Tracheoesophageal Fistula Ligation Thoracotomy

TEF ligation thoracotomy

TEF Ligation through Thoracotomy is a routine surgical procedure on infants with esophageal atresia (EA) and tracheoesophageal fistula (TEF) most often EA with distal TEF (Type C).

What is TEF Ligation?

• Surgical detachment and reunion of an abnormal fistula between the trachea and esophagus is called TEF ligation. This helps avoid entry of air in the stomach and refluxing of gastric contents into lungs.
• In the case of doing it through thoracotomy, the surgeon opens the chest using an incision.

Indications

• TEF distal (most common) with esophageal atresia.

Part of:

• Primary EA repair, or
• Repair (in preterm or unstable newborns)
• Unable or not possible to reach thoracoscopic approach.

Benefits of Thoracotomy Approach

• Excellent visualization
• Common practice in the majority of centers.

Ideal when:

• Infants with very low birth weight.
• Complex anatomy
• Resource-limited settings

Newborn TEF ligation procedure

TEF (Tracheoesophageal Fistula) repair of a newborn is a life-saving procedure that is used to remove the abnormal attachment between the trachea (windpipe) and esophagus (food pipe). Most frequently, it is performed on esophageal atresia and distal TEF (Type C).

Purpose of TEF Ligation

• Stops entry of milk and saliva in the lungs.
• Minimizes the possibility of aspiration pneumonia.
• Permits the safe feeding when the esophagus is repaired.
• Stabilizes breathing

Preoperative Preparation

• Newborn kept nil by mouth
• Unremitting suctioning of upper esophageal pouch.
• IV fluids and antibiotics
• X-ray of the chest and echocardiography (to observe the heart anomalies)
• Ventilator assistance as required.
• Operative Procedure: Right Thoracotomy.
• This approach is the most prevalent in newborns 

Procedure:

Anaesthesia & Positioning

• General anaesthesia
• Infant in the left lateral position.

Thoracotomy Incision

• Incision between ribs, right side (typically 4th intercostal space).
• Careful opening of chest to mediate.

Structures Identification

• Trachea, esophagus and fistula are detected.
• Azygos intact (azygos can be ligated when necessary) and vagus nerve intact.

TEF Ligation

• Fistula trachea and esophagus is independent.
• Doubly ligated and divided
• Close the tracheal side and side to avoid air leakage.

Esophageal Repair 

• End endoscopic movement of upper and lower esophagus.
• End to end anastomosis done.
• In case the gap is long then TEF ligation can be performed only (staged repair).

Chest Closure

• Skin and intercostal muscles shut.
• Chest drain may be placed

Duration of Surgery

• Depending on the level of complexity, usually 2-3 hrs.

Postoperative Care

• NICU monitoring
• Ventilator support for 1–3 days
• IV antibiotics and analgesics.
• First feeding through gastrostomy or NG tube.
• Oral feeds initiated post contrast study (typically day 5-7)

Thoracotomy fistula ligation recovery

Thoracotomy fistula ligation in a newborn with tracheoesophageal fistula (TEF) results in recovery in stages well observed in the NICU. Babies are likely to recover provided that they receive good after-surgery care and follow-up.

First (Day 0-2) Postoperative Period

NICU Care

• Baby continued on ventilator (typically 24-72 hours)
• Constant checking of oxygen level and heart rate.
• Pain management using IV drugs.

Feeding

• Nil by mouth
• IV fluids with or without total parenteral nutrition (TPN).
• Constant suction in case an esophageal repair was performed.

Early Recovery Phase (Day 3–7)

Breathing

• The weaning of oxygen support to ventilator.
• Physiotherapy of the chest, where necessary.

Chest Care

• Chest drain (when fitted) typically cleared out in 2- 4 days.
• X-ray of the chest to clear up on the expansion of lungs.

Assessment of Healing

• Contrast esophagogram (day 5-7) in case of anastomosis of the esophagus made.
• Looks for leaks or narrowing

Feeding Recovery (Day 5–14)

If contrast study is normal:

• Initiate tube nourishment (NG or gastrostomy)
• Slow transition to oral nutrition.
• Slow introduction of breastfeeding or bottle feeding.
• One might need feeding therapy.

Pain and Wound Healing

• Incision of thoracotomy takes 10-14 days to heal.
• Slight swelling or tenderness is healthy.
• Stitches normally absorbed or cut off in a week.
• Light treatment is advised.

Hospital Stay

• Average stay: 10–21 days

Longer if:

• Premature baby
• Long-gap esophageal atresia
• Related cardiac or pulmonary issues.

TEF thoracotomy complications

Thoracotomy-TEF repair is an established life-saving operation on infants. The majority of babies recover but it has its fair share of early and long-term complications just as any other major neonatal operation. The awareness of them aids in the early identification and prompt treatment.

Early (Immediate) Complications

• Respiratory Complications
• Anastomotic Leak
• Bleeding
• Recurrent Laryngeal Nerve Injury

Intermediate Complications (Weeks to Months)

• Stricture of the esophagus
• Recurrence of Tracheoesophageal Fistula
• Gastro-esophageal reflux disease (GERD)

Late Complications (Long-Term) 

• Tracheomalacia
• Chest Wall Deformities
• Adhesions

Best hospital for TEF ligation India

• Artemis Hospital, Gurgaon
• Medanta-The Medicity, Gurgaon
• Fortis Memorial Research Institute, Gurgaon
• Max Hospital, Saket

Conclusion

Thoracotomy repair of tracheoesophageal fistulad in neonates is a safe and accepted procedure for the correction of this disorder for centers without the availability of thoracoscopic surgery, as well as for neonates with associated anomalies or medical fragility. While the operation is very effective, it also has the short- and long-term complications of respiratory, anastomotic leak, esophageal stricture, and gastroesophageal reflux and chest wall deformities. The majority of complications may be addressed properly with the help of timely diagnosis, precise surgical procedure, quality NICU, and organized long-term follow-up. The general prognosis is good and most of the children end up attaining normal feeding, growth, and development. Parental education at an early age and frequent follow-up is important in securing optimum outcomes following TEF thoracotomy repair.

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FAQ

Why not thoracoscopy to use instead of thoracotomy?

• Thoracotomy is preferable in premature infants or low weight babies, in complicated anatomy or where low invasive facilities or skills are not available. It is very expository and dependable.

Can TEF thoracotomy be considered a high-risk surgery?

• It is a significant neonatal operation, however, in developed ones; more than 90 percent of the healthy infants survive.

Will my baby experience difficulties in feeding later?

• Cases of difficulty in feeding reflux or narrowing of the esophagus might manifest in some babies within the first year. The majority of the problems can be treated through medication or minor interventions.

Will the fistula reoccur postoperative?

• Yes, in a small percentage of cases (3-10 per cent) recurrent TEF may appear. It normally comes in the form of coughing or choking during medications and can lead to additional surgery.

Does thoracotomy cause permanent scar?

• It will leave a scar on the chest, but it generally subsides with time and may seldom lead to functional difficulties.