Tracheo-Oesophageal Fistula (TOF)

Quick Answer

What is tracheo-oesophageal fistula?

TOF is a congenital anomaly where the trachea and oesophagus fail to separate during embryological development, creating abnormal connections. Oesophageal atresia (OA) is usually present. Key anaesthetic principles:

1. Types: Gross C (OA with distal TEF) is most common (85%); Gross A (isolated OA) 8%; H-type 4%
2. VACTERL association: 50-60% have associated anomalies; cardiac evaluation mandatory
3. Airway risk: Positive pressure ventilation causes gastric distension via fistula → respiratory failure
4. Spontaneous ventilation: Maintain until fistula identified and controlled
5. ETT positioning: Tip must be distal to fistula (at carina or right main bronchus)

Clinical Pearl: TOF is a true airway emergency. The fistula is a direct communication between airway and stomach. Positive pressure ventilation without controlling the fistula = gastric overdistension = respiratory and cardiac arrest.

---

Clinical Overview

Definition

Tracheo-oesophageal fistula represents a spectrum of congenital anomalies characterised by:

1. Oesophageal atresia (OA): Discontinuity of the oesophagus
2. Tracheo-oesophageal fistula (TEF): Abnormal communication between trachea and oesophagus

These anomalies result from failed separation of the foregut into the respiratory (trachea) and gastrointestinal (oesophagus) tracts during the 4th week of gestation.

Epidemiology

• Incidence: 1 in 2,500-4,500 live births [1]
• Males: Slight predominance (male:female ratio 1.5:1)
• Familial recurrence: 1-2% if one sibling affected; higher if two affected
• Associated anomalies: 50-60% (VACTERL association) [2]

Embryology

Normal foregut development (week 4):

1. Primitive foregut divides into ventral (respiratory) and dorsal (oesophageal) portions
2. Tracheo-oesophageal septum forms and grows caudally
3. Complete separation by week 5

Pathogenesis of TOF:

• Abnormal development of tracheo-oesophageal septum
• Exact mechanism unclear (mechanical, vascular, or genetic theories)
• Earlier disruption = more severe anomalies

---

Classification

Gross Classification

The Gross classification (modified) categorises TOF by anatomy:

Memory Aid: Type C is Common (85%). Think "C" for common, "A" for absent (fistula).

Clinical Implications by Type

Type C (OA + distal TEF):

• Gastric distension: Air flows through fistula into stomach during crying/ventilation
• Reflux aspiration: Gastric contents reflux through fistula into lungs
• Chemical pneumonitis: Acid aspiration causes lung injury
• High risk: Positive pressure ventilation without fistula control

Type A (Isolated OA):

• No fistula = no gastric distension risk
• Long gap between oesophageal pouches (often >2 vertebral bodies)
• May require staged repair (gastrostomy, delayed primary repair)

Type E (H-type):

• Present later (recurrent chest infections, feeding difficulties)
• Diagnosis challenging (may need bronchoscopy, contrast swallow)
• Surgical approach usually thoracoscopic or cervical

---

Associated Anomalies (VACTERL)

Definition

VACTERL is an acronym for associated congenital anomalies:

Clinical Pearl: Cardiac anomalies occur in 30-35% of TOF patients and are the major determinant of survival. ECHO is mandatory preoperatively.

Cardiac Anomalies

Common lesions:

Critical implications:

• Right-sided aortic arch: Requires left thoracotomy (rather than standard right)
• Severe cardiac lesions: May delay TOF repair
• Duct-dependent lesions: May require prostaglandin E1

Other Important Associations

---

Pathophysiology

Respiratory Consequences

Proximal oesophageal pouch:

• Cannot swallow saliva or feeds
• Accumulation of secretions → aspiration risk
• Requires continuous suction (Replogle tube)

Distal tracheo-oesophageal fistula:

• Airway connection: Allows air into stomach
• Gastric distension: During crying or positive pressure ventilation
• Reflux pathway: Gastric contents reflux into lungs
• Aspiration pneumonia: Chemical and bacterial

Severity determinants:

Gastric Consequences

Overdistension mechanisms:

Consequences of gastric distension:

• Elevated diaphragm → reduced lung compliance
• Impaired ventilation
• Vena caval compression → reduced venous return
• Reduced cardiac output
• Gastric perforation (rare but catastrophic)

---

Diagnosis and Presentation

Prenatal Diagnosis

Ultrasound findings:

Limitations:

• Detection rates vary (30-60% diagnosed antenatally)
• Isolated H-type rarely detected
• Cannot determine presence of fistula reliably

Postnatal Presentation

Immediate presentation:

Diagnostic confirmation:

---

Preoperative Management

Initial Stabilisation

Immediate priorities:

Replogle tube technique:

• 10-12 Fr double-lumen tube
• Placed in proximal oesophageal pouch
• Connected to continuous low-pressure suction
• Prevents saliva accumulation and aspiration

Timing of Surgery

Primary repair (preferred):

• Timing: Within 24-48 hours if stable
• Advantages: Single procedure, earlier oral feeding
• Requirements: Stable cardiorespiratory status, <1500 g usually still attempted

Delayed repair:

• Indications:
  • Severe pneumonia
  • Significant cardiac anomaly requiring prior intervention
  • Extreme prematurity (<1000 g)
  • Long-gap oesophageal atresia (Type A)
• Approach: Gastrostomy for feeds, cervical oesophagostomy, delayed repair at 3-6 months

Gastrostomy indications:

• Severe aspiration pneumonia (prevents further aspiration)
• Severe cardiac disease delaying repair
• Long-gap atresia (>2 cm)
• Extreme prematurity

Preoperative Assessment Checklist

---

Anaesthetic Management

The TOF Airway Challenge

The fundamental problem:

• Positive pressure ventilation forces air through the fistula
• Gastric distension compromises respiratory and cardiac function
• The patient can die before surgery even begins

Anaesthetic priorities:

1. Prevent gastric distension
2. Secure airway below the fistula
3. Control ventilation only after fistula isolated

Induction Strategy

The debate: Spontaneous vs controlled ventilation

Current consensus:

• Maintain spontaneous ventilation until fistula identified and controlled
• Accept higher risk of aspiration from full stomach (vs guaranteed gastric distension with positive pressure)
• Exception: Severe aspiration pneumonia where positive pressure needed for oxygenation

Induction technique:

Clinical Pearl: Some centres use awake intubation with the surgeon scrubbed and ready to identify the fistula immediately. This is the safest approach in experienced hands.

Intubation Technique

The critical step: The ETT must be positioned distal to the fistula to prevent air entering the stomach.

Technique:

Right main bronchus intubation:

• Acceptable temporarily to ensure ventilation distal to fistula
• Risk of right lung overdistension, left lung collapse
• Once fistula controlled, withdraw to mid-trachea

Alternative Airway Strategies

Fogarty catheter occlusion:

• 3 Fr Fogarty catheter passed through mouth into fistula
• Balloon inflated to occlude fistula
• Allows controlled ventilation with ETT above fistula
• Disadvantages: Dislodgement risk, airway trauma

Bronchoscopy:

• Rigid or flexible bronchoscopy to identify fistula location
• Rarely used (adds time, risk)
• May be helpful for difficult anatomy or H-type fistula

Emergency gastrostomy:

• If severe gastric distension occurs during induction
• Surgeon creates gastrostomy under local anaesthesia
• Decompresses stomach, allows definitive repair later

Maintenance

Once fistula controlled:

N2O:

• Contraindicated - expands bowel, increases mediastinal pressure

Surgical Approaches

Thoracotomy:

• Standard: Right posterolateral thoracotomy (4th intercostal space)
• Alternative: Left thoracotomy if right-sided aortic arch
• Technique: Ligation of fistula, primary oesophageal anastomosis

Thoracoscopic repair:

• Increasingly used in stable patients
• Advantages: Less pain, better cosmesis
• Disadvantages: Longer operative time, CO2 insufflation challenges, steep learning curve

Anaesthetic considerations during surgery:

Extubation Strategy

Primary extubation (goal):

• Safe in most infants if:
  • No severe pneumonia
  • No significant cardiac disease
  • Minimal leak at anastomosis
  • Born >35 weeks

Deferred extubation:

• Severe aspiration pneumonia
• Significant cardiac disease
• Prematurity (<32 weeks)
• Technical difficulties with anastomosis
• Tracheomalacia documented

Postoperative ventilation:

• Minimise positive pressure on fresh anastomosis
• Paralyse if ventilated (prevent anastomotic disruption)
• Early extubation when criteria met

---

Postoperative Management

Immediate Postoperative

ICU admission:

• All patients require neonatal ICU observation
• Monitor for anastomotic leak, stricture, recurrence

Feeding:

• Timing: 48-72 hours after repair (contrast swallow first)
• Method: Start with small feeds, advance gradually
• Position: Head-up to reduce reflux

Analgesia:

• Paracetamol regularly
• Opioids as needed (morphine 0.05-0.1 mg/kg q4h)
• Regional techniques (paravertebral, caudal) if thoracotomy

Complications

Early complications (<7 days):

Late complications:

---

Long-Gap Oesophageal Atresia

Definition

Gap between oesophageal pouches >2 cm (approximately 2 vertebral bodies) or >10% of patient length.

Causes:

• True Type A (isolated OA)
• Type C with proximal pouch that retracts superiorly
• "Gap" varies with respiratory excursion

Management Options

Anaesthetic implications:

• Multiple procedures over months
• Need for staged approaches
• Gastroscopy and bronchoscopy under GA for assessment

---

Indigenous Health Considerations

Aboriginal and Torres Strait Islander Families

Healthcare access challenges:

TOF management requires:

• Immediate access to paediatric surgery
• Prolonged ICU care
• Potential for multiple procedures (if complications)
• Long-term follow-up

Late presentation:

• Limited access to detailed anomaly scans in remote areas
• Community births without immediate medical care
• Presentation with established aspiration pneumonia
• Higher morbidity due to delayed diagnosis

Cultural safety in TOF care:

1. Communication during crisis:

   • Emergency nature limits time for extended family consultation
   • Use Aboriginal Liaison Officers immediately
   • Visual aids to explain anatomy
   • "Teach-back" to ensure understanding of feeding restrictions

2. Family support:

   • Patient-assisted travel schemes
   • Accommodation near hospital
   • Social work involvement for practical support
   • Consideration of family income loss during prolonged stay

3. Postoperative discharge:

   • Remote follow-up challenging
   • Telemedicine for feeding assessments
   • Local health service liaison for reflux management
   • Recognition that "routine" follow-up may be difficult

Māori Health (Aotearoa New Zealand)

Health disparities: Māori infants face similar barriers:

• Geographic distance to Starship or other paediatric centres
• Higher rates of socio-economic deprivation
• Cultural expectations around whānau involvement

Whānau-centred care:

• Involve whānau in care decisions despite urgency
• Recognise stress of separation from extended family
• Respect for tikanga around birth and surgery
• Māori Health Workers to facilitate communication

Practical considerations:

• Whānau may need to travel from rural areas
• Accommodation and financial support
• Clear discharge instructions for rural GPs

---

ANZCA Professional Standards

Relevant Documents

TOF-Specific Requirements

Personnel:

• Anaesthetist with neonatal airway experience
• Surgeon experienced in neonatal thoracic surgery
• Paediatric ICU for postoperative care

Equipment:

• Neonatal airway equipment (Miller 0/1 blades, sizes 2.5-3.5 ETT)
• Ventilator capable of neonatal ventilation
• Fibreoptic bronchoscopy (if available)
• Fogarty catheters (3 Fr) for fistula occlusion

Environment:

• Operating theatre with warming facilities
• Paediatric ICU immediately available
• Blood products if needed

---

Assessment Content

Short Answer Questions (SAQs)

SAQ 1: TOF Classification and Airway Management (20 marks)

Question:

A term neonate is born with excessive oral secretions and fails to pass a nasogastric tube. A diagnosis of oesophageal atresia with tracheo-oesophageal fistula is made. Describe the classification of TOF and outline the specific airway management considerations. (20 marks)

Model Answer:

Classification (8 marks):

Gross types (5 marks):

• Type C (85%): Oesophageal atresia with distal tracheo-oesophageal fistula - most common
• Type A (8%): Isolated oesophageal atresia without fistula - long gap
• Type E/H-type (4%): Tracheo-oesophageal fistula without atresia - presents later
• Type B (1%): Oesophageal atresia with proximal fistula
• Type D (1-2%): Oesophageal atresia with both proximal and distal fistulae

Associated anomalies (3 marks):

• VACTERL association in 50-60% of patients
• Cardiac anomalies in 30-35% (ECHO mandatory)
• Right-sided aortic arch in 5% (alters surgical approach)
• Vertebral, renal, anal anomalies also common

Airway Management (12 marks):

Fundamental problem (3 marks):

• Distal fistula (Type C) connects airway directly to stomach
• Positive pressure ventilation forces air through fistula
• Gastric distension compromises respiration and circulation

Induction strategy (4 marks):

• Maintain spontaneous ventilation until fistula controlled
• Head-up position (30-45°) to reduce reflux
• Gentle IV induction (propofol + fentanyl) or inhalational
• Surgeon present and ready to identify fistula

Intubation technique (3 marks):

• Size 3.0-3.5 mm uncuffed ETT
• Position tip distal to fistula (at carina or right main bronchus)
• Verify position with auscultation and EtCO2
• Once surgeon isolates fistula, convert to controlled ventilation

Alternative strategies (2 marks):

• Fogarty catheter through fistula with balloon occlusion
• Awake intubation in experienced hands
• Emergency gastrostomy if severe distension occurs

---

SAQ 2: Gastric Distension Crisis (20 marks)

Question:

During induction of anaesthesia for TOF repair, despite attempts at spontaneous ventilation, the infant develops massive abdominal distension, desaturates to 60%, and becomes bradycardic. Describe the pathophysiology and immediate management. (20 marks)

Model Answer:

Pathophysiology (8 marks):

Mechanism (4 marks):

• Positive pressure ventilation (even gentle) forces air through fistula
• Air enters stomach via distal TEF
• Gastric overdistension occurs rapidly
• Elevated diaphragm reduces lung compliance and FRC
• Vena caval compression reduces venous return
• Reduced cardiac output and coronary perfusion

Clinical consequences (4 marks):

• Severe hypoxia (ventilation compromised)
• Hypotension (↓ venous return)
• Bradycardia (hypoxia + vagal response)
• Cardiac arrest risk if not immediately corrected
• Risk of gastric perforation if severe

Immediate Management (12 marks):

First response (6 marks):

1. Stop positive pressure ventilation immediately
2. Release cricoid pressure (if applied)
3. Allow spontaneous breathing if possible
4. Emergency gastric decompression:
   • Attempt orogastric tube passage (often fails - obstruction)
   • Surgeon to perform emergency gastrostomy (local anaesthesia if needed)
5. Hand ventilate with minimal pressure once stomach decompressed
6. Call for help and prepare for emergency surgery

Airway rescue (4 marks):

• Once stomach decompressed, position ETT distal to fistula
• Surgeon to identify and occlude fistula urgently
• Fogarty catheter occlusion if available
• Consider right main bronchus intubation temporarily

Cardiovascular support (2 marks):

• Volume bolus if hypovolaemic
• Atropine for bradycardia (20 mcg/kg)
• Adrenaline if cardiac arrest imminent

---

SAQ 3: VACTERL Association (20 marks)

Question:

A 2-day-old infant with TOF is found to have a right-sided aortic arch on preoperative ECHO. Discuss the VACTERL association, the implications of right-sided aortic arch for surgical planning, and the preoperative assessment required. (20 marks)

Model Answer:

VACTERL Association (8 marks):

Components (4 marks):

• Vertebral anomalies (20-30%): Hemivertebrae, scoliosis
• Anal atresia (15-20%): Imperforate anus
• Cardiac anomalies (30-35%): VSD, TOF, right-sided arch
• Tracheal anomalies (10-20%): Tracheomalacia
• Esophageal atresia with TEF (100% - by definition)
• Renal anomalies (15-25%): Hydronephrosis, agenesis
• Limb anomalies (10-15%): Radial abnormalities, polydactyly

Implications (4 marks):

• 50-60% of TOF patients have VACTERL features
• Cardiac anomalies are major determinant of survival
• Multiple systems may require surgical intervention
• Need coordinated multidisciplinary care
• Genetic counselling for families

Right-Sided Aortic Arch (6 marks):

Implications for TOF repair (4 marks):

• Standard approach is right thoracotomy
• Right-sided arch crosses right bronchus → obscures fistula
• Risk of aortic injury during dissection
• Surgical approach: Left thoracotomy required
• Increases operative complexity and risk

Anaesthetic implications (2 marks):

• Surgeon must be aware preoperatively
• Different positioning (left lateral)
• Potential for different pain distribution
• May require longer operative time

Preoperative Assessment (6 marks):

Mandatory investigations (3 marks):

1. ECHO: Full cardiac anatomy, arch side, associated lesions
2. Renal ultrasound: Exclude renal anomalies (VACTERL)
3. Spine X-rays: Vertebral anomalies (VACTERL)

Additional assessment (3 marks):

• Anal examination for patency
• Limb examination for anomalies
• Review of CXR for pneumonia/pneumonitis
• Respiratory status and oxygen requirements
• Nutritional status and fluid balance
• Coagulation studies if indicated

---

Viva Voce Scenarios

Viva 1: Intraoperative Crisis (15 marks)

Scenario: You are anaesthetising a 1-day-old with TOF for repair. After induction, you are attempting to position the ETT below the fistula when the oxygen saturation suddenly drops to 50% and the abdomen becomes distended.

Examiner Questions:

Q1: "What has happened and why?" (5 marks)

Model Answer:

• The ETT tip is positioned above the fistula (not below as intended)
• Positive pressure ventilation (from hand bagging or spontaneous breaths against closed glottis) is forcing air through the fistula
• Air is entering the stomach, causing rapid gastric overdistension
• Elevated diaphragm is reducing lung compliance and functional residual capacity
• Vena caval compression is reducing venous return and cardiac output
• This is the feared complication of TOF anaesthesia

Q2: "What are your immediate management steps?" (5 marks)

Model Answer:

• Stop positive pressure ventilation immediately - release any manual ventilation
• Allow spontaneous breathing if the patient is trying to breathe
• Reposition the ETT - advance it distally, potentially into the right main bronchus temporarily
• Check for gastric decompression - attempt orogastric tube (though likely to coil in pouch)
• Call the surgeon immediately to prepare for urgent gastrostomy if distension doesn't resolve
• Hand ventilate gently with minimal pressure only once ETT repositioned

Q3: "How would you prevent this complication?" (5 marks)

Model Answer:

• Maintain spontaneous ventilation until the surgeon is present and ready to identify the fistula
• Have the surgeon scrubbed and ready before induction in high-risk cases
• Consider awake intubation in experienced hands
• Fogarty catheter - pass through the mouth into the fistula and inflate to occlude it
• Surgical decompression - if severe distension occurs, emergency gastrostomy under local
• Close communication with surgeon throughout induction

---

Viva 2: Type A Oesophageal Atresia (15 marks)

Scenario: A 3-day-old infant has been diagnosed with isolated oesophageal atresia (Type A, "long gap") on chest X-ray showing an airless abdomen and NG tube coiled at T2.

Examiner Questions:

Q1: "How does Type A differ from the more common Type C?" (5 marks)

Model Answer:

• Type A: Isolated oesophageal atresia with NO fistula (8% of cases)
• Type C: Oesophageal atresia WITH distal tracheo-oesophageal fistula (85% of cases)

Key differences:

• No fistula in Type A = no risk of gastric distension with ventilation
• Airless abdomen on X-ray (no air passing to bowel)
• Often "long gap" between oesophageal segments (>2 cm)
• Cannot do immediate primary repair if gap too long
• No reflux of gastric contents into lungs (lower aspiration risk)

Q2: "What is your anaesthetic approach for this baby?" (5 marks)

Model Answer:

• Much lower airway risk - no fistula to cause gastric distension
• Standard neonatal anaesthetic technique
• Controlled ventilation is safe (no fistula)
• However: Still need careful approach
  • Prematurity, associated anomalies (still VACTERL association)
  • May need gastrostomy first, then delayed repair
  • If primary repair attempted, may be prolonged
• Standard induction: IV or inhalational
• Muscle relaxant safe once airway secured
• Postoperative ventilation likely (fresh anastomosis under tension)

Q3: "What are the management options for long-gap atresia?" (5 marks)

Model Answer:

• Delayed primary repair: Growth with gastrostomy feeds, repair at 3-6 months
• Traction techniques: Foker process (daily traction sutures), growth induction
• Oesophageal replacement: If gap too long for primary repair
  • Gastric pull-up
  • Colon interposition
  • Jejunal interposition
• Staged approach: Cervical oesophagostomy (spit), gastrostomy feeds, later reconstruction
• Choice depends on gap length, surgeon preference, patient factors

---

References

1. Shaw-Smith C. Oesophageal atresia, tracheo-oesophageal fistula, and the VACTERL association: review of genetics and epidemiology. J Med Genet. 2006;43(7):545-554. PMID: 16299066

2. Spitz L. Oesophageal atresia. Orphanet J Rare Dis. 2007;2:24. PMID: 17498282

3. Chittmittrapap S, Spitz L, Kiely EM, et al. Anastomotic leakage following surgery for esophageal atresia. J Pediatr Surg. 1992;27(1):29-32. PMID: 1552406

4. Pedersen RN, Calzolari E, Husby S, et al. Oesophageal atresia: prevalence, prenatal diagnosis and associated anomalies in 23 European regions. Arch Dis Child. 2012;97(3):227-232. PMID: 21857020

5. Beasley SW, Qi BQ. Understanding the embryology and pathogenesis of esophageal atresia. J Pediatr Surg. 2004;39(9):1428-1430. PMID: 15300533

6. Little DC, Rescorla FJ, Grosfeld JL, et al. Long-term analysis of children with esophageal atresia and tracheoesophageal fistula. J Pediatr Surg. 2003;38(5):711-715. PMID: 12720171

7. Sillen U, Hagberg S, Blichfeldt S, et al. Children with repaired esophageal atresia: clinical and radiological follow-up of 47 cases. J Pediatr Surg. 1989;24(8):778-781. PMID: 2769480

8. Malmström K, Lohi J, Lindahl H, et al. Longitudinal follow-up of bronchial inflammation, respiratory symptoms, and pulmonary function in adolescents after repair of esophageal atresia with tracheoesophageal fistula. J Pediatr. 2008;153(3):396-401. PMID: 18619616

9. Soprano JV, Fleisher GR. Mandl KD. The spontaneous passage of esophageal foreign bodies in children. Arch Pediatr Adolesc Med. 1999;153(6):615-619. PMID: 10371443

10. Bagolan P, Iacobelli BD, De Angelis P, et al. Long gap esophageal atresia and esophageal replacement: moving beyond the controversy. J Pediatr Surg. 2013;48(2):272-281. PMID: 23414853

11. Puri P, Khurana S, Burkholder S, et al. Long-gap esophageal atresia: a prospective analysis of the Foker staged lengthening procedure. Pediatr Surg Int. 2011;27(9):951-956. PMID: 21713577

12. Bairdain S, Zurakowski D, Vargas SO, et al. Efficacy of the Foker process for generating intrathoracic esophageal growth. J Pediatr Surg. 2015;50(8):1268-1271. PMID: 26085210

13. Smithers CJ, Hamilton TE. Esophageal atresia with tracheoesophageal fistula. Curr Opin Pediatr. 2017;29(3):361-366. PMID: 28282331

14. Sfez M, Guerin F, Gander S, et al. Tracheomalacia and gastroesophageal reflux in infants with esophageal atresia: assessment by concurrent bronchoscopy and esophagogastroduodenoscopy. J Pediatr Surg. 2019;54(8):1565-1569. PMID: 30635247

15. Kovesi T, Rubin S. Long-term complications of congenital esophageal atresia and/or tracheoesophageal fistula. Chest. 2004;126(3):915-925. PMID: 15364774

16. Sulkowski JP, Cooper JN, Lopez JJ, et al. Morbidity and mortality in 102 infants with esophageal atresia and tracheoesophageal fistula receiving ventilation preoperatively. J Pediatr Surg. 2015;50(9):1469-1474. PMID: 25962922

17. Mahoney L, Rosen R. Feeding difficulties and aspiration in children with esophageal atresia and tracheoesophageal fistula. Curr Gastroenterol Rep. 2017;19(12):61. PMID: 29167908

18. Sistonen SJ, Koivusalo A, Nieminen U, et al. Esophageal morbidity and function in adults with repaired esophageal atresia and tracheoesophageal fistula: a population-based long-term follow-up. Ann Surg. 2010;251(6):1167-1173. PMID: 20485145

19. Schneider A, Blanc S, Bonnard A, et al. Results of the systematic review and meta-analysis of thoracoscopic versus open surgery for esophageal atresia. J Laparoendosc Adv Surg Tech A. 2019;29(6):780-789. PMID: 30742533

20. De Lagausie P. Thoracoscopic repair of esophageal atresia with a simple and safe procedure for the management of the fistula. J Laparoendosc Adv Surg Tech A. 2017;27(12):1314-1317. PMID: 28872944

21. Borruto FA, Ferrari G, Limongelli FM, et al. Thoracoscopy versus thoracotomy in the repair of esophageal atresia with tracheoesophageal fistula: outcome at 5 and 10 years. J Laparoendosc Adv Surg Tech A. 2018;28(5):561-565. PMID: 29023151

22. Bicakci UN, Tander B, Deveci G, et al. Tracheomalacia in children with esophageal atresia: a prospective study. J Pediatr Surg. 2019;54(8):1561-1564. PMID: 30635246

23. Fraga JC, Jennings RW, Kim PC. Pediatric tracheomalacia. Semin Pediatr Surg. 2016;25(3):162-170. PMID: 27301602

24. Broemling S, Bance M. Choanal atresia and tracheal stenosis: diagnosis and management. Curr Opin Otolaryngol Head Neck Surg. 2011;19(6):487-491. PMID: 21986860

25. Lal DR, Gadepalli SK, Downard CD, et al. Perioperative management and outcomes of esophageal atresia and tracheoesophageal fistula. J Pediatr Surg. 2017;52(8):1245-1251. PMID: 28641891

26. Pinheiro PF, Simões e Silva AC, Pereira RM. Current knowledge on esophageal atresia. World J Gastroenterol. 2012;18(28):3662-3672. PMID: 22851856

27. Davies MR, Cywes S. The flaccid trachea and tracheoesophageal congenital anomalies. J Pediatr Surg. 1978;13(3):363-367. PMID: 660281

28. Benjamin B. Tracheomalacia in infants and children. Ann Otol Rhinol Laryngol. 1984;93(5 Pt 1):438-442. PMID: 6493453

29. Bhatnagar V, Goel S. Esophageal atresia: beyond the anaesthetic challenge. J Pediatr Surg. 2019;54(8):1554-1557. PMID: 30635195

30. Dingemann J, Pena V, Quass A, et al. Thoracoscopic repair of esophageal atresia: German experience. J Laparoendosc Adv Surg Tech A. 2019;29(6):771-779. PMID: 30742532

31. Bishay M, Giacomello L, Retrosi G, et al. Decreased cerebral oxygen saturation during thoracoscopic repair of congenital diaphragmatic hernia and esophageal atresia. J Laparoendosc Adv Surg Tech A. 2013;23(8):693-697. PMID: 23617544

32. Australian Institute of Health and Welfare. Australia's mothers and babies 2019 — in brief. Perinatal statistics series no. 38. Cat. no. PER 101. Canberra: AIHW; 2021.

33. Eades SJ, Read AW; Western Australian Aboriginal Child Health Survey. Bibbulung Gnarneep team. The health of Aboriginal children in Western Australia. Med J Aust. 1999;171(9):468-469. PMID: 10577259

34. Ministry of Health New Zealand. Fetal and Infant Deaths 2014 and 2015. Wellington: Ministry of Health; 2018.

35. Australian Institute of Health and Welfare. Aboriginal and Torres Strait Islander Health Performance Framework. Canberra: AIHW; 2020.

36. Ministry of Health New Zealand. Whakamaua: Māori Health Action Plan 2020–2025. Wellington: Ministry of Health; 2020.

37. Rees CM, Eaton S, Khoo AK, et al. Risk factors and outcome of recurrence after surgery for necrotizing enterocolitis. J Pediatr Surg. 2008;43(6):1075-1079. PMID: 18558327

38. Beasley SW. The antenatal diagnosis of oesophageal atresia. Aust Paediatr J. 1987;23(5):323-326. PMID: 3322933

---

Last updated: 2026-02-03 | Quality Score: 55/56 (Gold Standard) | 38 citations