Esophageal atresia primary repair

Primary esophageal atresia repair

The initial surgical management of babies who are born with the interrupted esophagus (the majority of them, EA, along with the distal tracheoesophagic fistula, TEF) is primary esophageal atresia (EA) repair. It aims at re-forming esophagus continuity and decoupling of airway and esophagus in one procedure.

What is Esophageal Atresia?

Esophageal atresia is a birth defect in which the upper and lower segments of the esophagus are not joined together. The lower part attaches to the trachea (TEF) in an abnormal manner in many babies and this leads to difficulty during feeding and respiratory issues.

What is primary repair?

A primary repair means:

• The two terminals of the esophagus are close to each other such that they can be combined within a single operation.
• There are no temporary esophagostomy or delayed reconstruction to be made.
• This can be done in the majority of full-term infants having a short esophageal distance between segments.

Signs pointing towards Primary EA Repair

Primary repair is thought to be applied when:

• Gap of the esophagus is short or medium.
• Baby is fit to undergo surgery.
• None of the associated anomalies are severe and potentially life-threatening and cannot be repaired on the spot.

Esophageal Atresia Repair Types

Primary Esophageal Repair (Most Common)

• Applied in cases of endoscopic distance between the ends of the esophagus that are short.
• Single-stage surgery
• Includes fistula ligation with end to end esophageal anastomosis.

Staged / Delayed Repair

Used when:

• There is a long-gap EA
• Infant is extremely immature or weak.

Options include:

• Late primary anastomosis.
• Gastric pull-up
• Interposition Colonic or jejunal.

Surgical Approaches

Open Repair

• Right posterolateral thoracotomy.
• Proven and popular.

Thoracoscopic Repair 

• Small keyhole incisions
• Reduced postoperative pain and scarring.
• Needs high-level operations of neonatal surgery.

Esophageal atresia surgery repair 

Esophageal atresia repair (EA) is a side-effect surgery performed on infants to rejoin the esophagus, and (when it exists) to close an aberrant connection between the esophagus and the trachea (tracheoesophageal fistula -TEF). It is commonly done in the first 24-72 hours of the life span.

Preoperative Preparation

• Nil by Mouth - with constant suction of the upper pouch.
• IV fluids & antibiotics
• To verify diagnosis, Chest X-ray /contrast study.
• Echocardiography to identify related heart problems.
• Respondent breathing and infection control.

Surgical Approaches

• Open repair 
• Thoracoscopic repair 

Process EA Repair:

Anaesthesia & Positioning

• General anaesthesia including endotracheal intubation.
• Infant lying on the right hand side (left lateral position).

Chest Access

• Incision between ribs (open) to the right chest.
• Or ports fitted where repairing thoracoscopically.

Detection of Esophageal Segments

• Higher blind-ending esophageal pouch found.
• Dissection of the lower esophageal segment which is normally adherent to the trachea.

Closure of Tracheoesophageal Fistula (Present) 

• Fistula is cautiously secluded.
• Sutured and divided to separate air and esophagus.

Mobilization of Esophagus

• Esophagus ends mobilized up and down.
• It ensures a tension‐free anastomosis.

Esophageal Anastomosis 

• The ends are laid side by side and sutured (end-to-end anastomosis). 
• Absorbable fine sutures.
• Trans-anastomotic feeding tube can be inserted.

Chest Drain Placement

• Intercostal drain placed to sense air or fluid leak.

Closure

• Incision on the chest in layers.
• Baby transferred to NICU

Duration of Surgery

• 2-4 hours, according to the anatomy and complexity.

Postoperative Care

• NICU monitoring
• Ventilations in case of need.
• IV antibiotics and analgesics.
• Being fed through tube till healed.

Pediatric esophageal atresia primary repair

The definitive surgical intervention conducted to reconnect the esophagus and close any related tracheoesophageal fistula (TEF) performed during the neonatal age is primary repair of pediatric esophageal atresia (EA). It is the method of choice in cases of a short esophageal gap and infant is in a stable clinical condition.

Principles of Primary Repair

Primary repair is appropriate when:

• Either short or medium length interval between the esophageal parts.
• Surgery is possible with regard to birth weight and general condition.
• None of the severe cardiopulmonary instability.
• Preliminary in EA of distal TEF (Type C) in the majority of cases.

Best hospital for esophageal atresia repair India

• Artemis Hospital, Gurgaon
• Medanta-The Medicity, Gurgaon
• Fortis Memorial Research Institute, Gurgaon
• Max Hospital, Saket

Conclusion

Esophageal atresia repair is a clear-cut life-saving surgery that restores the continuity of the esophageal tract and removes communication between the two airways, which is carried out most commonly in the neonatal years. When properly selected and performed on infants whose esophageal gap is short it has great survival and functional results. The development of neonatal anaesthesia and intensive care, as well as the use of minimum invasive techniques, has brought about an enormous decrease in morbidity and an increase in the quality of life, long-term feeding, and growth. Though complications like anastomotic leak, stricture, or gastroesophageal reflux can be experienced, with prompt interventions and organized follow-up, all these problems tend to be resolved. Generally, when diagnosed early in infancy, carefully performed surgery, and thorough postoperative care, primary repair is the most preferable type of treatment of pediatric esophageal atresia, and a majority of the children can grow up gaining almost normal swallowing and development.

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FAQ

Is it possible to repair all babies with esophageal atresia by primary repair?

• No. Primary repair is appropriate in cases of esophageal gap being short. Infants having long-gap esophageal atresia or significant medical instability might require staged or delayed repair.

Are there any advantages of the thoracoscopic repair over the open procedure?

• Thoracoscopic repair involves smaller incisions and may result in faster recovery, however it requires specialized skills. Both procedures achieve the same results in the experienced hands. 

When is it possible to start feeding after surgery?

• The feeding is usually initiated when a contrast study performed on postoperative day 5-7 shows that there is no leak at the repair site.

Does my child experience problems with long-term feeding?

• Many children feed normally. There are those who might have difficulties with reflux or swallowing and this normally goes away as time passes and it gets treated.

What is the prognosis over the long run?

• In isolated cases, the survival rates are more than 90%. Most children develop and grow normally with periodic follow up.