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Figure 173-1. The Five Types of TEF

Type IIIB represents 90% of cases. Reproduced from Morgan GE, Mikhail MS, Murray MJ. Clinical Anesthesiology. 4th ed. Figure 44-3. Available at: http://www.accessmedicine.com. Copyright © The McGraw-Hill Companies, Inc. All rights reserved.

  • Approximately 1 in 3,000 babies is born with tracheoesophageal fistula (TEF)
  • Thirty to 40% neonates are premature
  • Associated anomalies such as cardiac, gastrointestinal, genitourinary, musculoskeletal, or craniofacial anomalies are present in 30–50% of newborns with esophageal atresia and TEFs
    • VATER (i.e., vertebral and vascular anomalies, imperforate anus, TEF, radial aplasia, and renal abnormalities)
    • VACTERL (i.e., vertebral anomalies, imperforate anus, cardiac anomalies, TEF, renal abnormalities, radial limb aplasia) association
  • Most common abnormality is blind upper esophageal pouch with distal fistulous tract between the trachea and distal esophagus (Type IIIB), observed in 90% of cases

  • Prenatal diagnosis by ultrasound; associated with polyhydramnios (decreased fluid swallowing)
  • Confirmed postnatally by failure to pass orogastric tube into newborn’s stomach
  • Neonatal symptoms: coughing and choking with first feeding:
    • Recurrent pneumonias associated with feeding
  • Radiographic confirmation: tip of radio-opaque catheter in esophagus:
    • Air in stomach if fistula present
  • Occasionally TEF diagnosis not made until later in the child’s life
  • Morbidity and mortality associated with pulmonary and cardiac complications. Ascertain position of the aorta to decide on side of thoracotomy
  • Minimize risk of aspiration pneumonitis by placing neonate in semirecumbent position and inserting oroesophageal catheter to decrease accumulation of secretions
  • All feeds are held as these patients are at high risk of aspiration. Patients are often started on a dextrose intravenous solution, TPN or PPN
  • Antibiotics may be necessary for treatment of pneumonia
  • Emergency gastrostomy under local anesthesia may be necessary to relieve gastric distension and improve ventilation before the definitive surgery 48–72 hours later
  • The Waterson classification was used extensively in the past. However, patients currently are individually categorized based on clinical status
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    Waterson Classification for Neonates with TEF
    ABirthweight over 2.5 kg and healthy95% survival
    BBirthweight between 1.8 and 2.5 kg and healthy, or weight >2.5 kg with moderate pneumonia or other congenital anomalies68% survival
    CBirthweight under 1.8 kg or weight >1.8 kg with severe pneumonia or severe congenital anomalies6% survival
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    Spitz Classification for Neonates with TEF
    IBirthweight greater than 1.5 kg and no congenital heart defect99% survival
    IIBirthweight less than 1.5 kg or congenital heart defect82% survival
    IIIBirthweight less than 1.5 kg and presence of congenital heart defect50% survival
  • With improved ICU care, respiratory status has become a smaller factor in survival
  • In general, whatever classification system is used, infants who have stable cardiac and respiratory status undergo expedition thoracotomy and repair. High-risk infants, especially those who are premature (<1,000 g) and ...

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