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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: 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 have severe respiratory ailments or congestive heart failure, may require delay in therapy and may be treated initially with an emergency gastrostomy along with distal esophageal Fogarty balloon obstruction under local anesthesia
  • Atropine generally ...

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