Chapter 83 Tracheoesophageal Fistula and Esophageal Atresia Repair
INTRODUCTION
Esophageal atresia (EA) occurs in approximately 1 in every 3000 to 4500 live births and has no described sex predilection. EAs with and without tracheal fistulas have been classified into five types: (1) EA with distal tracheoesophageal fistula (TEF), (2) EA without TEF, (3) EA with proximal TEF, (4) EA with proximal and distal fistula, and (5) isolated TEF (H type). EA with a TEF between the distal esophagus and the trachea occurs in approximately 86% of cases.1–3 EA occurs with other significant congenital anomalies in 30% to 76% of children.2,4 Importantly, these associated congenital anomalies are the major source of morbidity and mortality associated with EA repair.1 The most common congenital anomaly is congenital heart disease, which is found in up to 20% of children.5 The acronym VACTERL groups associated defects into vertebral, anal, cardiac, tracheoesophageal, renal, and limb abnormalities.
Children present at various times depending on the type of anomaly. EA prevents the child from swallowing amniotic fluid, with a resultant polyhydramnios. Prenatal ultrasound can demonstrate polyhydramnios, absent or small stomach bubble, and an esophageal pouch.6,7 Those not detected prenatally become symptomatic soon after birth with drooling, choking, and the inability to tolerate feeding. In contrast, patients with an H-type TEF may not be diagnosed until later in life. The diagnosis should be suspected in a child with recurrent episodes of aspiration pneumonia, choking, and coughing with feedings.
OPERATIVE PROCEDURE
Posterolateral Thoracotomy
Right-sided Aortic Arch
• Consequence
• Repair
• Prevention
Long Thoracic Nerve Injury
• Consequence
• Repair
• Prevention
Thoracoscopic repair has been shown to be a safe alternative when performed by experienced surgeons.15 The thoracoscopic approach decreases the morbidity associated with the thoracotomy with no subsequent increase in morbidity and/or mortality.
Division of the Fistula
Missed Upper Pouch Fistula
• Consequence
Ligation of the Fistula Too Close or Too Far from the Trachea
• Consequence
• Repair
Dissection of the Proximal and Distal Esophageal Pouch
Esophageal/Tracheal Injury
• Prevention
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