Tracheomalacia caused by arterial compression in esophageal atresia

After surgical repair of esophageal atresia (EA), any persistent respiratory distress unexplained by operative complications should lead to performance of tracheoscopy to evaluate the possibility of tracheomalacia. In a review of 46 cases of EA repair, 12 patients developed severe airway problems, manifested mainly by acute apneic episodes. These were related to an anterior extrinsic tracheal compression from vascular structures: the innominate artery alone in 8 patients, and in combination with the aortic arch in 4 patients. Aortopexy, evaluated by intraoperative tracheoscopy, provided good results in 10 patients with a mean follow-up of 2 years. After EA repair, respiratory symptoms, often related to feeding, should be recognized as a possible indication of severe compression of the trachea by the great vessels. The analysis of endoscopic features should allow consideration of patients as candidates for aortopexy, as long as they have resolved their symptoms after conservative therapy, and after investigation of all other possible sources of pulmonary problems. Gastroesophageal reflux must be recognized (7 cases in the series), but does not contraindicate aortopexy if the latter is deemed necessary. In selected cases, the relief of compression, controlled by intraoperative endoscopy, is considered a key component of a comprehensive program to treat children after EA repair.