RT Book, Section A1 Gomella, Tricia Lacy A1 Eyal, Fabien G. A1 Bany-Mohammed, Fayez SR Print(0) ID 1168358355 T1 Surgical Diseases of the Newborn: Alimentary Tract Obstruction T2 Gomella's Neonatology: Management, Procedures, On-Call Problems, Diseases, and Drugs, 8e YR 2020 FD 2020 PB McGraw-Hill Education PP New York, NY SN 9781259644818 LK accesspediatrics.mhmedical.com/content.aspx?aid=1168358355 RD 2024/03/29 AB DefinitionsType C esophageal atresia is the most common type, accounting for up to 85% of cases. It consists of proximal esophageal atresia with distal tracheoesophageal fistula.Type A esophageal atresia is the second most common type, accounting for about 10% of cases. This is a pure esophageal atresia without fistula.Other forms of esophageal atresia are less common.PathophysiologyEmbryologic failure of migration and separation of longitudinal tracheoesophageal fold. Normally, folding results in larynx and trachea anteriorly and esophagus posteriorly.Clinical presentationPolyhydramnios due to proximal esophageal obstruction; fetus cannot swallow amniotic fluid.Neonates display feeding intolerance, excess salivation, and respiratory distress from aspiration of feeds.In type C, gastric distention may cause respiratory compromise, and gastric reflux into airway may cause chemical pneumonitis and pneumonia.DiagnosisPrenatal ultrasound may show small or absent gastric bubble if pure esophageal atresia.Inability to pass an orogastric tube. The chest radiograph shows an orogastric tube in the proximal esophagus. Air below the diaphragm confirms presence of a distal fistula.VATER/VACTERL association (vertebral defects, anal atresia, tracheoesophageal fistula, and radial or renal dysplasia/vertebral defects, anal atresia, cardiac malformations, tracheoesophageal fistula, renal dysplasia, and limb abnormalities) workup necessary.ManagementPreoperative optimization is focused on minimizing risk of aspiration and gastric distention.Place Replogle tube in proximal esophageal pouch to evacuate oral secretions.Keep baby in upright position (45 degrees) to lessen risk of reflux and aspiration.If possible, avoid positive-pressure ventilation.If mechanical ventilation is necessary, low tidal volumes and inspiratory pressures are preferable. In select babies, high-frequency oscillatory ventilation may provide gentler ventilation.Broad-spectrum antibiotics should be administered.VATER/VACTERL association workup should be performed. This includes an echocardiogram prior to surgery to assess for cardiac and aortic arch anomalies.Goals of operative therapy are to ligate fistula and establish esophageal continuity if possible.Repair via open or thoracoscopic techniques.If long-gap esophageal atresia (>3 vertebral bodies) is present, one may not be able to perform immediate esophageal anastomosis and a gastrostomy tube should be placed.If defect cannot be bridged with native esophagus, use of gastric or intestinal conduits may be necessary.