• Paediatric oesophageal atresia and TOF
    • Oesophageal atresia (OA) and TOF
      • 92% with OA have TOF
      • 4% with TOF do not have OA
      • Sonic hedgehog implicated
      • 50% have associated abnormalities, commonly heart disease
      • VACTERL (vertebral, anal, cardiac, tracheo-oesophageal, renal, limb) is a recognised association
      • Rarely associated with DiGeorge or Pierre-Robin
    • Diagnosis
      • If diagnosed antenatally, deliver close to a specialist centre
      • Prevents inadvertent feeding and aspiration
      • Postnatal
        • Suspect if difficulty in clearing saliva
        • Choking and coughing
        • Respiratory distress following feeding
        • Failure to pass ngt
    • Pre-op preparation
      • IV fluids to prevent dehydration
      • Look for associated comorbidities - echo
      • Prophylactic antibiotics
      • Upper oesophageal pouch should be aspirated
      • Surgery within 24hrs in otherwise well infants
      • Prognosis depends on birth weight (<1500g worse) and presence of a cardiac anomaly
    • Complications
      • Early
        • Tracheomalacia can occur
        • Susceptibility to chest infection
        • Anastomotic leak (10-20%)
          • Most small and heal spontaneously
          • Sometimes need pleural drainage
        • Oesophageal stricture
        • Pneumothorax
        • Reflux
          • Treated with PPI and prokinetics
      • Late
        • Respiratory complications
        • Anastomotic stricture
        • Recurrent TOF
        • Oesophageal stricture
    • Anaesthetic management
      • Upper pouch aspirated
      • Induce in operating theatre
      • Gas induction
      • 3.0-3.5 ETT inserted
      • Avoid BMV
      • Storz bronchoscope used then to confirm the position of the TOF
      • T-piece attached to the bronchoscope and the pt allowed to breathe
      • Following Bronchoscopy examination, the ETT is inserted to occlude the TOF; may need a flexible bronchoscope to aid positioning
      • Occasionally OLV may be needed if the TOF is distal until the TOF is ligated
      • Once the ETT is positioned, muscle relaxation is used
      • Keep airway pressures low until the fistula is divided
      • Once stable consider IABP and CVC
      • Positioning is usually lateral (right side up)
      • Azygous is divided intra-op after occlusion test
      • Integrity of the TOF repair is tested by applying airway pressure and looking for bubble leak from the suture line
      • ITU post op
    • CEACCP
      Link:ceaccp.oxfordjournals.org/content/7/1/15.full.pdf?sid=f66a452e-8900-487f-aeee-abd41725275e