A retrospective review of the perioperative management of patients with congenital oesophageal atresia and tracheo-oesophageal fistula at a South African third level hospital

Abstract

Background: The perioperative management of neonates with oesophageal atresia and tracheo-oesophageal fistula (OA/TOF) is challenging. There is currently very little South African data available about the perioperative management of this condition. Current management is therefore informed by institutional experience and international studies. This study aims to describe the patient population with OA/TOF presenting for surgery, to evaluate the preoperative factors affecting early mortality, and to report on intraoperative ventilation and haemodynamic complications. 
Methods: A single-centre retrospective review was conducted of electronic medical records of patients less than 28 days old undergoing initial surgical intervention between January 2007 and December 2017 at a third level hospital. 
Results: A total of 107 patients were included in this study. A delay in transfer to our institution was found in 63% of the patients. Roughly half of the patients (52%) required preoperative mechanical ventilation. The incidence of major cardiac and other congenital abnormalities was 29% and 33%, respectively. Survival rates within the lowest and the highest risk groups (Okamoto class 1 and 4) were 90% and 45%, respectively. Airway and ventilation difficulties were described in 8.4% of patients and these patients required intervention in the form of reintubation, gastrostomy or abandoning surgery. Haemodynamic instability occurred in 27% of the patients, more commonly in those with preoperative pneumonia and major cardiac comorbidities. 
Conclusion: The lack of antenatal diagnosis, together with delays in transferring patients to an appropriate referral centre, resulted in a high incidence of pneumonia requiring ventilatory support and delays in first surgical intervention. The incidence of major cardiac and other abnormalities was similar to other international data, with the exception of VACTERL associated anomalies, which was lower in this cohort. Survival outcome, however, was worse in this cohort than international studies. This study gives local context to risk stratification systems and highlights the challenges of managing these patients in a developing country.