAGNOSIS


 High clinical suspicion

 Cine esophagogram

 Rigid / Flexible Bronchoscopy

 CTscan /MRI / Radionuclide esophagogram

 Thoracoscopy

 Measurement of respiratory flow in esophageal
 lumen & o2 conc. in stomach

                            Dnbpaediatrics.blogspot.in
BRONCHOSCOPY




       Dnbpaediatrics.blogspot.in
Surgical Management
 Bronchoscopic repair
     cauterization
     tissue adhesives application

 Ligation & repair of the TEF by cervical
 approach

 Thoracoscopic repair

 Repair of fistula by thoracotomy approach

 Nd-YAG laser coagulation
                             Dnbpaediatrics.blogspot.in
Surgical Management
 LIGATION & REPAIR OF FISTULA
     BY CERVICAL APPROACH




                 Dnbpaediatrics.blogspot.in
Anaesthesia




       Dnbpaediatrics.blogspot.in
Position




      Dnbpaediatrics.blogspot.in
Incision & Approach




           Dnbpaediatrics.blogspot.in
Identification of
Trachea & Oesophagus




          Dnbpaediatrics.blogspot.in
Identification of fistula




              Dnbpaediatrics.blogspot.in
Ligation of fistula at
Tracheal & Oesophageal end




              Dnbpaediatrics.blogspot.in
Repair of fistula with meticulous closure of
       Tracheal & Oesophageal end




                       Dnbpaediatrics.blogspot.in
Post op investigations

 Gastrograffin study




              Dnbpaediatrics.blogspot.in
Healed Neck wound


                        HAPPY BABY




                    Dnbpaediatrics.blogspot.in
TEAM APPROACH
        PAEDIATRIC SURGEON




              PAEDIATRICIAN



EXPERIENCED                     TRAINED
ENT SURGEON                   ANAESTHETIST
                       Dnbpaediatrics.blogspot.in
THANK YOU

Visit dnbpaediatrics.blogspot.in

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HTF

  • 1. „H‟type Tracheo-esophageal Fistula SPEAKER- DR. VIJAYLAXMI SHRIVASTAVA DR. ASHWIN.A.JAISWAL MODERATOR- DR.M.K.MOHANTY DEPARTMENT OF PAEDIATRIC SURGERY J.L.N.H & R.C, BHILAI Dnbpaediatrics.blogspot.in
  • 2.  SIMMY  3 MONTHS/FEMALE  NONCONSANGUINOUS MARRIAGE Dnbpaediatrics.blogspot.in
  • 3.  NASAL REGURGITATION OF FEEDS SINCE DAY 15 OF LIFE  RECURRENT PNEUMONIA SINCE BIRTH  CHOKING ON FEEDING Dnbpaediatrics.blogspot.in
  • 4.  HOSPITAL DELIVERY  LSCS-MSAF  VIGOROUS AT BIRTH  BREAST FEEDING  PHYSIOLOGICAL JAUNDICE Dnbpaediatrics.blogspot.in
  • 5.  NASAL & ORAL REGURGITATION OF FEEDS ON LYING SUPINE EVEN AFTER BURPING Dnbpaediatrics.blogspot.in
  • 6.  RECURRENT PNEUMONIA  TREATED ON OPD BASIS FOR 10 DAYS  ADMITTED FOR PNEUMONIA FOR 15 DAYS THRICE IN 3 DIFFERENT HOSPITALS Dnbpaediatrics.blogspot.in
  • 7.  REFERRED TO OUR HOSPITAL FOR NONRESOLUTION OF SYMPTOMS  PEDIATRICIANS TREATED PNEUMONIA WITH ANTIBIOTICS Dnbpaediatrics.blogspot.in
  • 8. Xray Dnbpaediatrics.blogspot.in
  • 9. “DUE TO RECURRENCE OF PNEUMONIA POSSIBILITY OF GERD OR TRACHEOESOPHAGEAL FISTULA WAS SUSPECTED” Dnbpaediatrics.blogspot.in
  • 10.  CASE WAS DISCUSSED WITH PEDIATRIC SURGEON  BARIUM MEAL DONE –GERD RULED OUT Dnbpaediatrics.blogspot.in
  • 11.  BRONCHOSCOPY DONE  H-TYPE TRACHEOESOPHAGEAL FISTULA WAS CONFIRMED Dnbpaediatrics.blogspot.in
  • 12. PREOPERATIVE MANAGEMENT  PROPPED UP POSITION  MINIMAL HANDLING  PROKINETIC AGENTS  THICK SMALL FEEDS  PNEUMONIA WAS TREATED Dnbpaediatrics.blogspot.in
  • 13.  PLANNED FOR SURGERY  PRIOR TO SURGERY PATIENT HAD PNEUMONIA TWICE  EFFICIENTLY TREATED Dnbpaediatrics.blogspot.in
  • 14. ESOPHAGEAL ATRESIA & TRACHEOESOPHAGEAL FISTULA COMMON LIFE-THREATENING MALFORMATIONS INCIDENCE OF 1 IN 3500 TO 1 IN 4500 BIRTH EQUAL SEX DISTRIBUTION / SLIGHT MALE PREPONDERANCE ASSOCIATED WITH CONGENITAL ANOMALIES (40-55%) Dnbpaediatrics.blogspot.in
  • 15. Embryology Dnbpaediatrics.blogspot.in
  • 16. Normal development of the Oesophagus and Trachea Dnbpaediatrics.blogspot.in
  • 17. Gross-Vogt Classification Dnbpaediatrics.blogspot.in
  • 18. Type A - EA without fistula / Pure EA(10%) Dnbpaediatrics.blogspot.in
  • 19. Type B - EA with proximal TEF(<1%) Dnbpaediatrics.blogspot.in
  • 20. Type C - EA with distal TEF (85%)
  • 21. Type D -EA with proximal & distal TEF‟s(<1%) Dnbpaediatrics.blogspot.in
  • 22. Type E - TEF without EA/ H-type fistula (4%) Dnbpaediatrics.blogspot.in
  • 23. „H‟ TYPE TEF  lamb ( 1873)  Rare, isolated type of tef,4-5%  m>f  Level of fistula-2nd thoracic vertebra Dnbpaediatrics.blogspot.in
  • 24. „H‟ TYPE TEF  70% occurs at /above the level of 2nd thoracic vertebra ( high as C7 and as low as T4)  Types – „N‟ type & „H‟ type  Oblique course –tracheal end cranially while esophagus caudally  „N‟ type > „H‟ type Dnbpaediatrics.blogspot.in
  • 25. „H‟ TYPE TEF  Classical triad of symptoms Coughing & choking precipitated by feeds with or without cyanosis Recurrent lower respiratory tract infections Gaseous abdominal distension Dnbpaediatrics.blogspot.in
  • 26. „H‟ TYPE TEF  Excessive tracheal secretions with bubbly respirations  Improvement of symptoms with gastric tube feedings Dnbpaediatrics.blogspot.in
  • 27. „H‟ TYPE TEF  Delayed diagnosis  Least associated with congenital anomalies (25- 30%)  Incidence of polyhydramnios is rare & lbw is less common  Better prognosis Dnbpaediatrics.blogspot.in
  • 28. DIAGNOSIS  High clinical suspicion  Cine esophagogram  Rigid / Flexible Bronchoscopy  CTscan /MRI / Radionuclide esophagogram  Thoracoscopy  Measurement of respiratory flow in esophageal lumen & o2 conc. in stomach Dnbpaediatrics.blogspot.in
  • 29. BRONCHOSCOPY Dnbpaediatrics.blogspot.in
  • 30. Surgical Management  Bronchoscopic repair cauterization tissue adhesives application  Ligation & repair of the TEF by cervical approach  Thoracoscopic repair  Repair of fistula by thoracotomy approach  Nd-YAG laser coagulation Dnbpaediatrics.blogspot.in
  • 31. Surgical Management LIGATION & REPAIR OF FISTULA BY CERVICAL APPROACH Dnbpaediatrics.blogspot.in
  • 32. Anaesthesia Dnbpaediatrics.blogspot.in
  • 33. Position Dnbpaediatrics.blogspot.in
  • 34. Incision & Approach Dnbpaediatrics.blogspot.in
  • 35. Identification of Trachea & Oesophagus Dnbpaediatrics.blogspot.in
  • 36. Identification of fistula Dnbpaediatrics.blogspot.in
  • 37. Ligation of fistula at Tracheal & Oesophageal end Dnbpaediatrics.blogspot.in
  • 38. Repair of fistula with meticulous closure of Tracheal & Oesophageal end Dnbpaediatrics.blogspot.in
  • 39. Post op investigations Gastrograffin study Dnbpaediatrics.blogspot.in
  • 40. Healed Neck wound HAPPY BABY Dnbpaediatrics.blogspot.in
  • 41. TEAM APPROACH PAEDIATRIC SURGEON PAEDIATRICIAN EXPERIENCED TRAINED ENT SURGEON ANAESTHETIST Dnbpaediatrics.blogspot.in