Paediatric surgery case

Abstract

A complicated type of paediatric surgery case as reviewed in this paper consists of a neonate with two special types of GI atresias; a duodenal atresia (DA) and oesophageal atresia (OA) with distal tracheo-oesophageal fistula (TEF). Atresia can be defined as the congenital absence or obstruction of a normally patent lumen or orifice. While most small and large bowel atresias are thought to be due to ante-natal ischaemic events (vascular insult hypothesis), DA is due to a failure of duodenal recanalization around the 4th to 10th week of gestation. OA/TEF arises from a defect in the formation of the tracheo-oesophageal septum. The patient was prenatally diagnosed with DA via the double bubble sign on ultrasound. Post natally, an attempted nasogastric (NG) tube insertion failed and coiled , confirming OA. The double bubble sign being present simultaneously (such as in DA) therefore indicated a connection between the oesophagus and the trachea such that air is blown into the stomach despite the OA. This is how the TEF was diagnosed , and both conditions necessitate immediate surgical intervention in the first 24 hours of birth. Surgical goals involve fistula ligation , division and restoration of continuous lumen. The standard procedure for OA/TEF (most commonly type C) is primary repair via thoracotomy or thoracoscopy, with end to end anastomosis. DA is primarily repaired via duodeno-duodenostomy, using the Diamond shaped (Kimura) procedure/anastomosis. The management includes pre and post operative care , utilising a replogle tube for suction and sham feeding to maintain oral motor skills and gut stimulation , feeding prior to oral feeds is done with total parenteral nutrition. Post op following both repairs a transanastomotic tube is inserted where the duodenum dilates , in order to allow for the dilation to repair bypassing the surgical site in the meantime. Post operative complications include anastomotic leakage , structures , motility issues and increased risk of chronic issues. Associated conditions like VACTERL association and Downs syndrome are important risk factors for consideration in these patients.