Surgical management of neonate presenting with type 3 b 4 variety of TEF (KLUTH)

• Author Details:   
• Sukrit Singh Shah ^*
• Vikram Khanna

---

View PDF

Introduction: TEF is a common neonatal surgical emergency that presents shortly after birth with drooling of saliva from the mouth, inability to feed, and respiratory distress with or without cyanosis.

The definitive treatment for this condition is surgery. Essentially the defect involves agenesis of a part of the esophagus with a fistulous communication with the trachea. There are a large number of anatomical variants of this anomaly, Kluth has described nearly 96 different varieties. The type B variety involves a blind-ending upper pouch with a fistulous communication between the lower pouch and the trachea. There are 20 subtypes described for type B anomaly.

Type 3b4 variety involves the overlapping upper and lower esophageal pouches. The long TEF courses parallel in proximity to the upper pouch (UP) and the trachea. This mandates a very meticulous dissection of the upper pouch from the trachea.

Case Presentation: A 1-day female presented with presumptive diagnosis of TEF. On exploration, after ligating the right azygous vein, we found that it was a type 3B4 variant of TEF. The dissection was modified. Careful separation of the fistula from the trachea and from the undersurface of the upper pouch was done. After completely freeing the fistula, rest of the surgery proceeded as is done normally.

Conclusion: In this case report, we describe how an on-table diagnosis of this variant forced us to modify the steps of dissection so as to prevent tracheal injury. Also, the the importance of doing pre-operative bronchoscopy in diagnosing such variants, although these cannot be over-emphasised. Thoracoscopic approaches are proving to be of high value in management of these cases with significant success rates and lower complications