Zwerchfellparese nach extremer Frühgeburtlichkeit mit Ösophagusatresie

Esophageal atresias (EA) is a life-threatening emergency in extreme low birth weight infants (ELBW). Presence of tracheoesophageal fistula might cause abdominal distension or aspiration and EA makes enteral nutrition impossible. Management of ELBWs with EA is challenging. A premature neonate at 25 weeks of gestation and a birth weight of 575 g presented a respiratory distress syndrome, an intracerebral hemorrhage and an EA. Banding of the esophageal cardia and a gastrostomy were conducted. After sufficient thriving, a thoracoscopic anastomosis of the esophagus and closure of the tracheoesophageal fistula were performed at 4.5 months. However, the esophagus was interrupted at the level of the banding. Subsequent to recovery, the esophago-gastral interruption was re-anastomosed by means of a transhiatal left-thoracoscopic approach. Hereupon, he showed biliary reflux and elevation of the left diaphragm. Due to an aspiration event, he showed respiratory insufficiency and a tracheotomia was indicated. After recovery, the infant was transferred to a center of pediatric home ventilation. A fundoplication and two plications of the diaphragm followed. At 20 month, the boy was discharged but required home ventilation and intermittent oxygen. Presence of EA in ELBW infants is a dilemma. Banding of the cardia and gastrostomy as well as therapy of the diaphragmatic palsy are controversial issues. Interdisciplinary collaboration including centers of pediatric home ventilation might improve management of such dilemmas.