Download MBBS (Bachelor of Medicine, Bachelor of Surgery) 1st Year, 2nd Year, 3rd Year and Final year Pediatric Surgery 9 Esophageal Atresia And Tracheo Esophageal Fistula Malformations PPT-Powerpoint Presentations and lecture notes
We rely on ads to keep our content free. Please consider disabling your ad blocker or whitelisting our site. Thank you for your support!
Esophageal Atresia And Tracheo
-esophageal Fistula
Malformations
? Introduction
? Embryology
? Epidemiology
? Associated anomalies
? Classification
? Diagnosis-
?Antenatal diagnosis
?Postnatal diagnosis
? Management-
?Pre-operative management
?Operative management
?Post-operative management
? Complications
Introduction
? To anastomose the ends of an infant's esophagus, the surgeon must
be as delicate and precise as a skilled watchmaker. No other
operation offers a greater opportunity for pure technical artistry.
-Dr. Willis Potts(1950)
? The first successful repair was done in 1940.
? Most-neonatal centres are performing repair now days with success
up to 90%.
Embyrology
? 4th week of gestation:
? the foregut --------->a ventral respiratory part
--------->a dorsal esophageal part
Incomplete fusion of the folds
defective trachea-esophageal septum
abnormal connection between the trachea and esophagus
Epidemiology
Incidence: 1 in 2500 to 3000 live births.
Slight male preponderance- 1.26:1
? Chromosomal associations:
? Environmental associations:
? DiGeorge syndrome
? Methimazole in early pregnancy
? Trisomy 21, 13 and 18
? Prolonged use of contraceptive
? Opitz syndrome
pills
? 13q, 17q and 16q24deletions.
? Progesterone and estrogen
exposure
? Single gene mutations:
? Maternal diabetes
? Feingold syndrome
? Thalidomide exposure
? CHARGE syndrome
? Fetal alcohol syndrome
? Fanconi anaemia
? Maternal phenylketonuria
Associated anomalies
? The most frequent associated malformations encountered in
syndromic EA are:
? Cardiac (13?34%)
? Vertebral (6?21%)
? Limb (5?19%)
? Anorectal (10?16%)
? Renal (5?14%)
? Two syndromic associations:
? VACTER-L: Vertebral, anorectal, cardiac, tracheo-esophageal, renal and limb
? CHARGE: Coloboma, heart defects, atresia of the choanae, developmental
retardation, genital hypoplasia and ear deformities.
Classification
? Many classification system has been proposed:
? Vogt
? Waterston
? Ladd
? Gross
? Gross classification is most commonly used.
? Based on anatomic variation
Diagnosis
? Antenatal diagnosis: Ultrasonography
? Polyhydramnios
suggestive of EA
? Absent or small stomach bubble
? Fetal MRI.
Diagnosis
? Postnatal:
? Premature babies.
? Symptomatic within first few hours of life.
? Variants A, B, C and D- excessive drooling of saliva.
? Choking, regurgitation and coughing on oral feeds.
? Variants C and D- as the child cries, air goes into the stomach and causes abdominal
distension and respiratory distress.
? Variants C, D and E- gastric juice may regurgitate through the fistula causing
chemical pneumonitis.
? Inability to pass an orogastric tube into the stomach.
? X-ray:
? Plain chest radiograph: dilated upper pouch.
? If a soft feeding tube is used, the tube will coil in the upper pouch.
Gasless abdomen:
Pure esophageal atresia and proximal fistula
No route for gas to enter abdomen
? Plain chest radiographs help in assessment of the gap between the
proximal and distal end.
? Helps to plan for surgical management.
? Absence of air in abdomen is associated with long gap.
? Gap < 2 vertebrae -
Primary anastomosis
? Gap > 2and < 6 vertebrae -
Delayed anastomosis
? Gap > 6 vertebrae -
Esophageal replacement
Bronchoscopy
Pre-operative management
? Oral suctioning through 10F double lumen Replogle tube.
? Position of child: Propped up position- least gastric reflux.
? Intravenous access and I. V. antibiotics.
? I. V. fluids (10% dextrose and hypotonic saline)and Vitamin K
administration.
? If respiratory distress is present due to pneumonitis, mechanical
ventilation may be done at low pressures.
? High pressure ventilation may cause gastric dilatation and gastric perforation
as well as diaphragmatic splinting.
? Investigations for associated anomalies:
? Echocardiography- to look for cardiac defects
? USG abdomen- to look for any renal abnormality.
? X-rays spine- to look for any vertebral anomaly
? X-ray upper limbs- to look for any radial anomaly.
Operative management
? Open thoracotomy:
? Through 4th intercostal space
? Extrapleural approach
? Posterior mediastinum is exposed.
? Azygous vein is divided to reveal underlying TEF.
? TEF is dissected circumferentially.
? Attachment of the fistula to the membranous portion of the trachea is taken
down.
? Tracheal opening is closed with non absorbable interrupted sutures.
? Upper pouch of the esophagus is mobilised as much as possible.
? The distal end of the upper pouch is opened and a nasogastric tube is passed
through the nares to upper esophagus to the lower esophagus and then to
the stomach.
? Anastomosis of the ends of the esophagus are done over the nasograstric
tube with absorbable sutures.
? Wounds is closed after placement of chest drain.
? Thoracoscopic approach is also being used.
? Special cases:
? H type fistula: division of the fistula done through the cervical approach.
Long gap atresia
? Delayed closure with lengthening procedure (at about 12weeks of life)
? Spontaneous growth
? Bougienage
? Upper pouch mobilisation
? Kimura's extrathoracic elongation technique
? Foker traction suture technique
? Upper pouch myotomy and flaps
? Esophageal replacement
? Stomach
? Colon
? Jejunum
? Ileum
Complications
? Anastomotic leaks
? Anastomotic stricture
? Recurrent tracheoesophageal fistula
? Tracheomalacia
? Disordered peristalsis/ gastroesophageal reflux/ esophageal cancer
? Vocal cord dysfunction
? Respiratory morbidity
This post was last modified on 08 April 2022