Gastric perforation in infants with oesophageal atresia and distal tracheo-oesophageal fistula

Gastric perforation (GP) is a well-recognised complication of oesophageal a tresia (OA) with distal tracheo-oesophageal fistula (TOF), and is usually a ssociated with extreme prematurity, hyaline membrane disease, and the requi rement for assisted ventilation. The presentation is sudden, and leads to f urther deterioration in respiratory function because of increasing abdomina l distension from pneumoperitoneum and splinting of the diaphragm. Unreliev ed, the infant becomes increasingly hypoxic and may die. A review of sis in fants with OA and distal TOF in whom GP occurred has enabled us to develop the following guidelines for the appropriate initial surgical management of this complication: (1) Needle paracentesis of the abdomen en route to surg ery if the infant continues to deteriorate; (2) Urgent laparotomy to decomp ress the abdomen and to occlude the lower oesophagus with a catheter introd uced through the GP: (3) Thoracotomy and division of the fistula, (4) Oesop hageal anastomosis if the infant's condition improves sufficiently and the anatomy is favourable: and (5) Repair of the GP and formation of a gastrost omy.