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Oesophageal atresia: 10 years study.

INTRODUCTION

Oesophageal atresia is a life-threatening neonatal surgical emergency and the outcome reflects the quality of work done in the department. It occurs about 1 in 3000 live births. Manifestations of tracheo-oesophageal fistula and oesophageal atresia may take few minutes to days to present itself to the treating surgeon.

Embryologically the defect is probably due to incorporation of part of oesophagus into the developing trachea between 4th and 5th week of intrauterine life. (2)

The management of a neonate with oesophageal atresia and tracheo-oesophageal fistula without ventilatory support is a challenging job; not only in terms of anesthetic management. (3) but also in the pre- and post-operative care in the presence of prematurity. (4)

Low birth weight, aspiration pneumonia and associated major congenital cardiac anomalies, the outcome is poor. (5)

PATIENTS AND METHODS

Retrospective study of neonates admitted with a diagnosis of oesophageal atresia with or without tracheo-oesophageal fistula between August 2004 and July 2014.

Pre-operative evaluation for associated anomalies and basic surgical workup was done. A total number of 269 patients were treated during the said period.

Males were 143(53.1%) and females 126(46.9%); 223(82.8%) patients were operated and 46(17%) patients could not be operated because of their poor general condition.

Clinical presentation mostly was in the form of drooling of saliva, respiratory distress, cyanosis and choking on attempted feeding. Diagnosis was established by inability to pass nasogastric tube into stomach and chest x-ray showing coiling of feeding tube in the proximal pouch.

Age at presentation was 0-2 days in 205(76.2%), 3-5 days in 51(18.9%), 6-10 days in 6(2.25%), and more than 10 days in 7(2.6%) cases.

TYPE OF ANOMALY

Tracheo-oesophageal fistula with proximal pouch atresia was in 252(93.6%), (Male 135 and female 117), oesophageal atresia without tracheo-oesophageal fistula in 15(5.5%) (Male 6 and female 9) and 'H' type fistula without oesophageal atresia was in 2(0.74%) (Both were male) patients.

GROSS CLASSIFICATION (6)

8% 1% 85% 1% 4% 1% (7)

Waterston Classification (8)

Group  Survival %       Waterston Classification

 A    100    Birth weight >2500gm, with no chest infection
 B    85    BW 1800-2500gm, with moderate chest infection
 C    65    BW <1800gm, with major associated anomalies


Waterston's risk groups--type 'A'--139(52%), 'type B'--71(26%), 'type C'--59(22%).

Associated Anomalies (9) were noted in 53 patients (19.7%). Gastrointestinal - 17(6.3%); Anorectal malformation - 12; Genitourinary - 2(0.74%); Cardiovascular - 30(11.15%); Skeletal - 2(1.48%), xipho-omphalopagus conjoined twin 1(0.37%).

Two hundred and twenty three patients could be given operative management out of 269. Surgical procedures done were thoracotomy, ligation and division of fistula and primary oesophageal anastomosis in 202(90.5%), oesophagostomy and gastrostomy in 20(8.9%), colostomy in 12(5.3%), duodenoduodenostomy in 5 and separation of conjoined twin in 1(0.44%).

TREATMENT

After initial resuscitation for a period of 24 hrs in the form of repeated proximal pouch clearance, oxygenation by mask, correction of fluid deficit and initiation of broad-spectrum antibiotics and necessary emergency radiological workup, neonates were subjected to surgical procedures.

SURGICAL PROCEDURE

For tracheo-oesophageal fistula with atresia in 202 patients (90.5%) was in the form of right anterio-lateral thoracotomy through 4th intercostal space, extrapleural approach, division of azygos vein, ligation and division of tracheo-oesophageal fistula (Fistula closed by three interrupted proline sutures), adequate mobilization of proximal blind pouch and primary oesophageal anastomosis. (10) using interrupted 5-0 proline sutures over a trans-anastomotic no. 5 feeding tube. (11) In 9 patients because of long gap. (12) oesophagostomy and gastrostomy was done disowning the distal oesophagus after division of fistula. Left cervical oesophagostomy and feeding gastrostomy (using Fr 10G Foley's catheter) without thoracotomy was done for pure oesophageal atresia without tracheo-oesophageal fistula in 11 patients. (13)

TYPE       WT        Total   M    F    Operated

 A       >2.5KG       32     18   14      29
 B     1800g-2500g    145    70   75     140
 C       <1800g       92     55   37      54

TYPE   M    F      Un-      M    F    Survived   M    F       %
                 operated                                  Survival

 A     15   14      3       2    1       19      7    12     65%
 B     68   72      5       3    2      117      51   66     83%
 C     31   23      38      24   14      00      0    0       0


Post-Operative Management

Includes oxygenation by facemask or T piece, gentle throat clearance, saline nebulization and gentle chest physiotherapy. Expressed breast milk feeding was initiated through transanastomotic nasogastric tube from 2nd day onwards and gradually increased. Oral feeds were commenced on 6th postoperative day after ensuring the integrity of the anastomosis. Later nasogastric tube and intercostal tube drain were removed. Parents were instructed to nurse the baby in prone, head-end elevated position to take care of associated tracheomalacia and gastro-oesophageal reflux.

Oesophagostomy and gastrostomy (total-20) was done for cases of oesophageal atresia. (11) and in tracheooesophageal fistula with long gap. (9) where primary anastomosis was not feasible. Primary gastric pull up. (13) was done in one patient. Xipho-omphalopagus conjoined twin with oesophageal atresia and tracheo-oesophageal fistula in one baby was operated for the anomaly immediately after separation of the twin. Colostomy was done in 12 patients for associated high anorectal malformations and duodenoduodenostomy for 5 patients with associated duodenal atresia.

RESULTS

Two hundred and twenty three patients were operated. Out of 223, 136(61%) patients survived, males 58(42.6%), female 78(57.4%) and 87(39%) patients died {(Male 56(64.36%), Female 31(35.63%)}.

COMPLICATIONS

Most of the deaths occurred on 2nd post-operative day due to viscid tracheobronchial secretions blocking airway and subsequent were due to septicemia, cyanotic heart disease, gastro-oesophageal reflux and aspiration. (14)

Minor anastomotic leaks 5(4.2%) (Resolved spontaneously). (15), anastomotic stricture (16.17) 11(8.5%) (managed by Savary-Gilliard dilators). (18)

CONCLUSION

Out of 223 operated patients 136(61%) survived. This could be achieved in the absence of specialized nursing and intensive care setup and ventilator support. (19) Optimum oxygenation with nebulization, effective physiotherapy and throat clearance. (20) (Especially during the initial 48hrs) and early initiation of expressed breast milk feeds could bring about this positive outcome.

REFERENCES

(1.) Upadhyaya VD, Gangopadhyaya AN, Gupta DK, et al. "Prognosis of congenital tracheoesophageal fistula with esophageal atresia on the basis of gap length." Pediatric Surgery International, vol. 23, no. 8, pp. 767-771, 2007.

(2.) Spitz L, Kiely E, Pierro A. Gastric transposition in children: a 21-year experience. J Pediatr Surg 2004;39:276-81.

(3.) Spitz L. Esophageal atresia. Lessons I have learned in a 40-year experience. J Pediatr Surg 2006;41:1635-40.

(4.) Diaz LK, Akpek EA, Dinavahi R, et al.: Tracheoesophageal fistula and associated congenital heart disease: implications for anesthetic management and survival. Pediatric Anesthesia 2005;15:862-869.

(5.) Gupta A: Tracheo-oesophageal Fistula, Oesophageal Atresia and Anaesthetic Management. Indian J Anaesth 2002;46(5):353-355.

(6.) Merei J, Hutson J: Embryogenesis of tracheo-esophageal anomalies. Saudi Med J 2003;24(5 Suppl):39-40.

(7.) Koveski T, Rubin S: Long-term complications of congenital esophageal atresia and/or tracheoesophageal fistula. Chest 2004;126(3):915-925.

(8.) Richter GT, Ryckman F, Brown RL, et al. Endoscopic management of recurrent tracheoesophageal fistula. J Pediatr Surg 2008;43(1):238-45.

(9.) Ahamed H Al-Salem, Maaen Tayeb, et al. Oesophageal atresia with or without tracheoesophageal fistula: success and failure in 94 cases. Ann Saudi Med 2006;26(2):116-119.

(10.) Singh SJ and Shun A. "A new technique of anastomosis to avoid stricture formation in oesophageal atresia," Pediatric Surgery International, vol. 17, no. 7, pp. 575-577, 2001.

(11.) Spitz L, Kiely EM, Morecroft JA, et al. Oesophageal atresia: At-risk groups for the 1990s. J Pediatr Surg 1994;29:723-5.

(12.) Sharma AK and Wakhlu A. "Simple technique for proximal pouch mobilization and circular myotomy in cases of esophageal atresia with tracheoesophageal fistula," Journal of Pediatric Surgery, vol. 29, no. 10, pp. 1402-1403, 1994.

(13.) Tsai JY, Berkery L, Wesson DE, et al. "Esophageal atresia and tracheoesophageal fistula: surgical experience over two decades," Annals of Thoracic Surgery, vol. 64, no. 3, pp. 778-784, 1997.

(14.) Peter B Manning, MD, et al. Fifty years' experience with esophageal atresia and tracheoesophageal fistula. Presented at the 106th Annual Meeting of the American Surgical Association, Hot Springs, Virginia, April 24-26, 1986.

(15.) Louhimo I, Lindhal H. Esophageal atresia: primary results of 500 consecutively treated patients. J Pediatr Surg 1983;18:217.

(16.) Thomas Kovesi and Steven Rubin. Long-term complications of congenital esophageal atresia and/or tracheoesophageal fistula. Chest 2004;126.3.915.

(17.) Choudhury SR, Ashcraft KW, Sharp RJ, et al. Survival of patients with esophageal atresia: influence of birth weight, cardiac anomaly and late respiratory complications. J Pediatr Surg 1999;34:70-74.

(18.) Peyvasteh M, Askarpour S, Shoushtari MHS. A study of esophageal strictures after surgical repair of esophageal atresia. Pak J Med Sci 2006;22:269-272.

(19.) Orford J, Cass DT, Glasson MJ. Advances in the treatment of oesophageal atresia over three decades: the 1970s and the 1990s. Pediatr Surg Int 2004;20:402-407.

(20.) Rokitansky AM, Engels M, et al. Recent evaluation of prognostic risk factors in esophageal atresia - A multicenter review of 223 cases. Eur J Pediatr Surg 3(1993);196-201.

Chanda Bhaskar Rao [1], K. Jayapal [2],P. Subbarao [3], K. Narasimharao [4], MohdZakir Mohiddin Owois [5]

[1] Assistant Professor, Department of Paediatric Surgery, Government General Hospital and Guntur Medical College, Guntur, Andhra Pradesh.

[2] Assistant Professor, Department of Paediatric Surgery, Government General Hospital and Guntur Medical College, Guntur, Andhra Pradesh.

[3] Professor, Department of Paediatric Surgery, Government General Hospital and Guntur Medical College, Guntur, Andhra Pradesh.

[4] Assistant Professor, Department of Paediatric Surgery, Government General Hospital and Guntur Medical College, Guntur, Andhra Pradesh.

[5] Post Graduate, Department Paediatric Surgery, Government General Hospital and Guntur Medical College, Guntur, Andhra Pradesh.

Financial or Other, Competing Interest: None.

Submission 25-11-2015, Peer Review 26-11-2015, Acceptance 05-12-2015, Published 19-12-2015.

Corresponding Author: Dr. Chanda Bhaskar Rao, 26-1-96, 4A, B. G. Arcade, Nagarampalem Main Road, Guntur-522004, Andhra Pradesh.

E-mail: chandabhavana@rediffmail.com

DOI:10.14260/jemds/2015/2507
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Title Annotation:Original Article
Author:Rao, Chanda Bhaskar; Jayapal, K.; Subbarao, P.; Narasimharao, K.; Owois, Mohd Zakir Mohiddin
Publication:Journal of Evolution of Medical and Dental Sciences
Article Type:Report
Date:Dec 21, 2015
Words:1647
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