MOHANNAD IBN HOMAID

Esophageal Atresia and Trachesophageal Fistulas

Background Information

Definition of esophageal Artesia

The problem and its magnitude

The added problem of a TEF

Basic science

Embryology

Pathophysiology of different types

Associated anomalies

Embryology

Pathophysiology

The problem of a blocked esophagus During Pregnancy In the neonatal Period

The problem of a Fistula If proximal vs distal

Associated anomalies VACTERL and CAHRGE

The different Types

Back to the Clinical world

During pregnancy mother could develop Polydramnios

In the neonatal Period Excessive Drooling and secretion RDS and chocking upon feeding Aspiration Pneumonia Failure to pass an NG tube

Other Anomalies

Work Up

Routine Lab Work CBC and U/E,VBG and ABG BUN and Serum Cr

Imaging Studies Prenatal Ultrasonography Chest Radiography Echocardiography Renal Ultrasound

Gap-o-Gram

Esophageal atresia with distal TEF

Esophageal Atresia without TEF

Gap-o-Gram

Why is it preformed

How is it preformed

Interpretation

Gap-o-Gram

Prognostic Classification

Waterston classification: Category A: weigh>2.5 Kg and are other wise well Category B : 1.8-2.5 Kg mild pneumonia and mild congnital

anomalies Category C: <1.8 Kg and severe pneumonia or severe congenital

anomaliesSpitz Classification

Group 1: > 1.5 no major cardiac disease Group 2: < 1.5 OR major cardiac disease Group 3: <1.5 AND major Cardiac Disease

Poenaru classification low risk and do not meet criteria in class II high risk and ventilator-dependent or who have life-threatening

anomalies, regardless of pulmonary status

Treatment

Medical TherapySurgical TherapyPreoperative CarePostoperative CareComplications Follow up

Medical Therapy

Intravenous Fluid with adequate Glucose

Prophylactic Broad Spectrum Antibiotics

Replogle tube insertion

Surgical Therapy

In isolated Artesia Lengthening and anastomosis procedures Esophageal substitution Delayed vs immediate vs staged The gap-o-Gram

If TEF is present Divide and ligate the fistula

Pre operative care

In addition to medical therapyBronchoscopy for:

Detection of an upper pouch fistula Localization of the distal fistula Assessment of post operative risk for tracheomalacia Assessment of specific vascular anomalies ( right

sided aortic arch)

Post operative Care

Intubated and transferred to the NICUAntibiotics are continued until chest drain is

no longer neededSuctioning the oral secretions

Complications

Early : Anastomotic leak Recurrent TEF Anastomotic Stricture

Late GERD Esophageal Dysmotiliy Tracheomalacia May appear early

Follow up

Appointment 1 -3 – 12 months after discharge Focusing on sings of respiratory distress and

dysphagia Radiologic assessment only if significant

history of: Choking, cyanosis Regurgitation and dysphagia Failure to the thrive Coughing and wheezing

Out come and prognosis

Spitz Grouping Group I - Mortality rate of 3% Group II - Mortality rate of 41% Group III - Mortality rate of 78%

Waterston categorization Category A - Mortality rate of 0% Category B - Mortality rate of 4% Category C - Mortality rate of 11%

Prenatal diagnosis.

Questions