13 ribs as a predictor of long gap esophageal atresia: myth or reality? Analysis of associated findings of esophageal atresia and abnormal rib count

J Pediatr Surg. 2017 Aug;52(8):1252-1254. doi: 10.1016/j.jpedsurg.2017.04.019. Epub 2017 May 2.


Background: The presence of 13 pairs of ribs on pre-operative chest x-ray has been postulated to be an indicator for long gap esophageal atresia (EA). This study sought to determine the validity of this theory and identify associated pathological conditions in patients with EA and abnormal rib count.

Methods: Babies with EA from January 2005 - December 2012 were retrospectively analyzed. Information was gathered from neonatal health records and operation notes. Chest x-rays were reviewed to determine rib count. Long gap EA was defined as failure to achieve primary esophageal anastomosis. Statistical analysis performed with Fisher's exact test.

Results: Seventy-six patients were identified. Eight patients had long gap EA, with none of these patients having 13 pairs of ribs. Paradoxically, 10 patients with esophageal atresia +/- trachea-esophageal atresia (EA +/- TEF) and supernumerary ribs underwent primary repair. Nine patients had 11 pairs of ribs, of which 2 had pure EA and a long gap. Using Fisher's exact test to compare the groups of supernumary ribs and non-supernumary ribs there is a p value of 0.587. VACTERL association was identified in 40% of those with supernumerary ribs. Various associated syndromes and concomitant abnormalities were identified.

Conclusion: We found no association between 13 pairs of ribs and long gap in esophageal atresia. Those with 13 pairs of ribs were more likely to have associated anomalies, although this was not statistically significant. Our cohort of patients was found to have a range of pathology related to genetic syndromes, further atresias, and malformations, which is well known to be associated with children born with EA +/- TEF.

Level of evidence: Prognosis study - level IV.

Keywords: Long gap; Ribs; Tracheo-esophageal fistula; VACTERL.

MeSH terms

  • Abnormalities, Multiple*
  • Anastomosis, Surgical
  • Esophageal Atresia / pathology*
  • Esophageal Atresia / surgery
  • Female
  • Humans
  • Infant, Newborn
  • Male
  • Prognosis
  • Radiography
  • Retrospective Studies
  • Ribs / abnormalities*
  • Ribs / diagnostic imaging
  • Syndrome
  • Tracheoesophageal Fistula* / surgery