Preoperative Bronchoscopy in Esophageal Atresia: Unmasking a Proximal Tracheoesophageal Fistula

Abstract

Background: Preoperative bronchoscopy is not universally performed for primary repair of esophageal atresia (EA) but may aid with localization of tracheo-esophageal fistulas (TEF), detect associated airway abnormalities, and reduce the risk of missed additional fistulas.
Methods: We report a neonate with EA who underwent dynamic flexible bronchoscopic evaluation prior to primary repair. Initial bronchoscopy under spontaneous breathing assessed the larynx, trachea, airway collapsibility and localized the suspected distal TEF. The examination was continued via laryngeal mask airway (LMA), using positive end expiratory pressure (PEEP). In addition, low-flow oxygen jets were applied via the working channel to explore for further TEFs.
Results: A TEF was identified approximately 2 cm above the carina, with severe posterior intrusion type tracheomalacia at the same level. Using an LMA with 10cm H2O PEEP and 2L/min bronchoscopic oxygen jet insufflation, a second, more proximal fistula became visible approximately 2 cm above the distal fistula. Additional intraoperative bronchoscopy after repair confirmed successful closure of both fistulas.
Conclusion: Preoperative bronchoscopy may improve anatomical mapping and perioperative planning in EA. Detection of a fistula should not conclude the evaluation; additional fistulas require deliberate exclusion. PEEP and low-flow bronchoscopic oxygen insufflation may help expose occult fistulas.