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Child Health Guideline Identifier

Oesophageal Atresia / Tracheo-Oesophageal Fistula (OA/TOF)

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Pre-operative Management

Assessment and initial classification according to Spitz [5]

  1. BW>1.5kg, without major cardiac disease
  2. BW<1.5kg OR major cardiac disease
  3. BW<1.5kg AND major cardiac disease

Clinical examination

  • Associated anomalies (up to 50%) (cardiac - genitourinary - vertebral - anal (VACTERL, etc.)
  • Respiratory status (atelectasis - RDS - degree of ventilatory support)


  • Chest x-ray (tip of NG-tube, aspiration, etc.)
  • Abdominal x-ray (signs of obstruction - air in stomach (fistula)
  • Spine x-ray
  • ECHO (cardiac problem - left or/and right aortic arch) (if in doubt about aortic arch CT/MRI)
  • Renal US (can be post-op if passed urine - otherwise pre-op to exclude bilateral renal agenesis, a contraindication to surgery)

Initial management

  • Suction of upper pouch (Reploggle tube or intermittent - Consultant dependent)
  • Consider elevation of head in order to prevent aspiration
  • Consider antibiotics (Consultant dependent)
  • O2-monitoring



Primary repair (There may be major co-morbidities (e.g. cardiac or respiratory) that preclude early primary repair)

  • Bronchoscopy
  • Standard approach: Right extra-pleural thoracotomy (aim for left side in rare case of right aortic arch)
  • Normally no gastrostomy required (except in cases where a primary anastomosis is not possible)
  • One layer end-to-end anastomosis (+ ligation of fistula)
  • Chest drain depends on surgeon's preference (recommended in cases of intra-operative difficulties eg long gap, increased tension)
  • Insert transanastomotic NG-tube (Consultant dependent)

Post-operative Management

Observation on ward or PICU (dependent on respiratory/cardiac condition)

  • Continue with antibiotics (Consultant dependent)
  • Chest x-ray post-OP
  • Start feeding via NG-tube
  • Introduction of oral feeds is Consultant dependent (some Consultants would perform a contrast study on day 5-7 before introducing oral feeds)
  • Anastomosis under tension - consider PICU for ventilation and paralysis with head flexed for 5 days



  • Sepsis
  • Respiratory problems (aspiration, lung collapse, tracheomalacia)
  • Leak
  • Pneumothorax


  • Re-fistula
  • Stricture
  • Gastro-oesophageal Reflux
  • Dysmotility problems / swallowing disorders


Kay S, Shaw K: Revisiting the role of routine retropleural drainage after repair of esophageal atresia with distal tracheoesophageal fistula. J Pediatr Surg 7:1082-1085, 1999

Konkin DE, O'Hali WA, Webber EM, Blair GK: Outcomes in esophageal atresia and tracheoesophageal; fistula. J Pediatr Surg 38:1726-1729, 2003

Patel SB, Ade-Ajayi N, Kiely EM: Oesophageal atresia: a simplified approach to early management. Pediatr Surg Int 18:87-89, 2002

Spitz L, Kiely E, Brereton RJ: Esophageal atresia: five year experience with 148 cases. J Pediatr Surg 22:103-108, 1987

Spitz L, Kiely E, Morecroft JA, et al.: Oesophageal atresia: at-risk groups for the 1990s. J Pediatr Surg 35:723-725, 1994

Yanchar NL, Gordon R, Cooper M, et al.: Significance of the clinical course and early upper gastrointestinal studies in predicting complications associated wit repair of esophageal atresia. J Pediatr Surg 5:815-822, 2001

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Document Control

  • Date last published: 01 November 2007
  • Document type: Clinical Guideline
  • Services responsible: Paediatric Surgery
  • Author(s): Rainer Kubiac
  • Editor: Greg Williams
  • Review frequency: 2 years

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