Influence of anatomy and physiology on the management of oesophageal atresia.

Anatomical and physiological considerations specific to newborn infants with congenital thoracic abnormalities directly affect the timing and nature of surgical intervention during the neonatal period. This paper uses oesophageal atresia as an example of a common neonatal thoracic condition to highlight the way in which these considerations have influenced the approach to their surgical management. The type of surgical approach employed during thoracotomy determines the likelihood of subsequent chest wall deformity: an intercostal approach is preferable to rib resection. Multiple thoracotomies adversely affect the chest wall appearance and lung function. In premature infants with respiratory distress syndrome early surgical closure of the tracheo-oesophageal fistula is advantageous, and gastrostomy alone often prolongs the ventilatory difficulties. The upper oesophagus can be extensively mobilized with little danger to its blood supply, whereas the lower oesophagus, because it receives a segmental supply, is more vulnerable to ischaemia. The severity and distribution of tracheomalacia is reflected in its symptomatology. Tracheomalacia often coexists with gastro-oesophageal reflux, which should be corrected by a fundoplication if respiratory symptoms persist or an oesophageal stricture develops. The numerous factors producing heat loss in the newborn during thoracotomy are discussed. It is clear that an understanding of the anatomy and physiological changes which occur in the neonate is required if these infants are to be treated effectively and safely.