Morbidity and Mortality in Esophageal Atresia and Tracheoesophageal Fistula: A 20-Year Review

Abstract

Background: The outcome of newborns with esophageal atresia (EA) and tracheoesophageal fistula (TEF) has improved considerably. At present, the overall survival rates reported from developed countries are between 85 and 95%. This, however, is not the case from developing countries, where several factors contribute to higher morbidity and mortality rates. This study is an analysis of our experience with 158 patients of EA and TEF, with emphasis on factors contributing to morbidity and mortality.

Patients and methods: This is a retrospective study of 158 patients with EA and TEF treated over a period of 20 years (between January 1992 and December 2011). Their records were reviewed, the study period was divided into two equal periods, and the results were analyzed accordingly.

Results: A total of 158 patients (89 boys and 69 girls) with EA/TEF were treated. Their mean birth weight was 2.4 kg (700–3800 g). Their ages at diagnosis ranged from newborn to 8 months. Their gestational age ranged from 32 weeks to 41 weeks. Contrast study was used in 45 (28.5%) patients. Aspiration pneumonia was detected in 34.8% patients. The distribution of the number of patients according to the type of EA/TEF was as follows: 132 (83.5%) patients had EA with distal TEF, 14 (8.9%) had pure EA, five (3.2%) had EA with proximal and distal TEF, five (3.2%) had H-type TEF, and two (1.3%) had EA with proximal TEF. Forty-one (22.2%) patients had long-gap EA/TEF. Associated anomalies were seen in 82 (51.9%) patients, and 17 (10.8%) patients had severe anomalies. The postoperative complications included: anastomotic leak in 20 patients (12.7%), stricture in 22 (13.9%),gastroesophageal reflux in 18 (11.4%), tracheomalacia in two (1.3%), and recurrent TEF in one (0.6%). However, there was a marked decrease both in mortality and morbidity during the second period of the study. In our study, the overall mortality rate was 20.9%, but if those with severe associated anomalies were excluded, our postoperative mortality rate was 8.4%. Sepsis was the main cause of death.

Conclusion: This is a relatively large series from a developing country. Although our postoperative complication rates were similar to those from developed countries, the overall mortality was higher. There was, however, a marked improvement during the second period of the study. This is attributed to a better understanding, early diagnosis, prompt referral, and better surgical techniques. Prematurity, sepsis, and associated severe malformations were the main causes of death. Once major anomalies responsible for death were excluded, our postoperative mortality rate was 8.4%. Sepsis continues to be a major cause of death, and several factors contribute to this, including prematurity and delayed diagnosis with increased incidence of aspiration pneumonia. To decrease the mortality rate, these factors should be addressed, and every effort should be made to overcome them. Patients with long-gap EA/TEF continue to be a management challenge, and every attempt should be made to preserve the native esophagus. Delayed primary repair and/or esophageal stretching are at present the preferred techniques with good long-term functional results.

Keywords: Complications, Esophageal Atresia, Morbidity and Mortality, Tracheoesophageal Fistula