ESOPHAGEAL ATRESIA WITH OR WITHOUT TRACHEO-ESOPHAGEAL FISTULA (TEF):
A. Diagnosis and preoperative management:
•Esophageal atresia may often be suspected prior to the first feeding by a history of
polyhydramnios or observation of copious oral secretions than require very
frequent suctioning.
•Attempt to pass feeding tube with radiopaque line into the stomach. If the tube
does not pass, leave in place and obtain chest x-ray and KUB.
•Do not obtain contrast study. This may result in aspiration.
•If the tube curls up in blind esophageal pouch and there is no air in bowel, assume
a diagnosis of esophageal atresia.
•If the tube curls up in blind esophageal pouch and there is air in the distal bowel,
assume a diagnosis of esophageal atresia with distal TEF.
•Keep infant in a position with the head up to prevent aspiration.
•Place Replogle tube on continuous suction to drain the blind pouch.
•Avoid bag and mask ventilation and nasal CPAP to prevent over-distension of the
stomach. If the baby needs respiratory assistance, intubate the infant.
•If the baby has severe lung disease and a distal TE fistula, ventilation of the lungs
may be extremely difficult because of the low resistance through the fistula into
the stomach and bowel. Notify surgery immediately as the baby may need
immediate closure of the fistula or an emergency gastrostomy with placement of a
distal esophageal balloon to facilitate adequate ventilation.
•Examine infant carefully for other anomalies associated with VATER or
CHARGE, including vertebral abnormalities, radial anomalies, choanal atresia,
imperforate anus, renal abnormalities, congenital heart disease, coloboma or
evidence of Down syndrome.
B. Post operative management:
•Regular maintenance IV fluids with extra boluses of normal saline as needed for
oliguria, hypotension, or poor perfusion. If infant requires >15 mL/kg of extra
fluid, consider starting dopamine at 5 mcg/kg/min to ↑ blood pressure and
perfusion to kidneys.
•If a chest tube is in place draining the area of the anastomosis, do not connect the
pleuravac to suction without consulting with the Attending Surgeon. The chest
tube is usually in place for 7-10d until x-ray studies show no leak at the
anastomosis.
•If the anastomosis is under tension, the surgeons will often want to keep the baby
on muscle relaxants postoperatively for a few days to a week, to prevent
disruption of the anastomosis.
•Do not extubate until the baby is extremely stable on very low ventilatory settings,
because positive pressure mask ventilation must be avoided to prevent
transmission of pressure to the esophagus, which may rupture the anastomotic
suture line.
•If the baby needs to be reintubated, the most experienced person should do this.
Faulty (i.e., esophageal) intubation could result in injury to the anastomosis.
•Leave the orogastric or nasogastric tube in place until x-ray studies show no leak at
the anastomotic site, and Pediatric Surgery agrees to removal of the tube. If the
tube accidentally comes out, do not reinsert tube without consulting with the
Attending Pediatric Surgeon, as you may damage the anastomosis.
•X-ray contrast study should be done at approximately 10 days postoperatively to
assess for leakage at the anastomotic site prior to starting oral feedings.
Gastrostomy tube feedings and NG tube feedings may be started earlier.
