Introduction• Tracheo-oesophageal fistula and Oesophagal Atresia are the malformation of digestive system, In which oesophagus does not develop properly. The oesophagus is a tube that normally carries food from the mouth to stomach.
DEFINITIONOesophagal AtresiaOesophagal Atresia is the failure ofoesophagus to form a continuouspassage from the pharynx to thestomach.Tracheo-oesophageal fistulaTracheo-oesophageal fistula is anabnormal connection between thetrachea and the oesophagus.
EPIDEMIOLOGY• Tracheo-oesophageal fistula occurs in 1 in 3500 births, with slight male dominance. Oesophagus atresia with or without Tracheo-oesophageal fistula is common in prematurity, with 34% of cases weighing less than 2500 grams.• Approximately 50% of neonates with oesophagus atresia or Tracheo-oesophageal fistula have other anomalies also. Usually cardiac anomalies are seen in 14.7 – 28 % cases of TEF.
ETIOLOGY• The cause of Tracheo- oesophageal fistula and Oesophagal Atresia is still unknown.
PATHOPHYSIOLOGY• The upper part of oesophagus is developed from the retropharyngeal segment and lower part from the pregastric segment of foregut. At about 4 weeks of gestation, a laryngo-tracheal groove is formed which divides the foregut into two longitudinal tubes, which further develop into the respiratory tract and the digestive tract. Defective separation due to deviated or incomplete septum or incomplete fusion of tracheal fold results in malformation of trachea and oesophagus.
TYPES OF TEFType A:In this type, there is Oesophagal Atresiaand proximal and distal segments ofoesophagus are blind. There is nocommunication between trachea andoesophagus. This type is present in 3-7% of cases.
Types B:In this type, Oesophagal Atresia ispresent and the blind proximal segmentof oesophagus connects with trachea bya fistula. The distal end of oesophagus isblind. This type is present in 0.8 %cases.
Type C:In this type, Oesophagal Atresia ispresent. The proximal end of oesophagusis a blind pouch and distal segment ofoesophagus is connected by fistula totrachea. This is the commonest type,present in about 87 % cases.
Type D:It is the rarest type that occurs in 0.7 %cases. In this type, both upper andlower segments of oesophaguscommunicate with trachea.
Type E:In this type, oesophagus and tracheaare normal and completely formed butare connected by a fistula. This type isalso known as ‘H’ type and is present in4.2% cases.
CLINICAL MANIFESTATIONSThe disorder is usually detected soon after birth when feeding is attempted on the basis of following :1. Violent response occurs on feeding Infant coughs and chokes Fluid returns through nose and mouth. Cyanosis occur The infant struggles
Cont.… coming out of nose and constant2. Excessive secretions drooling of saliva.3. Saliva is frothy.4. Abdominal distension occurs in presence of type III, IV and V fistula.5. Intermittent unexplained cyanosis and laryngospasm, caused by aspiration of accumulated saliva in blind oesophageal pouch.6. Pneumonia may occur due to overflow of milk and saliva from oesophagus through fistula into the lungs.
DIAGNOSTIC EVLUATIONThe EA/TEF may be suspected prenatally if Ultrasound examination reveals polyhydramnios, absence of a fluid-filled stomach, a small abdomen, lower-than- expected fetal weight, and a distended esophageal pouch. Fetal MRI may be used to confirm the presence of EA/TEF
TEF may be detected postnatally by X-ray taken with radiopaque catheter placed in esophagus to check for obstruction; standard chest X- ray shows a dilated air-filled upper esophageal pouch and can demonstrate pneumonia. Inability to pass a NG tube into stomach because it meets resistance:; Bronchoscopy visualizes fistula between trachea and esophagus; Abdominal ultrasound and echocardiogram to check for cardiac abnormalities.
TREATMENT• The management of trachea- oesophageal fistula is mainly surgical. Surgical intervention depends on the distance between proximal and distal pouch of oesophagus, type of defect, condition of neonate and his weight.
If distance between upper and lower oesophageal segments is less than 2.5 cm and if the condition of infant is good, primary repair is done by division and ligation of the fistula along with end-to-end anastomosis of proximal and distal segments of oesophagus.
Staging Surgery: When the distance between the two oesophageal segments is large and condition of the infant is poor, a two- stage procedure may be required: Initially in the first stage, the trachea-oesophageal fistula is ligated and gastrostomy done to reduce the risk of reflux and to provide feeding. In the second stage, both proximal and distal oesophageal segments are anastomosed. If the gap is too large, a segment of colon is used for reconstruction of the oesophagus. This is done at about 18-24 months.
NURSING DIAGNOSISPre-OperativeRisk for aspiration related to structural abnormality.Risk for deficient fluid volume related to inability to take oral feeds.Impaired breathing related to frequent laryngospasm and excessive secretions in the trachea.
Post-OperativeIneffective airway clearance related to disease process.Impaired nutrition related to surgery.Altered comfort related to surgical process.
NURSING INTERVENTION A nasogastric tube is put in the upper oesophageal segment and is aspirated frequently, to prevent collection and aspiration of secretion into the trachea. Intravenous fluids are administered to maintain the hydration status of infant. Place the infant in semi-upright position and administer oxygen if cyanosis is present.
A cervical oesophagostomy is made to drain out secretions from blind oesophageal pouch and administer oxygen to infant.Feed the infant orally or by gastrostomy.Position the baby comfortably in semi-fowler’s position and administer analgesics.