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Oesophageal atresia and tracheo-oesophageal fistula (EA/TEF)
A newborn who drools and chokes on feeds and whose gastric tube stops and coils in the upper chest has oesophageal atresia; gas in the abdomen means there is a distal fistula (the common type), and a gasless abdomen means pure atresia with a long gap.
Why it matters in the exam
The exam asks about the common type (proximal atresia with a distal fistula, about 85%), the associated anomalies (VACTERL — vertebral, anorectal, cardiac, tracheo-oesophageal, renal and limb), the work-up before surgery — especially an echocardiogram, which finds a heart defect and also the side of the aortic arch, which decides the side of the thoracotomy — and late complications: anastomotic stricture, reflux, recurrent fistula and tracheomalacia.
The Gross types: C — atresia with a distal fistula (about 85%); A — pure atresia without a fistula (about 8%), gasless abdomen and a long gap; E — an H-type fistula without atresia (about 4%), which presents with coughing on feeds and recurrent pneumonia, is diagnosed by a prone contrast study with gradual tube pull-back or by bronchoscopy, and is usually repaired through a neck approach. Types B and D are rare. In pregnancy there is sometimes polyhydramnios and a small or absent stomach bubble.
The classic operation is a right thoracotomy (or thoracoscopy), an extrapleural approach, ligation of the fistula and primary anastomosis. With a long gap a gastrostomy is made, the upper pouch is kept on continuous suction and a delayed primary anastomosis is done after a few months. Anastomotic stricture is the common late complication and is treated by dilatation; reflux is very common and needs acid suppression and follow-up, including endoscopy over the years because of metaplasia.
Until surgery the upper pouch is kept empty by continuous suction through a double-lumen (Replogle) tube, the head of the bed is raised, positive-pressure ventilation is avoided where possible because it can inflate the stomach through the fistula, and the rest of VACTERL is sought: renal ultrasound, a spine X-ray and examination of the anus. Prognosis depends mainly on birth weight and a major heart defect (Spitz classification): weight above 1500 grams without a major heart defect — near-complete survival, and both factors together — the highest risk.
Key points
- A tube stopping in the chest in a drooling newborn — oesophageal atresia.
- The common type (about 85%): atresia with a distal fistula.
- Look for VACTERL; echocardiogram before surgery.
- Right thoracotomy, fistula ligation and primary anastomosis.
- Complications: stricture, reflux, recurrent fistula and tracheomalacia.
Summary table
| Type | Description | Frequency | Exam clue |
|---|---|---|---|
| C | Proximal atresia and distal fistula | About 85% | Coiled tube and gas in the abdomen |
| A | Pure atresia without a fistula | About 8% | Gasless abdomen, long gap |
| E (H) | Fistula without atresia | About 4% | Coughing on feeds, recurrent pneumonia |
| B and D | Proximal fistula (with or without a distal one) | Rare | Sometimes found only at bronchoscopy |
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Sources
- Holcomb and Ashcraft's Pediatric Surgery, 7th edition (2019) — Esophageal Atresia and Tracheoesophageal Fistula
- ESPGHAN-NASPGHAN Guidelines for the Evaluation and Treatment of Gastrointestinal and Nutritional Complications in Children With Esophageal Atresia-Tracheoesophageal Fistula, 2016 — Reflux, strictures and follow-up
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-06. The text may contain errors; when in doubt, check the source.