Not all neonates with oesophageal atresia and tracheoesophageal fistula are a surgical emergency

Aim: Infants with oesophageal atresia and distal tracheoesophageal fistula (OA-TOF) occasionally require endotracheal intubation prior to definitive surgery. This creates the risk of preferential ventilation of the fistula leading to gastric distention and subsequent perforation. We aimed to reassess the risk of preoperative positive-pressure ventilation and update recommendations for emergency surgery in this cohort.

Methods: A single centre retrospective review of all cases of OA-TOF from 2008 to 2018 was performed. Data were collected on birth demographics, presence and duration of preoperative intubation, timing of surgery, and outcome. Outcomes considered were gastric perforation and perioperative death. Data are expressed as median (range) unless otherwise stated.

Results: Sixty-two neonates with OA-TOF were identified (mean birthweight 2559 g, median gestational age 38 weeks). Seventeen were intubated for respiratory symptoms prior to surgery (1840 g, 34 weeks). The duration of intubation preoperatively was 19 (5-48) h. Seven cases were ventilated for >24 h. Three underwent emergency surgery 'out of hours'. Two were born at 28 weeks' gestation and developed gastric distention requiring urgent surgery. Both were intubated for 10 h preoperatively and underwent fistula ligation with no attempt at oesophageal reconstruction. The third had congenital heart disease and was intubated prior to transfer to our unit. There were no cases of gastric perforation. Five ventilated cases died prior to discharge from hospital from associated conditions.

Conclusions: The risk of gastric perforation is lower than perceived. Ventilated babies with OA-TOF do not necessarily require emergency surgery. This is only indicated in the presence of gastric distention or other instability.

Level of evidence: IV.