Oesophagal atresia with proximal tracheo-oesophageal fistula

Abstract

Oesophageal atresia with proximal tracheo-oesophageal fistula is an uncommon sub-group comprising 2% of infants with oesophageal atresia. Of those infants with oesophageal atresia presenting with a gasless abdomen on initial abdominal X-ray, 23.5% had oesophageal atresia with proximal tracheo-oesphageal fistula and these infants thus warrant a careful study of the upper oesophagus. The fistula may be difficult to demonstrate and the early appearance of contrast material in the trachea may be misinterpreted as due to aspiration or “spillover”. All cases were treated differently but a plan of management evolved whose main features are the accurate demonstration of anatomy by pre-operative contrast radiology, intra-operative assessment of the distal oesophagus, and, where possible, primary anastomosis. We recommend that a gastrotomy be routinely performed at the initial operation, at which time the length of the distal oesophagus is assessed by the passage of a sound. If sufficient length is present, then an immediate primary anastomosis should be performed with thoracic ligation of the fistula if exposure is adequate. If at initial assessment the length of the gap is judged to be too long, the fistula should be divided via the appropriate route, cervical or thoracic, and alimentary continuity can be affected at a later time by delayed anastomosis or oesophageal replacement. The major morbidity and mortality (40%) occurred in the group with a long gap between oesophageal segments.