a case presentation

1. Dr. Hafiz Mahmood Ahmad
PGR Paeds Surgery

2. Biodata
 Pt name :XYZ
 Father Name :XYZ
 Age 5 hours
 Sex: Male

3. Presenting Complaint
 Complaint of excessive salivation
 Respiratory Distress
 Cyanosis during 1st feed and regurgitation post feeding

4. Physical Examination
 Patient was a cyanosed neonate who presented to us
with
 Cyanosis
 Excessive Frothing from mouth
 Respiratory Rate :60/min

5. Management
 Oxygen was attached to infant.
 Patient was tried to pass NG but it couldn’t be passed
 Barium injected in NG and X-ray taken

6. Pre-op X-ray

7. Pre-op X-rays

8. Diagnosis
 Esophageal Atresia without distal communication was
made

9. Gross Classification
 A : Esophageal Atresia without tracheoesophageal
Fistula5%.
 B: Atresia with proximal Tracheoesophageal Fistula 6%
 C: Esophageal Atresia with Distal Tracheoesophageal
Fistula….Most common variant 84%

10. Gross Classification
 D: Atresia with double fistula( Proximal and distal)1%
 E:Tracheoesophageal fistula without atresia 4%
 F: Esophageal Stenosis

11. Gross Classification

12. Associated Anomalies
 Cardiovascular 24%
 Genitourinary 21%
 Gastrointestinal 21%
 Musculoskeletal 14%
 Central Nervous System 7%
 VACTREL 20%

13. VACTERL
 Vertebral 17%
 Anorectal 12%
 Cardiac 20%
 Tracheoesophageal
 Renal 16%
 Limb 5%.
 CHARGE association: ( Coloboma, Heart defect, Atresia
choanae, developmental Retardation, Genital hypoplasia,
Ear deformity).
 Schisis association: (omphalocele, neural tube defect,
cleft lip & palate and genital hypoplasia).

14. Pre-operative Treatment
 Measures to prevent aspiration
 Suction
 Upright sitting Position
 Antibiotic Coverage
 Physiotherapy
 I/V fluids
 Vitamin K

15. Treatment
 Waterston Group A: immediate operative repair
 Waterston Group B: delayed repair
 Waterston Group C: Staged repair .

16. Waterson Classification
Group Survival Waterson Classification
A 100 Birth weight >2500g and otherwise healthy
B 85 Birth weight 2000-2500 g and well or higher
rate with moderate associated
anomalies(noncardiac anomalies plus patent
ductus arteriosus,ventricular septal defect,
and atrial septal defect)
C 65 Birth weight < 2000 g or higher with severe
associated cardiac anomalies

17. Spitz Classification
Class Description Risk Survival
Class I No major cardiac anomaly, BW
>2000g
low 100%
Class II No major Cardiac anomaly, BW<
2000g
Moderate 81%
Class III Major Cardiac Anomaly BW>2000 g Relatively High 72%
Class IV Major Cardiac Anomaly BW <2000g High 27%

18. Surgery (Waterson Class A,B. Spitz
Class I,II)
 Open Thoracotomy
 Transpleural
 Extrapleural
 Thoracoscopic
 Division of Fistula and primary anastomosis

19. Surgery (Waterson Class C. Spitz
Class III,IV
 Esophagostomy
 Gastrostomy

20. Positioning the Child

21. Positioning the Child

22. Procedure
 Incision made below scapula
 Subcutaneous Tissue and muscles are divided
 Thorax entered between 4th or 5th intercostal space.
 Avoid incising pleura
 Identify azygos vein

23. Procedure
 Identify proximal pouch, distal pouch , trachea and
vagus nerve
 Tie the fistula if required
 Pass NG into the distal end and then anastomose over
it
 Put a tube in retropleural space.

24. Site of Incision Marked

25. Incision Made

26. Subcutaneous Tissue And Muscles
Opened

27. Intercostal Muscles Divided Pleura
visible

28. Pleura Retracted

29. Rib Retractor applied

30. Forceps Holding Proximal
Esophagus

31. Azygos vein visible

32. NG coming out from Proximal
Pouch

33. Distal Esophagus and Azygos Vein
visible

34. Esophagus Anastomosed and Extra
pleural Drain Placed

35. Thoracoscopic Approach
 2.5mm-5mm Transpleural trocar
 Advanatges:
 Avoids scoliosis
 Winged scapula
 Chronic pain
 Shoulder weakness
 Chest wall asymmetry
 Maldevelopment

36. Disadvantages
 Technically demanding
 Instrument dependant
 Lack of articulation

37. Post-op Ba Swallow

38. Post-op Course
 Smooth
 Patient was Kept NPO for 3 days
 NG feed was started on 4th post-op Day
 Ba swallow was done on 7th Post-op day which showed
no leak
 Chest drain removed on 7th post-op day

39. Post-op Course
 Patient was made oral free and oxygen free on 10th post
op day
 Patient discharged on 10th post-op Day

40. Post-op Complications
 Anastomotic Leak
 Rate 13-16%.
 Managed with adequate drainage & nutritional
support, 95% close spontaneously. • Major disruption
occur 3% to 5% of postoperative leak, typically
recognized early • Factors for leak: Poor surgical
technique Ischemia of esophageal ends Use of
myotomy Excessive tension at anastomotic site •
Reoperation: control sepsis with drainage and repair
by pleural or pericardial patch, with or with out
intercostals muscle flap buttress

41. Post-op Complications
Esophageal Stricture
Spitz & hitchcock defined stricture as the presence of
symptoms: dysphagia & recurrent respiratory probles from
aspiration or forgine bodu obstruction & narrowing noted
on endoscopy. • Stricture require dilatation occur upto 80%
of patient. • Factors responsible: Poor anastomotic
technique: excessive tension, two-layered anastomosis, silk
suture, Ischeamia at ends, GER, Anastomotic leak. •
Traditionally treated by dilatation: antegrade or retrograde
bouginage using Savory dilator, Gruntzig balloon dilator •
53% respond to single dilatation in the first month.

42. Post-op Complication
 Recurrent Tracheoesophageal Fistula 3-14%.
 Occur upto 3% to 14 %. • Attributed to anastomotic leak
with local inflammation & erosion through the previous
site of TEF. • Can be minimized by using: Pleural flap;
Vasculrized pericardial flap; Azygos vein flap. • 50% of
recurrent fistula missed in routine contrast study,
esophagography in the prone position under video
fluoroscopy; Bronchoscopy with cannulation of fistula is
gold standard. • Traditionally repaired by thoracotomy &
interposition; Fibrin glue, Endoscopic eradication of TEF
by chemicals or diathermy.

43. Late Complications
 Gastroesophageal Reflux Disease
 Tracheomalacia