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308 Oesophageal Atresia

ter and life threatening and require early intervention. Generally, gastro-
oesophageal reflux is addressed first. Occasionally, infants cannot be fed
at all without immediately refluxing and aspirating, and may be at risk
of sudden infant death syndrome (SIDS).
Other postoperative complications include anastomotic stricture;
gastro-oesophageal reflux; long-term Barrett’s oesophagus due to
chronic reflux; and chylothorax.
A well-recognised but uncommon pitfall in the operative management
of OA, tracheo-oesophageal fistula occurs in the event of a carinal fistula
Circular Myotomy through the neck Intrathoracic Circular Myotomy with tracheal communication into the fork of the carina. In this situation,
through the thoracotomy wound the relative position of the right main bronchus and distal oesophagus
just below the fistula is reversed. The surgeon should always confirm
Figure 48.5: Circular myotomy. that a structure isolated as the distal oesophagus is correctly identified by
atraumatic occlusion and confirmation that the right lung still ventilates
before dividing the structure.
Conclusion
In the Western world, current expectations of survival are that all patients
with oesophageal atresia will survive unless there are major congenital

malformations affecting other systems. There is no place for technical
risk or error to compromise survival. In Africa, however, limiting fac-
tors are delayed diagnosis and restricted access to a neonatal intensive
care unit (NICU). Shortages of medical and nursing personnel demand
techniques be selected that limit the NICU requirement, in-hospital stay,
and complications. The potential to rescue patients with surgical compli-
cations is probably not as good as it is in First World centres.
Evidence-Based Research
Table 48.1 presents a review of a 10-year personal experience with OA
and TOF.
Table 48.1: Evidence-based research.
Figure 48.6: Flap technique: (1) the closed upper pouch; (2) the upper pouch is
open and its lateral wall reaches the lower segment of the oesophagus; (3) the Title Oesophageal atresia and tracheo-oesophageal fistula: review
elongated upper pouch is anastomosed to the lower segment. of a 10-year personal experience.
Authors Adebo OA
Institution Department of Surgery, University College Hospital and
integrity of the anastomosis. A drain does no harm and can be removed in College of Medicine, University of Ibadan
2 or 3 days if one has confidence in the anastomosis. In cases anastomosed
under tension, a para-anastomotic drain is retained for a week, and feeds Reference West Afr J Med 1990; 9(3):164–169
are delayed until a contrast swallow confirms an intact oesophagus. Problem Outcomes of TOF and OA repair in the African setting is poor.
Gastrostomies are essentially used only for pure oesophagael Intervention This study seeks predictors to improve outcome.
atresia cases. The rest are fed via a transanastamotic tube initially, and Comparison/ Eleven neonates with oesophageal atresia and distal fistula
subsequently are fed orally. control were managed between July 1977 and January 1987. The
Minimally invasive endoscopic surgery has become the vogue in (quality of male-to-female ratio was 1.2:1. The patients were aged
between 1 to 14 days (median of 7 days) and weighed 1.85
paediatric surgery, and has excellent application for a considerable evidence) to 3.10 kg (mean of 2.6 kg) at presentation. Associated
range of procedures. Whether this is true for thoracoscopic repair of anomalies were present in 5, pneumonia in 4, and uraemia
OA since the first report in 1999 is debatable. The foremost and most (mean serum urea of 88 mg%) in all patients. A primary
repair and simultaneous gastrostomy (omitted in one) were
enthusiastic endoscopic surgeons promote this procedure and claim that performed for all cases. There were 5 operative deaths.
their results and complication rates are at least comparable with open Fifteen postoperative complications occurred in 10 patients,
operative procedures. The technique may be used if equipment and including septicaemia in 3, wound infection in 3, anastomotic
leak in 1, and tracheal mucous plug in 1. Statistical analysis
expertise are available. indicated no difference between survivors and nonsurvivors
Postoperative Complications on the basis of age, weight, degree of uraemia, or presence of
pneumonia. One of the 6 survivors (now 5 years after surgery)
An anastomotic leak may have dire consequences if a major intrapleural required bouginage after 26 months and has remained
asymptomatic; the other 5 are well and without symptoms 3 to
disruption occurs. Anastomotic leaks should be uncommon and, if extra-
11 months postoperative.
pleural and contained, can be treated expectantly by maintaining parenter-
Outcome/ High mortality and morbidity for this neonatal condition.
al nutrition and drainage until the leak seals and heals. A major intrapleural
effect
disruption can be life threatening and warrants early re-exploration. If
total disruption occurs, the oesophagus may have to be abandoned and the Historical The most significant determinants of survival are the
upper pouch exteriorised as a cervical oesophagostomy. significance/ effectiveness of pre- and postoperative managements of
comments patients.
A recurrent tracheo-oesophageal fistula requires operative interven-
tion, closure, and tissue interposition, although endoscopic injection of
glue has been described.
Another complication is stridor and cyanotic episodes related to
tracheomalacia and a collapsing upper airway. The combination of
gastro-oesophageal reflux and tracheomalacia may be particularly sinis-