Clinical Presentation

A newborn presents with respiratory distress and fluid return from the nose and mouth following the first few attempts at swallowing. The abdomen is noted to appear small. Attempts at placing a nasogastric tube failed, and the patient is sent for chest and abdominal radiographs. What should be done for this neonate?

Figure 107A

Figure 107B

Radiologic Findings

Esophageal atresia without evidence of a tracheoesophageal fistula (TEF), requiring definitive repair or gastrostomy tube prior to definitive repair

Differential Diagnosis

• Upper small bowel atresia
• Esophageal stenosis

Discussion

Background

Neonates with esophageal atresia may require a gastrostomy tube prior to definitive repair. Traditionally, the tube has been inserted via an open surgical approach. Recently, less invasive techniques for gastrostomy tube insertion, including the percutaneous image-guided gastrostomy, has been used in the pediatric population. The main advantage of this technique is the avoidance of a laparotomy.

In patients with esophageal atresia without TEF, percutaneous gastrostomy tube insertion is problematic. The stomach is small and gasless, and it cannot be inflated as is usually done with a nasogastric tube. Access to the abdomen under radiologic guidance is therefore risky. A novel transhepatic approach is used to instill air into the stomach, which can then permit percutaneous gastrostomy tube insertion under fluoroscopic guidance.

Indications

• Placing a gastrostomy tube is indicated for enteral nutrition to allow the child to receive appropriate nutrition; therefore, making a primary esophageal repair more successful.

Imaging Findings

• Ultrasonographic and fluoroscopic guidance are used in this procedure.

Technique