**2.12 Complications after repair of OA**

Complications [57–59] resulting from repair of OA are generally grouped into two: early and late complications (**Table 9**). Early complications include anastomotic leak, anastomotic stricture, and recurrent tracheo-oesophageal fistula. Tracheomalacia, gastro-oesophageal reflux and oesophageal dysmotility are the late complications. Factors that promote postoperative complications include preoperative intubation, birth weight less than 2.5 kg, long-gap OA [60], post-operative intubation for more than 4 days, anastomotic leak and inability to feed orally for more than 1 month [61]. Management of the complications may involve a multidisciplinary approach.

### *2.12.1 Early complications*

### *2.12.1.1 Anastomotic leak*

Anastomotic leak at the oesophago-oesophagostomy is found in about 14–16% of patients after primary repair of OA. Most often, the leaks are clinically insignificant and can be managed with adequate drainage and nutritional support. Up to 95% of the leaks close spontaneously when a retropleural approach is undertaken and a patent mediastinal drain is in place [62]. Even in transpleural repair with leakage, spontaneous closure occurs with adequate drainage. Anastomotic breakdown


#### **Table 9.**

*Complications associated with oesophageal atresia repair.*

usually leads to the formation of a stricture at the site and may be associated with a recurrent TOF. Only 3–5% of anastomotic leaks are known to result from major disruptions of the oesophageal anastomosis. They are found to be typically seen within 24–48 h after repair. Patients usually deteriorate as result of tension pneumothorax or mediastinitis. Hence, prompt reoperation with adequate drainage is imperative. Repair of the leak may be attempted, and this may be buttressed with the help of a pleural or pericardial patch, with or without intercostal muscle flap. Contributing factors to anastomotic leak include poor surgical technique, ischemia of the oesophageal ends, the use of myotomy and excessive tension at the anastomotic site [63, 64]. If reanastomosis is not possible, cervical oesophagostomy and delayed oesophageal replacement would be required.

#### *2.12.1.2 Anastomotic stricture*

Anastomotic stricture is found to be a common complication after repair of OA. It is characterised by dysphagia and recurrent respiratory problems due to aspiration or foreign body obstruction. The narrowing is noted on endoscopy or contrast oesophagography. Poor anastomotic technique (excessive tension, twolayered anastomosis and silk suture material), long gap, ischemia at the ends of the oesophagus, gastro-oesophageal reflux and anastomotic leak are factors implicated in the pathogenesis of oesophageal stricture.

Anastomotic stricture is treated by dilatation. However, a stricture resistant to repeated dilatations will require resection and reanastomosis or oesophageal replacement. Triamcinolone injection may be used at the stricture site. However, repeated injections may lead to adrenal suppression. Application of mitomycin C to the stricture under endoscopic control has also been reported to reduce stricture formation after dilation. It is important to determine whether the oesophageal stricture is associated with gastro-oesophageal reflux. This can be determined using contrast oesophagography, endoscopy, pH monitoring or a combination of these studies. The presence of gastro-oesophageal reflux is initially managed medically with proton pump inhibitors. Failure of medical management may warrant antireflux procedure.

#### *2.12.1.3 Recurrent tracheo-oesophageal fistula*

Recurrent TOF commonly results from anastomotic leak with local inflammation and erosion through the previous site of TOF repair. Recurrent TOF can be minimised by the use of a pleural flap, vascularized pericardial flap or azygous vein flap interposed between the oesophageal and tracheal suture lines. Symptoms of recurrent TOF can be typical of those seen with a congenital H-type TOF (coughing with feedings and recurrent respiratory distress). However, less obvious symptoms such as recurrent pulmonary infections are more common. Air-filled oesophagus on plain radiographs of the chest is suggestive of the diagnosis. As done in patients with congenital H-type fistula, contrast oesophagography performed in the prone position under videofluoroscopy is a reliable method of establishing the diagnosis. Another reliable diagnostic approach is bronchoscopy with cannulation of the fistula with a 2- to 3-French catheter. It is invaluable in locating the fistula

**63**

*Oesophageal Atresia: Drowning a Child in His/Her Own Saliva*

thermy or laser deepithelialization followed by fibrin glue.

are also suggestive of gastro-oesophageal reflux.

during the operative procedure. About 50% of recurrent TOF is missed on routine contrast swallow studies. A recurrent TOF rarely closes spontaneously and usually requires surgical repair. Operation of choice is thoracotomy with fistula ligation, and division is the operation of choice. Pleura, intercostal muscle or pericardium should be interposed between the oesophagus and trachea to minimise recurrence. Endoscopic treatment of TOF by means of various chemicals or diathermy has also been reported. Various case reports and case series have reported the use of dia-

Gastro-oesophageal reflux is a common complication after repair of OA [65]. It is probably related to shortening of the intra-abdominal portion of the oesophagus because of anastomotic tension and/or oesophageal motor dysfunction. The motor dysfunction may be intrinsic to the congenital anomaly or acquired from operative manipulation. Clinically, gastro-oesophageal reflux is suspected in

patients with symptoms of vomiting, dysphagia and recurrent anastomotic stenosis. Episodes of foreign body or food bolus impaction may occur. Respiratory symptoms such as stridor, cyanotic spells, recurrent pneumonia and reactive airway disease

Upper gastrointestinal contrast study and 24-h pH probe data are diagnostic tools for gastro-oesophageal reflux. Multichannel oesophageal impedance combined with pH monitoring may emerge as a superior test. Abnormal oesophageal peristalsis and decreased lower oesophageal sphincter pressures after OA repair have been documented on oesophageal manometry. Medical management typically consists of thickening of feedings, positioning of the infant in a prone or upright posture, administration of acid reduction agents such as histamine-2 blockers, proton pump inhibitors and prokinetic agents. Antireflux operations are offered for patients with failed medical management, failure to thrive, chronic pulmonary infection, refractory anastomotic stricture or the development of a distal oesopha-

Respiratory symptoms occurring after repair of OA can be due to tracheomalacia. Tracheomalacia is defined as generalized or localized weakness of the trachea that allows the anterior and posterior tracheal walls to come together during expira-

Symptoms of tracheomalacia are often difficult to clinically distinguish from those of recurrent TOF, anastomotic leak, or gastro-oesophageal reflux. Embryologic events leading to TOF are believed to contribute to the development of tracheomalacia [61]. The tracheal cartilage is shorter than normal, thereby failing to provide the support necessary to maintain a patent airway [61]. The trachea may also be compressed between the aorta anteriorly and the often dilated upper oesophagus posteriorly after repair of OA; and such compression has been considered a significant contributor to the pathophysiology of tracheomalacia [61]. The tracheal collapse usually occurs in the region of or just above the original site of TOF in the distal third of the trachea which is generally at the level of the aortic arch; and severe tracheomalacia appears less common in infants with pure OA. Tracheomalacia has broad clinical manifestations, ranging from a "brassy" or "barking" cough in mild cases to recurrent pneumonia or acute, life-threatening

*DOI: http://dx.doi.org/10.5772/intechopen.84525*

*2.12.2 Late complications*

geal stricture.

tion or coughing.

*2.12.2.2 Tracheomalacia*

*2.12.2.1 Gastro-oesophageal reflux*

### *Oesophageal Atresia: Drowning a Child in His/Her Own Saliva DOI: http://dx.doi.org/10.5772/intechopen.84525*

during the operative procedure. About 50% of recurrent TOF is missed on routine contrast swallow studies. A recurrent TOF rarely closes spontaneously and usually requires surgical repair. Operation of choice is thoracotomy with fistula ligation, and division is the operation of choice. Pleura, intercostal muscle or pericardium should be interposed between the oesophagus and trachea to minimise recurrence. Endoscopic treatment of TOF by means of various chemicals or diathermy has also been reported. Various case reports and case series have reported the use of diathermy or laser deepithelialization followed by fibrin glue.
