Tracheoesophageal Fistula Classification Essay

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  • Treatment

    Treatment may require the coordinated efforts of a team of specialists. Pediatric surgeon, pediatrician, cardiologists, speech therapist, intensive care specialists and nurses, and other healthcare professionals may need to systematically and comprehensively plan a program for the child’s treatment and ongoing care. Treatment is best performed at tertiary referral hospitals that are well versed in treating these conditions.

    EA/TEF requires surgical correction. Before surgery, affected infants should receive a thorough clinical evaluation for any potentially associated congenital defects, especially heart defects. In most cases, surgery is performed shortly after birth. However, surgery may be delayed in infants with certain additional congenital defects, pneumonia or in cases of isolated atresia where the gap between the two ends of the esophagus is too large for primary repair.

    While awaiting surgery, supportive care to prevent aspiration is necessary. A suction catheter is placed in the pouch at the end of the upper portion of the esophagus. A catheter is a hollow flexible tube. The suction catheter continually sucks out secretions that accumulate in the pouch to prevent aspiration. Broad spectrum antibiotics may be given to the infant if sepsis or pulmonary infection is present or suspected. In infants with respiratory failure, additional measures such as assisted ventilation may be required but should be used with extreme caution.

    A few risk classification systems have been developed to help assess EA/TEF. The prognosis regarding these conditions has continually and significantly improved for many years. One such system is the Spitz classification:

    Group 1 – birth weight greater than 1,500 grams (approximately 3.3 pounds) and no major heart defect
    Group 2 – birth weight less than 1,500 grams or major heart defect
    Group 3 – birth weight less than 1,500 grams and a major heart defect

    The survival rate for a full-term infant with EA/TEF and no associated cardiovascular abnormalities (Group 1) is near 100%. Group 2 is approximately 82% and group 3 is approximately 50%.

    In the majority of cases, surgery to reconnect the two segments of the esophagus and close the TEF is performed within the first 24-48 hours of birth. Surgery for EA/TEF requires the chest to be opened to allow disconnection of the fistula and closure of the resulting hole in the trachea. The esophagus is repaired through a procedure called anastomosis, in which the two separate segments of the esophagus are surgically reconnected. The procedure is increasingly performed by “key-hole surgery” by specially trained and experienced pediatric surgeons.

    In some cases, the gap between the upper and lower segments of the esophagus is too large to permit the two segments to be reconnected. This is referred to as long-gap esophageal atresia. Surgery is delayed to allow the continued growth of the esophagus which may take up to 3 months. In the interim, a gastrostomy (a tube inserted directly into the stomach through the abdominal wall) is used for feeding and the upper pouch is sucked out to prevent aspiration. Treatment for long gap esophageal atresia is complex. Several different surgical procedures have been created to treat long-gap esophageal atresia. Most researchers advocate procedures that use the child’s own esophagus (if possible) such as delayed primary anastomosis rather than procedures that require substitute tissue obtained from elsewhere in the body.

    The Foker technique, which is controversial, involves stimulating the two ends of the esophagus to grow until they are close enough to allow surgical reconnection. This procedure requires at least two operations. The first involves attaching traction sutures to appropriate ends of the two segments of the esophagus. Over the course of several weeks, the tension of these sutures is increased (to encourage the ends of the two segments to grow). A second operation will be performed, when the gap has sufficiently narrowed, to remove the sutures and surgically join the two segments of the esophagus together.

    Additional techniques used to treat long gap EA are the gastric pull-up and colonic or jejunum interposition. With gastric pull-up the stomach is repositioned and “pulled-up” and attached directly to the esophagus in the neck. With colonic interposition, a section of the colon is detached with its blood supply and used to bridge the gap between the upper and lower segments of the esophagus, creating one “esophageal tube” running from the mouth to the stomach. In jejunum interposition, a section of the jejunum (the middle portion of the small intestine) is used instead of a piece of the colon.

    Additional treatment is symptomatic and supportive. For example, treatment for conditions potentially associated with EA/TEF such as tracheomalacia, cardiac defects or gastroesophageal reflux follow standard treatment guidelines.

    Early complications
    Several side effects are associated with surgery to correct EA/TEF including those that occur within days or weeks of surgery such as a leak at the site of anastomosis, abnormal narrowing (stricture) near the site of anastomosis, and recurrence of the TEF.

    Late effects
    As the treatment of EA/TEF has improved over the years, more individuals are reaching adulthood and researchers are seeking to identify potential long-term complications associated with therapy for EA/TEF during infancy. Some degree of esophageal dysmotility, a condition where the smooth muscle of the esophagus contracts in an uncoordinated fashion, is invariably present. This affects the normal mechanism that propels food down the esophagus and to the stomach (motility) and results in swallowing difficulties. Esophageal dysmotility can contribute to the development of gastroesophageal reflux disease (GERD), a common finding in individuals who have undergone esophageal repair. Gastroesophageal reflux is a condition in which the stomach contents flow backward into the esophagus. GERD can cause swallowing problems, recurrent chest infections, heartburn and other symptoms and may lead to inflammation of the esophagus (esophagitis), Barrett’s esophagus, and respiratory complications such as asthma. Affected children often experience recurrent chest infections particularly in the first few years after the repair.

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