**2.14 Outcome and conclusion**

*Pediatric Surgery, Flowcharts and Clinical Algorithms*

apnoeic spells. Because of difficulty in breathing or cyanotic attacks during feeding, infants with tracheomalacia are often reluctant to feed. Life-threatening apnoeic and cyanotic spells occur during or within 5–10 min of a meal. They are characterized by cyanosis progressing to apnoea, bradycardia, and ultimately, cardiorespiratory arrest if not detected and managed promptly. Diagnosis is established by bronchoscopy with spontaneous ventilation. This reveals a slit-like lumen of the trachea at the involved area. However, because the symptoms overlap those of a stricture or gastro-oesophageal reflux, contrast oesophagogram is usually done as an initial investigation. Close attention to the tracheal air column on the lateral views during such a study will often reveal complete tracheal collapse during forced expiration (i.e., crying) or when contrast fills a distended upper oesophagus just above the anastomosis. Most mild to moderate symptoms of tracheomalacia tend to improve with time. Hence, operative intervention is not required. Operative treatment of choice for patients with severe symptoms, including acute life-threatening events, is aortopexy [46, 61, 66]. This is usually performed through a left anterior mediastinotomy (Chamberlain approach) or anterolateral thoracotomy [61]. The ascending aorta and arch are sutured to the posterior surface of the sternum after partial thymectomy [61]. The lifting of the aorta up in this fashion raises the anterior wall of the trachea and opens the tracheal lumen. In cases in which the aortic arch would not reach the posterior aspect of the sternum without undue tension, the use of a flap of pericardium based at the root of the aorta to be sutured to the sternum may be used [61]. Aortopexy and tracheopexy have also been done through

anterior mediastinal approach via a low transverse cervical incision.

Oesophageal replacement surgery is usually done for patients with OA when primary repair fails or when primary repair is impossible. Various operative procedures have been described; and the most commonly used ones are colon or ileocolon interposition, reversed (antiperistalsis) gastric tube interposition, isoperistalsis gastric tube interposition, jejunum interposition and gastric transposition (gastric

Among the methods, colon replacement, or ileocolon, has been widely practiced for many years as a method of oesophageal replacement. This involves placement of the right or left colon substernally or behind the hilum of the lung on the right or left side. To avoid stricture or ulceration at the cologastric anastomosis, vagotomy and a gastric drainage procedure are typically performed. Complications after colonic interposition include cervical anastomotic leak, stricture and intrathoracic redundant colon with stasis, gastric reflux, respiratory problems and diarrhoea.

Reversed gastric tube as a substitute is preferred by some surgeons. A tubularised portion of the greater curvature is brought up to the cervical oesophagus in the substernal or retrohilar position. This procedure has similar complications as described for colonic interposition. A portion of the greater curvature of the stomach can be fashioned into a "free" tube graft based on the right gastroepiploic artery; and this is used as a modification of the reversed gastric tube for oesophageal replacement.

**2.13 Oesophageal replacement**

pull-up) [67] (**Table 10**).

**64**

**Table 10.**

*Commonly used oesophageal replacement techniques.*

During the early years, the surgical management of OA was associated with lots of challenges and high mortality [1–4]. Respiratory failure, inadequate resuscitation, and complications of prematurity resulted in most deaths in the past. Complications of the surgical repair of the oesophageal atresia itself, particularly sepsis after dehiscence of the oesophageal anastomosis, and prolonged poor nutrition are other major causes of mortality.

Over the past two to three decades, however, the surgical outcome has improved significantly in most centres in the developed countries. This improvement is attributed to advances in neonatal anaesthesia, well-established neonatal intensive care units (NICU), availability of total parental nutrition (TPN) and refined surgical skills [1, 5–8]. The current major cause of mortality in most developed countries is from associated major congenital abnormalities. Death from prematurity or oesophageal complications is now rare. In view of this, the previously used Waterston classification has little relevance in developed countries. The prognosis however remains poor in developing countries where late presentation is the norm. Waterston classification may remain relevant in these countries.

Gastro-oesophageal reflux and poor oesophageal clearance due to some degree of ongoing oesophageal dysmotility may limit long-term survival. Dysplastic changes in the lower oesophageal mucosa may predispose to oesophageal carcinoma. Ongoing gastro-oesophageal reflux is a significant risk fact for oesophageal carcinoma. Hence, regular surveillance in these patients is important.
