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
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