pediatrics
Esophageal Atresia
Treatment of Esophageal Atresia
Surgical repair Preoperative managementaims to get the infant into optimal condition for surgery and prevent aspiration pneumonia, which makes surgical correction more hazardous. Oral feedings are withheld. Continuous suction with an NGT in the upper esophageal pouch prevents aspiration of swallowed saliva. The infant should be positioned prone with the head elevated 30 to 40°and with the right side down to facilitate gastric emptying and minimize the risk of aspirating gastric acid through the fistula. If definitive repair must be deferred because of extreme prematurity, aspiration pneumonia, or other congenital malformations, a gastrostomy tube is placed to decompress the stomach. Suction through the gastrostomy tube then reduces the risk that gastric contents will reflux through the fistula into the tracheobronchial tree. When the infant’s condition is stable, extrapleural surgical repair of the esophageal atresia and closure of the tracheoesophageal fistula can be done ( Treatment references ). If a fistula is noted, it needs to be ligated. In about 90% of cases, primary anastomosis of the esophagus can be done. In the remaining cases, where an extremely long gap exists, options are to do a gastric transposition procedure or a colonic interposition procedure. Some pediatric surgeons do a Foker procedure. In this procedure, traction sutures are placed in the ends of the esophageal pouches, brought out through the skin, and fixed with silastic buttons. Traction is gradually applied to the sutures, which stimulates elongation of the esophagus by as much as 1 to 2 mm/day. Once the ends of the esophagus have come together, or are in close proximity, a primary anastomosis is done ( Treatment references ). The most common acute complications are leakage at the anastomosis site and stricture formation. Feeding difficulties are common after successful surgical repair because of poor motility of the distal esophageal segment, which occurs in up to 85% of cases. This poor motility predisposes the infant to gastroesophageal reflux, which occurs in up to 50% of children, as well as dysphagia. It is recommended that all neonates with esophageal atresia be Acid-suppressive therapy ( 1.Dingemann C, Eaton S, Aksnes G, et al: ERNICA Consensus Conference on the Management of Patients with Esophageal Atresia and Tracheoesophageal Fistula: Diagnostics, Preoperative, Operative, and Postoperative Management.Eur J Pediatr Surg30(4):326-336, 2020. doi:10.1055/s-0039-1693116 2.Shieh HF, Jennings RW: Long-gap esophageal atresia.Semin Pediatr Surg26(2):72–77, 2017. doi: 10.1053/j.sempedsurg.2017.02.009 3.Krishnan U, Mousa H, Dall’Oglio L, et al: ESPGHAN-NASPGHAN guidelines for the evaluation and treatment of gastrointestinal and nutritional complications in children with esophageal atresia-tracheoesophageal fistula.J Pediatr Gastroenterol Nutr63(5):550–570, 2016. doi: 10.1097/MPG.0000000000001401 