Search

Die ��sophagusatresie (��A) betrifft ca. 1 von 3500 Neugeborenen. Durch eine Diskontinuit��t der Speiser��hre und Fistelbildung zur Luftr��hre (T��F) ist eine operative Korrektur in den ersten Lebenstagen erforderlich. Durch Fortschritte in der Neonatologie, intensivmedizinischen und operativen Versorgung ist die ��berlebenswahrscheinlichkeit in den letzten Jahren gestiegen und erfordert die Evaluation des Outcomes und der Lebensqualit��t, um eine angemessene Nachsorge zu gew��hrleisten und die medizinische Versorgung weiter zu verbessern. Die ��tiologie der ��A ist bislang ungekl��rt, mehrere Risikofaktoren stehen in der Diskussion einer multifaktoriellen Genese. Die pr��natale Diagnostik und das operative Management der langstreckigen ��A stellen nach wie vor Herausforderungen dar. Die vorliegende Studie untersuchte das Outcome und die Lebensqualit��t sowie potentielle Risikofaktoren in der Schwangerschaft anhand 31 Patienten im Alter von 0 - 12 Jahren der Sektion Kinderchirurgie des Universit��tsklinikums Ulm im Zeitraum von 2004 - 2015. Die Daten wurden retrospektiv aus den Krankenakten ausgewertet, zudem erfolgte eine Befragung der Patienten und deren Eltern mithilfe von Frageb��gen zur Schwangerschaftsanamnese (modifizierter Fragebogen des Fehlbildungsmonitorings Sachsen-Anhalt) und zur Lebensqualit��t (KINDL�� Frageb��gen) sowie eine klinische Nachuntersuchung (orientiert an den Nachsorgeb��gen der Patienten- und Selbsthilfeorganisation f��r Kinder und Erwachsene mit kranker Speiser��hre (KEKS) e.V.). Als klinische Kontrollgruppe dienten 30 Patienten zwischen 0 und 11 Jahren, die in der Sektion Kinderchirurgie behandelt wurden und keine Fehlbildungen aufwiesen. Am h��ufigsten trat im Ulmer Patientenkollektiv Vogt Typ III b mit 64,1 % auf. 77,4 % der Patienten wiesen Begleitfehlbildungen auf, 22,6 % eine VACTERL- Assoziation (vertebrale, anorektale, cardiale, tracheo��sophageale, renale Fehlbildungen und Fehlbildungen der Extremit��ten (limb)). 19 der 31 Patienten wurden in der Sektion Kinderchirurgie in Ulm operiert und bez��glich des postoperativen Outcomes analysiert. Die weiteren 12 Patienten wurden an externen Kliniken operiert und waren pr��- oder postoperativ in der Sektion Kinderchirurgie in Ulm in Behandlung. Bei den in Ulm operierten Patienten erfolgte bei 16 Patienten eine Prim��ranastomose und bei zwei Patienten ein Sekund��rverschluss. Postoperativ traten die folgenden Komplikationen auf: gastro��sophagealer Reflux (78,9 %), Anastomosenstenose (73,7 %), Tracheomalazie (31,6 %), Divertikelbildung (26,3 %), Anastomoseninsuffizienz (26,3 %), Rezidivfistel (10,5 %). In der Schwangerschaftsanamnese zeigte sich im Vergleich zur gesunden Kontrollgruppe ein niedrigerer Body-Mass-Index der M��tter, h��ufigere immunologische/allergische Erkrankung der M��tter und Unterschiede der Ern��hrungsgewohnheiten (weniger t��glicher Fleisch- und erh��hter t��glicher Milchkonsum). 64,5 % der M��tter wiesen pr��natal ein Polyhydramnion auf, bei 22,5 % der Neugeborenen lag eine singul��re Nabelschnurarterie vor. Der pr��natale Verdacht einer ��A wurde jedoch nur bei 25 % der M��tter ge��u��ert. Dies verdeutlicht die Bedeutung der pr��natalen Diagnostik und der Notwendigkeit weiterf��hrender diagnostischer Methoden bei sonographischen Auff��lligkeiten. Die Befragung zur Lebensqualit��t ergab in allen Altersklassen niedrigere Werte in den Kategorien ���Lebensqualit��t gesamt���, ���psychisches Wohlbefinden���, ���Freunde��� und ���Schule��� im Vergleich zur gesunden Kontrollgruppe, jedoch ohne statistische Signifikanz. In der klinischen Nachsorgeuntersuchung zeigte ca. ein Drittel der 16 teilnehmenden Kinder einen Wachstumsverlauf unterhalb der 10. Perzentile. ��ber 90 % der nachuntersuchten Kinder nutzten F��rderma��nahmen, die H��lfte der Kinder gab Probleme bei der Nahrungsaufnahme an. Die h��ufigsten genannten Symptome waren W��rgen, Aufsto��en, bellender Husten und Stridor. Die Ergebnisse zeigen die Notwendigkeit einer langj��hrigen, interdisziplin��ren Nachsorge. Erfreulicherweise scheint die Lebensqualit��t vergleichbar mit gesunden Kindern gleichen Alters, aufgrund der anhaltenden Komplikationen ist jedoch eine Einsch��tzung anhand krankheitsspezifischer Messinstrumente ratsam. Die Erkenntnisse der Schwangerschaftsanamnese k��nnen Ans��tze f��r weitere, multizentrische Studien zur Identifikation von Risikofaktoren bieten.

Oesophageal atresia is a rare congenital malformation occurring in 1 : 3000/1 : 4000 neonates. Surgical correction is always required. Perioperative management concepts depend on the type of malformation. Postoperative results are closely related to postsurgical complications. Interdisciplinary management should extend from prenatal diagnosis, birth and perinatal care to neonatal intensive care and paediatric surgical therapy with specialised pediatric anaesthesia. Other areas that should be available are logopedia, paediatric gastroenterology and paediatric pulmonology. Long-term care should include systematic aftercare and transition programs to adult medicine.Die Ösophagusatresie (ÖA) ist mit einer Inzidenz von 1 : 3000 bis 1 : 4000 Neugeborenen eine seltene, angeborene Erkrankung. Die Therapie beinhaltet obligatorisch die operative Korrektur. Behandlungskonzepte sind abhängig von der Variabilität der ösophagotrachealen Fistelmöglichkeiten, der variablen Distanz der Ösophagussegmente und der prognostischen Relevanz assoziierter Fehlbildungen. Die postoperativen Resultate werden entscheidend durch krankheitsspezifische Symptome und Komplikationen beeinflusst. Ein interdisziplinäres Betreuungskonzept von der pränatalen Diagnostik über die Geburt, die neonatalogische Intensivpflege und kinderchirurgische Versorgung mit hochspezialisierter Kinderanästhesie bietet in einem spezialisierten Kinderzentrum mit Logopädie, Gastroenterologie und Pulmologie die besten Voraussetzungen für eine optimale Lebensqualität. Systematische Nachsorge- und Transitionsprogramme sind für betroffene Kinder essenziell.

Esophageal atresia (EA) is a congenital anomaly that entails an interrupted esophagus with or without tracheoesophageal fistula (TEF). Depending on the distance of the two esophageal pouches a "short-gap" is distinguished from a "long-gap" variant. Up to 50% of newborns have additional anomalies. EA is prenatally diagnosed in 32-63% of cases. Recently, the interdisciplinary care in these children underwent substantial changes. Therefore, we summarize the current guideline of the German society of pediatric surgery for the treatment of patients with EA and distal TEF (Gross Type C). Controversies regarding the perioperative management include surgical-technical aspects, such as the thoracoscopic approach to EA, as well as general anesthesia (preoperative tracheobronchoscopy, intraoperative hypercapnia and acidosis). Moreover, postoperative complications and their management like anastomotic stricture are outlined. Despite significant improvements in the treatment of EA, there is still a relevant amount of long-term morbidity after surgical correction. This includes dysmotility of the esophagus, gastroesophageal reflux disease, recurrent respiratory infections, tracheomalacia, failure to thrive, and orthopedic complications following thoracotomy in the neonatal age. Therefore, close follow-up is mandatory to attain optimal quality of life.Die Ösophagusatresie (ÖA) ist eine angeborene Kontinuitätsunterbrechung der Speiseröhre mit oder ohne Fistel zur Trachea (Tracheoösophageale Fistel, TÖF). Je nach Abstand zwischen den beiden Ösophagusenden unterscheidet man eine „kurzstreckige“ von einer „langstreckigen“ Form. Bis zu 50% der Neugeborenen weisen weitere Anomalien auf. Eine pränatale Diagnose der ÖA gelingt in 32–63% der Fälle. Die interdisziplinäre Betreuung dieser Kinder hat sich in den letzten Jahren gewandelt. In der folgenden Arbeit wird die aktuelle S2K-Leitlinie der Deutschen Gesellschaft für Kinderchirurgie zur Behandlung der ÖA mit unterer TÖF, die etwa 90% aller Fälle ausmacht, zusammengefasst. Hierzu gehören das präoperative Management sowie operative und anästhesiologische Aspekte (u. a. Thorakoskopie vs. Thorakotomie, präoperative Tracheobronchoskopie, intraoperative Hyperkapnie und Azidose). Ferner wird das postoperative Management insbesondere von relevanten Komplikationen wie der Anastomosenstenose beschrieben. Trotz Fortschritten in der Behandlung der ÖA ist die Langzeitmorbidität mit Motilitätsstörungen des Ösophagus, gastroösophagealer Refluxkrankheit, rezidivierenden Infektionen der oberen und unteren Atemwege, Tracheomalazie, mangelhaftem Gedeihen sowie orthopädischen Problemen nach Thorakotomie weiterhin hoch. Zum Erreichen einer guten Lebensqualität ist daher eine gute interdisziplinäre Nachsorge wichtig.

Oesophageal atresia causes a dysplasia of the oesophagus with or without a connection to the adjoining trachea. Prenatal ultrasound results are not specific enough to confirm a suspected diagnosis. In addition to polyhydramnios and a small or absent stomach, the so-called "pouch sign" reinforces the suspected diagnosis. An MRI increases the prenatal detection rate. Due to the lack of reliable sonografic markers, ultrasonic testing is advised during pregnancy. Particularly, further causes for the polyhydramnios should be categorically excluded. Postnatally, children present with classic symptoms. Surgical treatment results in a very high quality of life and a very good prognosis. Nevertheless lifelong monitoring and follow-up of the patient is required.Bei der Ösophagusatresie kommt es zu einer Hemmungsfehlbildung der Speiseröhre mit oder ohne Verbindung zur angrenzenden Trachea. Eine pränatale Diagnostik mittels Ultraschalluntersuchungen ist durch die indirekten Hinweiszeichen relativ unspezifisch und nur als eine Verdachtsdiagnose möglich. Neben dem gleichzeitigen Vorliegen eines Polyhydramnions sowie der wiederholt nicht möglichen Darstellung einer Magenblase, bzw. zu kleiner Magenblase, bestärkt das Vorliegen eines sog. „Pouch-sign“ die Verdachtsdiagnose. Eine MRT erhöht die pränatale Detektionsrate. Aufgrund der fehlenden sicheren sonografischen Marker, neben der möglichen direkten Darstellung des Ösophagus, sollten Ultraschallkontrollen in der Schwangerschaft durchgeführt werden. Insbesondere sollten kategorisch weitere mögliche Ursachen eine Polyhydramnions ausgeschlossen werden. Postnatal fallen die Kinder mit der klassischen Symptomatik auf. Die operative Versorgung ermöglicht den Betroffenen eine sehr gute Lebensqualität und Prognose. Eine lebenslange Observation und Begleitung ist notwendig.

The creation of a primary anastomosis in newborns with oesophageal atresia and distal oesophageotracheal fistula (EA-DF) is technically challenging, especially in small children. The goal is to approximate the fragile oesophageal ends without suture disruption and to minimize the mobilisation of the lower segment. We describe an alternative anastomosis technique aiming at reducing the tension on the first sutures at the posterior wall.EA-DF was corrected in 13 newborns either by open (n = 11) or thoracoscopic (n = 2) surgery using this technique.The anastomosis technique is based on creation of a dorsal flap of the upper oesophageal pouch and insertion in the spatulated lower oesophageal segment after the fistula has been separated. Subsequently, the first sutures of the posterior wall can be accomplished with reduced tension. Upon completion of the anastomosis, a diagonally shaped anastomotic plane results.The method is a helpful alternative to approximate the oesophageal stumps of newborns with EA and distal oesophagotracheal fistula. By this technique, the first stabilising sutures of the posterior wall can be accomplished with reduced tension. This results in reduced tensile stress on the individual sutures and simplifies the anastomisation in comparison to the conventional end-to-end anastomosis.Die Durchführung einer primären Anastomose bei Neugeborenen mit Ösophagusatresie und distaler ösophagotrachealer Fistel (EA-DF) ist insbesondere bei kleinen Kindern technisch anspruchsvoll. Ziel ist es, die fragilen Enden des Ösophagus ohne Ausreißen der Nähte anzunähern und den distalen Ösophagus hierbei möglichst wenig zu mobilisieren. Wir beschreiben eine alternative Anastomosentechnik, welche die Spannung der ersten Nähte der Hinterwand reduzieren soll.Die operative Korrektur einer EA-DF wurde bei 13 Neugeborenen mit dieser Anastomosentechnik entweder offen (n = 11) oder thorakoskopisch (n = 2) durchgeführt.Die Anastomosentechnik basiert auf der Bildung eines dosalen Lappens aus dem oberen Ösophagusstumpf, der in das spatulierte Ende des unteren Ösophagussegmentes eingeschlagen wird. Die ersten Hinterwandnähte können anschließend unter verminderter Spannung angelegt werden. Bei Komplettierung der Anastomose resultiert eine schräg verlaufende Anastomosenebene.Die Methode stellt eine hilfreiche Alternative dar, um die Ösophagusstümpfe von Neugeborenen mit Ösophagusatresie und distaler ösophagotrachealer Fistel anzunähern. Durch die Technik können die stabilisierenden ersten Hinterwandnähte unter verminderter Spannung angelegt werden, wodurch die Zugbelastung auf einzelne Nähte reduziert und die Anastomosierung im Vergleich zur herkömmlichen End-zu-End-Anastomose erleichtert wird.

Hintergrund: Wir berichten uber eine 27-jahrige Patientin, die nach operativem Magenhochzug bei Osophagusatresie unter massiv einschrankenden Symptomen wie Sodbrennen, Erbrechen, Regurgitation, Ubelkeit und Magenkrampfen litt, trotz maximaler konservativer Therapie. Falldarstellung: Die Patientin erhielt im Rahmen einer Gastroskopie eine endoluminale Procaininfiltration in die narbige Anastomosenregion, woraufhin sich die klinische Symptomatik deutlich reduzierte und auch im Langzeitverlauf stabil vermindert blieb. Schlussfolgerung: Wir beschreiben die unseres Wissens nach erste endoluminale Infiltration von Procain in narbige Gewebsareale einer enteralen Anastomosenregion nach operativem Magenhochzug. BACKGROUND We present a 27-year-old female who, despite maximum conservative therapy, suffered from severely restricting symptoms such as heartburn, vomiting, regurgitation, nausea and stomach spasms after a gastric pull-up because of an esophageal atresia. CASE REPORT During a gastroscopy, an endoluminal injection of procaine in scar tissue in the area of the anastomosis was performed whereupon the symptoms diminished considerably and remained in this diminished state over a long course. CONCLUSION We described the first successful endoluminal injection with procaine into scar tissue after enteral anastomosis because of an esophageal atresia.

The treatment of newborns with esophageal atresia (EA) and tracheoesophageal fistula (TEF) is associated with a great logistic effort. The aim of the presented study was to analyse the possibility to influence the time of surgery.Data from 30 neonates with EA and TEF regarding the date and mode of birth, biometric data and preoperative acid-base and blood gas values were collected retrospectively. The newborns were divided into two subgroups: birth between Monday and Thursday ("week"), and birth from Friday to Sunday ("weekend").We observed a seasonal peak of births in November/December. The rate of prenatal ultrasound detection of polyhydramnions was 40%. In 14 of 16 cases with Caesarean section, maternal or foetal problems predicted the date and mode of delivery. In both groups, most newborns had an unimpaired postnatal adaptation. There were no significant differences regarding biometry. Delivery at the weekend was associated with later surgical repair (second vs. first day of life). Repeated estimations of acid-base and blood gas parameters over a median time span of 13 hours revealed a stable situation with a trend to normalisation.The time of birth is multifactorial and, in most cases, can neither be predicted nor influenced. Stable respiratory and metabolic parameters in the majority of patients allow a surgical intervention within a limited time frame during the first days of life.As it is hardly possible to plan the surgical procedure, an experienced team as well as neonatal intensive care facilities and operation room access must be available throughout the week.

Esophageal malformations are rare and can occur sporadically or as a component of various syndromes. The variations and classifications are manifold. With the available modern operation techniques most malformations can be resolved with good results. However, esophageal malformations are often combined with further malformations which limit the prognosis. The separation of the trachea and esophagus after gastrulation is not yet completely researched. The results so far indicate that the localized expression of various homeodomain transcription factors is essential for normal development of the trachea and esophagus.

Due to the advances in neonatal intensive care medicine, prenatal ultrasound-guided diagnostic measures and paediatric surgical options, conditions have been established to achieve long-term survival in newborns with severe diseases. In addition, this means that the "non-paediatric" physician can be increasingly confronted with patients who would not have survived childhood some decades ago. Therefore, the article summarises concisely selected diseases of premature infants and newborns, e. g., congenital abdominal wall defects, and outlines possible long-term consequences based on the surgical interventions and their basic diseases, respectively, which need to be adequately cared for in the case of a surgical disease of the former patient of paediatric surgery. The overview cannot be considered as a complete revision course; however, it might constitute a basic outline for thought-provoking impulses for personal professional skills and expertise in managing such patients in later age from a surgical perspective.

This report highlights the diagnostic and therapeutic challenges which occurred in a newborn with oesophageal atresia of the type Vogt III c in association with a tubular supracarinal tracheal stenosis.

Three cases of latex anaphylaxis occurring during surgery are reported. Sudden cardiorespiratory collapse 40 to 90 minutes after induction of anaesthesia was treated with oxygen, crystalloid solution, adrenaline and methylprednisolone. Laboratory findings showed markedly elevated antibodies against latex postoperatively. All three patients had anorectal malformations. As children with malformations have to be operated on in early childhood, they have a high risk of developing antibodies against latex. Primary prophylaxis requires a general avoidance of latex products in children with malformations from the time of birth on.

In this case report we discuss the anaesthetic management of newborns with esophageal atresia classified as Vogt III b. This type is characterised by an upper esophageal pouch which ends blindly and a distal tracheoesophageal fistula. Commonly associated diseases are cardiac, renal, vertebral and anal anomalies. The most important intraoperative anaesthesiological complications are acidosis, hypoxaemia, gastric distension, endotracheal tube obstruction, tracheal compression, cardiac arrhythmias and atelectasis. In the presented case an endotracheal tube obstruction with hypercapnia occurred which required a change of the airway. After changing the endotracheal tube the newborn could be ventilated sufficiently. Further postoperative course was uneventful.

Based on a case report of a duodenal atresia, diagnosed by ultrasound in the 30th week of gestation, the antenatal investigations and therapeutic proposals are demonstrated. Moreover the postapartal development with the extended diagnosis of an esophageal atresia as well as the early operative management are discussed.

The most common sites of atresia in the gastrointestinal tract are the oesophagus, the duodenum and the anorectum. Surgical intervention is always necessary. Because of the rapid progress in surgical techniques and peri- and postoperative intensive care management, lethality has been minimized, even when treating very small premature infants. In the meantime, the surgical intervention itself is no longer the great risk it was; associated congenital malformations such as complex cardial defects are now much greater risks.

This paper is a retrospective analysis of 280 children, who were treated with a gastrostomy by the technique of Stamm in the Pediatric Surgical Clinic at Dr. v. Haunersches Kinderspital of the University of Munich from 1st January 1978 until 31st December 1989. Points of interest were epidemiological data such as the age and the original illness of the patients and the duration of gastrostomy. In 229 children the gastrostomy was performed within the first week of life. The most frequent indication was the diagnosis of an esophageal atresia in 80 cases. 94 of the patients had further malformations, in 30% as a syndrome. In 50% of all cases the gastrostomy could be removed within 40 days after operation, in further 40% between the 40. and 90. postoperative day and in the last 10% later. Heavy complications could be diagnosed in 2.9% without any mortality, easy complications in 10%.

We report the unusual finding of brain malformations in a male newborn with anomalies of VACTERL association. Magnetic resonance imaging revealed hypoplasia of cerebellum, pons and corpus callosum as well as kinking of diencephalon and mesencephalon. These malformations of ectodermal tissue are suggestive of a defect of morphogenesis that occurred earlier than usually postulated for VACTERL cases. They resulted in severe neurologic complications and an early death. The fact that a cousin of this patient has VACTERL anomalies without cerebral involvement indicates that variable expressivity in genetically predisposed individuals may be possible for this subgroup of VACTERL cases.

This case report describes the prenatal diagnosis of an oesophageal atresia with the previously unpublished associated malformation of tracheal atresia. The knowledge of associated malformations or deformations in prenatally diagnosed oesophageal atresia can considerably improve the prognosis by an optimised post partum care of the newborn. Tracheal atresia can at present not be diagnosed prenatally; the possibility to identify it remains an isolated case and must therefore be taken into consideration whenever an oesophageal atresia is observed.

Magnetic Resonance Imaging of the pediatric chest was performed in 53 patients. All examinations were performed using a 1.0 and 1.5 Tesla superconducting MR imager. 80% of the children were examined using anesthesia with a ventilation of 20% inspiration and 80% expiration. After performing the MR examination in 55% of the cases an operation was performed. In 29 patients anomalies of the brachiocephalic trunc were found. In four patients MR detected a doubled aortic arch, in four patients we found a dilated arch. In eight children a dilated pulmonary artery was diagnosed. In combination with eight tracheobronchoscopy, MR imaging proved to be the diagnostic method of choice for the evaluation of anomalies of the mediastinum. New developments like fast imaging techniques and 3D acquisition promise a further diagnostic improvement in the mediastinum.

In intestinal anomalies, preventive surgical procedures include gastrostomies and enterostomies as well as some special operations such as ligature of the cardia and associated appendectomies. General indications for enterostomies are seen in life-threatening circumstances, i.e. prematurity, surfactant deficiency, major associated malformations and complications. Preventive surgical procedures are necessary in certain cases of esophageal atresia, complicated small bowel atresia, meconium ileus, anorectal malformations, Hirschsprung disease, neuronal intestinal dysplasia and necrotizing enterocolitis. Prophylactic surgery requires detailed knowledge of the definitive therapeutic procedure.

From 1986 to 1989 46 newborn were examined after correction of oesophageal atresia, defects of diaphragm or abdominal wall, to record postoperative cardial insufficiency. In 15 of 40 long-time pH metry analysis (37.5%) and in 11 of 22 x-ray studies (50%) a pathological result was found; in 8 times these findings were followed by operation and in 8 times by conservative therapy. pH metry is suitable even in very small newborn for postoperative screening of cardial function; if the results are positive, x-ray examination is supplementary to diagnosis and therapeutical planning.

Stenosis and malacia of the trachea wall can provoke chronic stridor and/or chronic bronchitis, but usually stenosis and malacia only exist separately. The finding of an infant born with atresia of the oesophagus and a lower tracheoesophageal fistula which was cured by surgery on the 1st day of life are discussed. During the following 8 months we observed persistent stridor, chronic cough and (4-times) relapsing episodes of respiratory insufficiency ("nearly-sudden-infant-death-syndrome"/NSIDS) due to gastrooesophageal reflux (GER with aspiration) and severe tracheomalacia combined with tracheostenosis and bacterial infections (Pseudomonas aeruginosa). The strategy of therapy for GER and for the tracheal abnormality are discussed.

To evaluate the quality of life of patients with esophageal atresia 122 questionnaires about children who underwent operations in several centres in the Federal Republic of Germany were analysed. On the basis of this information, the literature and our own cases, we found that these patients early childhood is complicated by operations, dilatations, difficulties of swallowing and frequent pulmonary infections. These problems improved in most cases during the first years of life. Subsequently the quality of life can be regarded as good.

This is a report on 30 cases of innominate artery compression of the trachea and its operative correction by an aorto-truncopexy. Tracheoscopy is the most important examination for arriving at the diagnosis. Magnetic resonance imaging (MRI), which offers representative pictures of many moments of expiration and inspiration, shows the anatomic relationship between the innominate artery, the aortic arch and the trachea, also demonstrating the extent of the tracheal compression. Surgical treatment is indicated if narrowing of the lumen of the trachea is greater than 70%. By fixing the aortic arch and the proximal innominate artery at the back of the sternum the trachea is relieved of its compression. In 30 children there was no unsuccessful operation, and none of them died.

The clinical pattern of signs and symptoms of respiratory complications due to flaccid trachea has been analysed in 83 children treated in our hospital between 1983 and 1988 for tracheo-oesophageal malformations. These signs and symptoms are classified according to endoscopic findings, and are thus arranged according to various degrees of severity. Of the surviving children who were followed up and who were suffering from oesophageal atresia Vogt III B, only 5 of 57 were without a pointer towards flaccid trachea, whereas in oesophageal atresia Vogt II there were two of three. The two children with an isolated tracheo-oesophageal fistula showed abnormal findings both clinically and via endoscopy. 16 of the 20 children with very severely pronounced flaccid trachea--defined by the occurrence of life-threating apnoeas and an endoscopically identifiable tracheal collapse of more than two-thirds of the lumen--were subjected to surgery via aortosternopexy. A marked and identifiable improvement was obtained in 15 cases. Complications caused by surgery consisted of temporary phrenicus lesions in two cases.

In up to 20% of newborns with esophageal atresia a primary anastomosis of the esophagus is not possible because of the long distance between the two ends. In some cases a circular myotomy can elongate the upper pouch to allow a primary anastomosis. If primary anastomosis is not possible bougienage of the upper and lower pouch may stimulate growth of the esophagus and allow direct anastomosis after several weeks. In all other cases esophageal replacement is necessary. Colonic replacement of the esophagus must be weighed against replacement by jejunum, gastric interposition and the gastric tube. Each technique for esophageal replacement involves characteristic complications, and these are discussed in detail. For about 80% of the patients esophageal replacement allows a normal life with normal oral uptake of nutrition.

The first successfully operated newborn with esophageal atresia dates back more than 55 years. During this period the concept of the unity of structure and function for surgical treated malformations has been retained. Primary anastomosis offers the best prerequisites. Main life threatening complications are leakage of the anastomosis, anastomotic strictures and gastroesophageal reflux. Avoiding vital complications the aim of undisturbed function can be achieved by appropriate surgical methods. The report describes own experiences over the past 20 years.

Twelve duplications of the alimentary tract in eleven children are reviewed. There was a predominance of the spheric type of duplication as well as the neonatal group of children with clinical sign of tumour in most cases. There were no major problems in resection of spheric duplications but tubular type cases afforded different procedure in each case. Three cases with associated atresias were noted. There was one death related to gastric duplication.

Between 1982 and 1987 27 Nissen's fundoplications were carried out in our institution. Postoperatively 7 infants showed a typical dumping syndrome. The symptoms were irritability, pallor, sweating, tachycardia, lethargy, diarrhoea and vomiting. In all cases an absolute refusal of feeding was observed. The diagnosis was confirmed by a typical early postprandial hyperglycaemia with hyperinsulinaemia leading to a reactive hypoglycaemia. Additionally, we were able to demonstrate an increased HbA1c as an expression of recurrent hyperglycaemias in 3 infants. In 6 infants the dumping syndrome was of short duration and the symptoms disappeared after application of a so-called dumping diet. In this diet the easily resorbable carbohydrates are replaced by uncooked starch. But in one case we were forced to use continuous enteral nutrition because of persistence of the symptoms 1 year after the Nissen fundoplication. Complete refusal of feeding is an early symptom of the dumping syndrome. If this symptom is observed after a Nissen's fundoplication, a dumping syndrome must be excluded.

A hydramnion occurring during the second half of pregnancy may be due to atresias in the upper intestinal tract. Generally, one case of oesophageal atresia is likely to occur in every 2,500 births, often together with other malformations. Prenatal diagnosis of such atresias substantially improves prognosis for these children via optimal cooperation between the obstetrician and the paediatric surgeon. Characteristic features of oesophageal atresia in the sonographic image are, besides the hydramnion, the absence of visualisation of the stomach. Sonographic diagnosis of duodenal atresias is based on visualisation of the stomach, which is excessively filled with fluid, and of the portion of the small intestine located cranially of the stenosis. The patients treated by the author and presented here were successfully operated on via termination of birth and immediate surgery by the paediatric surgeon.

Report of two cases of polysplenia with the typical syndrome of bilateral leftsidedness. Besides the typical findings hallmarking the syndrome in one child esophageal atresia and in the other the atresia of extrahepatic bile ducts were found. The authors point out the possibilities for a clinical premortem diagnosis of the polysplenia syndrome.

A new mechanical device is presented which approximates the two oesophageal pouches in long gap oesophageal atresia and possibly creates an anastomosis. The principle is similar to magnetic bougienage, only that purely mechanical force is employed instead. This offers several advantages: the instrument is considerably less bulky, technically simple, inexpensive, light and therefore easy to transport. Only normal electrical current is necessary. The tensile forces applied are easier to control. The child does not have to be placed inside a tube and is not restrained in its movements. The device has been experimentally tested in 6 dogs.