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“YOUR KIND ATTENTION PLEASE”

L/O/G/O

Esophageal Atresia- Epitome

Of Modern Surgery

Esophageal Atresia- Epitome

Of Modern Surgery

M M M C

Dr.B.SELVARAJ

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Esophageal AtresiaEsophageal AtresiaEsophageal AtresiaEsophageal Atresia---- Epitome of Modern Epitome of Modern Epitome of Modern Epitome of Modern surgerysurgerysurgerysurgery

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Dr.B.SELVARAJ MS;Mch;FICS;

• NEONATAL & PEDIATRIC SURGEON

• ASSOCIATE PROFESSOR

• MELAKA MANIPAL MEDICAL COLLEGE

• MELAKA- 75150

• MALAYSIA

Esophageal Atresia- Epitome of

Modern surgery

Recognise various conditions

Make early& accurate diagnosis

Prompt Life Saving treatment

Immediate surgical referral 4

1

2

3

Objectives

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A NeonateA NeonateA NeonateA Neonate’s request to Surgeons request to Surgeons request to Surgeons request to Surgeon

“Please exercise the greatest gentleness with my

diminutive tissues and try to correct the deformity at first operation; give me blood and proper amount of fluid and electrolytes; add

plenty of oxygen to anesthesia, and I will show you that I can tolerate a terrific amount of

surgery. You will be surprised at the speed of my recovery, and I shall be grateful to you”

--Dr. Willis Potts

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Neonatal Respiratory DistressNeonatal Respiratory DistressNeonatal Respiratory DistressNeonatal Respiratory Distress— Surgical CausesSurgical CausesSurgical CausesSurgical Causes

Causes

B

E

C

D

A Esophageal

Atresia

Diaphragmatic Hernia

Congenital

Lobar

Emphysema

Posterior

Choanal

Atresia

Pierre

Robin

Sequence

S

V

M

C

Embryology Of Esophageal Atresia

S

V

M

C

Esophageal AtresiaEsophageal AtresiaEsophageal AtresiaEsophageal Atresia

EA

Challenging&

Fascinating Problem

Team Work

Approach

Post op Ventilator

Care

VACTERL

Anomaly

Incidence 1 in 3500

livebirths

Epitome of Modern Surgery

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C

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Esophageal AtresiaEsophageal AtresiaEsophageal AtresiaEsophageal Atresia TypesTypesTypesTypes

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Esophageal AtresiaEsophageal AtresiaEsophageal AtresiaEsophageal Atresia---- Associated AnomaliesAssociated AnomaliesAssociated AnomaliesAssociated Anomalies

Vertebral

Anorectal

Cardiac- commonest

Tracheo

Esophageal Fistula

Renal

Limb

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C

Esophageal AtresiaEsophageal AtresiaEsophageal AtresiaEsophageal Atresia Clinical FeaturesClinical FeaturesClinical FeaturesClinical Features

Clinical

Features

Drooling of saliva

Maternal Polyhydramnios

Inability to pass NGT

into Stomach

In atresia with TEF���� Aspiration

of gastric contents

����Chemical Pneumonitis

Feeding ���� Cough,

choking &

Cyanosis

In pure atresia����

Gasless Abdomen

���� Scaphoid Abd

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Esophageal AtresiaEsophageal AtresiaEsophageal AtresiaEsophageal Atresia----Drooling of salivaDrooling of salivaDrooling of salivaDrooling of saliva

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C

Physiological Effect of Distal TEF

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• 1. Hyaline membrane disease may necessitate higher ventilator pressures, which encourage air to pass through the distal fistula.

• 2. A distended abdomen elevates and "splints" the diaphragm.

• 3. Gastric distension may result in gastric rupture and pneumoperitoneum.

• 4. Passage of air through a distal tracheoesophageal fistula diminishes the effective tidal volume.

(B) 1. Aspiration of gastric juices leads to soiling of the lungs and pneumonia

• 2. Gastroesophageal reflux

• 3. Direction of gastric fluid proximally through distal fistula.

• 4. Overflow of secretions or inadvertent feeding may contribute to aspiration and contamination of the airway.

Esophageal Atresia

Imaging Studies

AXR����Gasless in pure Atresia

CXR����Atelectasis&Pneumonia Antenatal MRI of Fetus

USG Abd����to R/O Urogenital anomaly

Echo to R/O cardiac

anomaly&Rt Aortic

arch

AXR &CXR����Curledup NGT in blind upper pouch

Imaging

Studies S

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Esophageal Atresia

Antenatal MRI

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Esophageal Atresia

Clinical Diagnosis

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• . (A) Diagnosis of

esophageal atresia is

confirmed when a 10-

gauge (French)

catheter cannot be

passed beyond 10 cm

from the gums. (B) A

smaller-caliber tube is

not used because it

may curl up in the

upper esophageal

segment, giving a false

impression of

esophageal atresia.

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Esophageal Atresia

CXR

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Esophageal Atresia With

TE Fistula- Bronchoscopy

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C

TE Fistula

Rt Bronchus

Esophageal Atresia

Pre op Management

Pre op Proximal pouch

Decompression

NPO

If for staged repair����

Do Gastrostomy

Head up position

In pure atresia����

Stretch proximal pouch

daily

I V Antibiotics S

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C

Esophageal Atresia

Pre op Management

Pre op Proximal pouch

Decompression

NPO

If for staged repair����

Do Gastrostomy

Head up position

In pure atresia����

Stretch proximal pouch

daily

I V Antibiotics S

V

M

C

Esophageal Atresia

Waterston’s Risk Categories

●Birth weight >2.5 Kgs

●No Anomalies

●No Pneumonitis

●Primary Repair����100%survival

●Birth weight 1.8 to 2.5 Kgs

●Non life threatening anomalies

●Mild Pneumonitis

●Delayed Primary Repair����80%survival

●Birth weight < 1.8 Kgs

●Life threatening anomalies

●Severe Pneumonitis

●Staged Repair����40%survival

Risk

Categories

Category

A

Category B

Category C

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Esophageal Atresia

Operative Management

1

2

3

Lanman’s Rt posterolateral retropleural

thoracotomy

Ligation & division of Azygos vein

Disconnect TEF; Repair tracheal defect

4 Liberally mobilise the upper pouch for tension

free anastomosis

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Esophageal Atresia

Operative Management

5

6

7

In wide gap����Livaditi’s circular myotomies

Never mobilise distal pouch much

Extra pleural drain

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M

C

8

Transanastomotic feeding tube for early gavage

feeding

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Esophageal Atresia

Operative Management

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Normal Mediastinum- Rt side

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Esophageal Atresia

Immediate Primary Repair

S

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C

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Esophageal Atresia

Immediate Primary Repair

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Esophageal Atresia

VATS Repair

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Esophageal atresia

Post op Management in NICU

Gastrograffin swallow on 7th POD; If no leak����oral

Feeding & remove chest drain

Feeding through transanastomotic feeding

Tube from 2nd POD

Regular chest Physio&Nasopharyngeal

suction

Otherwise exubate in 1st POD

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Electively paralyse&mechanically ventilate

For 3 to 5 days in tension anastomosis

Esophageal Atresia

Complications

LATE

Tracheomalacia

GE Reflux

EARLY

Anastomotic Leakage

Anastomotic Stricture

Recurrent TEF Esophageal Dysmotility

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Clinical

Features

Operation

Preop

Trt

•VACTERL

•Maternal Poly Hydramnios

•Drooling of saliva in baby

•Inability to pass NGT into stomach

•NPO

•Headup position

•IV Antibiotics

•Upper pouch suction

Complica

tions

Associ

Anomaly EA&

TEF

Esophageal Atresia

TE Fistula���� Recap

Imaging

CXR •Curledup NGT in blind

upper pouch

•Echo to R/O cardiac

Anomaly

• USG Abd to R/O

Urogenital anomaly

•Immediate primary

Repair

•Delayed primary

Repair

•Staged Repair

•Anastomotic leak

•Anastomotic stricture

•Tracheomalacia

•GE Reflux

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C

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