SEMINAR

“OESOPHAGEAL ATRESIA AND ITS

MANAGEMENT ”

PRESENTED BY :MAHENDRA SINGH GOND

MODERATOR :Dr. DEEPTI BALA SHARMA

 DEFINITION
Eosophageal atresia is a congenital
interruption or discontinuity of the
eosophagus resulting in eosophageal
obstruction.
 Introduction
 Eosophageal atresia is the most frequent
congenital anomaly of the eosophagus affecting
about 1 in 4000 neonate of these more than 90%
have an associated tracheo esophageal fistula.
 The surgical solution to the problem of
esophageal atresia referred as epitome of modern
surgery certainly its evaluation is an example of
incremental steps. Surgical inguinity and sheer
persistence can eventually lead to remarkable
success.
 A congenital abnormality incompatible with life that
was once referred to as hopeless from beginning and
not of much practical importance to the surgeon is
now successfully repair all over the world.
 ETIOLOGY :
Embryology of these anomalies is still debatable.
21-32 day of embryogenesis
 
elongation and growth separation of trachea branching and
from foregut growth of
bronchial tree
 
rapid elongation of trachea
and dimnition in esophagus
substance

oeiophageal atresia
Incidence:
Genetic contribution is relatively non specific.
Esophageal atresia has been noted in 1 of a set of
twins by many observer.
Holder Survey
 
Atresia distal fistula (85%)
Atresia, proximal fistula (2%)
Atresia, fistula both segment (1%)
Atresia alone (6%)
Fistula alone (2%)
0 20 40 60 80 100
 TYPES

A=Atresia without fistula – 6%

B=Atresia with fistula into proximal segment – 2%
C=Atresia with fistula into distal segment –85%
D=Atresia with fistula into both segment –1%
E=Fistula without atresia –2%
 ANATOMY
1.    In the common type of atresia with fistula into the distal
segment the proximal pouch varies in length from 1-3.5 cm.
This would result in pemaxilla of 10-13.5 cm. The diameter
range from normal of about 5-10 mm or more.
2.    The proximal pouch is usually hypertrophied due to
process of foetal swallowing of amniotic fluid. It has an
excellent blood supply and adherent to posterolateral wall of
trachea. If the proximal pouch is not hypertrophic and is small
and short, then there is possible existence of a fistula between
it and trachea.
3.    In atresia with distal fistula lower
segment usually membranous part of
trachea just cephalad of the carina within
1 cm but rarely be into right or left main
bronchus.
Distal segment supplied by intercostal
artery and branches from descending
aorta.
 MOST COMMON CONGENITAL ANOMALY ASSOCIATED WITH
ESOPHAGEAL ATRESIA WITH OR WITHOUT FISTULA:
V- VERTEBRAL BODY SEGMENTATION DEFECT - 30%
A- ANORECTAL MALFORMATION – 20.5%
C- CARDIAC VASCULAR ANOMALY – 27.6% (VSD >PDA > TOF)
T- TRACHEO
E- ESOPHAGEAL
R- RADIAL, RENAL AGENESIS – 11.1%
L- LIMB ABNORMALITY – 2%
CHROMOSOMAL ABNORMALITY – 5-8%
(DOWN, EDWARD SYNDROME)
 
C- COLOBOMATA
H- HEART DISEASE
A- CHONAL ATRESIA
R- MENTAL RETARDATION
G- GENITAL HYPOPLASIA
E- EAR ANOMALY WITH DEAFNESS
 DIAGNOSIS
Clinical feature:
-         H/o maternal polyhydromnias
-         First symptom noted immediately or soon after
the birth is excessive saliva from mouth which
require frequent aspiration (drooling of saliva)
-         Episodes of chocking, coughing, regurgitation,
respiration distress and even cynosis on feeding
attempt
-         Gastric distention is found with distal fistula
Associated with other anomaly like imperforated anus
radial dysplasia
 RADIOLOGICAL STUDY
Pass 10 or 12 french radiopaque catheter through oral or nostril route take X-ray
in erect posture in PA and lateral view.
1.    Coiling of catheter (obstruction will be met 9-13 cm from naros) i.e.,
oesophageal atresia
2.    Coiling of catheter with air in stomach i.e., esophageal atresia with distal
esophageal fistula
3.    Coiling of catheter with no gas in stomach i.e., oesophageal atresia without
fistula

Advantage :
1.    To confirm the location of catheter and extent of proximal pouch, from lateral
film the level of the blind end of pouch, relative to thoracic inlet. Lowest point of
pouch usually reaches to level of body of T2 - T3 vertebrae.

2.    Determine severity of pulmonary involvement aortic arch location

3.    Exclude other concominent anamalies like duodenal atresia (double bubble
sign), anorectal malformation
 RADIOPAQUE DYE STUDY
Instillation of radiopaque dye (gastrograffin,
micropaque dinosil) through catheter for further
radiological study.
Advantage:
Precise size location of proximal pouch is
accurately visualize and proximal fistula may be
seen.
Disadvantage:
Dye aspirated into airway causing chemical
pnemonitis.
 TRACHEOBRONCHOSCOPY
Visualize the exact location of fistulous opening in the
wall of the trachea but also access anatomy of air passage
and to rule out second fistula.
Preoperative bronchoscopy is helpful when preliminary
radiograph indicate short high proximal pouch
Endoscopy : Particular value in diagnosis of H type fistula
which within spectrum of tracheoesophageal defect being
consider difficult to diagnosis.
USG : Abdomen (to rule out congenital anomaly like renal
agenosis, duodenal atresia, pyloric stenosis, anorectal
malformation
Echocardiography : To rule out cardiac anomaly like (R) side
aortic arch TOF, VSD, PDA.
 SUSPECTED OA
(Prematurity and maternal polyhydromino) excessive mucousy at birth drooling) mild to
moderate respiratory distress
 
Insert No. 10 gauze catheter through mouth become arrested at 9-13 cm from gum
 
Plain X-ray chest/abdomen
 

1. Gas in abdomen on plain x-ray 2. no gas in abdomen

Distal tracheoesophageal no distal fistula
Fistula (20% have proximal fistula)

Endoscopy or mild oesophageal contrast

study
 
Demonstrate proximal tracheo-
Oesophageal fistula if present
Fistula division and esophageal
 MANAGEMENT
Medical care before and during transport.
1.    Oxygen therapy
2.    Care of upper pouch – proper suction of upper pouch
3.    Posture – infant nursed in right lat position to assist
the infant in maintaining a clear airway. This will minimise
regurgitation of gastric contact upto the distal fistula and
decrease work of breathing and improve oxygenation.
 The neonate depends almost entirely on contraction of
the diaphragm for effective ventilation which is more easily
accomplished in this position.
4.    I/M injection vitamin K
5. I/V Fluid, I/V antibiotic
 SURGICAL TREATMENT
Following criteria to be useful in making the
decision for primary repair.
1.    Clear lung to ausculate
2.    Clear lung by chest radiograph
3.    No undefined cardiac anomalies
4.    An arterial PaO2 of greater than 60 mmHg in
room air
5.    A recent study identified LBW (1500 gm) and
the presence of major cardiac anomaly as
two factors that are greater influence on
survival
WARTERSTON CLASSIFICATION
Group I = BW > 1500 gm without major cardiac
disease
Group II = BW < 1500 gm or major cardiac disease
Group III = BW < 1500 gm and major cardiac
disease
Using there criteria then survival rate for :
I = 97%
II = 59%
III = 22%
 PROCEDURE
The aim of primary repair of both end is tension free anastomosis
without compromising the blood supply.
 
Right side extrapleural thoractomy through fourth intercostal space
 
Lung retracted medially by retractor
 
Azygous vein identying ligate and divide
 
TEF dissected circumterentially and then ligated using interrupted non
absorbable suture
 
Proximal esophageal pouch is then mobilized as high as possible to afford a
tension free esophageal anastomosis
 
Anastomosis perform using single or double layer
If the two end of esophagus cannot
anastomoses without tension there are several
options.
(1)   Suture the divided end of distal esophagus to the
prevertebral fascia mark its location with metal clip close the
thoractomy. Over 2-3 months the proximal esophagous will
anastomosis with adequate length.
(2)   Circular or spiral myotomy of upper pouch. Done to gain
esophageal length. Each myotomy add up 1 cm of length
Disadvantage : Formation of diverticulum
(3)   Sump tube maintain in proximal pouch and with time the
proximal blind segment elongates into mediastinum 6-12
weeks
 (4)   If the all maneour failed : cervical esophagostomy with
gastrostomy will done.

(5)  esophageal replacement using the stomach (greater

curvature tube, gastric transposition), small intestine (jejunal
transposition), colon (eosophagocoloplasty) performed at
about 1 year of age or 10 kg weight.
 COMPLICATION
a. Dysphagia/stricture –
M/M – 1. Retrograde dilation guided by transanastomotic string approach.
1.    Radial dilation with balloon catheters.
2.    If stenosis with complete occlusion – double endoscopy preferred.
3.    Esophageal replacement1.    (transposition of gastric tube small intestine,
colon)
b. Major Anastomotic Leak
Complete disruption - do reanastomosis
Complete disruption with infection – Cervical esophagotomy with esophageal
replacement
c. Recurrent Tracheosophageal fistula
1.    Pleural or pericardial flap and interposition of muscle all have been used to
prevent another recurrence.
2.    Endoscopy plugging with fibrin glue
d. Chylothorax
e. Gastroesophageal reflex – partial wrap fundoplication
 CONCLUSION:
Survival has become the norm with
good result of eosophageal anastomosis with
fistula excision with undefined congenital
anomaly.