Introduction

Oesophageal atresia and tracheoesophageal fistula (TOF) are common neonatal conditions that remain a significant challenge to pediatric surgery. This pathology should be considered in the differential diagnosis of a neonate who develops feeding difficulties and respiratory distress in the first few days of life. Incidence is 1 in 4500 live births.

Oesophageal atresia is often associated with other congenital anomalies. Prompt recognition, appropriate clinical management to prevent aspiration and swift referral to an appropriate tertiary care center is very important.

Despite the improvement in survival, the morbidity associated with surgical repair remains high. In this study, we review our two-year experience with patients with EA/TOF. The results may be beneficial for further clinical management of these patients in future.

Aims Of Study

This is a case study of a total of 25 TOF repair cases, operated in GGH and M.P.Shah Medical College, Jamnagar, from Jan. 2006 to Oct. 2007 including 15 males and 10 females and follow-up to Oct. 2007 with the following aims: To find out

the common type of oesophageal atresia.

abnormalities commonly associated with oesophgeal atresia.

the impact of an associated abnormality on morbidity and mortality of patients with oesophageal atresia.

technical difficulties during the operative procedure and hurdles in the immediate and late postoperative period in our setup.

Materials And Methods

This comparative study was conducted in 25 patients admitted during the period from January 2006 to October 2007 in the surgical department of GGH at Jamnagar, between operated TOF cases with and without associated anomalies and on difficulties in our setup while managing.

Preoperative investigations

Chest x-ray

Figure 1

Dye study

Echocardiography

Blood grouping and keeping compatible blood ready

After giving antibiotics 10 minutes before surgery, a short right posterolateral incision (right side thoracotomy incision) was made below the level of the tip of the scapula in the fourth intercostal space.

After inserting an infant rib spreader, extrapleural dissection was carried out using a moistured cotton-tipped applicator, till the azygous vein was fully mobilised.

The azygous vein which is often a marker for the site of the TOF as it enters the trachea was divided between two 4-0 suture ties. The TOF was divided by fine tenotomy scissors and the tracheal side was oversewn with running or interrupted 5-0 sutures.

The upper atretic oesophageal pouch was identified with the aid of the anesthesiologist, who pushed down on the end of the pouch with a previously placed oral tube.

A traction suture was placed at the 3 & 9 o'clock position on the open distal oesophagus and by placing gentle traction in opposite directions, full-thickness suture bites were placed in the midportion of the posterior wall of both ends of the oesophagus with knots tied on the outside.

Figure 2

A nasogastric tube No. 8 to 10 was passed from above by the anesthesiologist through the anastomosis, into the stomach. The anterior wall of the oesophageal anastomosis was completed with full-thickness, interrupted, 4-0 PDS suture, completing a single layer and the anastomosis suture line was checked for a potential leak by instituting 5 to 10ml of saline.

Figure 3

A 12-French chest tube was placed entering in the posterior mediastinal space below the incision. A 3-0 polyprophylene suture affixed the tube to the skin at the exit site. The tube was then attached to an underwater sealed closed drainage system.

Closure

The lung was gently expanded and the chest wound was closed using a 2-0 vicryl pericostal suture to oppose the ribs and a running 3-0 vicryl suture to close the divided latissimus dorsi muscle.

The anesthesiologist can help at the closure by pushing down on the infant's right arm and shoulder, taking tension off from the wound. The subcutaneous fascia was approximated with a continuous running 4-0 vicryl suture and the skin edges were closed with 4.0 black silk verticae mattres suture and a dry occlusive dressing was applied.

Figure 4

Postoprative Care

Neonatal intensive care

Higher antibiotics

Drain care and removal between 4th to 6th day

Ryle's tube aspiration followed by Ryle's tube feeding when bowel sounds came

Removal of Ryle's tube followed by dye study between 8th and 12th day

Figure 5

Starting oral feeding after normal dye study between 8th and 12th day

Stitch removal in between 10th and 14th day

Most patients require injectable perinorm and buscopan as most have associated gastroesophageal reflux.

Figure 6

Table 1: Postoperative care of 9 surviving patients

Observation And Discussion

This is a case study of a total of 25 cases of oesophageal atresia with and without TOF repair in GGH and M.P.Shah Medical College, Jamnagar, done from Jan. 2006 to Oct. 2007.

The most common type was found to be type C with around 80% of cases followed by type A with 16% and type E with around 4%. The most frequent associated anomalies found were cardiac ones, among which patent ductus arteriosus was most common.

Figure 7

Table 2: Patient Demographics and associated anomalies

Figure 8

Associated anomalies caused intraoperative difficulty as well required special postoperative care. Duration of surgery also increased in cases of TOF with associated anomaly. But survival was 0%.

The most common postoperative complications that occurred in our setup were recurrent pneumonia and, in a small percentage of cases, gastroesophageal reflux and anastomotic stricture.

Discussion

The three priorities in treatment are:

To save life.

To achieve alimentary continuity.

To preserve the oesophagus.

But management of TOF is affected by:

Prematurity

Established pneumonia

Associated anomalies as shown in Table III below.

Such cases should be managed by 100% oxygen despite the risk of retinopathy of prematurity.

Figure 9

Table 3: Survival and average duration of operation

Conclusions

From our study of 25 cases of tracheoesophageal fistula repair, carried out at the Department of Surgery, M.P.Shah Medical College, Jamnagar, we conclude:

Common type: Oesophageal atresia with distal TOF.

Commonly associated anomaly: Cardiac (patent ductus arteriosus)

Morbidity and mortality both increased if oesphageal atresia with TOF was associated with another abnormality.

The survival rate of operated patients can be improved by

Early diagnosis and timely reference for surgery by a pediatrician

Good peroperative anesthetic care

Perfect knowledge of anatomy and meticulous, skilled dissection within the adequate minimum time by the surgeon

Better postoperative neonatal intensive care

Correspondence