Esophageal atresia and tracheoesophageal fistula

Classification and epidemiology

Depending on the location of the blind ends of the esophagus and the presence of a pathological communication with the trachea, five main anatomical variants of the malformation are distinguished:

• Atresia with a distal fistula is the absolute leader in frequency of occurrence (82%). In this form, the upper segment of the esophagus ends blindly, while the lower segment connects to the trachea.
• Isolated atresia (without fistula formation) is observed in 9% of cases.
• H-type tracheoesophageal fistula without esophageal atresia itself occurs in 6% of patients.
• Atresia with communication from both remnants (both proximal and distal) is diagnosed in 2% of cases.
• Atresia with a proximal fistula is the rarest form, accounting for only 1%.

Radiological signs and examination technique

Initial evaluation is often based on plain radiography with inserted tubes.

1. Presence of a distal fistula: The radiograph shows an endotracheal tube and a Replogle tube (Replogle tube). The main marker of distal communication is the presence of gas in the intestinal loops under the dome of the diaphragm. This means that air from the respiratory tract penetrates into the gastrointestinal tract below the zone of atresia.
2. Absence of a distal fistula: The Replogle tube is in place, but gas in the abdominal cavity is not visualized.

To detect an H-type fistula, a contrast study is used. The child is placed in a prone position. A catheter is inserted into the lower part of the esophagus, through which a water-soluble contrast agent is administered under pressure while slowly withdrawing the catheter (the X-ray tube is in a lateral position). If a defect is present, the contrast enters the large airways through an oblique channel just above the clavicles.

Important: A negative result of this test does not rule out the presence of an H-type fistula. If clinical suspicion persists, the patient is scheduled for rigid bronchoscopy combined with esophagoscopy.

Preoperative evaluation

Esophageal atresia is extremely rarely the only problem. The malformation is often part of the VACTERL association. That is why, at the stage of preparation for surgical intervention, all children are required to undergo an examination of:

• The cardiovascular system;
• The urinary tract;
• The spine (for example, radiography often reveals concomitant vertebral segmentation anomalies at the T5–T8 level).

Postoperative management and early complications

Following malformation correction, drug-induced myoplegia is performed for the first 3–5 days to minimize muscle tension in the area of the fresh anastomosis. Before starting enteral nutrition, the surgeon may place a transanastomotic tube to perform an esophagogram and check suture tightness.

Short-term complications (first days and weeks):

• Anastomotic leakage: Recorded in 5–20% of cases. The high-risk group includes children with a large diastase between the esophageal segments (long-gap OA). Radiologically, severe leakage may manifest as a tension pneumothorax.

Medium-term and long-term complications

Subsequently, patients also require careful radiological and clinical monitoring due to the high risk of specific problems:

• Anastomotic stricture: The most frequent complication (occurs in approximately 60% of patients, although some data indicate up to 80%). It can develop as early as the 5th day. A risk factor is a large diastase. It is treated using repeated X-ray endovascular balloon dilations.
• Recurrent fistula: Observed in 10% of cases. It forms against the background of micro-leakage of sutures, which causes inflammation and repeated rupture into the trachea. Diagnosis is extremely difficult.
• Functional disorders: More than half of patients suffer from severe gastroesophageal reflux, abnormal peristalsis, and decreased esophageal clearance. It is these motor defects, rather than the anastomosis itself, that most often determine the long-term prognosis.
• In older children, peptic stricture may form against the background of reflux, and food bolus obstruction in the anastomotic zone frequently occurs due to dysmotility and narrowing.

Briefly: answers to topical questions

Class and exam questions

What else to study on this topic

• VACTERL association: detailed analysis of components
• Technique of balloon dilation of esophageal strictures
• Differential diagnosis of vomiting syndrome in newborns
• Features of performing rigid bronchoscopy in pediatrics

Other Topics in "Pediatric Diagnostic Radiology"

Prepared by WhiteCoat Pro faculty in accordance with the medical school curriculum. For educational purposes only.