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 : Kg mild pneumonia and mild congnital anomalies  Category C: <1.8 Kg and severe pneumonia or severe congenital anomalies Spitz 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 Therapy Surgical Therapy Preoperative Care Postoperative Care Complications 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 therapy Bronchoscopy 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 NICU Antibiotics are continued until chest drain is no longer needed Suctioning 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