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Oesophageal Atresia 307
Investigations within 48 hours. Contrast swallows are discouraged due to the risk of
A babygram (Figure 48.2) with a radio-opaque nasogastric tube is the aspiration (Figure 48.3).
most informative imaging tool. This image helps with diagnosis, con- Cardiac echoes have proven unreliable in terms of identifying right
firms OA+TOF or isolated OA, diagnoses the associated anomalies of aortic arch; however, this identification hasn’t been particularly helpful
VACTERL, and identifies associated duodenal atresia. Renal ultrasound is because a right aortic arch has not been an impediment to repair via a right
helpful in confirming renal anomalies, and a cardiac assessment may con- posterolateral extrapleural access. Routine preoperative bronchoscopy is
firm the 30% associated cardiac anomalies. If dysmorhphic features are advocated in some centres, but is not essential, and thus is not practiced
suspected, karyotyping may confirm chromosomal anomalies. However, by many centres.
if life-threatening chromosomal anomalies are suspected, the treatment In the event of a gasless abdomen and pure atresia, an initial gastros-
may be delayed until karyotype results are obtained, which could be tomy may be required to establish the length of gap between proximal and
distal segments of the oesophagus (Figure 48.4).
OA with TOF OA without TOF Management
Surgical intervention is urgent only in the event of abdominal distention
causing ventilatory distress, gastric distention, or rupture. Otherwise,
oesophageal atresia constitutes an urgent elective case to be repaired
within 24 hours, preferably in the light of day, and after acquiring a
cardiac echo and convening a suitable team of anaesthesiologist and
operating room staff.
The patient is positioned in the left lateral position with a small
strut under the left chest wall. Nasotracheal intubation is encouraged to
ensure a stable endotracheal tube above the level of the carina. Surgery
necessitates retraction of the right lung, so it is essential that the left
lung is ventilated.
Depending on the size of the patient, a 16, 18, or 20 Wishard catheter
is introduced into the proximal oesophageal pouch, replacing the
Replogle tube, to be advanced by the anaesthetist when required.
Figure 48.2: A babygram showing OA+TOF on the left and isolated OA on the right. An approximate 3-cm incision is made just below the angle of the right
scapula, strictly in the skin lines to leave an optimal, almost imperceptible
scar. Non–muscle-cutting access to the rib cage is established through the
angle of auscultation between the latissimus and trapezius muscles.
The fourth intercostal space is opened on the superior margin of the fifth
rib, maintaining an extrapleural plane. This is possible in most cases—a
small breach of the pleura can be tied on a mosquito forcep at completion.
The azygos vein is tied and divided and the distal tracheo-oesophageal
fistula is identified, isolated, and serially divided with a 1-mm cuff
against the trachea, which is approximated with interrupted 6-0 proline
or polydiaxonone sutures.
A feeding tube is passed down the distal oesophagus to ensure
distal patency and to empty the stomach. The anaesthetist is then asked
to advance the Wishard catheter, and the upper pouch is mobilised, if
necessary, into the thoracic inlet and neck. This technique greatly facilitates
mobilisation and separation in the plane of close adherence to the trachea.
Figure 48.3: Examples of excessive volumes of contrast given to infants with The lower oesophagus is mobilised sufficiently to approximate the
oesophageal atresia, resulting in aspiration. two segments. Where limited gap allows, the fistulous proximal end
of the distal oesophagus is resected to achieve anastomosis to a better
calibre, and to have mild distraction of the two ends.
A single transverse incision is made across the end of the upper pouch
onto the Wishard catheter, and lateral and medial angle sutures are placed
across the segments. The Wishard catheter is withdrawn, and the posterior
anastomotic sutures are completed. The angle and posterior layer sutures
are then tied. If necessary, the chest wall strut is removed to relieve tension.
The anaesthetist is then asked to advance a Replogle or feeding tube, which
is guided through the anastomosis. The anterior layer is completed.
The extent of proximal mobilisation overcomes most gaps. In the event
of a 2.5cm+ vertical gap, options include the use of several techniques,
including circular myotomies (Figure 48.5). If this is required, it is usually
in the circumstance of a very high upper pouch, in which case the upper
pouch needs to be mobilised out of the neck, myotomised, and placed
back in the thoracic inlet. This is done with the Wishard catheter in the
lumen prior to opening the apex of the pouch. Other options include an
Figure 48.4: An on-table gastrogram in a baby with pure oesophageal atresia oesophageal flap (Figure 48.6).
and duodenal atresia. A duodenoduodenostomy was performed, followed by Some recent controversy has arisen as to whether to drain the
oesophageal atresia repair after a 3-day interval. extrapleural para-anastomotic space when one is very confident of the