title: Esophageal atresia associated with anorectal malformation: Is the outcome better after surgery in two stages in a limited resources scenario?
abstract: OBJECTIVE
  To analyze whether outcome of neonates having esophageal atresia with or without tracheoesophageal fistula (EA±TEF) associated with anorectal malformation (ARM) can be improved by doing surgery in 2 stages.
  
  
  METHODS
  A prospective study of neonates having both EA±TEF and ARM from 2004 to 2011. The patients with favorable parameters were operated in a single stage, whereas others underwent first-stage decompression surgery for ARM. Thereafter, once septicemia was under control and ventilator care available, second-stage surgery for EA±TEF was performed.
  
  
  RESULTS
  Total 70 neonates (single stage = 20, 2 stages = 30, expired after colostomy = 9, only EA±TEF repair needed = 11) were enrolled. The admission rate for this association was 1 per 290. Forty-one percent (24/70) neonates had VACTERL association and 8.6% (6/70) neonates had multiple gastrointestinal atresias. Sepsis screen was positive in 71.4% (50/70). The survival was 45% (9/20) in neonates operated in a single stage and 53.3% (16/30) when operated in 2 stages (P = 0.04). Data analysis of 50 patients revealed that the survived neonates had significantly better birth weight, better gestational age, negative sepsis screen, no cardiac diseases, no pneumonia, and 2-stage surgery (P value 0.002, 0.003, 0.02, 0.02, 0.04, and 0.04, respectively). The day of presentation and abdominal distension had no significant effect (P value 0.06 and 0.06, respectively). This was further supported by stepwise logistic regression analysis.
  
  
  CONCLUSIONS
  In a limited resources scenario, the survival rate of babies with this association can be improved by treating ARM first and then for EA±TEF in second stage, once mechanical ventilator care became available and sepsis was under control.
authors.affiliation: Department of Pediatric Surgery, CSM Medical University (Erstwhile King George Medical University), Lucknow, Uttar Pradesh, India.
authors.forename: Sunita
authors.initials: S
authors.lastname: Singh
authors.forename: Ashish
authors.initials: A
authors.lastname: Wakhlu
authors.forename: Anand
authors.initials: A
authors.lastname: Pandey
authors.forename: Anita
authors.initials: A
authors.lastname: Singh
authors.forename: Shiv N
authors.initials: SN
authors.lastname: Kureel
authors.forename: Jiledar
authors.initials: J
authors.lastname: Rawat
authors.forename: Payal Mishra
authors.initials: PM
authors.lastname: Srivastava