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Reddy S, Jester I, Soccorso G, Pachl M, Gavens E, Patel H, Arul GS. Thoracoscopic external traction suture elongation for the management of long-gap oesophageal atresia: a two-centre experience. Pediatr Surg Int 2024; 40:135. [PMID: 38767779 DOI: 10.1007/s00383-024-05707-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/21/2024] [Indexed: 05/22/2024]
Abstract
AIM Van der Zee (VdZ) described a technique to elongate the oesophagus in long-gap oesophageal atresia (LGOA) by thoracoscopic placement of external traction sutures (TPETS). Here, we describe our experience of using this technique. METHOD Retrospective review of all LGOA + / - distal tracheo-oesophageal fistula (dTOF) cases where TPETS was used in our institutions. Data are given as medians (IQR). RESULTS From 01/05/2019 to 01/03/2023, ten LGOA patients were treated by the VdZ technique. Five had oesophageal atresia (Gross type A or B, Group 1) and five had OA with a dTOF (type C, Group 2) but with a long gap precluding primary anastomosis. Age of first traction procedure was Group 1 = 53 (29-55) days and Group 2 = 3 (1-49) days. Median number of traction procedures = 3; time between first procedure and final anastomosis was 6 days (4-7). Four cases were converted to thoracotomy at the third procedure. Three had anastomotic leaks managed conservatively. Follow-up was 12-52 months. All patients achieved oesophageal continuity and were orally fed; no patient required an oesophagostomy. CONCLUSION In this series, TPETS in LGOA facilitated delayed primary anastomoses and replicated the good results previously described but, in addition, was successful in cases with dTOF. We believe traction suture placement and tensioning benefit from being performed thoracoscopically because of excellent visualisation and the fact that the tension does not change when the chest is closed. Surgical and anaesthetic planning and expertise are crucial. It is now our management of choice in OA patients with a long gap with or without a distal TOF.
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Affiliation(s)
- Snigdha Reddy
- Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Ingo Jester
- Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | | | - Max Pachl
- Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | | | - Hetal Patel
- Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - G Suren Arul
- Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK.
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Ishikawa M, Tomita H, Ito Y, Tsukizaki A, Abe K, Shimotakahara A, Shimojima N, Hirobe S. Analysis of gap length as a predictor of surgical outcomes in esophageal atresia with distal fistula: a single center experience. Pediatr Surg Int 2024; 40:99. [PMID: 38581456 DOI: 10.1007/s00383-024-05678-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/19/2024] [Indexed: 04/08/2024]
Abstract
PURPOSE Long-gap esophageal atresia (LGEA) is still a challenge for pediatric surgery. No consensus exists as to what constitutes a long gap, and few studies have investigated the maximum gap length safely repairable by primary anastomosis. Based on surgical outcomes at a single institution, we aimed to determine the gap length in LGEA with a high risk of complications. METHODS The medical records of 51, consecutive patients with esophageal atresia (EA) with primary repair in the early neonatal period between 2001 and 2021 were retrospectively reviewed. Three, major complications were found in the surgical outcomes: (1) anastomotic leakage, (2) esophageal stricture requiring dilatation, and (3) GERD requiring fundoplication. The predictive power of the postsurgical complications was assessed using receiver operating characteristic analysis, and the area under the curve (AUC) and the cutoff value with a specificity of > 90% were calculated. RESULTS Sixteen patients (31.4%) experienced a complication. The AUC of gap length was0.90 (p < 0.001), and the gap length cutoff value was ≥ 2.0 cm for predicting any complication (sensitivity: 62.5%, specificity: 91.4%). CONCLUSION A gap length ≥ 2.0 cm was considered as defining LGEA and was associated with an extremely high complication rate after primary repair.
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Affiliation(s)
- Miki Ishikawa
- Department of Surgery, Tokyo Metropolitan Children's Medical Center, 2-8-29 Musashidai, Fuchu, Tokyo, 183-8561, Japan.
| | - Hirofumi Tomita
- Department of Surgery, Tokyo Metropolitan Children's Medical Center, 2-8-29 Musashidai, Fuchu, Tokyo, 183-8561, Japan
| | - Yoshifumi Ito
- Department of Surgery, Tokyo Metropolitan Children's Medical Center, 2-8-29 Musashidai, Fuchu, Tokyo, 183-8561, Japan
| | - Ayano Tsukizaki
- Department of Surgery, Tokyo Metropolitan Children's Medical Center, 2-8-29 Musashidai, Fuchu, Tokyo, 183-8561, Japan
| | - Kiyotomo Abe
- Department of Surgery, Tokyo Metropolitan Children's Medical Center, 2-8-29 Musashidai, Fuchu, Tokyo, 183-8561, Japan
| | - Akihiro Shimotakahara
- Department of Surgery, Tokyo Metropolitan Children's Medical Center, 2-8-29 Musashidai, Fuchu, Tokyo, 183-8561, Japan
| | - Naoki Shimojima
- Department of Surgery, Tokyo Metropolitan Children's Medical Center, 2-8-29 Musashidai, Fuchu, Tokyo, 183-8561, Japan
| | - Seiichi Hirobe
- Department of Surgery, Tokyo Metropolitan Children's Medical Center, 2-8-29 Musashidai, Fuchu, Tokyo, 183-8561, Japan
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3
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Zhang N, Wu W, Zhuang Y, Wang W, Pan W, Wang J. Experience in the treatment of long-gap esophageal atresia by intraluminal esophageal stretching elongation. Front Pediatr 2024; 12:1367935. [PMID: 38523834 PMCID: PMC10957633 DOI: 10.3389/fped.2024.1367935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 02/27/2024] [Indexed: 03/26/2024] Open
Abstract
Objective To summarize the experience with intraluminal esophageal stretching elongation (ILESE) in the successful treatment of long-gap esophageal atresia (LGEA) at a single center. Methods Clinical data of 68 neonates who underwent LGEA between February 2015 and January 2022 were retrospectively analyzed. Four patients died of multiple associated severe malformations and did not undergo ILESE. Esophageal anastomosis was successfully performed in 60 cases (93.75%) and failed in 4 cases (6.25%) treated with ILESE. The ILESE techniques, esophageal reconstruction, results, postoperative complications, and follow-up treatment were analyzed. Results The beginning time of performing ILESE preoperation was 53.4 ± 39.4 days after birth, and the age of esophageal reconstruction was 122.2 ± 70.3 days after birth in 60 cases. The gap length of proximal and distal esophageal segments which were evaluated the first time at admission was 4.8 ± 1.3 vertebral bodies, whereas the gap before anastomosis was -0.46 ± 0.90 vertebral bodies. Among the patients with esophageal primary-anastomosis, 55 received thoracoscopic surgery, and 5 underwent thoracotomy in the early stage. Of the 60 children with ILESE, 58 underwent end-to-end esophagostomy, of which 17 cases were combined with circular esophagotomy (livaditis), and 2 cases of esophageal lengthening were combined with the reversal of the ligulate loop of the proximal esophagus (flap). Overall, 59 cases were cured (98.3%), and 1 patient died of respiratory failure postoperatively. All patients were followed up for 7-96 months. Postoperative anastomotic leakage occurred in 16 patients (27.6%), all of whom were successfully treated conservatively. Anastomotic stenosis occurred in 49 cases (83.1%), all of which were successfully managed by non-surgical treatment, including 12.7 ± 9.3 times of esophageal balloon dilatation and 2 cases of stent dilatation. Gastroesophageal reflux occurred in 44 patients (74.6%), including associated or acquired esophageal hiatal hernia in 22 patients, and Nissen fundoplication was performed in 17 patients. Conclusions ILESE is an effective method for prolonging the proximal and distal esophagus of the LGEA to reconstruct esophageal continuity using its esophageal tissue, with an efficacy rate of 93.75%. Postoperative anastomotic stricture and gastroesophageal reflux are common and require long-term, standardized follow-up and treatment.
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Affiliation(s)
- Ning Zhang
- Department of Pediatric Surgery, Children’s Hospital of Soochow University, Suzhou, Jiangsu, China
- Department of Pediatric Surgery, The Affiliated Xuzhou Children’s Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, China
| | - Wenjie Wu
- Department of Pediatric Surgery, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yujia Zhuang
- Department of Pediatric Surgery, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Weipeng Wang
- Department of Pediatric Surgery, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Weihua Pan
- Department of Pediatric Surgery, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jun Wang
- Department of Pediatric Surgery, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Dimitrov G, Aumar M, Duhamel A, Wanneveich M, Gottrand F. Proton pump inhibitors in esophageal atresia: A systematic review and meta-analysis. J Pediatr Gastroenterol Nutr 2024; 78:457-470. [PMID: 38262739 DOI: 10.1002/jpn3.12115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 12/09/2023] [Accepted: 12/18/2023] [Indexed: 01/25/2024]
Abstract
Gastroesophageal reflux disease (GERD) is frequent and prolonged in esophageal atresia (EA) pediatric patients requiring routine use of proton pump inhibitors (PPIs). However, there are still controversies on the prophylactic use of PPIs and the efficacy of PPIs on GERD and EA complications in this special condition. The aim of the study is to assess the prophylactic use of PPIs in pediatric patients with EA and its complications. We, therefore, performed a systematic review including all reports on the subject from 1980 to 2022. We conducted meta-analysis of the pooled proportion of PPI-and no PPI groups using random effect model, meta-regression, and estimate heterogeneity by heterogeneity index I2 . Thirty-eight reports on the topic met the criteria selection, representing a cumulative 6044 patients with EA. Prophylactic PPI prescription during the first year of life does not appear to prevent GERD persistence at follow-up and is not associated with a significantly reduced rate of antireflux surgical procedures (ARP). PPIs improve peptic esophagitis and induce remission of eosinophilic esophagitis at a rate of 50%. Their effect on other GERD outcomes is uncertain. Evidence suggests that PPIs do not prevent anastomotic stricture, Barrett's esophagus, or respiratory complications. PPI use in EA can improve peptic and eosinophilic esophagitis but is ineffective on the other EA complications. Side effects of PPIs in EA are almost unknown.
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Affiliation(s)
- Georges Dimitrov
- Unit of Pediatric Surgery, Unit of Pediatrics, Competence Centre for Rare Esophageal Diseases, University Hospital Center of Orléans, Orléans, France
| | - Madeleine Aumar
- Reference Centre for Rare Esophageal Diseases, University of Lille, CHU Lille, Lille, France
| | - Alain Duhamel
- Biostatistics Unit, University Hospital of Lille, Lille, France
| | | | - Frédéric Gottrand
- Reference Centre for Rare Esophageal Diseases, University of Lille, CHU Lille, Lille, France
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5
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Gördü B, Oğuz B, Soyer T. The role of distance between upper and lower esophageal pouches to predict the possibility of delayed repair in children with isolated esophageal atresia. Pediatr Surg Int 2023; 39:245. [PMID: 37523004 DOI: 10.1007/s00383-023-05528-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/21/2023] [Indexed: 08/01/2023]
Abstract
AIM A retrospective study was performed to evaluate the role of distance between upper and lower esophageal pouches and pouch lengths to predict delayed primary repair (DPR) in patients with isolated esophageal atresia (EA). METHODS Patients with isolated EA were evaluated for demographic features, associated anomalies, surgical options, and complications. The babygrams obtained for evaluating gap assessment were examined for the distance between pouches and pouch lengths. Patients were divided into two groups: DPR and esophageal replacement (ER). RESULTS Fourteen cases with a mean age of 4.1 ± 1.9 years (1-9 years) were included. Female to male ratio was 6:8. There was no significant difference between DPR and ER groups for pouch lengths. The median distance between two pouches were significantly higher in ER group [50 mm (29.4-83.6) vs 18.8 mm (3.4-34.5) (p < 0.05)]. The distance between two pouches and pouch lengths were similar in patients with and without anastomotic strictures (p > 0.05). CONCLUSION Both upper and lower pouch lengths were shorter in ER group compared to DPR group. However, pouch lengths cannot be considered as a single criterion to predict the need for ER. Large cohort of patients are needed to define the cut-off values for shortest pouch length to achieve a DPR.
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Affiliation(s)
- Bilge Gördü
- Department of Pediatric Surgery, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Berna Oğuz
- Pediatric Radiology Division, Department of Radiology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Tutku Soyer
- Department of Pediatric Surgery, Faculty of Medicine, Hacettepe University, Ankara, Turkey.
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Penikis AB, Salvi PS, Sferra SR, Engwall-Gill AJ, Rhee DS, Solomon DG, Kunisaki SM. Delayed primary repair in 100 infants with isolated long-gap esophageal atresia: A nationwide analysis of children's hospitals. Surgery 2023; 173:1447-1451. [PMID: 37045622 DOI: 10.1016/j.surg.2023.03.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 02/20/2023] [Accepted: 03/08/2023] [Indexed: 04/14/2023]
Abstract
BACKGROUND This study aimed to evaluate the contemporary surgical management of long-gap esophageal atresia, a rare and challenging problem managed by pediatric general surgeons. METHODS A retrospective review of the Pediatric Health Information System database for infants who underwent neonatal gastrostomy, followed by surgical reconstruction for long-gap esophageal atresia (2014-2021). Patients with birthweight less than 1.5 kg and those who received neonatal cardiac surgery were excluded. Outcomes were analyzed, including the need for further procedures, length of stay, and mortality. RESULTS Of 1,346 infants who underwent repair across 47 major children's hospitals, 100 (7%) met the inclusion criteria for long-gap esophageal atresia. Cardiac anomalies were identified in 43% of patients. The median age at repair was 87 days (interquartile range, 62-133). Ten percent of patients had a planned or unplanned reoperation ≤30 days after index surgery, and 4% underwent reoperation at >30 days. The median time to reoperation was 9 days (interquartile range, 7-60). Mortality during index admission was 5%, and the median hospital length of stay was 143 days (interquartile range, 101-192). Length of stay was significantly longer in patients with cardiac anomalies (cardiac: 179 days, non-cardiac: 125 days; P < .001), and 52% of patients required at least 1 postoperative dilation. The median time to the first dilation was 70 days (interquartile range, 42-173). CONCLUSION This large multicenter study highlights the challenges of infants with long-gap esophageal atresia but suggests a high rate of successful delayed primary reconstruction. Hospitalizations are prolonged, and anastomotic stricture rates remain high. These data are useful for pediatric surgeons in counseling families on surgical repair strategy, timing, and postoperative outcomes.
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Affiliation(s)
- Annalise B Penikis
- Division of General Pediatric Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Pooja S Salvi
- Division of Pediatric Surgery, Department of Surgery, Yale University School of Medicine, New Haven, CT
| | - Shelby R Sferra
- Division of General Pediatric Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Abigail J Engwall-Gill
- Division of General Pediatric Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Daniel S Rhee
- Division of General Pediatric Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Daniel G Solomon
- Division of Pediatric Surgery, Department of Surgery, Yale University School of Medicine, New Haven, CT
| | - Shaun M Kunisaki
- Division of General Pediatric Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD.
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Bourg A, Gottrand F, Parmentier B, Thomas J, Lehn A, Piolat C, Bonnard A, Sfeir R, Lienard J, Rousseau V, Pouzac M, Liard A, Buisson P, Haffreingue A, David L, Branchereau S, Carcauzon V, Kalfa N, Leclair MD, Lardy H, Irtan S, Varlet F, Gelas T, Potop D, Auger-Hunault M. Outcome of long gap esophageal atresia at 6 years: A prospective case control cohort study. J Pediatr Surg 2023; 58:747-755. [PMID: 35970676 DOI: 10.1016/j.jpedsurg.2022.07.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 07/07/2022] [Accepted: 07/26/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND DATA EA is the most frequent congenital esophageal malformation. Long gap EA remains a therapeutic challenge for pediatric surgeons. A case case-control prospective study from a multi-institutional national French data base was performed to assess the outcome, at age of 1 and 6 years, of long gap esophageal atresia (EA) compared with non-long gap EA/tracheo-esophageal fistula (TEF). The secondary aim was to assess whether initial treatment (delayed primary anastomosis of native esophagus vs. esophageal replacement) influenced mortality and morbidity at ages 1 and 6 years. METHODS A multicentric population-based prospective study was performed and included all patients who underwent EA surgery in France from January 1, 2008 to December 31, 2010. A comparative study was performed with non-long gap EA/TEF patients. Morbidity at birth, 1 year, and 6 years was assessed. RESULTS Thirty-one patients with long gap EA were compared with 62 non-long gap EA/TEF patients. At age 1 year, the long gap EA group had longer parenteral nutrition support and longer hospital stay and were significantly more likely to have complications both early post-operatively and before age 1 year compared with the non-long gap EA/TEF group. At 6 years, digestive complications were more frequent in long gap compared to non-long gap EA/TEF patients. Tracheomalacia was the only respiratory complication that differed between the groups. Spine deformation was less frequent in the long gap group. There were no differences between conservative and replacement groups at ages 1 and 6 years except feeding difficulties that were more common in the native esophagus group. CONCLUSIONS Long gap strongly influenced digestive morbidity at age 6 years.
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Affiliation(s)
- Agate Bourg
- Pediatric Surgery Unit, University Hospital Center of Poitiers, 86000 Poitiers, France.
| | - Frédéric Gottrand
- Univ. Lille, CHU Lille, Reference center for rare esophageal diseases, Inserm U1286, F59000, Lille, France
| | - Benoit Parmentier
- Pediatric Surgery Unit, University Hospital Center of Poitiers, 86000 Poitiers, France
| | - Julie Thomas
- Pediatric Surgery Unit, University Hospital Center of Poitiers, 86000 Poitiers, France
| | - Anne Lehn
- Pediatric Surgery Unit, University Hospital of Strasbourg, 67200 Strasbourg, France
| | - Christian Piolat
- Pediatric Surgery Unit, University Hospital of Grenoble, 38700 Grenoble, France
| | - Arnaud Bonnard
- Pediatric Surgery Unit, Robert Debré Hospital APHP, 75019 Paris, France
| | - Rony Sfeir
- Pediatric Surgery Unit, University Hospital of Lille Jeanne de Flandre, 59000 Lille, France
| | - Julie Lienard
- Pediatric Surgery Unit, University Hospital of Nancy, 54035 Nancy, France
| | | | - Myriam Pouzac
- Pediatric Surgery Unit, Hospital of Orléans, 45100 Orléans, France
| | - Agnès Liard
- Pediatric Surgery Unit, University Hospital of Rouen, 76000 Rouen, France
| | - Philippe Buisson
- Pediatric Surgery Unit, University Hospital of Amiens-Picardie, 80054 Amiens, France
| | - Aurore Haffreingue
- Pediatric Surgery Unit, University Hospital of Caen Normandie, 14000 Caen, France
| | - Louis David
- Pediatric Surgery Unit, University Hospital of Dijon F.Mitterand, 21000 Dijon, France
| | - Sophie Branchereau
- Pediatric Surgery Unit, Bicetre Hospital APHP, 94270 Le Kremlin-Bicêtre, France
| | | | - Nicolas Kalfa
- Pediatric Surgery Unit, University Hospital of Montpellier, 34295 Montpellier, France
| | - Marc-David Leclair
- Pediatric Surgery Unit, University Hospital of Nantes Hotel Dieu, 44093 Nantes, France
| | - Hubert Lardy
- Pediatric Surgery Unit, University Hospital of Tours, 37000 Tours, France
| | - Sabine Irtan
- Pediatric Surgery Unit, Armand Trousseau Hospital APHP, 75012 Paris, France
| | - François Varlet
- Pediatric Surgery Unit, University Hospital of Saint-Etienne, 42055 Saint-Etienne Cedex 2
| | - Thomas Gelas
- Pediatric Surgery Unit, University Hospital of Lyon HCL Women Mother Children Hospital, 69500 Bron, France
| | - Diana Potop
- Pediatric Surgery Unit, University Hospital Center of Poitiers, 86000 Poitiers, France
| | - Marie Auger-Hunault
- Pediatric Surgery Unit, University Hospital Center of Poitiers, 86000 Poitiers, France
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Friedmacher F. Delayed primary anastomosis for repair of long-gap esophageal atresia: technique revisited. Pediatr Surg Int 2022; 39:40. [PMID: 36482208 PMCID: PMC9732069 DOI: 10.1007/s00383-022-05317-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/22/2022] [Indexed: 12/13/2022]
Abstract
The operative management of patients born with long-gap esophageal atresia (LGEA) remains a major challenge for most pediatric surgeons, due to the rarity and complex nature of this malformation. In LGEA, the distance between the proximal and distal esophageal end is too wide, making a primary anastomosis often impossible. Still, every effort should be made to preserve the native esophagus as no other conduit can replace its function in transporting food from the oral cavity to the stomach satisfactorily. In 1981, Puri et al. observed that in newborns with LGEA spontaneous growth and hypertrophy of the two segments occur at a rate faster than overall somatic growth in the absence of any form of mechanical stretching, traction or bouginage. They further noted that maximal natural growth arises in the first 8-12 weeks of life, stimulated by the swallowing reflex and reflux of gastric contents into the lower esophageal pouch. Since then, creation of an initial gastrostomy and continuous suction of the upper esophageal pouch followed by delayed primary anastomosis at approximately 3 months of age has been widely accepted as the preferred treatment option in most LGEA cases, generally providing good functional results. The current article offers a comprehensive update on the various aspects and challenges of this technique including initial preoperative management and subsequent gap assessment, while also discussing potential postoperative complications and long-term outcome.
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Affiliation(s)
- Florian Friedmacher
- Department of Pediatric Surgery, University Hospital Frankfurt, Goethe University Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany
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Subramaniam T, Martin BP, Jester I, Soccorso G, Pachl MJ, Robb A, Singh M, Lander A, Arul GS. A single centre experience using internal traction sutures in managing long gap oesophageal atresia. J Pediatr Surg 2022; 57:516-519. [PMID: 35690479 DOI: 10.1016/j.jpedsurg.2022.05.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 04/13/2022] [Accepted: 05/06/2022] [Indexed: 11/18/2022]
Abstract
AIM Thoracoscopically placed internal traction sutures (ITS) for the initial management of long gap oesophageal atresia (LGOA), not amenable to primary anastomosis, was first described in 2015. Here we describe our experience using ITS both thoracoscopically and at thoracotomy where the gap between upper and lower oesophagus is too wide for primary anastomosis. METHOD The case notes of all infants treated with ITS for oesophageal atresia (01/10/2015 to 01/12/2019) were reviewed. Gaps considered too wide for an anastomosis had ITS placed between the two pouches as described by Patkowski in 2015. All patients were gastrostomy fed. Patients returned to theatre with an expectation to complete the anastomosis or re-tighten the traction sutures. RESULTS Seven patients (4 OA, 1 OA with proximal fistula, 2 OA/distal TOF) median birthweight 2.28 kg (1.2-3.6 kg) were managed using ITS. Median gap length 4.5 (3-9) vertebral bodies. ITS were placed thoracoscopically in 5 cases and at thoracotomy in 2 at median 46 days (1-120) old. In all cases, ITS was associated with significant intra-thoracic adhesions. Five patients leaked from the traction sutures. Four patients had a delayed primary anastomosis performed at thoracotomy and 3 required a cervical oesophagostomy. The median length of stay was 159 days (98-282). All patients started thoracoscopically eventually required thoracotomy. CONCLUSION The use of ITS in our department was associated with significant complications, particularly intra-thoracic leaks and adhesions. In our hands ITS did not improve the feasibility of thoracoscopic repair for LGOA and has been abandoned by us. LEVEL OF EVIDENCE Level IV Case Series.
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Affiliation(s)
- Thejasvi Subramaniam
- Department of Paediatric Surgery, Birmingham Children's Hospital, Birmingham, United Kingdom
| | - Benjamin P Martin
- Department of Paediatric Surgery, Birmingham Children's Hospital, Birmingham, United Kingdom
| | - Ingo Jester
- Department of Paediatric Surgery, Birmingham Children's Hospital, Birmingham, United Kingdom
| | - Giampiero Soccorso
- Department of Paediatric Surgery, Birmingham Children's Hospital, Birmingham, United Kingdom
| | - Max J Pachl
- Department of Paediatric Surgery, Birmingham Children's Hospital, Birmingham, United Kingdom
| | - Andrew Robb
- Department of Paediatric Surgery, Birmingham Children's Hospital, Birmingham, United Kingdom
| | - Michael Singh
- Department of Paediatric Surgery, Birmingham Children's Hospital, Birmingham, United Kingdom
| | - Anthony Lander
- Department of Paediatric Surgery, Birmingham Children's Hospital, Birmingham, United Kingdom
| | - G Suren Arul
- Department of Paediatric Surgery, Birmingham Children's Hospital, Birmingham, United Kingdom.
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10
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Pediatric esophageal stenoses: Challenges and new surgical device promoting tension-free esophageal anastomosis. Exp Ther Med 2022; 23:220. [PMID: 35222697 DOI: 10.3892/etm.2022.11144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 11/25/2021] [Indexed: 11/05/2022] Open
Abstract
Esophageal stenoses of childhood have a broad spectrum of underlying causes. Their treatment is usually minimally invasive by endoscopic means, but sometimes surgery is necessary in refractory cases. Techniques employed in the surgical treatment of esophageal strictures include resection of the stenotic esophageal segment or esophageal substitution procedures. Esophageal anastomosis has always been a challenge in pediatric surgery. Anastomosis complications are linked to anatomical, biological and technical aspects. Mechanical tension between esophageal ends is an important cause of complications including anastomotic leaks or dehiscence. Eleven cases of esophageal stenoses, surgically treated in the Pediatric Surgery Department of Emergency Clinical Hospital for Children 'Marie S. Curie' by a single team in 5 years, were included in the present study. The results showed that, the main causes of esophageal stenosis were represented by corrosive esophageal injury in five cases, complications of esophageal atresia repair in three cases, congenital esophageal stenosis in two cases and chemotherapy-induced esophageal necrosis in acute lymphoblastic leukemia treatment in one case. The authors also designed and presented a device facilitating esophageal anastomosis under tension. Its principle involved temporary absorption of tension at secure points of the two esophageal pouches and reallocating it in equal amounts following anastomosis while decreasing any stretch-related tissue trauma. In conclusion, this auxiliary tool is beneficial for esophageal anastomosis; however, the standard steps of the esophageal anastomosis procedure should still be considered when necessary.
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11
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van Tuyll van Serooskerken ES, Lindeboom MYA, Verweij JW, van der Zee DC, Tytgat SHAJ. Childhood outcome after correction of long-gap esophageal atresia by thoracoscopic external traction technique. J Pediatr Surg 2021; 56:1745-1751. [PMID: 34120739 DOI: 10.1016/j.jpedsurg.2021.05.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 05/04/2021] [Accepted: 05/04/2021] [Indexed: 01/21/2023]
Abstract
BACKGROUND Thoracoscopic external traction technique (TTT) is a relatively new surgical intervention for patients with long-gap esophageal atresia (LGEA) that preserves the native esophagus. The major accomplishment with TTT is that esophageal repair can be achieved within days after birth. This study evaluates the childhood outcome in LGEA patients treated with TTT, including gastrointestinal outcome, nutritional status and Health-Related Quality of Life (HRQoL). METHODS A cohort study including all LGEA patients that underwent TTT between 2006-2017 was conducted. Patients and/or their parents were invited to fill out questionnaires regarding reflux symptoms and HRQoL. RESULTS TTT was successful in 11/13 patients (85%). Esophageal anastomosis was accomplished at a median age of 12 days (range 7-138), first oral feeding was started at a median of 16 days postoperatively (range 5-37). All patients required multiple dilatations and 10 patients required anti-reflux surgery. At median follow-up of seven years, five patients reported mild and one moderate reflux complaints. All patients but one reached age-appropriate oral diet. Most patients (80%) were within normal growth range. Overall HRQoL was comparable to healthy controls. CONCLUSION TTT provides acceptable results in childhood. Oral feeding can be started as soon as two weeks postoperatively. Almost all patients are able to eat an age-appropriate oral diet. Overall HRQoL was comparable to healthy controls.
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Affiliation(s)
- E Sofie van Tuyll van Serooskerken
- Congenital Esophageal and Airway Team Utrecht, Department of Pediatric Surgery, Wilhelmina Children's Hospital, University Medical Center Utrecht, P.O. Box 85090, AB Utrecht 3508, the Netherlands
| | - Maud Y A Lindeboom
- Congenital Esophageal and Airway Team Utrecht, Department of Pediatric Surgery, Wilhelmina Children's Hospital, University Medical Center Utrecht, P.O. Box 85090, AB Utrecht 3508, the Netherlands.
| | - Johannes W Verweij
- Congenital Esophageal and Airway Team Utrecht, Department of Pediatric Surgery, Wilhelmina Children's Hospital, University Medical Center Utrecht, P.O. Box 85090, AB Utrecht 3508, the Netherlands
| | - David C van der Zee
- Congenital Esophageal and Airway Team Utrecht, Department of Pediatric Surgery, Wilhelmina Children's Hospital, University Medical Center Utrecht, P.O. Box 85090, AB Utrecht 3508, the Netherlands
| | - Stefaan H A J Tytgat
- Congenital Esophageal and Airway Team Utrecht, Department of Pediatric Surgery, Wilhelmina Children's Hospital, University Medical Center Utrecht, P.O. Box 85090, AB Utrecht 3508, the Netherlands
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12
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Tullie L, Kelay A, Bethell GS, Major C, Hall NJ. Barrett's oesophagus and oesophageal cancer following oesophageal atresia repair: a systematic review. BJS Open 2021; 5:6346856. [PMID: 34370830 PMCID: PMC8405903 DOI: 10.1093/bjsopen/zrab069] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 06/17/2021] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Concern exists that patients born with oesophageal atresia (OA) may be at high risk for Barrett's oesophagus (BO), a known malignant precursor to the development of oesophageal adenocarcinoma. Screening endoscopy has a role in early BO identification but is not universal in this population. This study aimed to determine prevalence of BO after OA repair surgery, to quantify the magnitude of this association and inform the need for screening and surveillance. METHODS A systematic review, undertaken according to PRISMA guidelines, was preregistered on PROSPERO (CRD42017081001). PubMed and EMBASE were interrogated using a standardized search strategy on 31 July 2020. Included papers, published in English, reported either: one or more patients with either BO (gastric/intestinal metaplasia) or oesophageal cancer in patients born with OA; or long-term (greater than 2 years) follow-up after OA surgery with or without endoscopic screening or surveillance. RESULTS Some 134 studies were identified, including 19 case reports or series and 115 single- or multi-centre cohort studies. There were 13 cases of oesophageal cancer (9 squamous cell carcinoma, 4 adenocarcinoma) with a mean age at diagnosis of 40.5 (range 20-47) years. From 6282 patients under long-term follow-up, 317 patients with BO were reported. Overall prevalence of BO was 5.0 (95 per cent c.i. 4.5 to 5.6) per cent, with a mean age at detection of 13.8 years (range 8 months to 56 years). Prevalence of BO in series reporting endoscopic screening or surveillance was 12.8 (95 per cent c.i. 11.3 to 14.5) per cent. CONCLUSION Despite a limited number of cancers, the prevalence of BO in patients born with OA is relatively high. While limited by the quality of available evidence, this review suggests endoscopic screening and surveillance may be warranted, but uncertainties remain over the design and effectiveness of any putative programme.
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Affiliation(s)
- L Tullie
- Department of Paediatric Surgery and Urology, Southampton Children's Hospital, Southampton, UK.,National Institute for Health Research Great Ormond Street Hospital Biomedical Research Centre, University College London Great Ormond Street Institute for Child Health, London, UK.,Stem Cell and Cancer Biology Laboratory, The Francis Crick Institute, London, UK
| | - A Kelay
- Department of Paediatric Surgery and Urology, Southampton Children's Hospital, Southampton, UK
| | - G S Bethell
- Department of Paediatric Surgery and Urology, Southampton Children's Hospital, Southampton, UK.,University Surgery Unit, Faculty of Medicine, University of Southampton, Southampton, UK
| | - C Major
- Department of Paediatric Surgery and Urology, Southampton Children's Hospital, Southampton, UK
| | - N J Hall
- Department of Paediatric Surgery and Urology, Southampton Children's Hospital, Southampton, UK.,University Surgery Unit, Faculty of Medicine, University of Southampton, Southampton, UK
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13
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Oliver DH, Martin S, Belkis DMI, Lucas WM, Steffan L. Favorable Outcome of Electively Delayed Elongation Procedure in Long-Gap Esophageal Atresia. Front Surg 2021; 8:701609. [PMID: 34295918 PMCID: PMC8290357 DOI: 10.3389/fsurg.2021.701609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 05/27/2021] [Indexed: 11/13/2022] Open
Abstract
The ideal approach to long gap esophageal atresia is still controversial. On one hand, preserving a patient's native esophagus may require several steps and can be fraught with complications. On the other hand, most replacement procedures are irreversible and disrupt gastrointestinal physiology. The purpose of this study was to evaluate the short- and medium-term outcome of electively delayed esophageal elongation procedures before esophageal reconstruction in patients with long-gap esophageal atresia. Since the neonatal esophagus grows over-proportionally and can increase its wall thickness in the first few months of life, we hypothesized that postponing the elongation steps until 3 months of age would lead to a lower complication rate. We thus retrospectively recorded complications such as mediastinitis, anastomotic leakage, stricture formation, or gastroesophageal reflux requiring surgery, and compared it to reported outcomes. In our treatment protocol, patients born with long-gap esophageal atresia underwent gastrostomy placement and were sham fed until 3 months of age. We then assessed the gap between the esophageal ends and started serial elongation procedures. We only proceeded to the reconstruction of the esophagus when its length allowed a tension-free anastomosis. From April 2013 to April 2019, we treated 13 Patients with long-gap esophageal atresia. Nine patients without prior surgical procedures underwent Foker procedures. Four patients arrived with a pre-existing cervical esophagostomy and thus underwent Kimura's procedure, two of them with a concomitant Foker elongation of the lower pouch. Esophageal reconstruction was feasible in all patients, while none of them developed mediastinitis at any point in their treatment. We managed the only anastomotic leak conservatively. Almost half of the patients did not require any further intervention following reconstruction, while three patients required multiple (≥5) anastomotic dilatations. All but one patient achieved full oral nutrition. Only one child required a fundoplication to manage gastroesophageal reflux symptoms. Electively delayed esophageal elongation procedures in patients with long-gap esophageal atresia allowed preservation of the native esophagus in all patients. The approach had low peri-procedural morbidity, and patients enjoy favorable functional outcomes. Therefore, we suggest considering this method in the management of patients with long-gap esophageal atresia.
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Affiliation(s)
- Diez H Oliver
- Department of Pediatric Surgery, Klinikum Stuttgart, Stuttgart, Germany
| | - Sidler Martin
- Department of Pediatric Surgery, Klinikum Stuttgart, Stuttgart, Germany
| | | | - Wessel M Lucas
- Department of Pediatric Surgery, University Medical Centre Mannheim, Heidelberg University, Mannheim, Germany
| | - Loff Steffan
- Department of Pediatric Surgery, Klinikum Stuttgart, Stuttgart, Germany
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14
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Jensen AR, McDuffie LA, Groh EM, Rescorla FJ. Outcomes for Correction of Long-Gap Esophageal Atresia: A 22-Year Experience. J Surg Res 2020; 251:47-52. [DOI: 10.1016/j.jss.2020.01.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 11/20/2019] [Accepted: 01/25/2020] [Indexed: 12/29/2022]
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15
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Baumgart J, Deigendesch N, Lindner A, Muensterer OJ, Schröder A, Heimann A, Oetzmann von Sochaczewski C. Using multidimensional scaling in model choice for congenital oesophageal atresia: similarity analysis of human autopsy organ weights with those from a comparative assessment of Aachen Minipig and Pietrain piglets. Lab Anim 2020; 54:576-587. [PMID: 32063097 DOI: 10.1177/0023677220902184] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Swine models had been popular in paediatric oesophageal surgery in the past. Although being largely replaced by rodent models, swine experienced a revival with the establishment of minipig models. However, none of them has ever been investigated for similarity to humans. We conducted a pilot study to determine whether three-week old Pietrain piglets and three-month old Aachen Minipigs are suitable for experimental paediatric oesophageal atresia surgery. We tested the operation's feasibility, performed a necropsy, weighed organs, measured organ length and calculated relative weights and lengths, and measured laboratory parameters. We used multidimensional scaling to assess the similarity of the swine breeds with previously published human data. Pietrain piglets had a higher a priori bodyweight than Aachen Minipigs (Δ = 1.31 kg, 95% confidence interval (CI): 0.37-2.23, p = 0.015), while snout-to-tail length was similar. Pietrain piglets had higher absolute and relative oesophageal lengths (Δ = 5.43 cm, 95% CI: 2.2-8.6; p = 0.0062, q1* = 0.0083 and Δ = 11.4%, 95% CI: 5.1-17.6; p = 0.0025, q3* = 0.0053). Likewise, absolute and relative small intestinal lengths were higher in Pietrains, but all other parameters did not differ, with the exception of minor differences in laboratory parameters. Multidimensional scaling revealed three-week old Pietrain piglets to be similar to two-month old humans based on their thoracoabdominal organ weights. This result indicates three-week old Pietrain piglets are a suitable model of paediatric oesophageal atresia surgery, because clinically many procedures are performed at around eight weeks age. Three-month old Aachen Minipigs were more dissimilar to eight-week old humans than three-week old Pietrain piglets.
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Affiliation(s)
- Jan Baumgart
- Translational Animal Research Centre, Johannes-Gutenberg-Universität Mainz, Germany
| | | | - Andreas Lindner
- Department of Paediatric Surgery, Universitätsmedizin Mainz, Germany
| | | | - Arne Schröder
- Department of Paediatrics, Elisabeth-Krankenhaus Essen, Germany
| | - Axel Heimann
- Institute for Neurosurgical Pathophysiology, Universitätsmedizin Mainz, Germany
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16
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Stadil T, Koivusalo A, Svensson JF, Jönsson L, Lilja HE, Thorup JM, Sæter T, Stenström P, Qvist N. Surgical treatment and major complications Within the first year of life in newborns with long-gap esophageal atresia gross type A and B - a systematic review. J Pediatr Surg 2019; 54:2242-2249. [PMID: 31350044 DOI: 10.1016/j.jpedsurg.2019.06.017] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Revised: 04/16/2019] [Accepted: 06/21/2019] [Indexed: 01/22/2023]
Abstract
BACKGROUND The surgical repair of long-gap esophageal atresia (LGEA) is still a challenge and there is no consensus on the preferred method of reconstruction. We performed a systematic review of the surgical treatment of LGEA Gross type A and B with the primary aim to compare the postoperative complications related to the different methods within the first postoperative year. METHODS Systematic literature review on the surgical repair of LGEA Gross type A and B within the first year of life published from January 01, 1996 to November 01, 2016. RESULTS We included 57 articles involving a total of 326 patients of whom 289 had a Gross type A LGEA. Delayed primary anastomosis (DPA) was the most applied surgical method (68.4%) in both types, followed by gastric pull-up (GPU) (8.3%). Anastomotic stricture (53.7%), gastro-esophageal reflux (GER) (32.2%) and anastomotic leakage (22.7%) were the most common postoperative complications, with stricture and GER occurring more often after DPA (61.9% and 40.8% respectively) compared to other methods (p < 0.001). CONCLUSION The majority of patients in this review were managed by DPA and postoperative complications were common despite the surgical method, with anastomotic stricture and GER being most common after DPA. LEVEL OF EVIDENCE Systematic review of case series and case reports with no comparison group (level IV).
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Affiliation(s)
- Tatjana Stadil
- Surgical Department A, Odense University Hospital, Odense, Denmark.
| | - Antti Koivusalo
- Dept. of Pediatric Surgery, Children's Hospital, University of Helsinki, Helsinki, Finland.
| | - Jan F Svensson
- Department of Pediatric Surgery, Karolinska University Hospital and Department of Women's and Children's Health, Karolinska Intitutet, Stockholm, Sweden.
| | - Linus Jönsson
- Department of Pediatric Surgery, Queen Silvia Children's Hospital, Gothenburg, Sweden.
| | - Helene Engstrand Lilja
- Department of Pediatric Surgery, Children's Hospital and Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden.
| | - Jørgen Mogens Thorup
- Dept. of Pediatric Surgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.
| | - Thorstein Sæter
- Dept. of Pediatric Surgery, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway.
| | - Pernilla Stenström
- Dept. of Pediatrics, Children's Hospital, Lund University, Lund, Sweden..
| | - Niels Qvist
- Surgical Department A, Odense University Hospital, Odense, Denmark.
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17
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Baird R, Lal DR, Ricca RL, Diefenbach KA, Downard CD, Shelton J, Sømme S, Grabowski J, Oyetunji TA, Williams RF, Jancelewicz T, Dasgupta R, Arthur LG, Kawaguchi AL, Guner YS, Gosain A, Gates RL, Sola JE, Kelley-Quon LI, St Peter SD, Goldin A. Management of long gap esophageal atresia: A systematic review and evidence-based guidelines from the APSA Outcomes and Evidence Based Practice Committee. J Pediatr Surg 2019; 54:675-687. [PMID: 30853248 DOI: 10.1016/j.jpedsurg.2018.12.019] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Revised: 11/17/2018] [Accepted: 12/26/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Treatment of the neonate with long gap esophageal atresia (LGEA) is one of the most challenging scenarios facing pediatric surgeons today. Contributing to this challenge is the variability in case definition, multiple approaches to management, and heterogeneity of the reported outcomes. This necessitates a clear summary of existing evidence and delineation of treatment controversies. METHODS The American Pediatric Surgical Association Outcomes and Evidence Based Practice Committee drafted four consensus-based questions regarding LGEA. These questions concerned the definition and determination of LGEA, the optimal method of surgical management, expected long-term outcomes, and novel therapeutic techniques. A comprehensive search strategy was crafted and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were utilized to identify, review and report salient articles. RESULTS More than 3000 publications were reviewed, with 178 influencing final recommendations. In total, 18 recommendations are provided, primarily based on level 4-5 evidence. These recommendations provide detailed descriptions of the definition of LGEA, treatment techniques, outcomes and future directions of research. CONCLUSIONS Evidence supporting best practices for LGEA is currently low quality. This review provides best recommendations based on a critical evaluation of the available literature. Based on the lack of strong evidence, prospective and comparative research is clearly needed. TYPE OF STUDY Treatment study, prognosis study and study of diagnostic test. LEVEL OF EVIDENCE Level II-V.
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Affiliation(s)
- Robert Baird
- Department of Pediatric General and Thoracic Surgery, BC Children's Hospital, University of British Columbia, 4480 Oak, Vancouver V6H3V4, British Columbia.
| | - Dave R Lal
- Division of Pediatric Surgery, Department of Surgery, Medical College of Wisconsin
| | - Robert L Ricca
- Division of Pediatric Surgery, Naval Medical Center, Portsmouth, Virginia
| | - Karen A Diefenbach
- Department of Pediatric Surgery, Nationwide Children's Hospital, The Ohio State University, Columbus, OH
| | - Cynthia D Downard
- Hiram C. Polk Jr, MD Department of Surgery, University of Louisville, Louisville, KY
| | - Julia Shelton
- University of Iowa Stead Family Children's Hospital, Iowa City, IA
| | - Stig Sømme
- Division of Pediatric Surgery, Children's Hospital Colorado, University of Colorado, Aurora, CO
| | - Julia Grabowski
- Division of Pediatric Surgery, Department of Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Tolulope A Oyetunji
- Department of Surgery, Children's Mercy Kansas City, University of Missouri-Kansas City School of Medicine, Kansas City, MO
| | - Regan F Williams
- Division of Pediatric Surgery, Le Bonheur Children's Hospital, Memphis, TN
| | - Tim Jancelewicz
- Division of Pediatric Surgery, Le Bonheur Children's Hospital, Memphis, TN
| | - Roshni Dasgupta
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH
| | - L Grier Arthur
- Division of General, Thoracic, and Minimally Invasive Surgery, St. Christopher's Hospital for Children, Drexel University, Philadelphia, PA
| | - Akemi L Kawaguchi
- Department of Pediatric Surgery, University of Texas Health Science Center at Houston, Houston, TX
| | - Yigit S Guner
- Department of Surgery University of California Irvine and Division of Pediatric Surgery Children's Hospital of Orange County
| | - Ankush Gosain
- Division of Pediatric Surgery, Department of Surgery, University of Tennessee Health Science Center, Children's Foundation Research Institute, Le Bonheur Children's Hospital, Memphis, TN
| | - Robert L Gates
- Clinical University of South Carolina-Greenville, Division of Pediatric Surgery, Greenville, SC
| | - Juan E Sola
- Division of Pediatric Surgery, University of Miami Miller School of Medicine, Miami, FL
| | - Lorraine I Kelley-Quon
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Shawn D St Peter
- Children's Mercy Hospital, 2401 Gillham Rd, Kansas City, MO 64108
| | - Adam Goldin
- Department of Pediatric General and Thoracic Surgery, Seattle Children's Hospital, Seattle, WA
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18
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Oetzmann von Sochaczewski C, Tagkalos E, Lindner A, Baumgart N, Gruber G, Baumgart J, Lang H, Heimann A, Muensterer OJ. Bodyweight, not age, determines oesophageal length and breaking strength in rats. J Pediatr Surg 2019; 54:297-302. [PMID: 30503022 DOI: 10.1016/j.jpedsurg.2018.10.085] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Accepted: 10/30/2018] [Indexed: 02/05/2023]
Abstract
BACKGROUND/PURPOSE Delayed primary repair is still the method of choice in the management of long-gap oesophageal atresia in many centres, but the timing of anastomoses varies. Some assume the infant's bodyweight to be an important factor, whereas others prefer age. We therefore aimed to clarify whether age or bodyweight determined oesophageal length in a rodent model. METHODS We explanted the oesophagi of 20 Sprague-Dawley rats, aged 15 to 444 days (n = two per time point), measured bodyweight, oesophageal length, weight, and linear breaking strength to measure tissue resilience. Univariate and multivariate regression analyses were conducted to determine the influence of age and bodyweight on oesophageal length and linear breaking strength. RESULTS All parameters were highly correlated (R > 0.8), except for age and linear breaking strength (R = 0.65). Both age and bodyweight were univariate significant predictors of oesophageal length, weight, and linear breaking strength (p < 0.0001). Multivariate analyses showed bodyweight to be a significant predictor of oesophageal length (p < 0.0001), whereas age was not (p = 0.18) [adjusted R2 = 0.9031]. This was also true for linear breaking strength (p = 0.0007 and p = 0.97, respectively) [adjusted R2 = 0.71]. Moreover, the influence of age was negligible, as the adjusted R2 and the regression coefficient of bodyweight and its 95% confidence interval were almost identical between univariate und multinomial regressions. CONCLUSIONS Only weight determines oesophageal length and tissue resilience in rodents, whereas age is irrelevant. If a similar relationship exists in humans, it may facilitate choosing the optimum time point for delayed primary anastomosis. LEVEL OF EVIDENCE IV - Experimental Paper.
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Affiliation(s)
| | - Evangelos Tagkalos
- Department of General, Visceral and Transplant Surgery, Universitätsmedizin Mainz der Johannes Gutenberg-Universität, Langenbeckstraße 1, D-55131 Mainz, Germany.
| | - Andreas Lindner
- Department of Paediatric Surgery, Universitätsmedizin Mainz der Johannes Gutenberg-Universität, Langenbeckstraße 1, D-55131 Mainz, Germany.
| | - Nadine Baumgart
- Translational Animal Research Centre, Johannes Gutenberg-Universität Mainz, Hanns-Dieter-Hüsch-Weg 19, D-55128 Mainz, Germany.
| | - Gudrun Gruber
- Translational Animal Research Centre, Johannes Gutenberg-Universität Mainz, Hanns-Dieter-Hüsch-Weg 19, D-55128 Mainz, Germany.
| | - Jan Baumgart
- Translational Animal Research Centre, Johannes Gutenberg-Universität Mainz, Hanns-Dieter-Hüsch-Weg 19, D-55128 Mainz, Germany.
| | - Hauke Lang
- Department of General, Visceral and Transplant Surgery, Universitätsmedizin Mainz der Johannes Gutenberg-Universität, Langenbeckstraße 1, D-55131 Mainz, Germany.
| | - Axel Heimann
- Institute of Neurosurgical Pathophysiology, Universitätsmedizin Mainz der Johannes Gutenberg-Universität, Langenbeckstraße 1, D-55131 Mainz, Germany.
| | - Oliver J Muensterer
- Department of Paediatric Surgery, Universitätsmedizin Mainz der Johannes Gutenberg-Universität, Langenbeckstraße 1, D-55131 Mainz, Germany.
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19
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Abstract
The management of long-gap esophageal atresia remains challenging with limited consensus on the definition, evaluation, and surgical approach to treatment. Efforts to preserve the native esophagus have been successful with delayed primary anastomosis and tension-based esophageal growth induction processes. Esophageal replacement is necessary in a minority of cases, with the conduit of choice and patient outcomes largely dependent on institutional expertise. Given the complexity of this patient population with significant morbidity, treatment and long-term follow-up are best done in multidisciplinary esophageal and airway treatment centers.
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Affiliation(s)
- Hester F Shieh
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, 300 Longwood Ave, Fegan 3, Boston, MA 02115
| | - Russell W Jennings
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, 300 Longwood Ave, Fegan 3, Boston, MA 02115.
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20
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van der Zee DC. Endoscopic surgery in children - the challenge goes on. J Pediatr Surg 2017; 52:207-210. [PMID: 27890314 DOI: 10.1016/j.jpedsurg.2016.11.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Accepted: 11/08/2016] [Indexed: 11/25/2022]
Abstract
UNLABELLED Paediatric endoscopic surgery is greatly indebted to Karl Storz for developing paediatric endoscopic instruments. In more recent years, there is an increasing interest in endoscopic surgery in neonates. Now more complex procedures are being performed, although it will take another generation before these will be more generally applied. One of the key factors to success is training. More sophisticated training models are becoming available, allowing practicing in a safe environment before putting the procedure to practice. A key question in performing complex procedures is whether such procedures should not be concentrated into centres of expertise. Finally, a critical appraisal is warranted in regard to safety of surgery in neonates, as they fail to have cerebral autoregulation. As endoscopy may add additional risk factors, close monitoring is obligatory. LEVEL OF EVIDENCE V.
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Affiliation(s)
- David C van der Zee
- Department of Pediatric Surgery, University Medical Center Utrecht, Wilhelmina Children's Hospital, KE 04.140.5, P.O. Box 85090, 3508AB Utrecht, The Netherlands.
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21
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Rintala RJ. Fundoplication in Patients with Esophageal Atresia: Patient Selection, Indications, and Outcomes. Front Pediatr 2017; 5:109. [PMID: 28555181 PMCID: PMC5430410 DOI: 10.3389/fped.2017.00109] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Accepted: 04/25/2017] [Indexed: 11/16/2022] Open
Abstract
Patients with esophageal atresia (EA) suffer from abnormal and permanent esophageal intrinsic and extrinsic innervation that affects severely esophageal motility. The repair of EA also results in esophageal shortening that affects distal esophageal sphincter mechanism. Consequently, gastroesophageal reflux (GER) is common in these patients, overall approximately half of them suffer from symptomatic reflux. GER in EA patients often resists medical therapy and anti-reflux surgery in the form of fundoplication is required. In patients with pure and long gap EA, the barrier mechanisms against reflux are even more damaged, therefore, most of these patients undergo fundoplication during first year of life. Other indications for anti-reflux surgery include recalcitrant anastomotic stenoses and apparent life-threatening episodes. In short term, fundoplication alleviates symptoms in most patients but recurrences are common occurring in at least one third of the patients. Patients with fundoplication wrap failure often require redo surgery, which may be complicated and associated with significant morbidity. A safe option in a subset of patients with failed anti-reflux surgery appears to be long-term medical treatment with proton pump inhibitors.
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Affiliation(s)
- Risto J Rintala
- Children's Hospital, Helsinki University Central Hospital, Helsinki, Finland
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22
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Soccorso G, Parikh DH. Esophageal replacement in children: Challenges and long-term outcomes. J Indian Assoc Pediatr Surg 2016; 21:98-105. [PMID: 27365900 PMCID: PMC4895746 DOI: 10.4103/0971-9261.182580] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Replacement of a nonexistent or damaged esophagus continues to pose a significant challenge to pediatric surgeons. Various esophageal replacement grafts and techniques have not produced consistently good outcomes to emulate normal esophagus. Therefore, many techniques are still being practiced and recommended with no clear consensus. We present a concise literature review of the currently used techniques and with discussions on the advantages and anticipated morbidity. There are no randomized controlled pediatric studies to compare different types of esophageal replacements. Management and graft choice are based on geographical and personal predilections rather than on any discernible objective data. The biggest series with long-term outcome are reported for gastric transposition and colonic replacement. Comparison of different studies shows no significant difference in early (graft necrosis and anastomotic leaks) or late complications (strictures, poor feeding, gastro-esophageal reflux, tortuosity of the graft, and Barrett's esophagus). The biggest series seem to have lower complications than small series reflecting the decennials experience in their respective centers. Long-term follow-up is recommended following esophageal replacement for the development of late strictures, excessive tortuosity, and Barrett's changes within the graft. Once child overcomes initial morbidity and establishes oral feeding, long-term consequences and complications of pediatric esophageal replacement should be monitored and managed in adult life.
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Affiliation(s)
- Giampiero Soccorso
- Department of Paediatric Surgery, Birmingham Children's Hospital NHS Foundation Trust, Birmingham, UK
| | - Dakshesh H. Parikh
- Department of Paediatric Surgery, Birmingham Children's Hospital NHS Foundation Trust, Birmingham, UK
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Zani A, Cobellis G, Wolinska J, Chiu PPL, Pierro A. Preservation of native esophagus in infants with pure esophageal atresia has good long-term outcomes despite significant postoperative morbidity. Pediatr Surg Int 2016; 32:113-7. [PMID: 26520653 DOI: 10.1007/s00383-015-3821-x] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/09/2015] [Indexed: 01/28/2023]
Abstract
PURPOSE To evaluate long-term outcomes of pure esophageal atresia (EA) repair with preservation of native esophagus. METHODS Infants with pure EA treated at our institution (2000-2010) and with minimum 5-year follow-up were reviewed (REB:1000046653). Data analysed included demographics, management and outcomes and are reported as mean ± SD/median (range). RESULTS Of 185 infants with EA, 12 (7 %) had pure EA (gestational age: 36 ± 2.4 weeks, birth weight: 2353 ± 675 g). Ten had associated anomalies, including trisomy-21 (n = 2) and duodenal atresia (n = 1). SURGERY 1 patient (short gap) underwent primary thoracoscopic anastomosis, 11 had gastrostomy (Stamm, n = 5; image-guided, n = 6) as initial procedure. At definitive repair (age: 128 ± 91 days; weight 5.5 ± 2.3 kg): ten had primary anastomosis and 1 had Collis gastroplasty. No patient had esophageal replacement surgery. OUTCOMES three patients had gastrostomy dehiscence requiring re-operation. At post-operative esophagram, seven had anastomotic leak successfully treated conservatively. Seven patients developed strictures requiring balloon dilatations (median two dilatations, range 1-10), six received antireflux surgery. At 7-year follow-up (range 5-15 years), all patients had the gastrostomy closed and were on full oral feeds. CONCLUSIONS The management of pure EA continues to be challenging. The preservation of native esophagus is possible with significant morbidity. The long-term outcomes are favourable.
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Affiliation(s)
- Augusto Zani
- Division of General and Thoracic Surgery, Physiology and Experimental Medicine Program, The Hospital for Sick Children, 1526-555 University Ave, Toronto, ON, M5G 1X8, Canada
| | - Giovanni Cobellis
- Division of General and Thoracic Surgery, Physiology and Experimental Medicine Program, The Hospital for Sick Children, 1526-555 University Ave, Toronto, ON, M5G 1X8, Canada
| | - Justyna Wolinska
- Division of General and Thoracic Surgery, Physiology and Experimental Medicine Program, The Hospital for Sick Children, 1526-555 University Ave, Toronto, ON, M5G 1X8, Canada
| | - Priscilla P L Chiu
- Division of General and Thoracic Surgery, Physiology and Experimental Medicine Program, The Hospital for Sick Children, 1526-555 University Ave, Toronto, ON, M5G 1X8, Canada
| | - Agostino Pierro
- Division of General and Thoracic Surgery, Physiology and Experimental Medicine Program, The Hospital for Sick Children, 1526-555 University Ave, Toronto, ON, M5G 1X8, Canada. .,University of Toronto, Toronto, Canada.
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Foker process for the correction of long gap esophageal atresia: Primary treatment versus secondary treatment after prior esophageal surgery. J Pediatr Surg 2015; 50:933-7. [PMID: 25841281 DOI: 10.1016/j.jpedsurg.2015.03.010] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2015] [Accepted: 03/10/2015] [Indexed: 11/23/2022]
Abstract
PURPOSE The Foker process (FP) uses tension-induced growth for primary esophageal reconstruction in patients with long gap esophageal atresia (LGEA). It has been less well described in LGEA patients who have undergone prior esophageal reconstruction attempts. METHODS All cases of LGEA treated at our institution from January 2005 to April 2014 were retrospectively reviewed. Patients who initially had esophageal surgery elsewhere were considered secondary FP cases. Demographics, esophageal evaluations, and complications were collected. Median time to esophageal anastomosis and full oral nutrition was estimated using the Kaplan-Meier method. Multivariate Cox-proportional hazards regression identified potential risk factors. RESULTS Fifty-two patients were identified, including 27 primary versus 25 secondary FP patients. Median time to anastomosis was 14 days for primary and 35 days for secondary cases (p<0.001). Secondary cases (p=0.013) and number of thoracotomies (p<0.001) were identified as significant predictors for achieving anastomosis and the development of a leak. Predictors of progression to full oral feeding were primary FP cases (O.R.=17.0, 95% CI: 2.8-102, p<0.001) and patients with longer follow-up (O.R.=1.06/month, 95% CI: 1.01-1.11, p=0.005). CONCLUSIONS The FP has been successful in repairing infants with primary LGEA, but the secondary LGEA patients proved to be more challenging to achieve a primary esophageal anastomosis. Early referral to a multidisciplinary esophageal center and a flexible approach to establish continuity in secondary patients is recommended. Given their complexity, larger studies are needed to evaluate long-term outcomes and discern optimal strategies for reconstruction.
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Lee HQ, Hawley A, Doak J, Nightingale MG, Hutson JM. Long-gap oesophageal atresia: comparison of delayed primary anastomosis and oesophageal replacement with gastric tube. J Pediatr Surg 2014; 49:1762-6. [PMID: 25487479 DOI: 10.1016/j.jpedsurg.2014.09.017] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2014] [Accepted: 09/05/2014] [Indexed: 01/21/2023]
Abstract
BACKGROUND Long-gap oesophageal atresia (LGOA) causes significant early and long-term morbidity. We conducted a retrospective 25-year review comparing outcomes of delayed primary anastomosis versus oesophageal replacement with greater curvature gastric tube. METHODS Records of 44 consecutive patients undergoing LGOA repair (1986-2010) were obtained from OA database with ethics approval and were analysed for complication and long-term outcomes. Analysis was conducted using Student's t-test for quantitative and Fisher exact test for qualitative data. RESULTS Thirty (68%) patients underwent delayed primary anastomosis and 14 (32%) had oesophageal replacement. Oesophageal replacement patients had longer gaps (mean 5.5 vertebrae, range 4-9) compared to delayed primary anastomosis (mean 3.9, range 2-6) (p=0.004), but no difference in perioperative complications (p=0.2) (Table 1). Oesophageal replacement had more long-term complications (86%) compared to delayed primary anastomosis (30%) (p=0.005). Almost all patients (>90%) experienced gastro-oesophageal reflux and 21 delayed primary anastomosis patients (70%) underwent fundoplication. 60% of delayed primary anastomosis and 64.3% of oesophageal replacement patients had continued gastrointestinal symptoms years after repair. CONCLUSIONS Our experience indicates that LGOA can be repaired safely using both methods, with no deaths and similar perioperative risk, but high long-term morbidity mandates long-term follow-up of these patients. Delayed primary anastomosis has a better long-term outcome compared to oesophageal replacement with gastric tube.
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Affiliation(s)
- Hui Qing Lee
- Department of Paediatric and Neonatal Surgery, Royal Children's Hospital, Flemington Road, Parkville Victoria 3052, Australia
| | - Alisa Hawley
- Department of Paediatric and Neonatal Surgery, Royal Children's Hospital, Flemington Road, Parkville Victoria 3052, Australia
| | - Joe Doak
- Department of Paediatric and Neonatal Surgery, Royal Children's Hospital, Flemington Road, Parkville Victoria 3052, Australia
| | - Michael G Nightingale
- Department of Paediatric and Neonatal Surgery, Royal Children's Hospital, Flemington Road, Parkville Victoria 3052, Australia
| | - John M Hutson
- Department of Urology, Royal Children's Hospital; Department of Paediatrics, University of Melbourne; Douglas Stephens Laboratory, Murdoch Children's Research Institute.
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Liszewski MC, Bairdain S, Buonomo C, Jennings RW, Taylor GA. Imaging of long gap esophageal atresia and the Foker process: expected findings and complications. Pediatr Radiol 2014; 44:467-75. [PMID: 24366604 DOI: 10.1007/s00247-013-2847-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2013] [Revised: 10/13/2013] [Accepted: 11/21/2013] [Indexed: 01/21/2023]
Abstract
Long gap esophageal atresia (EA) is characterized by esophageal segments that are too far apart for primary anastomosis. Surgical repair utilizing interposition grafts or gastric transposition are often employed. The Foker staged lengthening procedure is an alternative surgical method that utilizes continuous traction on the esophagus to induce esophageal growth and allow for primary esophageal anastomosis. This pictorial review presents the step-by-step radiographic evaluation of the Foker procedure and illustrates the radiographic findings in the most commonly encountered complications in our cohort of 38 patients managed with this procedure from January 2000 to June 2012.
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Affiliation(s)
- Mark C Liszewski
- Department of Radiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA,
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Huh YJ, Kim HY, Lee SC, Park KW, Jung SE. Comparison of outcomes according to the operation for type A esophageal atresia. Ann Surg Treat Res 2014; 86:83-90. [PMID: 24761413 PMCID: PMC3994598 DOI: 10.4174/astr.2014.86.2.83] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2013] [Revised: 10/13/2013] [Accepted: 10/23/2013] [Indexed: 02/08/2023] Open
Abstract
Purpose The purpose was to evaluate outcomes according to different operative strategies of type A esophageal atresia (EA). Methods All patients who underwent surgery for type A EA between 1980 and 2011 were included. Patients were divided into 2 groups: E-E group included patients who received esophageal end-to-end anastomosis, whereas E-G group included patients who received esophago-gastric tube anastomosis. Results Twenty-two patients were included. The median gestational age was 37.5 weeks. The median birth weight was 2.5 kg. Twenty-one patients underwent gastrostomy as initial procedures, and one patient underwent primary esophageal end-to-end anastomosis. The median gap between both esophageal ends was six vertebral distance (VD). Seven patients underwent primary anastomosis of the esophagus, and 14 patients underwent gastric replacement. Three patients (13.6%) had anastomotic leakage and 10 patients (45.5%) had anastomotic stenosis. Most of the patients (90.9%) had gastroesophageal reflux, but only two patients required antireflux surgery. The median VD was significantly shorter in E-E group than in E-G group (3 VD vs. 6 VD). Stenosis was significantly more often in E-E group, but there was no significant difference in leakage and reflux symptoms. Conclusion The treatment for type A EA can include E-E anastomosis or E-G anastomosis, depending on the length of the end-to-end interval after performing gastrostomy. Appropriate tension and blood flow in the anastomosis site are essential for preventing postoperative stenosis and leakage, and esophageal replacement with gastric tube is believed to be feasible and safe in cases where excessive tension is present.
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Affiliation(s)
- Yeon-Ju Huh
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Hyun-Young Kim
- Division of Pediatric Surgery, Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Seong-Cheol Lee
- Division of Pediatric Surgery, Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Kwi-Won Park
- Division of Pediatric Surgery, Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Sung-Eun Jung
- Division of Pediatric Surgery, Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
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Type-A long-gap esophageal atresia treated by thoracoscopic esophagoesophagostomy after sequential extrathoracic esophageal elongation (Kimura's technique). Pediatr Surg Int 2013; 29:1171-5. [PMID: 23996146 DOI: 10.1007/s00383-013-3372-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
INTRODUCTION We report four cases of long-gap esophageal atresia (LGEA) treated with thoracoscopic esophagoesophagostomy (TEE) after sequential extrathoracic esophageal elongation (SEEE: Kimura's technique). METHODS All initially had gastrostomy, then SEEE. The proximal end of the esophagus was introduced into the apex of the thorax under direct vision during TEE. RESULTS Mean birth weight was 1.9 kg. Mean gestational age was 35.0 weeks (range 30-39); mean age at initial esophagostomy was 43.2 days (range 15-110); SEEE was performed for a mean of 3 times (range 2-4) at mean intervals of 5.3 months (range 2-10), with the upper esophageal segment lengthened by a mean of 2.1 cm each time (range 1.1-3.5). Mean age and weight at TEE were 22.3 months and 9.8 kg, respectively. Gap was initially 4.5 vertebrae (range 4-5). Mean operating time was 9.6 h. TEE was successful in 3; 1 required thoracotomy, then re-anastomosis after 11 months of anastomosis leakage; 2 cases with post-TEE anastomosis leakage were treated conservatively. Postoperatively, all cases required fundoplication and esophageal dilatation (2, 3, 5, 8 times, respectively). At mean follow-up of 3.6 years, 2 eat normally and 2 eat minced food. CONCLUSIONS TEE after SEEE appears to be a feasible option for treating LGEA.
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Bairdain S, Ricca R, Riehle K, Zurakowski D, Saites CG, Lien C, Anderson GF, Wahoff DC, Linden BC. Early results of an objective feedback-directed system for the staged traction repair of long-gap esophageal atresia. J Pediatr Surg 2013; 48:2027-31. [PMID: 24094952 DOI: 10.1016/j.jpedsurg.2013.05.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2013] [Revised: 05/03/2013] [Accepted: 05/07/2013] [Indexed: 10/26/2022]
Abstract
PURPOSE Treatment of long-gap esophageal atresia challenges pediatric surgeons. Dr. Foker described utilization of external traction sutures to promote in-vivo growth through tension-induced lengthening, but reproducibility of this technique is difficult. We describe a safe and reproducible traction system using transduction of hydrostatic pressure as a surrogate for tension. METHODS We conducted a multi-institutional review of patients treated with this system from 2005 to 2012. All children had sutures applied to both pouches with continuous measurement of associated hydrostatic pressures (tension). Main outcome measures were days to delayed primary repair and thoracotomies prior to primary repair. RESULTS Seven children were included. Median time to delayed repair was 15 days (range: 6-47 days). Three patients required repeat thoracotomies owing to mechanical entrapment of a pouch, all identified early by this system. All required postoperative dilations. Three had self-limited postdilation leaks, and there was one operation-related leak. CONCLUSIONS This system provides reproducible traction application, facilitating staged primary repair by preventing major failures through limiting excessive traction and guides re-exploration for trapped segments. Larger studies are needed to determine the optimal tension protocol, prevent postoperative leaks, while decreasing the need for dilations and time to enteral feeding.
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Affiliation(s)
- Sigrid Bairdain
- Department of Pediatric Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
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Maheshwari R, Trivedi A, Walker K, Holland AJA. Retrospective cohort study of long-gap oesophageal atresia. J Paediatr Child Health 2013; 49:845-9. [PMID: 23782058 DOI: 10.1111/jpc.12299] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/22/2013] [Indexed: 12/13/2022]
Abstract
AIM Long-gap oesophageal atresia (LGOA) remains a rare variant of a relatively common congenital malformation. Objectives of this study were to review the short-term results including survival, length of stay and post-operative complications for infants with LGOA managed at a single centre in addition to their growth and neurodevelopmental assessment. METHODS Retrospective review of the case notes of all infants admitted with oesophageal atresia to our institution from January 2001 to May 2011. Infants with LGOA were selected based on pre-defined criteria. Demographic and clinical variables and details of follow-up visits including developmental assessments were extracted from their case notes. RESULTS Of 101 infants with oesophageal atresia, 15 fulfilled the criteria for LGOA. Overall survival was 80%. Median length of stay was 83 days. Additional congenital anomalies were present in nine (60%). A fall in weight centile during hospitalisation or outpatient follow-up signifying growth failure was seen in a majority with 11 of 13 patients showing this phenomenon. Follow-up at our institution ranged from 6 months to 9 years. Developmental assessments (Bayley-III) commenced in August 2006 were available in four patients (age 5-13 months) and were abnormal in all, with particular delay in the gross motor domain. CONCLUSIONS Infants with LGOA spend a long time in hospital. They remain at significant risk of growth failure during hospitalisation and following discharge. There appears to be a risk of developmental delay that warrants close monitoring.
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Affiliation(s)
- Rajesh Maheshwari
- Grace Centre for Newborn Care, The Children's Hospital, Sydney, New South Wales, Australia
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31
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Su P, Yuan Y, Zhang Z, Huang Y, Wang W. Application of high-frequency ultrasound in esophageal atresia with distal fistula. Dis Esophagus 2013; 27:325-9. [PMID: 23980565 DOI: 10.1111/dote.12113] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The present study was designed to evaluate the accuracy of preoperative ultrasonography (US) in depicting the structure of esophageal atresia with distal fistula (EA-DF) and to determine its role in planning the surgical strategy by digitally measuring the interpouch distance (ID). Thirty-six neonates (20 males and 16 females) born with EA-DF were included in this study. After obtaining chest radiographs of the neonates with a coiled nasogastric tube in the upper esophageal pouch, longitudinal esophageal high-frequency US was performed. The esophageal structures were displayed, and the IDs measured on US images were compared with the surgical findings. With the use of US, the structure of EA-DF was accurately depicted, and the ID detected by US correlated well with the surgical findings. Statistical analysis demonstrated no significant difference in the ID as assessed by US and surgery (R = 0.99, P < 0.001).). US findings were crucial for planning the surgical strategy in 9 (25.0%) patients. Preoperative US could provide more accurate information on the structure of EA-DF and play a crucial role in planning the surgical strategy.
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Affiliation(s)
- P Su
- Department of Pediatric Surgery, Shengjing Hospital, China Medical University, Shenyang, China
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Bagolan P, Valfrè L, Morini F, Conforti A. Long-gap esophageal atresia: traction-growth and anastomosis - before and beyond. Dis Esophagus 2013; 26:372-9. [PMID: 23679026 DOI: 10.1111/dote.12050] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Long-gap esophageal atresia (LGEA) is still a major surgical challenge. Options for esophageal reconstruction include the use of native esophagus or esophageal replacement with stomach, colon, or small intestine. Nonetheless, there is a consensus among most pediatric surgeons that the preservation of the native esophagus is associated with better postoperative outcomes. Thus, every effort should be made to conserve the native esophagus. The present study is aimed at critically reporting our experience focused on a standardized protocol based on the preoperative assessment of the gap in all cases and reviewing the present literature because no consensus is available regarding many aspects of LGEA (from definition to treatment). All newborn infants treated since 1995 for esophageal atresia (EA), regardless of type, were included in the present study. Identification of LGEA patients (gap ≥3 vertebral bodies) was performed based on preoperative esophageal gap measurement. The selected patients were grouped based on EA type (A/B vs. C/D) and whether they were referred from an outside institution or not. Postoperative outcome was compared. Statistical analysis was performed with the Fisher's exact test and Mann-Whitney test as appropriate, with P < 0.05 considered statistically significant. Two hundred and nineteen patients have been consecutively treated between 1995 and 2012 with the following EA subtypes: type: A 25 (11.4%); B 6 (2.7%); C 182 (83.1%); D 3 (1.4%); E 3 (1.4%). Fifty-seven patients (26%) were classified as LGEA: type A-B, 31 (54.4%); type C-D, 26 (45.6%). Twenty seven (47%) of these patients were referred after at least one failed attempt at esophageal correction: type A-B, 15 (55%); type C-D, 12 (45%). Only one patient ultimately required esophageal substitution, with an overall survival rate of 94%. A standardized perioperative protocol enhances the possibility of preserving the native esophagus in cases of LGEA. Gap measurement can be accurately defined before surgery in all patients with EA. Esophageal anastomosis (either immediate or delayed repair) is almost always feasible; esophageal substitution should only be considered after a rigorous attempt at achieving end-to-end esophageal anastomosis.
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Affiliation(s)
- P Bagolan
- Department of Medical and Surgical Neonatology, Bambino Gesu' Research Children's Hospital, 00165 Rome, Italy.
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Abstract
Gastroesophageal reflux (GER) is almost constant in esophageal atresia and tracheoesophageal fistula (EA/TEF). These patients resist medical treatment and require antireflux surgery quite often. The present review examines why this happens, the long-term consequences of GER and the main indications and results of fundoplication in this particular group of patients. The esophagus of EA/TEF patients is malformed and has abnormal extrinsic and intrinsic innervation and, consequently, deficient sphincter function and dysmotility. These anomalies are permanent. Fifty percent of patients overall have GER, and one-fifth have Barrett's metaplasia. Close to 100%, GER of pure and long-gap cases require fundoplication. In the long run, these patients have 50-fold higher risk of carcinoma than the control population. GER in EA/TEF does not respond well to dietary, antacid, or prokinetic medication. Surgery is necessary in protracted anastomotic stenoses, in pure and long-gap cases, and when there is an associated duodenal atresia. It should be indicated as well in other symptomatic cases when conservative treatment fails. However, confection of a suitable wrap is anatomically difficult in this condition as shown by a failure rate of 30% that is also explained by the persistence for life of the conditions facilitating GER.
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Affiliation(s)
- J A Tovar
- Department of Pediatric Surgery, La Paz University Hospital, Autonomous University of Madrid, 28046 Madrid, Spain.
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Delayed primary anastomosis for management of long-gap esophageal atresia: a meta-analysis of complications and long-term outcome. Pediatr Surg Int 2012; 28:899-906. [PMID: 22875461 DOI: 10.1007/s00383-012-3142-2] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE Management of newborns with long-gap esophageal atresia (LGEA) remains a challenge for pediatric surgeons. Since spontaneous growth of the esophageal segments occurs without mechanical stretching, initial gastrostomy followed by delayed primary anastomosis (DPA) comprises treatment in most LGEA patients. This meta-analysis aimed to investigate the complications and long-term outcome in patients with LGEA managed by DPA. METHODS A systematic literature search was conducted for relevant articles published between 1981 and 2011, and a meta-analysis of complications and long-term outcome was performed. RESULTS Forty-four articles presented data on 451 newborns with LGEA managed by DPA. Most common variants were pure LGEA (194/451) and LGEA with tracheoesophageal fistula (257/451). Initial gap lengths ranged from 1.9 to 7.0 cm. At the time of DPA, performed at a mean of 11.9 weeks (range 0.5-54.0), the gap had decreased to 0.5-3.0 cm. Mean follow-up was 5.5 years (range 0.5-27.0). Frequent complications were anastomotic leaks/strictures, gastroesophageal reflux (GER), esophagitis and dysphagia. Relative risk for strictures was significantly higher in patients who previously had a leak (p < 0.0001) or GER (p < 0.0001). Patients with GER also had a significantly higher risk for esophagitis (p = 0.0283) and dysphagia (p = 0.0174). The majority of patients could eat without swallowing difficulties at follow-up. CONCLUSION DPA provides good long-term functional results. However, the high incidence of GER and associated strictures requires early intervention to prevent feeding problems.
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Pinheiro PFM, Simões e Silva AC, Pereira RM. Current knowledge on esophageal atresia. World J Gastroenterol 2012; 18:3662-72. [PMID: 22851858 PMCID: PMC3406418 DOI: 10.3748/wjg.v18.i28.3662] [Citation(s) in RCA: 129] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2011] [Revised: 08/26/2011] [Accepted: 06/08/2012] [Indexed: 02/06/2023] Open
Abstract
Esophageal atresia (EA) with or without tracheoesophageal fistula (TEF) is the most common congenital anomaly of the esophagus. The improvement of survival observed over the previous two decades is multifactorial and largely attributable to advances in neonatal intensive care, neonatal anesthesia, ventilatory and nutritional support, antibiotics, early surgical intervention, surgical materials and techniques. Indeed, mortality is currently limited to those cases with coexisting severe life-threatening anomalies. The diagnosis of EA is most commonly made during the first 24 h of life but may occur either antenatally or may be delayed. The primary surgical correction for EA and TEF is the best option in the absence of severe malformations. There is no ideal replacement for the esophagus and the optimal surgical treatment for patients with long-gap EA is still controversial. The primary complications during the postoperative period are leak and stenosis of the anastomosis, gastro-esophageal reflux, esophageal dysmotility, fistula recurrence, respiratory disorders and deformities of the thoracic wall. Data regarding long-term outcomes and follow-ups are limited for patients following EA/TEF repair. The determination of the risk factors for the complicated evolution following EA/TEF repair may positively impact long-term prognoses. Much remains to be studied regarding this condition. This manuscript provides a literature review of the current knowledge regarding EA.
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Tovar JA, Fragoso AC. Current Controversies in the Surgical Treatment of Esophageal Atresia. Scand J Surg 2011; 100:273-278. [DOI: 10.1177/145749691110000407] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Abstract
Background and Aims:Esophageal atresia (EA) with or without tracheo-esophageal fistula (TEF) is a rare condition that can be nowadays succesfully treated. The current interest therefore is focused on the management of the difficult cases, on thoracoscopic approach, and on some aspects of the long-term results.Methods:The current strategies for the difficult or impossible anastomoses in pure and long-gap EA, the introduction of thoracoscopic repair and the causes, mechanisms and management of post-operative gastro-esophageal reflux (GER) are reviewed.Results:Methods of esophageal elongation and multi-staged repair of pure and long-gap EA allow anastomosis but with functional results that are often poor. Esophageal replacement with colon or stomach achieves at least similar results and often requires less procedures. Thoracoscopic repair is a promising adjunct, but the difficulties for setting it as a gold-standard are pointed out. GER is a part of the disease and its surgical treatment, that is often required, is burdened by high failure rates.Conclusions:EA with or without TEF can be successfully treated in most cases, but a number of unsolved issues remain and the current approach to difficult cases will certainly evolve in the future.
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Affiliation(s)
- J. A. Tovar
- Department of Pediatric Surgery, Hospital Universitario La Paz and Universidad Autonoma de Madrid, Madrid, Spain
| | - A. C. Fragoso
- Department of Pediatric Surgery, Hospital Universitario La Paz and Universidad Autonoma de Madrid, Madrid, Spain
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Jönsson L, Gatzinsky V, Jennische E, Johansson C, Nannmark U, Friberg LG. Piglet model for studying esophageal regrowth after resection and interposition of a silicone stented small intestinal submucosa tube. ACTA ACUST UNITED AC 2011; 46:169-79. [PMID: 21454984 DOI: 10.1159/000324401] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2010] [Accepted: 01/17/2011] [Indexed: 11/19/2022]
Abstract
PURPOSE To investigate the use and subsequent healing of a silicone stented small intestinal submucosa (SIS) tube as a full-circumference replacement following surgical resection of the esophagus in piglets. MATERIAL AND METHODS Three centimeters of the intrathoracic esophagus was replaced with a silicone stented SIS tube (Cook Medical) in 6 growing piglets. The esophageal stent was retained for 4 weeks. Esophageal dilations were performed, if needed, after stent removal. RESULTS The piglets were sacrificed 1-17 weeks after surgery. Recurrent dilations were needed after stent removal. Histology showed that the gap between the resection margins was filled with new loose connective tissue consisting of fibroblasts and few inflammatory cells. In this tissue, intense angiogenesis was seen at the early time points, which then gave way to the proliferation of immature-looking smooth-muscle-like cells in the submucosa, which appeared to stem from the pericytes of the ingrowing capillaries. CONCLUSIONS Through using a stented SIS tube as a circumferential esophageal replacement in a piglet model, this study suggests that pericytes from ingrowing capillaries may play a role in the remodeling of the SIS mesh. It remains to be seen if this process gives a favorable end result because stricture formation after stent removal remains a problem.
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Affiliation(s)
- L Jönsson
- Department of Pediatric Surgery, Queen Silvia Children's Hospital, Sahlgrenska Academy, Gothenburg, Sweden. linus.jonsson @ vgregion.se
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Sung SC, Kim H, Ra YJ, Byun SY, Kwon KA, Jo YH. Staged Repair of Esophageal Atresia with Tracheoesophageal Fistula in a Very Low-birth-weight Infant -A case report-. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2010. [DOI: 10.5090/kjtcs.2010.43.6.820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Si Chan Sung
- Department of Thoracic and Cardiovascular Surgery, School of Medicine, Pusan National University
| | - Hyungtae Kim
- Department of Thoracic and Cardiovascular Surgery, Ajou University School of Medicine
| | - Yong Joon Ra
- Department of Thoracic and Cardiovascular Surgery, School of Medicine, Pusan National University
| | - Shin Yun Byun
- Department of Pediatric, School of Medicine, Pusan National University
| | - Kyung Ah Kwon
- Department of Pediatric, School of Medicine, Pusan National University
| | - Yong Hoon Jo
- Department of Surgery, School of Medicine, Pusan National University
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Zandueta Pascual L, Giménez López V, Campos Bernal A, Clavero Montañés N, Olivares López JL, Elías Pollina J. [Assessment of nutritional status in esophageal atresia]. An Pediatr (Barc) 2010; 73:74-7. [PMID: 20634157 DOI: 10.1016/j.anpedi.2010.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2009] [Revised: 05/04/2010] [Accepted: 05/16/2010] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE The aim of the study was to find out whether patients who underwent esophageal atresia (EA) surgery suffered from nutritional problems, to compare the nutritional status of these patients with a control group, and to determine if there is a relationship between the type of atresia and the nutritional condition. MATERIAL AND METHODS We selected 25 patients out of a total of 32 who underwent EA surgery in our hospital from 2000 to 2006. A retrospective was conducted study based on the information obtained from the medical histories. A case-control study was also carried out by selecting a control group from a randomized population. RESULTS The analyses performed showed that the mean weight and height Z-score was always negative, but not below -2 SD. There was a significant decrease in the weight Z-score between 3 and 9 months and in the weight/size Z-score between 3 and 24 months. Significant differences in weight and size Z-score were found between cases and controls, but not in skin-fold thickness. Independently of the type of atresia and the presence or not of congenital heart defects, no significant differences were found. CONCLUSIONS There are significant differences in the weight and height Z-score between cases and controls. We stress the need to be aware of the nutritional status in order to prevent changes that could lead to a further deterioration of the patient.
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Holland AJA, Fitzgerald DA. Oesophageal atresia and tracheo-oesophageal fistula: current management strategies and complications. Paediatr Respir Rev 2010; 11:100-6; quiz 106-7. [PMID: 20416546 DOI: 10.1016/j.prrv.2010.01.007] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The successful operative management of oesophageal atresia and tracheo-oesophageal atresia has been available for approximately 70 years. During this time neonatal intensive care has evolved, surgical techniques have improved and consequently near 100% survival for this condition may now be achieved. In keeping with promising results, the co-morbidities of the condition have gained increasing recognition. In this article, the clinical course from antenatal assessments, neonatal surgery and co-morbidities from infancy to adulthood are reviewed to provide a broad overview of the condition.
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Affiliation(s)
- Andrew J A Holland
- Douglas Cohen Department of Paediatric Surgery, The Children's Hospital at Westmead, Locked Bag 4001, Westmead, NSW 2145, Australia
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41
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Holland AJA, Ron O, Pierro A, Drake D, Curry JI, Kiely EM, Spitz L. Surgical outcomes of esophageal atresia without fistula for 24 years at a single institution. J Pediatr Surg 2009; 44:1928-32. [PMID: 19853749 DOI: 10.1016/j.jpedsurg.2009.02.008] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2008] [Revised: 02/02/2009] [Accepted: 02/02/2009] [Indexed: 12/29/2022]
Abstract
PURPOSE The aim of the study was to evaluate the surgical outcome of esophageal atresia (EA) without fistula for 24 years at a single tertiary center for pediatric surgery. METHODS The study used a retrospective chart review of infants diagnosed with EA without fistula between 1981 and 2005. RESULTS Of 33 patients with EA without fistula, 31 charts were available. Mean birth weight was 2327 g (range, 905-3390 g), and 71% were male. Most common associated anomalies were cardiac (n = 6; 19%) and renal (n = 5; 16%), followed by vertebral (n = 4; 13%) and anorectal (n = 2; 7%). The median initial esophageal gap was 5 vertebral bodies. Six had a primary repair, and 25 patients had esophageal replacement at a median age of 7 months. This involved gastric transposition in 20 (1 followed failed jejunal interposition), colonic interposition in 5, jejunal interposition in 1 (after a failed colonic), and repair at another center in 1. With a median review of 9 years, 21 patients had long-term sequelae with the need for multiple further surgical procedures including an antireflux procedure in 5. One patient died. CONCLUSIONS Management of EA without fistula remains challenging. Most patients required staged treatment that included esophageal replacement. The frequency of late complications indicates the need for programmed long-term review.
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Affiliation(s)
- Andrew J A Holland
- Department of Pediatric Surgery, Institute of Child Health and Great Ormond Street Hospital for Children, University College London, London, UK.
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Charlesworth P, Mahomed A. A radiological chronicle of the presentation and management of a long gap oesophageal atresia. J Radiol Case Rep 2009; 3:17-21. [PMID: 22470672 DOI: 10.3941/jrcr.v3i7.203] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Long gap oesophageal atresia is a clinically and technically challenging condition to manage. Documentation of the gap between the upper and lower pouches is critical to deciding the timing and feasibility of a primary anastamosis. Integral to this process is the role of radiology. We present a case of long gap oesophageal atresia accompanied by chronological radiography demonstrating its' staged management and highlighting some common complications.
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Affiliation(s)
- Paul Charlesworth
- Department of Pediatric Surgery, Royal Alexandra Children's Hospital, Brighton, UK
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Abstract
The outcome of cases of esophageal atresia depends on many factors that affect the prognosis. These factors have been identified since Waterston aimed to classify the anomaly according to the risk factors. There are other factors that affect the outcome, and these differ in different parts of the globe. This comprehensive review attempts to incorporate all the factors--preoperative, operative, and postoperative--that can pose risks to the ultimate survival of the baby. Early detection for proper management of these cases is essential. Feasibility to perform early esophageal replacement has come as a boom for these high-risk cases. Total care in a high-risk population of esophageal atresia depends on the investigative modalities adopted, available neonatal ICU care, and the surgeon's experience. An attempt continues to decrease the associated morbidity and mortality in high-risk babies born with esophageal atresia and tracheoesophageal fistula.
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Affiliation(s)
- Devendra K Gupta
- Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, India.
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Abstract
The most common surgery on the esophagus by pediatric surgeons the world over is performed in the newborn period in babies with congenital esophageal atresia with tracheo-esophageal fistula. Post-operative complications like recurrent fistula, anastomotic stricture and some patients with gastroesophageal reflux would also require surgical intervention. Apart from esophageal dilatation, gastrostomy and feeding jejunostomy, children with strictures secondary to caustic ingestion, reflux or previous esophageal anastomosis may require esophageal substitution. This operation may also be required in babies with pure esophageal atresia as well as those with a long gap esophageal atresia with fistula. The entire stomach, stomach tubes, colon or jejunum are often used but techniques preserving as much of the original esophagus as possible are preferable and more physiological. Surgery is also required in children with congenital esophageal stenosis and duplication cyst.
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Golonka NR, Hayashi AH. Early “sham” feeding of neonates promotes oral feeding after delayed primary repair of major congenital esophageal anomalies. Am J Surg 2008; 195:659-62; discussion 662. [DOI: 10.1016/j.amjsurg.2008.02.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2007] [Revised: 02/13/2008] [Accepted: 02/13/2008] [Indexed: 12/19/2022]
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