Oesophageal atresia and tracheo-oesophageal fistula

Oesophageal atresia and tracheo-oesophageal fistula is a congenital structural abnormality that affects 1:4500 live infants. It is due to failure of the primitive foregut tube to separate correctly into the oesophagus and trachea. About 50% have associated abnormalities, of which the VACTERL (Vertebral, Anorectal, Cardiac, Tracheo-oEsophageal, Renal and Limb) association is the most common. Prematurity is common and all have some degree of tracheomalacia. Surgery of the common type can be performed through a fourth interspace thoracotomy or by thoracoscopy. It involves division of the distal tracheo-oesophageal fistula and anastomosing together the two ends of the oesophagus. The absence of a distal fistula reveals itself as a 'gasless abdomen' on plain radiology, and usually indicates a long gap between the blind oesophageal ends: this sometimes necessitates an oesophageal replacement if extensive oesophageal mobilization fails to achieve an end-to-end anastomosis of the oesophagus. Potential postoperative problems include anastomotic leak, anastomotic stricture, recurrence of the fistula, gastro-oesophageal reflux, oesophageal dysmotility, and food impaction. Survival is determined mainly by coexisting congenital abnormalities. The long-term risk of oesophageal malignancy is yet to be established. Isolated tracheo-oesophageal fistula ('H fistula') can occur without atresia, and often presents after feeding has commenced. It is divided through a cervical incision.