Complications of anaesthesia and surgery for laryngotracheo-oesophageal cleft

Laryngotracheo-oesophageal cleft presents great difficulty in airway management. Tracheostomy and/or bilateral endobronchial intubation to secure the airway and a feeding gastrostomy are essential to sustain life until major definitive surgery can be planned. We describe the anaesthesia for these emergency life saving procedures in a 1.1-kg, 2-day-old neonate of 29 weeks gestation with apnoeic spells. Endoscopy to diagnose the extent of cleft, probable tracheostomy and gastrostomy were planned. Oesophagoscopy and bronchoscopy revealed a grade 3-4 cleft. Inadequate spontaneous ventilation during these procedures necessitated positive pressure ventilation. This resulted in a gaseous distension of an intact stomach which could be decompressed into the oesophagus. After the bronchoscopy, the use of a 3-mm tracheal tube without a Murphy's eye minimized the distension during gastrostomy. There was an accidental extubation after gastrostomy. Emergency reintubation with a 4-mm tracheal tube with a Murphy's eye resulted in gastric distension which led to tension pneumoperitoneum with a disappearance of PECO2. Misdiagnosis of this as loss of airway led to repeated intubations and extubation until the pneumoperitoneum was suspected and decompressed. After this setback, the baby's condition deteriorated over the next few hours ending fatally. The problems and suggestions to avoid these complications are discussed.