Evaluation of factors influencing

morbidity and mortality in cases

of oesophageal atresia and/or
tracheo-oesophageal fistula
repair
Guide:-Dr A.K.Sharma(MS)
Prof. and HOD
Deptt. Of surgery
Co-guide- Dr A.Memon(Mch)
Asstt. Professor
(paediatric surgery unit)
Pt.J.N.M. MEDICAL COLLEGE & DR. B.R.A.M.HOSPITAL RAIPUR
Duration of work- JULY 2006 TO SEPTEMBER 2008
Name of candidate:- Dr Rajan Kumar
 INTRODUCTION

Tracheo – oesophageal fistula and/or

oesophageal atresia are common life
threatening malformations with an incidence of
approximately 1 in 3500 birth.
OA/TOF are among the most gratifying
paediatric surgical conditions to treat
In the distant past, nearly all infants born with
OA/TOF died
Despite the facts that there are several
common varieties of this anomaly,and the
underlying cause remain obscure,a careful
approach consisting of meticulous
perioperative care and attention to the
technical detail of the operation can result
in excellent prognosis in most cases.
There are several factors influencing the
outcome –
Birth weight
Sepsis
Pneumonia
Associated congenital anomaly
Others
Anatomic varieties
 Type C (most common)
Proximal oesophageal atresia
(esophagus continous with mouth ending in a
blind loop superior to sternal angle) with a distal
esophagus communicating from lower trachea
or carina.
Type A
Proximal and distal oesophageal bud.
A normal oesophagus with missing segment.
Type D
Proximal esophageal termination on
lower carina or trachea with distal oesophagus
arising from the carina.
 Type E (H) :- A variant of type D
If the two segments of oesophagus
communicate, this is termed as H – type
fistula due to its resemblance to letter H.
 Late presentation
 Prognosis good
 Most easy to treat, but difficult to diagnose.

Type B
Proximal esophageal termination
on lower trachea with distal esophageal
bud
 Etiology and pathology
presentations
The esophagus and trachea share a common
embryologic origin. They typically divide into separate
tubes by approximately the thirty sixth day of gestation.
Failure of this occurrence can results in spectrum of
anomalies.
Recent studies are suggestive of some molecular
mechanisms underlying this condition like deficiency in
sonic-hedgehog signaling pathway,
Expression of thyroid transcription factor1(TTF-1) and
fibroblast growth factor(FGF-10)
Some reports are suggestive of genetic basis but no
definitively results obtained
 Associated anomalies
Cardiovascular 29% (PDA , VSD, )
Anorectal 14%
Genitourinary 14%
Gastrointestinal 13%
Vertebral/skeletal 10%
Respiratory 6%
Genetic 4%
Other 11%
- VACTER : Vertebral anomalies, Anorectal malformation, Cardiac
anomalies, Tracheo- esophageal fistula, Renal agenesis, Radial
limb deformities.
- Anopthalmia – oesophageal genital syndrome
- Associated with fanconi anaemia
- Asso. With Trisomy 18 & 21
- Feingold syndrome (oculodigito esophagoduodenal syndrome)
 Clinical presentations

Frothing /excessive salivation from mouth

Respiratory distress
Cyanosis
Regurgitation of feed from mouth and nose
Abdominal distension
Tracheo – oesophageal fistula can be suspected
antenatally by USG of mother if polyhydramnios
is present and fetal gastric shadow absent.
 Diagnosis

If in a new born 10-12 F rigid catheter will not

pass per orally >10cm from the lower alveolar
ridge.
Plain radiograph of chest abdomen shows the tip
of catheter arrested in superior mediastinum
suggestive of oesophageal atresia where as ,
gas in gastrointestinal tract (stomach) S/o distal
trachaeo oesophageal fistula.
 AIMS AND OBJECTIVES
To evaluate the factors influencing morbidity and
mortality in cases of tracheo oesophageal fistula repair.
To know the preoperative causes responsible for poor
outcome of operation
To know the intraoperative events/findings which can
lead to poor outcome.
To know the important causes leading to morbidity and
mortality of cases of tracheo-oesophageal fistula in post-
operative period.
This study can help us to improve outcome in
oesophageal atresia and/or tracheo-oesophageal fistula
cases in future.
 MATERIAL AND METHODS
In our study we are including all cases of
oesophageal atresia and/or tracheo-
oesophageal fistula which were admitted in
Dr.B.R.A.M.Hospital,Raipur from july 2006 to
september 2008.
Our aim is to evaluate the various factors which
are responsible for morbidity and mortality of
TOF repair in our setup.
 Material required

All cases of tracheo – oesophageal fistula

admitted in paediatric surgery unit (gen.
surgery) Dr.B.R.A.M.Hospital,Raipur
during july 2006 to September 2008
After stabilizing the child, posted for
surgery
All the clinical data of child , intraoperative
findings , post operative result filled in
proforma and results will be evaluated.
 Preparation of patient

Patients should be prepared for surgery with stabilization

of vitals , infection and correction of sugar or electrolyte
abnormalities
Risk categorization
On basis of
Birth weight
Presence of pneumonia
Severity of associated congenital anomaly
Baby with low birthweight, pneumonia and associated
congenital anomaly are on very high risk .
 Operative approach
-Operation is performed under general endotracheal anaesthesia
with dependable vascular access.
-Position : left lateral position with right upper limb over the ear
-Incision – Curved incision approx 5 to 6cm long is made 1cm below
the scapula extending anteriorly towards nipple and to the midline in
between vertebrae and medial border of scapula
-The chest is opened through the 4th or 5th intercostals space by
dividing the intercostal muscle .
-Extra pleural approach
The following intraoperative findings are noted in proforma :
-Length of gap between proximal and distal oesophageal end
-If long gap – feeding gastrostomy/oesophagostomy and ligation of
fistula
-If short gap-end to end oesophago-oesophagostomy done with
ligation of fistula.
-Intra-operative ABG
-Intra operative SPO2 monitoring
-Intra operative complication (if any)
-Duration of surgery
-Immediate post op extubation done or not
 Complications

Early- sepsis, pneumonia, pleural

effusion, leakage and pneumothorax.

Late- recurrent fistula

formation,stricture,gastro-oesophageal
reflux,pneumonitis.
 Evaluation of case

The all findings recorded and filled in the

proforma.

Observations and results

All the observations will be recorded in
proforma and will be evaluated to find out
the factors influencing the outcome of
cases tracheo-oesophageal fistula repair.
 Discussion and conclusion
It will be done with observation and results
of present study and will be compared with
observations and results presented by
other workers in past.