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NICU guideline identifier

Surgery - management of oesophageal atresia with a distal TOF in the neonate

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Overview

The incidence of tracheo-oesophageal fistula is approximately 1:3000 live births. There are a number of different types, although the most common is proximal oesophageal atresia with a distal tracheo-oesophageal fistula.

Surgery is usually performed within the first few hours of life. An echocardiogram is usually performed to rule out significant congenital cardiac disease, and to identify the position of the aortic arch. A renal tract scan should also be performed if possible prior to surgery.

Surgery

The surgical procedure involves the following steps:

  • The baby is intubated. 
  • A thoracotomy is performed, with the upper pouch dissected off the back of the trachea and the tracheo-oesophageal fistula divided. 
  • The proximal pouch is anastomosed to the distal oesophagus. 
  • A extrapleural chest drain is inserted, without suction being applied. 
  • A nasogastric tube inserted. 

Preoperative care

  1. Follow standard steps for preoperative care.
  2. The head of radiant heat table or incubator is elevated at all times even during x-rays to prevent gastro-oesophageal reflux/aspiration into the trachea via the fistula. Baby is nursed prone with head elevated to prevent reflux.
  3. Adequate drainage of the upper pouch is essential. This can be either by intermittent suction every 15 minutes or via insertion of a Replogle tube as far as it will go and placed on continuous low pressure suction. Flush with 0.9% NaCl usually Q15-30 minutes. The baby will also need frequent oral suction.
  4. When x-raying for diagnosis the baby's neck, chest and abdomen are on the x-ray plate to determine if there is air in the stomach - therefore ruling out pure atresia with no connection between trachea and oeseophagus.
  5. Air may be used as contrast medium (contrast fluid could aspirate into the lungs) which when pushed in at the time of the x-ray demonstrates the pouch more clearly.
  6. Observe for abdominal distension. For babies who are difficult to ventilate, there may be excessive abdominal distension from ventilation of the stomach through the distal fistula. This may require temporary drainage (via insertion of a needle into the stomach) to allow drainage of air to improve ventilation.
  7. Maintain the baby nil by mouth. 
  8. Administer antibiotics as prescribed (usually triple - Amoxycillin, Gentamicin, and Metronidazole) to reduce the risk of pneumonia. 
  9. During transport ensure Replogle tube is aspirated every 15 minutes to prevent aspiration.

Postoperative care 

  1. Follow standard steps for postoperative care.
  2. Baby is nursed with head up to prevent gastric contents going over the anastomosis suture line. 
  3. Endotracheal tube is kept higher than the operation site (takes 7-10 days for suture line to heal). Up till then anastomosis line is weak. Do not extend neck. 
  4. Carefully measure the ET tube and suction catheters (recorded on nursing notes). Avoid reintubation and NCPAP if possible DO NOT SUCTION PAST END OF ET TUBE (7cm is usually sufficient). For smaller babies, the distance may be shorter. 
  5. Ensure the nasogastric tube is kept in the correct position. If it slips out it must not be reinserted (as the tube can go through the wall of the oesophagus) and the surgeon is notified immediately. Monitor output through the nasogastric tube and replace losses as prescribed. 
  6. Measure and record gastric aspirates Q2-4 hourly. Place on free drainage in between. Fluid loss replaced intravenously, with 0.9% NaCl with 10mmol KCl/500ml. 
  7. The initiation of feeds will be determined by the surgeon. 
  8. Maintain extrapleural chest drain (not necessarily on continuous suction) as per standards of care for chest drains and monitor drainage. ENSURE THE CHEST DRAIN IS NOT REMOVED UNTIL FEEDING IS ESTABLISHED. 
  9. A contrast study to evaluate the anastomosis will usually be performed within the first week, at the direction of the surgeon. Following this, the drain may be removed and oral feedings commenced if no leak is present. 
    1. The drain may be removed earlier on surgeon's instructions only. 
    2. If saliva is coming out extrapleural chest drain, this indicates suture line is not healed. An anastomotic leak can occur rarely, and recurrence of the fistula may also occur. 
    3. Check with surgeons regarding the use of pacifier - may be used prn. 

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Document Control

  • Date last published: 24 September 2018
  • Document type: Clinical Guideline
  • Services responsible: Neonatology, Paediatric Surgery
  • Owner: Newborn Services Clinical Practice Committee
  • Editor: Sarah Bellhouse
  • Review frequency: 2 years