Oesophageal Atresia And Tracheoesophageal Fistula At Kenyatta National Hospital ; A Review Of Pre-operative, Intra-operative, Post-operative And Anaesthetic Management

Abstract

A review of pre-operative, intra-operative, post-operative and anaesthetio management of 54 patients, operated on at Kenyatta National Hospital, for oesophageal atresia with tracheoesophageal fistula, was done o. These were patients operated on during a period of 8 yrs. ( 1976 - 1987 ). Four aspects of the supportive management for these patients, during the pre-operative, intra-oprative and post-operative periods, were chosen to form the main subject for this study i e 1). Prophylaxis against and treatment of pulmonary complications of this congenital anomaly, during the three periods of treatment 2). Fluid therapy for these patients, during the three stages Qf treatment. 3). Body temperature control and maintenance, during the three periods of management 4). Nutritional management of these patienta, pre-operatively and post-operatively. This study sought to establish the mortality rate in this series of patients and to compare it with those mortality those mortality rates reported elsewhere in other centres. Concerning the four aspects of supportive management chosen for this study, inadequencies were found as follows:- a). Measures taken to prevent pulmonary complications were inadequate especially during the preoperative period, with these improving post-operatively 0 b). Fluid therapy was occasionally inadequate both qualitatively and quantatively, during all the three periodsof management. Occasionally, fluid overload was also seen. c). Body temperature maintenance and regulation measures were often inadequate, especially during the pre-operative and intra-operative periods, with some patients remaining hypothermic during this two periods of their management. d). Insufficient use of hyperalimentation where this was indicated, hence twenty-two of the patients had no extra nutritional support, other than interaveuous dextrose solutions. Some patients were introduced to oral feeding before radiological screening to rule out anastomotic leaks. The importance of this aspect of investigation can not be over emphasised, since mortality rate amoungest patients who developed anastomotic leak, was 100 % in this study. Mortality rates were seen to raise and fall, depending on the efficency of the supportive care offered. Together with these four aspects of supportive care, other factors affecting survival in patients born with oesophageal atresia with tracheoesophageal fistula were reviewed ; a). Prematurity with low birthweight, mortality rate was 100 % for babies who were born prematurely and who weighed less' than 1800 gms at birth. b). Age in days at time of operation was also seen to reflect on mortality in this study. Survival was less likely, the older the patient in days at time of operation. c. Patient's A. S. A. grade on admission, as determined by their general condition, presence and severity of systemic illness, complicating either the oesophageal atresia, with tracheoesophageal fistula, or other congenital malformations mortality rate rose, the poorer the &. S. A. grade of the patient; was at admission. d). Post-operative complications, amongst which, alJPiratipn pneumonaa ' and mecha m.caL and lor technical faults occured most frequently and were responsible for mortality rate~ of 75 % and 6607% respectively in the groups of Ratients who developed them. Inadequate supportive care combined with the other extra factors listed above caused a mortality rat~ of 61.1% in total, in thia series of patients, which was thought to be unacceptably high, when compare~ to mortality rates reported from other centres. Scanty investigations that were considered helpful in the management of these patients, and inadequate record keeping , especially during the pre-operative; and intra-operative periods, were frequently observed. Anaesthetic techniques applied on these patients locally, were seen to conrespond well, with with these applied elsewhere, but monitoring was minimal, which resulted into failure to recognise various intra-operative complications. No intra-operative deaths were recorded but four patients had cardiac arrests, while two patient patients developed hypothemia • Post-operative complications , mainly pulmonary and circulatory caused high mortality, Mechanical and lor technical faults, occuring during the post-operative management of these patients, also resulted with frequent deaths. These faults occured mainly in those patients who remained intubated and were either on spontenous breathing or mechanical ventilation post-operatively in the Intensive Care Unit.