Unusual Nasogastric Tube Position Leading to Delay in Diagnosis of Tracheoesophageal Fistula

Aim: This case highlights the importance of high index of suspicion for early diagnosis and thorough clinical examination of a newborn with tracheoesophageal atresia and fistula. Case Report: We report a case of most common type of tracheoesophageal atresia with fistula where diagnosis was missed due to unusual gastric position of nasogastric tube. Nasogastric tube reached stomach in esophageal atresia with fistula, delaying the diagnosis and management of condition. After accidental removal of tube and failure to pass again raised suspicion and was confirmed with coiled tube in esophageal pouch in X-Ray chest. Baby shifted to surgical unit for treatment, fortunately baby recovered and discharged home after surgical correction. Conclusion: Tracheoesophageal atresia with fistula can present with atypical symptoms and unusual events, challenging the early diagnosis and treatment of common types of conditions. Other association like VACTERL should be looked for, in patients.

CORRELATION BETWEEN POSITION OF RED RUBBER CATHETER ON X RAY AND GAP LENGTH IN TYPE C ESOPHAGEAL ATRESIA (EA)

BACKGROUND AND AIM: Gap length is important determinant for feasibility of primary repair in atresia and also for the preparedness and prognosis of delayed or staged operative procedures. A diagnostic plain radiograph with a red rubber catheter in situ might provide reliable information regarding the gap length without involving additional risk and cost. The present study was conducted to assess the gap length between the two esophageal pouches by preoperative plain radiography with in situ red rubber catheter in upper esophageal pouch and to know the correlation between position of red rubber catheter and measured gap length between upper and lower pouch. METHODOLOGY: Out of all patients admitted and diagnosed as gross's type C EA during September 2018 to November 2019 were included in the present study. The data regarding clinical history, general and systemic examination, pre-operative investigations including plain radiograph with in situ red rubber catheter and intraoperative measured gap length were recorded. Statistically correlation assessed between position of red rubber catheter and intraoperatively measured gap length among patients with type c EA. RESULTS: Total 283 patients were included in the present study. Radiologically position of red rubber catheter was found at level of T2, T3 and T4 in 18.7%, 55.5% and 25.8% respectively. A correlation was found between the preoperative radiological assessments of position of red rubber catheter with intra operatively measured gap length in this study and association between these two variable were found statistically signicant (r=-0.66, P=0). CONCLUSION: The preoperatively radiographic position of upper pouch should be assessed carefully to predict the gap width and it helps in preparedness of surgical management of the patients.

Esophageal elongation using Foley catheter in long-gap esophageal atresia

Esophageal atresia/tracheoesophageal fistula (EA/TEF) is a rare congenital anomaly that poses major surgical challenges, particularly when the distance between the two esophageal ends exceeds 3 cm. Many surgical techniques are advocated for bridging the gap between the two esophageal ends. In this paper, we propose a simple and effective technique to elongate the esophagus in the long gap EA. This technique has successfully been applied in two infants with type C EA/TEF, where a primary end to end esophageal anastomosis was not feasible. The technique uses two Foley catheters for traction of upper and lower esophageal ends in long-gap EA/TEF. This method helps preserve the native esophagus, providing comfortable suction of the upper esophageal pouch, and assuring postoperative continuous feeding through the lower esophageal segment.

Kluth type I3 and intra-abdominal variants of esophageal atresia: A case series

Background: Esophageal atresia (EA) encompasses a group of congenital anomalies (one in 2500 live births) comprising an interruption in the continuity of the esophagus combined with or without a persistent communication with the trachea. It is confirmed by passing no. 10 sterile, blunt‑tipped red rubber catheter into the esophagus, which gets failed to pass beyond 10 cm. Case Series: We describe two male neonates in whom the infant feeding tube could be passed to 18-20 cm in the upper esophageal pouch. A babygram with a blunt-tipped soft red rubber catheter in situ confirmed the esophageal atresia (EA) with the long upper pouch in the first case and EA with obstruction at the gastroesophageal junction in the second one. Conclusion: The importance of recognizing rare Kluth variants of EA is stressed. A low threshold for performing a red rubber catheter test is stressed.

Tracheoesophageal Fistula Repair

Tracheoesophageal fistula (TEF) with esophageal atresia (EA) is a congenital malformation occurring in approximately 1:4,000 live births. TEF/EA is characterized by disrupted continuity of the esophagus. There are five distinct types, but the most common is EA with a distal TEF. Most cases are diagnosed postnatally after an inability to pass a nasogastric tube (NGT), with subsequent radiographic imaging finding the NGT coiled within the esophageal pouch. The anesthetic management of TEF/EA repair can be complicated by the presence of cardiac, renal, and vertebral anomalies. Additionally, ventilation can be challenging, and care must be taken to minimize insufflation of the stomach through the fistula. Postoperative analgesia should include consideration of intravenous opioids, nonopioid adjunct medications, and regional and neuraxial techniques.

Surgical Surprise in a Case of Pure esophageal atresia: How High Can the Lower Pouch Be?

The gap between the upper and lower pouches in case of pure esophageal atresia (EA) is usually long and requires multistaged repair. However, in rare cases, the gap may be short and can be repaired primarily commonly through thoracotomy approach. We report an unusual case of a 2-day-old baby girl who presented with short gap EA where the lower esophageal pouch was found adjacent to the blind upper pouch in the neck and primary repair could be performed through the cervical route itself.