Factors contributing to poor results of treatment of esophageal atresia in developing countries

Analysis of Prognostic Factors and Mortality in Children with Esophageal Atresia

OBJECTIVE

The survival rate in newborns with congenital esophageal atresia (EA) is about 85-90 %, and it raises over 95 % in the developed countries. The survival rate in developing countries is much lower and the authors describe their experience with 60 newborns.

METHODS

Medical records of 60 newborns (40 boys and 20 girls) with congenital EA were reviewed for the prognostic factors and mortality.

RESULTS

The birth weight, mean Apgar score (AS) value, gestational age and birth-operative treatment time had significant influence on the mortality of treated patients (p < 0.05). Thirty five percent newborns had aspirational pneumonia at the moment of hospitalization and 86.7 % of them were operated during the first 48 h. The presence of associated anomalies considerably affected the death rate of treated patients (p < 0.05). The incidence of postoperative complications was similar to those in developed countries but the total mortality was higher (28.3 %); sepsis being the main cause of mortality. The postoperative complications and sepsis significantly influenced the mortality of patients (p < 0.05).

CONCLUSIONS

Total mortality in newborns with EA was high; sepsis being the most frequent cause of death. The high total mortality was also caused by prematurity, delay in diagnosis, increased incidence of the aspiration pneumonia and shortage of qualified nurses.

Congenital anomalies in low- and middle-income countries: the unborn child of global surgery

Surgically correctable congenital anomalies cause a substantial burden of global morbidity and mortality. These anomalies disproportionately affect children in low- and middle-income countries (LMICs) due to sociocultural, economic, and structural factors that limit the accessibility and quality of pediatric surgery. While data from LMICs are sparse, available evidence suggests that the true human and financial cost of congenital anomalies is grossly underestimated and that pediatric surgery is a cost-effective intervention with the potential to avert significant premature mortality and lifelong disability.

Esophageal atresia with or without tracheoesophageal fistula: success and failure in 94 cases

BACKGROUND

The management of newborns with esophageal atresia (EA) with or without tracheoesophageal fistula (TEF) has evolved considerably over the years. Currently an overall survival of 85% to 90% has been reported from developed countries. In developing countries, several factors contribute to higher mortality rates. We describe our experience with 94 consecutive cases of EA with or without TEF.

PATIENTS AND METHODS

We retrospectively studied 94 patients with EA with or without TEF treated at our hospital over a period of 15 years. Medical records were reviewed for age at diagnosis, sex, birth weight, associated anomalies, aspiration pneumonia, method of diagnosis, treatment, postoperative complications and outcome.

RESULTS

Ninety-four newborns (55 males and 39 females) with EA/TEF were treated at our hospital. Their mean birth weight was 2.2 kg (700 g to 3800 g). Age at diagnosis ranged from birth to 7 days. At the time of admission 37 (39.4%) had aspiration pneumonia. Associated anomalies were seen in 46 (49%) patients. Thirteen patients had major associated anomalies that contributed to mortality. Postoperative complications were similar to those from developed countries but overall operative mortality (30.8%) was high.

CONCLUSIONS

The overall mortality was high but excluding major congenital malformations, sepsis was the most frequent cause of death. Factors contributing to mortality included prematurity, delay in diagnosis with an increased incidence of aspiration pneumonia and a shortage of qualified nurses. To improve overall outcome, factors contributing to sepsis should be evaluated and efforts should be made to overcome them.

Respiratory distress in neonates

Respiratory distress due to either medical or surgical causes occurs commonly in neonates. It is the most common cause of admission to a neonatal surgical intensive care facility in a tertiary care hospital. The distress can be caused by a variety of clinical conditions; common conditions treated in medical intensive care units are transient tachypnea of the new born, respiratory distress syndrome, pulmonary air leak and pneumothorax. In surgical causes of respiratory distress in neonates the underlying mechanisms include airway obstruction, pulmonary collapse or displacement and parenchymal disease or insufficiency; the common causes are congenital diaphragmatic hernia, congenital cystic adenomatoid malformation, congenital lobar emphysema and esophageal atresia with or without tracheo-esophageal fistula. Obstructive lesions of the new born airway include choanal atresia, macroglossis, Pierre-Robin syndrome, lymphangioma, teratoma or other mediastinal masses, cysts, subglottic stenosis and laryngo tracheomalacia. Imaging plays a very major role in the pre-operative diagnosis of these conditions and proper pre-operative resuscitation helps in improving the results of surgery dramatically.

Esophageal atresia and tracheo-esophageal fistula: a review

The improved survival of neonates with esophageal atresia and tracheo-esophageal fistula reflects the advancement in neonatal care and anaesthesia over the years. Chick embryo studies have given new insights in the embryopathy of esophageal atresia. It is now apparent that the various types of esophageal atresia could be explained due to selective discrepancy in the growth of the 3 folds in the region of tracheo-esophageal separation. The early disturbances in organogenesis which result in esophageal atresia also lead to other associated anomalies, the incidence of which varies from 40 to 55%. These anomalies have an important bearing on the survival outcome. The physiological aspects of esophageal atresia such as esophageal dysmotility and gastro-esophageal reflux are also vital in the long term and proper treatment of the associated defects. The criteria for an ideal esophageal substitute in long gap esophageal atresia have been determined and several options are now available with good results, such as: gastric transposition, colon, gastric tube and small intestine. IN developing countries, however, a high mortality is still attributed to late referrals, low birth weight, hypothermia and chest infection.

Exteriorization of the distal esophagus in the abdomen in esophageal atresia

METHODS

The distal esophagus was exteriorized on to the left upper abdominal wall (abdominal esophagostomy) in 15 babies who had esophageal atresia with or without tracheo-esophageal fistula. The indications for this procedure were long gap atresia with or without tracheoesophageal fistula in which primary anastomosis was not possible and a major anastomotic dehiscence requiring cervical esophagostomy and gastrostomy. In all these patients a decision to replace the esophagus had been made, and a cervical esophagostomy was constructed. The distal esophagus was mobilized either from the thorax if thoracotomy had been done or by a transhiatal abdominal route.

CONCLUSIONS

Advantages of the abdominal esophagostomy include absence of gastroesophageal reflux, no indwelling catheter, early institution of enteral feeds, intermittent catheterization for feeding, easy nursing care, and no stomal complications. In addition, this procedure allows the entire stomach to be available for esophageal replacement and retains the natural gastroesophageal junction and the lower esophagus for anastomosis to any bowel segment being used for the esophageal replacement.