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Tracheo-oesophageal fistula and pre-operative mechanical ventilation
P S Malone1, E M Kiely, A J Brain
1Department of Paediatric Surgery, Hospital for Sick Children, London, UK.
Insights
Tracheo-oesophageal fistula (TOF) in neonates with severe lung disease presents surgical challenges. Prompt fistula ligation with esophageal repair, not gastrostomy alone, improves survival rates for these critically ill infants.
Area of Science:
- Pediatric Surgery
- Neonatal Respiratory Medicine
- Thoracic Surgery
Background:
- Tracheo-oesophageal fistula (TOF) often co-occurs with oesophageal atresia and severe lung disease in neonates.
- Restrictive lung disease necessitating mechanical ventilation complicates surgical management of TOF.
- Associated conditions include respiratory distress syndrome and aspiration pneumonia.
Purpose of the Study:
- To report outcomes of surgical management for neonates with TOF and severe lung disease.
- To evaluate the efficacy of different surgical approaches, including gastrostomy and fistula ligation.
- To determine optimal treatment strategies for this high-risk patient population.
Main Methods:
- Retrospective review of twelve neonates with TOF and pre-operative ventilation.
- Surgical interventions included preliminary gastrostomy, emergency fistula ligation, and oesophageal repair (immediate or delayed).
- Analysis of patient survival and respiratory function post-intervention.
Main Results:
- Two patients undergoing preliminary gastrostomy died.
- Emergency fistula ligation in 10 patients resulted in nine survivors.
- Post-fistula division, three patients showed improved respiratory function and underwent primary oesophageal repair; three had delayed repair, and three had oesophageal sacrifice.
Conclusions:
- TOF in neonates with poorly compliant lungs requiring ventilation is a significant surgical challenge.
- Gastrostomy alone is contraindicated.
- Fistula ligation with immediate or delayed primary oesophageal repair is the recommended treatment approach.
Abstract:
Twelve patients with tracheo-oesophageal fistula (TOF) and restrictive lung disease necessitating pre-operative ventilation are reported. Eight patients had respiratory distress syndrome, four had aspiration pneumonia, and 11 had associated oesophageal atresia. Two patients in whom a preliminary gastrostomy was performed died. Emergency ligation of the fistula was performed in 10 patients, nine of whom survived. Following division of the fistula, respiratory function improved dramatically in three patients and primary oesophageal repair was performed. Three patients underwent delayed primary repair and the oesophagus was sacrificed, with a view to replacement at a later date, in the remaining three patients. We believe that the presence of a TOF in a neonate with poorly compliant lungs requiring mechanical ventilation represents a serious surgical challenge. Gastrostomy alone should never be performed. Ligation of the fistula with either immediate or delayed primary repair of the oesophagus are the treatments of choice.