Which of the following is most common after primary esophagostomy for esophageal atresia with a distal tracheoesophageal fistula?

d. Gastroesophageal reflux

The preferred approach for esophageal atresia with a distal tracheoesophageal fistula in a patient without other problems is an extrapleural right thoracotomy with division of the tracheoesophageal fistula and primary esophagostomy. No gastrostomy is ordinarily used. The results with this approach are better than those with a staged approach. Three major complications are related to the esophageal anastomosis: leak, stricture and recurrent fistula. The incidence of leak varies from 10% to 20% depending on the type of anastomosis done and the degree of tension. A distinct advantage of an extrapleural anastomosis is the predictable resolution of these leaks if adequately drained. Similarly, the stricture rate varies between 10% and 25%, again depending on the type of anastomosis done. Many infants require one or two dilations, but few have significant long-term problems. The incidence of recurrent esophageal fistula is difficult to determine since few authors emphasize this technical problem, but it appears to be about 10% in most reports.

Gastroesophageal reflux secondary to dysmotility of the distal esophagus is a significant problem and occurs to some degree in virtually all of these patients. A significant number of these infants, 25% to 30% or more, are refractory to medical therapy and require surgical fundoplication. Tracheomalacia is a complication of the malformation, not of the repair. This appears to result from inadequate cartilagenous tracheal rings at the level of the fistula. The reported incidence is up to 25% in some recent series. Most infants with tracheomalacia improve with growth and time, but a small percentage develop severe respiratory difficulty which requires surgical aortopexy.