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Oesophageal atresia: a simplified approach to early management
S B Patel1, N Ade-Ajayi, E M Kiely
1Department of Paediatric Surgery, The Great Ormond Street Hospital for Children, Great Ormond Street, London WC1N 3JH, UK.
Insights
Simplified management for oesophageal atresia (OA) with tracheooesophageal fistula (TOF) repair is safe. Omitting routine chest drains, transanastomotic tubes (TATs), and contrast swallows (CS) allows early feeding without increasing complications in infants.
Area of Science:
- Pediatric Surgery
- Neonatal Care
- Gastroenterology
Background:
- Traditional management of oesophageal atresia (OA) with tracheooesophageal fistula (TOF) repair involved routine intercostal chest drains, gastrostomy, or transanastomotic tubes (TATs) for nutrition, and contrast swallows (CS) before oral feeding.
- A trend towards simplifying this management exists but is not universally adopted.
Purpose of the Study:
- To evaluate the safety and efficacy of a simplified management protocol for infants undergoing primary repair of OA with TOF.
- To assess the impact of omitting routine chest drains, TATs, and CS on feeding progression and complication rates.
Main Methods:
- Retrospective case note review of 40 infants undergoing OA with TOF repair over 12 years.
- Management strategies compared included the use (group 2, n=23) or omission (group 1, n=17) of a TAT.
- Key parameters: time to first enteral/oral feeds, time to full oral feeds, and complications. CS was only performed for specific anastomotic concerns.
Main Results:
- No significant differences in sex distribution, gestational age, or birth weight between groups.
- The non-TAT group (group 1) achieved full oral feeds faster (average 3.9 days) compared to the TAT group (group 2, average 5.9 days).
- Stricture rates were similar (4 infants in each group), with comparable need for intervention. One death occurred due to cardiac failure.
Conclusions:
- The majority of infants with OA and TOF can be safely managed without routine chest drainage or CS.
- A significant proportion of infants do not require a TAT, and early oral feeding in this group is not associated with increased complications.
- Simplified management protocols, including early oral feeding, appear safe and effective for OA with TOF repair.
Abstract:
Management following the repair of oesophageal atresia (OA) with tracheooesophageal fistula (TOF) in the past included the routine use of an intercostal chest drain, a gastrostomy, or a transanastomotic tube (TAT) for enteral nutrition and a routine contrast swallow (CS) before oral feeds. There has been a trend towards simplification of the management, but this is not universal. The aim of this study was to evaluate the safety of a simplified management regime in infants undergoing primary repair of OA in a retrospective case note review of infants undergoing surgery for OA with TOF under the care of one consultant over a 12-year period. Intercostal chest drains, TATs, and CSs were not routinely used. Early enteral feeding was initiated and oral feeding was allowed in babies of adequate birth weight (BW) and gestation. A CS was only performed when there were specific anastomotic concerns. Parameters recorded included demographic details, time to first enteral feed by tube or mouth, time to full oral feeds, and complications. Forty patients were studied; 17 were managed without (group 1) and 23 with (group 2) a TAT. Sex distribution, gestational age, and BW were comparable in the two groups. In group 1, the time to the establishment of full oral feeds was 2-8 days (average 3.9). Four infants developed strictures; 2 were managed with dilatation alone and 2 required surgery. In group 2, the time to the establishment of full enteral feeds was 2-12 days (average 5.9). Four patients developed strictures; 2 underwent an anti-reflux procedure and a 3rd resection of a cartilaginous remnant. There was 1 death in a patient with intractable cardiac failure. The majority of infants with OA and TOF can thus be safely managed without routine chest drainage or CS. A sizeable minority do not require a TAT. Early introduction of oral feeds in the non-TAT group is not associated with an increased complication rate.