ENDOSCOPIC ASPECTS OF POST-SURGICAL MANAGEMENT OF CONGENITAL ESOPHAGEAL ATRESIA AND TRACHEOESOPHAGEAL FISTULA

Abstract

SUMMARY 1. One hundred and forty-six infants with congenital esophageal atresia, tracheoesophageal fistula, or both, were observed on the endoscopic service of The Children's Memorial Hospital between 1947 and 1964. One hundred and twenty-three, or 84.2 per cent, were Type III, 12 were Type IV (“H”), and 10 were Type I with both segments blind. One had an esophageal atresia with both upper and lower segments entering the trachea. 2. Laryngeal problems included congenital anomalies, paralyses, and postoperative edema. Twelve infants had laryngeal paralyses: 6 bilateral, 2 right and 4 left cord paralysis. Laryngeal paralysis invariably increased the respiratory and deglutition difficulties of the postoperative period. 3. Tracheal problems included congenital tracheomalacia and stenoses. The most serious post-surgical complications occur at the site of the fistula leading to the lower esophageal segment. Obstruction due to inversion of the edges, granulomas, and too tight a closure were present in 14 infants. Diverticula, consisting of a residual piece of the lower esophageal segment not completely removed, were found in 11 infants. There were 12 recurrent tracheoesophageal fistulas. 4. Bronchial secretions, chemical bronchitis, and atelectasis constitute the principal bronchopulmonary complications. These appear to increase in severity with delay in closure of the tracheoesophageal fistula. The alteration of respiratory physiology associated with resection of portions of several ribs may play a part in increasing the severity of the bronchopulmonary problems. 5. Esophageal strictures were present in 103 of the 146 infants; 93 at the site of a direct end-to-end anastomosis, 8 at the esophagogastric, -colic, or -jejunal site, and 2 at the cologastric site. Early recognition and treatment of the narrowing lumen in the immediate postoperative period is stressed. Swallowing function is usually normal until semisolids are added to the infant diet, at which time the anastomosis stricture is already firm and tough. Techniques of bougienage in the early postoperative period and management of the late fibrous strictures are outlined. 6. Reanastomosis was necessary in 6 infants because of inability to reestablish a lumen endoscopically. All were dilated early in the postoperative period following the revision and have attained a normal swallowing function.