esophageal atresia-- epitome of modern surgery
TRANSCRIPT
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“YOUR KIND ATTENTION PLEASE”
L/O/G/O
Esophageal Atresia- Epitome
Of Modern Surgery
Esophageal Atresia- Epitome
Of Modern Surgery
M M M C
Dr.B.SELVARAJ
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Esophageal AtresiaEsophageal AtresiaEsophageal AtresiaEsophageal Atresia---- Epitome of Modern Epitome of Modern Epitome of Modern Epitome of Modern surgerysurgerysurgerysurgery
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Dr.B.SELVARAJ MS;Mch;FICS;
• NEONATAL & PEDIATRIC SURGEON
• ASSOCIATE PROFESSOR
• MELAKA MANIPAL MEDICAL COLLEGE
• MELAKA- 75150
• MALAYSIA
Esophageal Atresia- Epitome of
Modern surgery
Recognise various conditions
Make early& accurate diagnosis
Prompt Life Saving treatment
Immediate surgical referral 4
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Objectives
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A NeonateA NeonateA NeonateA Neonate’s request to Surgeons request to Surgeons request to Surgeons request to Surgeon
“Please exercise the greatest gentleness with my
diminutive tissues and try to correct the deformity at first operation; give me blood and proper amount of fluid and electrolytes; add
plenty of oxygen to anesthesia, and I will show you that I can tolerate a terrific amount of
surgery. You will be surprised at the speed of my recovery, and I shall be grateful to you”
--Dr. Willis Potts
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Neonatal Respiratory DistressNeonatal Respiratory DistressNeonatal Respiratory DistressNeonatal Respiratory Distress— Surgical CausesSurgical CausesSurgical CausesSurgical Causes
Causes
B
E
C
D
A Esophageal
Atresia
Diaphragmatic Hernia
Congenital
Lobar
Emphysema
Posterior
Choanal
Atresia
Pierre
Robin
Sequence
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Embryology Of Esophageal Atresia
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Esophageal AtresiaEsophageal AtresiaEsophageal AtresiaEsophageal Atresia
EA
Challenging&
Fascinating Problem
Team Work
Approach
Post op Ventilator
Care
VACTERL
Anomaly
Incidence 1 in 3500
livebirths
Epitome of Modern Surgery
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Esophageal AtresiaEsophageal AtresiaEsophageal AtresiaEsophageal Atresia TypesTypesTypesTypes
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Esophageal AtresiaEsophageal AtresiaEsophageal AtresiaEsophageal Atresia---- Associated AnomaliesAssociated AnomaliesAssociated AnomaliesAssociated Anomalies
Vertebral
Anorectal
Cardiac- commonest
Tracheo
Esophageal Fistula
Renal
Limb
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Esophageal AtresiaEsophageal AtresiaEsophageal AtresiaEsophageal Atresia Clinical FeaturesClinical FeaturesClinical FeaturesClinical Features
Clinical
Features
Drooling of saliva
Maternal Polyhydramnios
Inability to pass NGT
into Stomach
In atresia with TEF���� Aspiration
of gastric contents
����Chemical Pneumonitis
Feeding ���� Cough,
choking &
Cyanosis
In pure atresia����
Gasless Abdomen
���� Scaphoid Abd
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Esophageal AtresiaEsophageal AtresiaEsophageal AtresiaEsophageal Atresia----Drooling of salivaDrooling of salivaDrooling of salivaDrooling of saliva
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Physiological Effect of Distal TEF
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• 1. Hyaline membrane disease may necessitate higher ventilator pressures, which encourage air to pass through the distal fistula.
• 2. A distended abdomen elevates and "splints" the diaphragm.
• 3. Gastric distension may result in gastric rupture and pneumoperitoneum.
• 4. Passage of air through a distal tracheoesophageal fistula diminishes the effective tidal volume.
(B) 1. Aspiration of gastric juices leads to soiling of the lungs and pneumonia
• 2. Gastroesophageal reflux
• 3. Direction of gastric fluid proximally through distal fistula.
• 4. Overflow of secretions or inadvertent feeding may contribute to aspiration and contamination of the airway.
Esophageal Atresia
Imaging Studies
AXR����Gasless in pure Atresia
CXR����Atelectasis&Pneumonia Antenatal MRI of Fetus
USG Abd����to R/O Urogenital anomaly
Echo to R/O cardiac
anomaly&Rt Aortic
arch
AXR &CXR����Curledup NGT in blind upper pouch
Imaging
Studies S
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Esophageal Atresia
Antenatal MRI
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Esophageal Atresia
Clinical Diagnosis
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• . (A) Diagnosis of
esophageal atresia is
confirmed when a 10-
gauge (French)
catheter cannot be
passed beyond 10 cm
from the gums. (B) A
smaller-caliber tube is
not used because it
may curl up in the
upper esophageal
segment, giving a false
impression of
esophageal atresia.
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Esophageal Atresia
CXR
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Esophageal Atresia With
TE Fistula- Bronchoscopy
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TE Fistula
Rt Bronchus
Esophageal Atresia
Pre op Management
Pre op Proximal pouch
Decompression
NPO
If for staged repair����
Do Gastrostomy
Head up position
In pure atresia����
Stretch proximal pouch
daily
I V Antibiotics S
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Esophageal Atresia
Pre op Management
Pre op Proximal pouch
Decompression
NPO
If for staged repair����
Do Gastrostomy
Head up position
In pure atresia����
Stretch proximal pouch
daily
I V Antibiotics S
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Esophageal Atresia
Waterston’s Risk Categories
●Birth weight >2.5 Kgs
●No Anomalies
●No Pneumonitis
●Primary Repair����100%survival
●Birth weight 1.8 to 2.5 Kgs
●Non life threatening anomalies
●Mild Pneumonitis
●Delayed Primary Repair����80%survival
●Birth weight < 1.8 Kgs
●Life threatening anomalies
●Severe Pneumonitis
●Staged Repair����40%survival
Risk
Categories
Category
A
Category B
Category C
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Esophageal Atresia
Operative Management
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3
Lanman’s Rt posterolateral retropleural
thoracotomy
Ligation & division of Azygos vein
Disconnect TEF; Repair tracheal defect
4 Liberally mobilise the upper pouch for tension
free anastomosis
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Esophageal Atresia
Operative Management
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In wide gap����Livaditi’s circular myotomies
Never mobilise distal pouch much
Extra pleural drain
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Transanastomotic feeding tube for early gavage
feeding
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Esophageal Atresia
Operative Management
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Normal Mediastinum- Rt side
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Esophageal Atresia
Immediate Primary Repair
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Esophageal Atresia
Immediate Primary Repair
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Esophageal Atresia
VATS Repair
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Esophageal atresia
Post op Management in NICU
Gastrograffin swallow on 7th POD; If no leak����oral
Feeding & remove chest drain
Feeding through transanastomotic feeding
Tube from 2nd POD
Regular chest Physio&Nasopharyngeal
suction
Otherwise exubate in 1st POD
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Electively paralyse&mechanically ventilate
For 3 to 5 days in tension anastomosis
Esophageal Atresia
Complications
LATE
Tracheomalacia
GE Reflux
EARLY
Anastomotic Leakage
Anastomotic Stricture
Recurrent TEF Esophageal Dysmotility
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Clinical
Features
Operation
Preop
Trt
•VACTERL
•Maternal Poly Hydramnios
•Drooling of saliva in baby
•Inability to pass NGT into stomach
•NPO
•Headup position
•IV Antibiotics
•Upper pouch suction
Complica
tions
Associ
Anomaly EA&
TEF
Esophageal Atresia
TE Fistula���� Recap
Imaging
CXR •Curledup NGT in blind
upper pouch
•Echo to R/O cardiac
Anomaly
• USG Abd to R/O
Urogenital anomaly
•Immediate primary
Repair
•Delayed primary
Repair
•Staged Repair
•Anastomotic leak
•Anastomotic stricture
•Tracheomalacia
•GE Reflux
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