Cervical repair of esophageal atresia

Cervical approach for the repair of esophageal atresia

Repair of esophageal atresia is usually performed by a thoracic approach. In cases associated with a tracheoesophageal fistula (TEF) located in a high position, however, the cervical approach is a reasonable alternative. In the literature, the authors found only three patients repaired by this approach. This report describes three additional cases of esophageal atresia successfully repaired by the cervical approach. Three neonates with esophageal atresia and TEF were confirmed as having an unusually high position of the distal TEF by the preoperative bronchoscopy and contrast study. The transcervical approach for repair was chosen. The skin was incised transversely at the right supraclavicular region, and the sternocleidomastoid muscle and the carotid sheath were retracted posterolaterally. After the division of the TEF, the suture site of the tracheal fistula was covered by a flap of the sternothyroid muscle that was inserted between the trachea and the esophagus, thus avoiding opposing suture lines. These cases emphasize that pediatric surgeons should be aware of the presence of cervical esophageal atresia in which distal TEF is located above the clavicle, and suggest that cervical repair is feasible for the patient whose distal TEF moves up above the first rib on inspiration. The most reliable methods for detecting the location of the distal TEF are telescopic bronchoscopy and contrast study.

Paediatric emergencies

During the last decade neonatal surgical results have improved considerably. Except for infants born with serious congenital heart disease, diaphragmatic hernia or exomphalos, postoperative mortality rates for infants with single anomalies have fallen to the region of 10%. This dramatic success story has been marred by a corresponding increase in the number of individuals with several anomalies entering late childhood with severe chronic handicaps. During the remainder of this century much effort will be expended in devising programmes of investigation which will attempt to predict which individuals will have a poor long-term prognosis. Such programmes will necessitate very close liaison between obstetricians, radiologists, neonatologists, local paediatricians, paediatric surgeons, general practitioners and parents. Very urgent surgery is necessary for the best results in infants with gastroschisis, intestinal volvulus and irreducible inguinal hernia, but for most other conditions there have been recent trends away from very urgent surgery to operation during daylight hours within the ensuing 24 h. Surgery within a few hours of presentation is necessary for intussusception and for early acute appendicitis, but perforated appendicitis should be treated by aggressive fluid replacement and intravenous antibiotics and surgery should be contemplated only in the rare cases of continued deterioration.

Success and failure with neonatal tracheo-oesophageal anomalies

In seven and a half years, one surgical team treated 67 consecutive neonates with oesophageal atresia and/or tracheo-oesophageal fistula. According to Waterston's classification, 28 were in group A, 12 in group B and 27 in group C. The mortality rate during the initial admission was 10 per cent, all seven deaths being unavoidable in infants in group C with multiple anomalies. Birthweight alone had no bearing upon the chances of survival. Primary oesophageal repair, including one suture-fistula procedure and one delayed primary repair, was attempted in 54 (84 per cent) of the 64 patients with atresia and was successful in 46 (85 per cent). All three H-type tracheo-oesophageal fistulae were successfully divided in infants in group A. Recurrent tracheo-oesophageal fistula developed in four (7 per cent) infants, one of whom (group A) underwent successful repair. One disrupted anastomosis was successfully resutured (group A), so an intact oesophagus was finally achieved in 51 patients, of whom six (12 per cent) developed anastomotic strictures and 21 (41 per cent) underwent surgery for gastro-oesophageal reflux. Of the 60 early survivors, 10 (17 per cent) underwent aortopexy for tracheomalacia. Whenever possible, primary repair is advocated in all infants. Even for those in group C with multiple, severe associated anomalies, the combined early and late mortality was no greater following primary repair (7 died of 12 operated) than after staged repair (4 died of 7 operated), but major anastomotic complications were more common in infants in group C (5 out of 19) than in those in groups A and B (3 out of 38).