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Esophageal atresia-- Epitome of modern surgery

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Esophageal atresia is one of the challenging problems to pediatric surgeons. It needs a team work approach and it is an epitome of modern surgery

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Esophageal atresia-- Epitome of modern surgery

  1. 1. “YOUR KIND ATTENTION PLEASE” www.themegallery.com
  2. 2. M M M C Esophageal Atresia- Epitome Of Modern Surgery L/O/G/O Dr.B.SELVARAJ
  3. 3. EEEEssssoooopppphhhhaaaaggggeeeeaaaallll AAAAttttrrrreeeessssiiiiaaaa- EEEEppppiiiittttoooommmmeeee ooooffff MMMMooooddddeeeerrrrnnnn www.themegallery.com ssssuuuurrrrggggeeeerrrryyyy
  5. 5. Esophageal Atresia- Epitome of Modern surgery Objectives Recognise various conditions Make early& accurate diagnosis Prompt Life Saving treatment 1 2 3 Immediate 4 surgical referral M M M C
  6. 6. AAAA NNNNeeeeoooonnnnaaaatttteeee’ssss rrrreeeeqqqquuuueeeesssstttt ttttoooo SSSSuuuurrrrggggeeeeoooonnnn “Please exercise the greatest gentleness with my diminutive tissues and try to correct the deformity at first operation; give me blood and proper amount of fluid and electrolytes; add plenty of oxygen to anesthesia, and I will show you that I can tolerate a terrific amount of surgery. You will be surprised at the speed of my recovery, and I shall be grateful to you” --Dr. Willis Potts M M M C
  7. 7. Neonatal Respiratory NNNeeeooonnnaaatttaaalll RRReeessspppiiirrraaatttooorrryyy DDDDiiiissssttttrrrreeeessssssss— SSSSuuuurrrrggggiiiiccccaaaallll CCCCaaaauuuusssseeeessss B Causes E C D Esophageal A Atresia Diaphragmatic Hernia Congenital Lobar Emphysema Posterior Choanal Atresia Pierre Robin Sequence S V M C
  8. 8. Embryology Of Esophageal Atresia S V M C
  9. 9. EEEEssssoooopppphhhhaaaaggggeeeeaaaallll AAAAttttrrrreeeessssiiiiaaaa EA Challenging& Fascinating Problem Team Work Approach VACTERL Anomaly Post op Ventilator Care Incidence 1 in 3500 livebirths Epitome of Modern Surgery S V M C
  10. 10. www.themegallery.com EEEEssssoooopppphhhhaaaaggggeeeeaaaallll AAAAttttrrrreeeessssiiiiaaaa TTTTyyyyppppeeeessss S V M C
  11. 11. EEEEssssoooopppphhhhaaaaggggeeeeaaaallll AAAAttttrrrreeeessssiiiiaaaa- AAAAssssssssoooocccciiiiaaaatttteeeedddd AAAAnnnnoooommmmaaaalllliiiieeeessss Vertebral Anorectal Cardiac- commonest Tracheo Esophageal Fistula Renal Limb S V M C
  12. 12. EEEEssssoooopppphhhhaaaaggggeeeeaaaallll AAAAttttrrrreeeessssiiiiaaaa CCCClllliiiinnnniiiiccccaaaallll FFFFeeeeaaaattttuuuurrrreeeessss Clinical Features Drooling of saliva Maternal Polyhydramnios Inability to pass NGT into Stomach In atresia with TEF Aspiration of gastric contents Chemical Pneumonitis Feeding Cough, choking Cyanosis In pure atresia Gasless Abdomen Scaphoid Abd S V M C
  13. 13. EEEEssssoooopppphhhhaaaaggggeeeeaaaallll AAAAttttrrrreeeessssiiiiaaaa-DDDDrrrroooooooolllliiiinnnngggg ooooffff ssssaaaalllliiiivvvvaaaa S V M C
  14. 14. Physiological Effect of Distal TEF S V M C • 1. Hyaline membrane disease may necessitate higher ventilator pressures, which encourage air to pass through the distal fistula. • 2. A distended abdomen elevates and splints the diaphragm. • 3. Gastric distension may result in gastric rupture and pneumoperitoneum. • 4. Passage of air through a distal tracheoesophageal fistula diminishes the effective tidal volume. (B) 1. Aspiration of gastric juices leads to soiling of the lungs and pneumonia • 2. Gastroesophageal reflux • 3. Direction of gastric fluid proximally through distal fistula. • 4. Overflow of secretions or inadvertent feeding may contribute to aspiration and contamination of the airway.
  15. 15. Esophageal Atresia Imaging Studies AXR CXRCurledup NGT in blind upper pouch CXRAtelectasisPneumonia AXRGasless in pure Atresia Antenatal MRI of Fetus Imaging S Studies USG Abdto R/O Urogenital anomaly Echo to R/O cardiac anomalyRt Aortic arch V M C
  16. 16. www.themegallery.com Esophageal Atresia Antenatal MRI S V M C
  17. 17. Esophageal Atresia Clinical Diagnosis S V M C • . (A) Diagnosis of esophageal atresia is confirmed when a 10- gauge (French) catheter cannot be passed beyond 10 cm from the gums. (B) A smaller-caliber tube is not used because it may curl up in the upper esophageal segment, giving a false impression of esophageal atresia.
  18. 18. www.themegallery.com Esophageal Atresia CXR S V M C
  19. 19. Esophageal Atresia With TE Fistula- Bronchoscopy S V M C Rt Bronchus TE Fistula
  20. 20. Esophageal Atresia Pre op Management NPO Pre op Proximal pouch Decompression S I V Antibiotics If for staged repair Do Gastrostomy Head up position In pure atresia Stretch proximal pouch daily V M C
  21. 21. Esophageal Atresia Pre op Management NPO Pre op Proximal pouch Decompression S I V Antibiotics If for staged repair Do Gastrostomy Head up position In pure atresia Stretch proximal pouch daily V M C
  22. 22. Esophageal Atresia Waterston’s Risk Categories /Birth weight 2.5 Kgs /No Anomalies /No Pneumonitis /Primary Repair100%survival /Birth weight 1.8 to 2.5 Kgs /Non life threatening anomalies /Mild Pneumonitis /Delayed Primary Repair80%survival /Birth weight 1.8 Kgs /Life threatening anomalies /Severe Pneumonitis /Staged Repair40%survival Risk Categories Category A Category B Category C S V M C
  23. 23. Esophageal Atresia Operative Management 1 2 3 Lanman’s Rt posterolateral retropleural thoracotomy Ligation division of Azygos vein Disconnect TEF; Repair tracheal defect 4 Liberally mobilise the upper pouch for tension free anastomosis S V M C
  24. 24. Esophageal Atresia Operative Management 5 6 7 In wide gapLivaditi’s circular myotomies Never mobilise distal pouch much Extra pleural drain S V M C 8 Transanastomotic feeding tube for early gavage feeding
  25. 25. www.themegallery.com Esophageal Atresia Operative Management S V M C
  26. 26. Normal Mediastinum- Rt side S V M C
  27. 27. Esophageal Atresia Immediate Primary Repair S V M C
  28. 28. www.themegallery.com Esophageal Atresia Immediate Primary Repair
  29. 29. www.themegallery.com
  30. 30. www.themegallery.com Esophageal Atresia VATS Repair S V M C
  31. 31. Esophageal atresia Post op Management in NICU Otherwise exubate in 1st POD Regular chest PhysioNasopharyngeal suction Feeding through transanastomotic feeding Tube from 2nd POD Gastrograffin swallow on 7th POD; If no leakoral Feeding remove chest drain S V M C Electively paralysemechanically ventilate For 3 to 5 days in tension anastomosis
  32. 32. Esophageal Atresia Complications LATE Tracheomalacia GE Reflux EARLY Anastomotic Leakage Anastomotic Stricture Recurrent TEF Esophageal Dysmotility S V M C
  33. 33. Esophageal Atresia TE Fistula Recap Clinical Features Complica tions Operation EA TEF Preop Trt •VACTERL •Maternal Poly Hydramnios •Drooling of saliva in baby •Inability to pass NGT into stomach •NPO Associ Anomaly Imaging CXR •Headup position •IV Antibiotics •Upper pouch suction •Curledup NGT in blind upper pouch •Echo to R/O cardiac Anomaly • USG Abd to R/O Urogenital anomaly •Anastomotic leak •Anastomotic stricture •Tracheomalacia •GE Reflux •Immediate primary Repair •Delayed primary Repair •Staged Repair S V M C
  34. 34. www.themegallery.com
  35. 35. www.themegallery.com
  36. 36. www.themegallery.com