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Tracheooesophageal fistula
Paediatric Surgery

Tracheooesophageal fistula

6 day old male was referred from a regional hospital to KATH on account of continous frothy discharge from mouth and nose since birth. Attempts at passing a nasogastric tube was unsuccessful  and a diagnosis of oesophageal atresia was made at time of referral.
Baby is the second child of a 22 year old mother, delivered by Caesarean section on account of postdatism,  cried at birth and passed meconium .Baby has not been feeding well since birth so was put on IV fluids
Examination: Wt 2.6kg,     PCV 63%,       RBS 6.5mmol/l,     RR 69cpm,   HR 152bpm CRT<3s
Tonic clonic seizures of the upper extremeties, lasting 30 to 40 seconds.
Oronasal secretions stained with bile, Ill looking, afebrile, anicteric, well hydrated, flaring of alae nasae
Chest : lower chest in drawing, air entry adequate bilaterally with transmitted sounds
Abdomen : distended , tip of liver palpable , all other viscera not palpable.
CNS : Tonic clonic seizures, a flat anterior fontanelle.
Thoracoabdominal xray showed the tip of the feeding tube in the chest and gaseous distension of bowel loops
Diagnosis : Tracheooesophageal fistula
Baby was put on antiobiotics, iv fluids, phenobarbitone
Investigations:
FBC, electrolytes,  were checked and found to be normal.
CXR showed with NGT insitu showed tip of NGT in the chest
Echocardiography, abdominal USG later
Decision taken peform exploratory thoracotomy, oesophagostomy to divert saliva to the exterior and feeding gastrostomy to build the baby nutritionally
Surgery :
1.Thoracotomy
2.Oesophagostomy
3.Placement of feeding gastrostomy
Findings : Type C oesophageal atresia, cardiomegally
Procedure :
Left lateral position, with arm extended over head. Through a right subcostal muscle cutting incision, below lower angle of scapular, through 5th intercostal space
Pleura seperated from chest wall. Right lung retracted and  azygous vein  doubly ligated with vicryl 2/0, 3/0 and divided.
Distal tracheooesophagel fistula was identified, corners held with stay sutures fistula disconnected .
Defect of the the trachea closed with vicryl 5/0
Chest  wound closed and thoracostomy tube placed
Cervical approach used to mobilised proximal oesophagus for oesophagostomy
Placement of feeding gastrostomy done
Baby currently in ICU with stable vitals.
Credits : Dr Nimako Boateng ( Consultant Paediatric surgeon) , Dr Wadada ( Paediatric surgeon)
 

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