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Borselle D, Davidson J, Loukogeorgakis S, De Coppi P, Patkowski D. Thoracoscopic Stage Internal Traction Repair Reduces Time to Achieve Esophageal Continuity in Long Gap Esophageal Atresia. Eur J Pediatr Surg 2024; 34:36-43. [PMID: 38154482 DOI: 10.1055/a-2235-8766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2023]
Abstract
OBJECTIVE Management of long gap esophageal atresia (LGOA) is controversial. This study aims at comparing the management of LGOA between two high-volume centers. METHODS We included patients with LGOA (type A and B) between 2008 and 2022. Demographics, surgical methods, and outcomes were collected and compared. RESULTS The study population involved 28 patients in center A and 24 patients in center B. A surgical approach was thoracoscopic in center A, only for one patient was open for final procedure. In center B, 3 patients were treated only thoracoscopically, 2 converted to open, and 19 as open surgery. In center A primary esophageal anastomosis concerned 1 case, two-staged esophageal lengthening using external traction 1 patient, and 26 were treated with the multistaged internal traction technique. In 24 patients a full anastomosis was achieved: in 23 patients only the internal traction technique was used, while 1 patient required open Collis-Nissen procedure as final management. In center B primary anastomosis was performed in 7 patients, delayed esophageal anastomosis in 8 patients, esophageal lengthening using external traction in 1 case, and 9 infants required esophageal replacement with gastric tube. Analyzed postoperative complications included: early mortality, 2/28 due to accompanied malformations (center A) and 0/24 (center B); anastomotic leakage, 4/26 (center A) treated conservatively-all patients had a contrast study-and 0/24 (center B), 1 case of pleural effusion, but no routine contrast study; recurrent strictures, 13/26 (center A) and 7/15 (center B); and need for fundoplication, 5/26 (center A) and 2/15 (center B). Age at esophageal continuity was as a median of 31 days in center A and 110 days in center B. Median time between initial procedure and esophageal anastomosis was 11 days in center A and 92 days in center B. CONCLUSION Thoracoscopic internal traction technique reduces time to achieve esophageal continuity and the need for esophageal substitution while maintaining a similar early complication rate.
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Affiliation(s)
- Dominika Borselle
- Department of Paediatric Surgery and Urology, Wroclaw Medical University, Wroclaw, Poland
| | - Joseph Davidson
- Great Ormond Street Institute of Child Health, University College London, London, United Kingdom of Great Britain and Northern Ireland
| | - Stavros Loukogeorgakis
- Great Ormond Street Institute of Child Health, University College London, London, United Kingdom of Great Britain and Northern Ireland
- Department of Specialist Neonatal and Paediatric Surgery, Great Ormond Street Hospital for Children, NIHR, London, United Kingdom of Great Britain and Northern Ireland
| | - Paolo De Coppi
- Great Ormond Street Institute of Child Health, University College London, London, United Kingdom of Great Britain and Northern Ireland
- Department of Specialist Neonatal and Paediatric Surgery, Great Ormond Street Hospital for Children, NIHR, London, United Kingdom of Great Britain and Northern Ireland
| | - Dariusz Patkowski
- Department of Paediatric Surgery and Urology, Wroclaw Medical University, Wroclaw, Poland
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Hall LA, Jackson R, Soccorso G, Lander AD, Pachl MJ. Assessment of jejunal interposition perfusion using indocyanine green. Photodiagnosis Photodyn Ther 2023; 43:103687. [PMID: 37399912 DOI: 10.1016/j.pdpdt.2023.103687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 06/15/2023] [Accepted: 06/30/2023] [Indexed: 07/05/2023]
Abstract
INTRODUCTION Jejunal interposition (JI) is an option for oesophageal replacement in children; ensuring good graft perfusion is essential. We report three cases where Indocyanine Green (ICG) with Near-Infrared Fluorescence (NIRF) was used to assess perfusion during graft selection, passage into the chest and anastomotic assessment. This extra assessment may reduce risk of anastomotic leak and/or stricture. METHODS We describe the technique and salient features of all patients who have undergone ICG/NIRF-assisted JI in our centre. Patient demographics, indications for surgery, intra-operative plan, video of NIR perfusion assessment, complications and outcomes were reviewed. RESULTS ICG/NIRF was used in three patients (2M:1F) at a dose of 0.2 mg/kg. ICG/NIRF imaging helped select the jejunal graft and confirmed perfusion after division of segmental arteries. Perfusion was assessed before and after passing the graft through the diaphragmatic hiatus and before and after making the oesophago-jejunal anastomosis. Intrathoracic assessment at the end of the procedure confirmed good perfusion of mesentery and intrathoracic bowel. In two patients, the reassurance contributed to successful procedures. In the third patient, graft selection was satisfactory, but borderline perfusion on clinical assessment after passing the graft to the chest, confirmed by ICG/NIRF meant the graft was abandoned. CONCLUSIONS ICG/NIRF imaging was feasible and augmented our subjective assessment of graft perfusion, giving greater confidence during graft preparation, movement, and anastomosis. In addition, the imaging helped us abandon one graft. This series demonstrates the feasibility and benefit of ICG/NIR use in JI surgery. Further studies are required to optimise ICG use in this setting.
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Affiliation(s)
- Lewis A Hall
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Raef Jackson
- Department of Paediatric Surgery and Urology, Birmingham Children's Hospital, Birmingham, UK
| | - Giampiero Soccorso
- Department of Paediatric Surgery and Urology, Birmingham Children's Hospital, Birmingham, UK
| | - Anthony D Lander
- Department of Paediatric Surgery and Urology, Birmingham Children's Hospital, Birmingham, UK
| | - Max J Pachl
- Department of Paediatric Surgery and Urology, Birmingham Children's Hospital, Birmingham, UK; Institute of Cancer and Genomics, University of Birmingham, Birmingham, UK.
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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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Evans LL, Chen CS, Muensterer OJ, Sahlabadi M, Lovvorn HN, Novotny NM, Upperman JS, Martinez JA, Bruzoni M, Dunn JCY, Harrison MR, Fuchs JR, Zamora IJ. The novel application of an emerging device for salvage of primary repair in high-risk complex esophageal atresia. J Pediatr Surg 2022; 57:810-818. [PMID: 35760639 DOI: 10.1016/j.jpedsurg.2022.05.018] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 05/17/2022] [Accepted: 05/24/2022] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Preservation of native esophagus is a tenet of esophageal atresia (EA) repair. However, techniques for delayed primary anastomosis are severely limited for surgically and medically complex patients at high-risk for operative repair. We report our initial experience with the novel application of the Connect-EA, an esophageal magnetic compression anastomosis device, for salvage of primary repair in 2 high-risk complex EA patients. Compassionate use was approved by the FDA and treating institutions. OPERATIVE TECHNIQUE Two approaches using the Connect-EA are described - a totally endoscopic approach and a novel hybrid operative approach. To our knowledge, this is the first successful use of a hybrid operative approach with an esophageal magnetic compression device. OUTCOMES Salvage of delayed primary anastomosis was successful in both patients. The totally endoscopic approach significantly reduced operative time and avoided repeat high-risk operation. The hybrid operative approach salvaged delayed primary anastomosis and avoided cervical esophagostomy. CONCLUSION The Connect-EA is a novel intervention to achieve delayed primary esophageal repair in complex EA patients with high-risk tissue characteristics and multi-system comorbidities that limit operative repair. We propose a clinical algorithm for use of the totally endoscopic approach and hybrid operative approach for use of the Connect-EA in high-risk complex EA patients.
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Affiliation(s)
- Lauren L Evans
- Department of Pediatric Surgery, University of California San Francisco, 550 16th Street Box 0570, San Francisco, CA 94143 USA
| | - Caressa S Chen
- Department of Pediatric Surgery, University of California San Francisco, 550 16th Street Box 0570, San Francisco, CA 94143 USA
| | - Oliver J Muensterer
- Department of Pediatric Surgery, Dr. von Hauner Children's Hospital, LMU Munich, Lindwurmstrasse 4, 80337 Munich, Germany
| | - Mohammad Sahlabadi
- Department of Pediatric Surgery, University of California San Francisco, 550 16th Street Box 0570, San Francisco, CA 94143 USA
| | - Harold N Lovvorn
- Department of Pediatric Surgery, Monroe Carell Jr. Children's Hospital at Vanderbilt, 2200 Children's Way 7th Floor, Nashville TN 37212 USA
| | - Nathan M Novotny
- Section of Pediatric Surgery, Beaumont Children's, 3535W. 13 Mile Road, Royal Oak, MI 48073 USA
| | - Jeffrey S Upperman
- Department of Pediatric Surgery, Monroe Carell Jr. Children's Hospital at Vanderbilt, 2200 Children's Way 7th Floor, Nashville TN 37212 USA
| | - J Andres Martinez
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Vanderbilt University Medical Center, 2200 Children's Way, Nashville TN 37232 USA
| | - Matias Bruzoni
- Division of Pediatric Surgery, Stanford University School of Medicine, 453 Quarry Road, Palo Alto, CA 94304 USA
| | - James C Y Dunn
- Division of Pediatric Surgery, Stanford University School of Medicine, 453 Quarry Road, Palo Alto, CA 94304 USA
| | - Michael R Harrison
- Department of Pediatric Surgery, University of California San Francisco, 550 16th Street Box 0570, San Francisco, CA 94143 USA
| | - Julie R Fuchs
- Division of Pediatric Surgery, Stanford University School of Medicine, 453 Quarry Road, Palo Alto, CA 94304 USA
| | - Irving J Zamora
- Department of Pediatric Surgery, Monroe Carell Jr. Children's Hospital at Vanderbilt, 2200 Children's Way 7th Floor, Nashville TN 37212 USA.
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Muensterer OJ, Evans LL, Sterlin A, Sahlabadi M, Aribindi V, Lindner A, König T, Harrison MR. Novel Device for Endoluminal Esophageal Atresia Repair: First-in-Human Experience. Pediatrics 2021; 148:peds.2020-049627. [PMID: 34615695 DOI: 10.1542/peds.2020-049627] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/20/2021] [Indexed: 12/22/2022] Open
Abstract
Thoracoscopic esophageal atresia (EA) repair affords many benefits to the patient; however, intracorporeal suturing of the anastomosis is technically challenging. Esophageal magnetic compression anastomosis (EMCA) is a compelling option for endoluminal EA repair, but available EMCA devices have prohibitive rates of recalcitrant stricture. Connect-EA is a new endoluminal EMCA device system that employs 2 magnetic anchors with a unique mating geometry designed to reliably create a robust anastomosis and decrease rates of leak and stricture. We describe our first-in-human experience with this novel endoluminal device for staged EA repair in 3 patients (Gross type A, B, and C) at high risk for conventional surgical repair. First, the esophageal pouches were approximated thoracoscopically. After acute tension subsided, the device anchors were endoscopically placed in the esophageal pouches and mated. Anchors were spontaneously excreted in 2 cases. Endoscopic repositioning and retrieval of the anchors were required in 1 patient because of narrowed esophageal anatomy. There were no perioperative complications. Patients were managed for 14 to 18 months. The strictures that developed in the patients were membranous and responded well to dilation alone, resolving after 4 to 5 outpatient dilations. Gastrostomies were closed between 6 and 11 months and all patients are tolerating full oral nutrition. Early experience with this new endoluminal EMCA device system is highly favorable. The device offers considerable benefit over conventional handsewn esophageal anastomosis and anastomotic outcomes are superior to available EMCA devices.
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Affiliation(s)
- Oliver J Muensterer
- Department of Pediatric Surgery, Johannes Gutenberg University Mainz, Mainz, Germany .,Department of Pediatric Surgery, Dr. von Hauner Children's Hospital, Ludwig-Maximilians-University of Munich, Munich, Germany
| | - Lauren L Evans
- Division of Pediatric Surgery, Department of Surgery, University of California San Francisco, San Francisco, California
| | - Alexander Sterlin
- Department of Pediatric Surgery, Johannes Gutenberg University Mainz, Mainz, Germany
| | - Mohammad Sahlabadi
- Division of Pediatric Surgery, Department of Surgery, University of California San Francisco, San Francisco, California
| | - Vamsi Aribindi
- Division of Pediatric Surgery, Department of Surgery, University of California San Francisco, San Francisco, California
| | - Andreas Lindner
- Department of Pediatric Surgery, Johannes Gutenberg University Mainz, Mainz, Germany.,Department of Pediatric Surgery, Dr. von Hauner Children's Hospital, Ludwig-Maximilians-University of Munich, Munich, Germany
| | - Tatjana König
- Department of Pediatric Surgery, Johannes Gutenberg University Mainz, Mainz, Germany
| | - Michael R Harrison
- Division of Pediatric Surgery, Department of Surgery, University of California San Francisco, San Francisco, California
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6
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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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7
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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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Dingemann C, Eaton S, Aksnes G, Bagolan P, Cross KM, De Coppi P, Fruithof J, Gamba P, Goldschmidt I, Gottrand F, Pirr S, Rasmussen L, Sfeir R, Slater G, Suominen J, Svensson JF, Thorup JM, Tytgat SHAJ, van der Zee DC, Wessel L, Widenmann-Grolig A, Wijnen R, Zetterquist W, Ure BM. ERNICA Consensus Conference on the Management of Patients with Long-Gap Esophageal Atresia: Perioperative, Surgical, and Long-Term Management. Eur J Pediatr Surg 2021; 31:214-225. [PMID: 32668485 DOI: 10.1055/s-0040-1713932] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Evidence supporting best practice for long-gap esophageal atresia is limited. The European Reference Network for Rare Inherited Congenital Anomalies (ERNICA) organized a consensus conference on the management of patients with long-gap esophageal atresia based on expert opinion referring to the latest literature aiming to provide clear and uniform statements in this respect. MATERIALS AND METHODS Twenty-four ERNICA representatives from nine European countries participated. The conference was prepared by item generation, item prioritization by online survey, formulation of a final list containing items on perioperative, surgical, and long-term management, and literature review. The 2-day conference was held in Berlin in November 2019. Anonymous voting was conducted via an internet-based system using a 1 to 9 scale. Consensus was defined as ≥75% of those voting scoring 6 to 9. RESULTS Ninety-seven items were generated. Complete consensus (100%) was achieved on 56 items (58%), e.g., avoidance of a cervical esophagostomy, promotion of sham feeding, details of delayed anastomosis, thoracoscopic pouch mobilization and placement of traction sutures as novel technique, replacement techniques, and follow-up. Consensus ≥75% was achieved on 90 items (93%), e.g., definition of long gap, routine pyloroplasty in gastric transposition, and avoidance of preoperative bougienage to enable delayed anastomosis. Nineteen items (20%), e.g., methods of gap measurement were discussed controversially (range 1-9). CONCLUSION This is the first consensus conference on the perioperative, surgical, and long-term management of patients with long-gap esophageal atresia. Substantial statements regarding esophageal reconstruction or replacement and follow-up were formulated which may contribute to improve patient care.
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Affiliation(s)
- Carmen Dingemann
- Department of Pediatric Surgery, Hannover Medical School, Hannover, Germany
| | - Simon Eaton
- NIHR Biomedical Research Centre at UCLH, Developmental Biology and Cancer Programme, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Gunnar Aksnes
- Department of Pediatric Surgery, Oslo University Hospital, Oslo, Norway
| | - Pietro Bagolan
- Department of Medical and Surgical Neonatology, Research Institute, Bambino Gesù Children's Hospital, Rome, Italy
| | - Kate M Cross
- Department of Neonatal and Paediatric Surgery, Great Ormond Street Hospital for Children, London, United Kingdom
| | - Paolo De Coppi
- NIHR Biomedical Research Centre at UCLH, Developmental Biology and Cancer Programme, UCL Great Ormond Street Institute of Child Health, London, United Kingdom.,Department of Neonatal and Paediatric Surgery, Great Ormond Street Hospital for Children, London, United Kingdom
| | - JoAnne Fruithof
- Esophageal Atresia and Tracheo-Esophageal Fistula Support Federation and VOKS, Lichtenvoorde, The Netherlands
| | | | - Imeke Goldschmidt
- Department of Pediatric Gastroenterology and Hepatology, Hannover Medical School, Hannover, Germany
| | - Frederic Gottrand
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Reference Center for Rare Esophageal Diseases, CHU Lille, University of Lille, Lille, France
| | - Sabine Pirr
- Department of Pediatric Pulmonology, Allergology and Neonatology, Hannover Medical School, Hannover, Germany
| | - Lars Rasmussen
- Department of Pediatric Surgery, Odense University Hospital, Odense, Denmark
| | - Rony Sfeir
- Department of Pediatric Surgery, Reference Center for Rare Esophageal Diseases, CHU Lille, University of Lille, Lille, France
| | - Graham Slater
- Esophageal Atresia and Tracheo-Esophageal Fistula Support Federation and TOFS, Nottingham, United Kingdom
| | - Janne Suominen
- Department of Pediatric Surgery, University of Helsinki, Helsinki, Finland
| | - Jan F Svensson
- Department of Pediatric Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Joergen M Thorup
- Department of Pediatric Surgery, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Stefaan H A J Tytgat
- Department of Pediatric Surgery, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
| | - David C van der Zee
- Department of Pediatric Surgery, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Lucas Wessel
- Department of Pediatirc Surgery, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Anke Widenmann-Grolig
- Esophageal Atresia and Tracheo-Esophageal Fistula Support Federation and KEKS, Stuttgart, Germany
| | - René Wijnen
- Department of Pediatric Surgery, Erasmus MC, Rotterdam, The Netherlands
| | - Wilhelm Zetterquist
- Department of Woman and Child Health, Karolinska University Hospital, Stockholm, Sweden
| | - Benno M Ure
- Department of Pediatric Surgery, Hannover Medical School, Hannover, Germany
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9
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Primary anastomosis in difficult cases of type "C" esophageal atresia: The atraumatic microvascular clamp technique of minimal tension with good outcome. J Pediatr Surg 2021; 56:1076-1081. [PMID: 33342605 DOI: 10.1016/j.jpedsurg.2020.12.005] [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] [Received: 08/14/2020] [Revised: 11/17/2020] [Accepted: 12/06/2020] [Indexed: 11/21/2022]
Abstract
BACKGROUND Surgical maneuvers for esophageal anastomosis in difficult cases of Gross type "C" esophageal atresia (EA) are challenging. The methods of early primary anastomosis are technically difficult and staged surgeries expose the child to repeated general anesthesia with problems of nursing care. We describe a simple method of partial disconnection of the lower esophagus from the fistula followed by approximation by an atraumatic microvascular clamp. The suitability of this method and its outcomes are discussed. METHODS It was a prospective observational study that included 32 patients of type "C" EA between January 2014 and December 2016. Babies with birth weight more than 2 kg without cyanotic heart defects and requirement of intensive care were included. An early primary anastomosis using this technique was tried in all. A cervical esophagostomy with feeding gastrostomy was done where it was not possible. Analysis of the gap and post operative outcomes i.e. gastroesophageal reflux (GER), stricture, tracheomalacia, dysmotility, recurrence and survival were analyzed. RESULTS The mean gap between esophageal ends was 4.3 cm. Primary anastomosis was possible in 26 (81.25%). Minor and major leak occurred in 3 (11.54%) and 1 (3.85%) patients respectively. Survival was 84.62% (22/26). All mortalities were early post operative. During mean follow up of 23.73 months (till December 2019), GER decreased from 63.64% (14/22) to 13.64% (3/22), partial stricture was seen in 18.18% (4/22), tracheomalacia in 36.36% (8/22) and dysmotility in 77.27% (17/22). There was no recurrence of fistula. Complications with this method did not show any significant difference as mentioned with other methods. CONCLUSION This technique seems to be physiologically suitable as it enables anastomosis with minimal trauma to the esophageal ends. It is easy, reproducible and produces favorable outcomes comparable with other methods for difficult cases of type "C" esophageal atresia (EA).
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10
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Usefulness of Gastrojejunostomy Prior to Fundoplication in Severe Gastro-Esophageal Reflux Complicating Long-Gap Esophageal Atresia Repair: A Preliminary Study. CHILDREN-BASEL 2021; 8:children8010055. [PMID: 33477368 PMCID: PMC7830350 DOI: 10.3390/children8010055] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Revised: 01/11/2021] [Accepted: 01/14/2021] [Indexed: 12/27/2022]
Abstract
BACKGROUND Gastro-esophageal reflux disease (GERD), requiring surgical correction, and nutritional problems are reported after long-gap esophageal atresia (LGEA) repair and might jeopardize the postoperative course in some babies. We report an exploratory evaluation of the role of transgastric jejunostomy (TGJ) as a temporary nutritional tool before surgery for GERD in LGEA. METHODS Seven infant patients operated on for LGEA with intra-thoracic gastro-esophageal junction (GEJ) and growth failure, requiring improvement in their nutritional profile in anticipation of surgery, were retrospectively evaluated. Post-surgical follow-up, including growth evolution, complications, and parental quality of life (QoL), were considered. RESULTS The TGJ was placed at a mean age of 8.6 ± 5.6 months. The procedure was uneventful and well-tolerated in all seven cases. At 6.6 ± 2.0 months after TGJ placement, significant weight gain (weight z-score -2.68 ± 0.8 vs -0.9 ± 0.2, p < 0.001) was recorded, allowing the GERD surgery to proceed. A significant difference in hospital admissions between 3 months before and post-TGJ insertion was noted (4.8 ± 0.75 vs. 1.6 ± 0.52, p < 0.01). A significant amelioration of QoL after TGJ placement was also recorded; in particular, the biggest improvements were related to parents' perceptions of the general health and emotional state of their babies (p < 0.001). CONCLUSIONS The placement of TGJ as a temporary nutritional tool in selected cases of LGEA could improve nutritional conditions and parental QoL before fundoplication, allowing successful surgical treatment of GERD to be carried out.
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Bindi E, Torino G, Noviello C, Simonini A, Torre M, D'Agostino R, Cobellis G. Recurrent tracheoesophageal fistula secondary to clips migration after thoracoscopic esophageal atresia repair. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2020. [DOI: 10.1016/j.epsc.2020.101651] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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12
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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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13
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Cano Novillo I, Aneiros Castro B, Godoy Lenz J, Puentes Rivera MC, García Vázquez A, Moreno Zegarra C. Thoracoscopic approach for complications after esophageal atresia repair: initial experience. Asian J Endosc Surg 2020; 13:147-151. [PMID: 31066217 DOI: 10.1111/ases.12714] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Revised: 03/06/2019] [Accepted: 04/09/2019] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Improvements in technology and health care have helped reduce morbidity and mortality in patients with esophageal atresia. However, postoperative complications such as dehiscences, strictures, and recurrent fistulas still occur in a large percentage of patients. Here, we present our initial experience using the thoracoscopic approach for complications after esophageal atresia repair. METHODS We retrospectively analyzed the medical records of patients who developed complications after esophageal atresia repair and underwent thoracoscopic reoperation at two centers. Anastomotic leakage, anastomotic stricture, and recurrent tracheoesophageal fistula were assessed as complications after esophageal atresia repair. RESULTS We reoperated on four patients (range of age 3 days - 2 years) by thoracoscopy. Two patients who had undergone thoracoscopic atresia repair presented with anastomotic dehiscence. The anastomoses were thoracoscopically reconstructed without tension. One patient had undergone thoracoscopic atresia repair presented with esophageal stricture refractory to endoscopic dilatations. Thoracoscopic esophagoesophagostomy was performed in this 2-year-old patient. One patient who had undergone esophageal atresia repair and tracheoesophageal fistula closure by thoracotomy presented with a recurrent fistula at 1 year of age. The patient underwent thoracoscopic fistula closure with a 5-mm endostapler. All patients remain asymptomatic after reoperation. CONCLUSIONS Reoperation after esophageal atresia repair is challenging and carries a relatively high risk of developing complications. Compared to conventional surgery, the thoracoscopic approach in experienced hands offers better visualization and more accurate dissection and drainage of the thoracic cavity. Therefore, we want to encourage the use of thoracoscopy in the treatment of complications after esophageal atresia repair.
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Affiliation(s)
| | | | - Jorge Godoy Lenz
- Department of Pediatric Surgery, Clínica Las Condes, Santiago de Chile, Chile
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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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Slater BJ, Borobia P, Lovvorn HN, Raees MA, Bass KD, Almond S, Hoover JD, Kumar T, Zaritzky M. Use of Magnets as a Minimally Invasive Approach for Anastomosis in Esophageal Atresia: Long-Term Outcomes. J Laparoendosc Adv Surg Tech A 2019; 29:1202-1206. [PMID: 31524560 DOI: 10.1089/lap.2019.0199] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Introduction: The majority of esophageal atresia (EA) patients undergo surgical repair soon after birth. However, factors due to patient characteristics, esophageal length, or surgical complications can limit the ability to obtain esophageal continuity. A number of techniques have been described to treat these patients with "long-gap" EA. Magnets are a nonsurgical alternative for esophageal anastomosis. The purpose of this study was to report long-term outcomes for the use of magnets in EA. Materials and Methods: Between July 2001 and December 2017, 13 patients underwent placement of a magnetic catheter-based system under fluoroscopic guidance at six institutions. Daily chest radiographs were obtained until there was union of the magnets. Magnets were then removed and replaced with an oro- or nasogastric tube. Complications and outcomes were recorded. The average length of follow-up was 9.3 years (range 1.42-17.75). Results: A total of 85% of the patients had type A, pure EA, and 15% had type C with previous fistula ligation. The average length of time to achieve anastomosis was 6.3 days (range 3-13). No anastomotic leaks occurred, and all of the patients had an expected esophageal stenosis that required dilation given the 10F coupling surface of the magnets (average 9.8, range 3-22). Six patients (46%) had retrievable esophageal stents, and two underwent surgery; yet all maintained their native esophagus without interposition. A total of 92% were on full oral feeds at the time of follow-up. Conclusion: The use of magnets for treatment of long-gap EA is safe and feasible and accomplished good long-term outcomes. The main complication was esophageal stricture, although all patients maintained their native esophagus. A prospective observational study is currently enrolling patients to evaluate the safety and benefit of a catheter-based magnetic device for EA.
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Affiliation(s)
- Bethany J Slater
- Department of Pediatric Surgery, University of Chicago, Chicago, Illinois
| | - Paula Borobia
- Department of Pediatric of Gastroenterology, Hospital de Niños, de La Plata, Argentina
| | - Harold N Lovvorn
- Department of Pediatric Surgery, Monroe Carell, Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
| | - Muhammad A Raees
- Department of Pediatric Surgery, Monroe Carell, Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
| | - Kathryn D Bass
- Department of Pediatric Surgery, Oishei Children's Hospital, Buffalo, New York
| | - Stephen Almond
- Department of Pediatric Surgery, Driscoll Children's Hospital, Corpus Christi, Texas
| | | | | | - Mario Zaritzky
- Department of Radiology, University of Chicago, Chicago, Illinois
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Stadil T, Koivusalo A, Pakarinen M, Mikkelsen A, Emblem R, Svensson JF, Ehrén H, Jönsson L, Bäckstrand J, Lilja HE, Donoso F, Thorup JM, Sæter T, Rasmussen L, Pedersen RN, Stenström P, Arnbjörnsson E, Óskarsson K, Qvist N. Surgical repair of long-gap esophageal atresia: A retrospective study comparing the management of long-gap esophageal atresia in the Nordic countries. J Pediatr Surg 2019; 54:423-428. [PMID: 30220451 DOI: 10.1016/j.jpedsurg.2018.07.023] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Revised: 07/03/2018] [Accepted: 07/31/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND Several surgical procedures have been described in the reconstruction of long-gap esophageal atresia (LGEA). We reviewed the surgical methods used in children with LGEA in the Nordic countries over a 15-year period and the postoperative complications within the first postoperative year. METHODS Retrospective multicenter medical record review of all children born with Gross type A or B esophageal atresia between 01/01/2000 and 12/31/2014 reconstructed within their first year of life. RESULTS We included 71 children; 56 had Gross type A and 15 type B LGEA. Delayed primary anastomosis (DPA) was performed in 52.1% and an esophageal replacement procedure in 47.9%. Gastric pull-up (GPU) was the most frequent procedure (25.4%). The frequency of chromosomal abnormalities, congenital heart defects and other anomalies was significantly higher in patients who had a replacement procedure. The frequency of gastroesophageal reflux (GER) was significantly higher after DPA compared to esophageal replacement (p = 0.013). At 1-year follow-up the mean body weight was higher after DPA than after organ interposition (p = 0.043). CONCLUSION DPA and esophageal replacement procedures were equally applied. Postoperative complications and follow-up were similar except for the development of GER and the body weight at 1-year follow-up. Long-term results should be investigated. TYPE OF STUDY Treatment study. LEVEL OF EVIDENCE Level III.
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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.
| | - Mikko Pakarinen
- Dept. of Pediatric Surgery, Children's Hospital, University of Helsinki, Helsinki, Finland.
| | - Audun Mikkelsen
- Dept. of Gastric and Pediatric Surgery, Oslo University Hospital, Rikshospitalet and Ullevål, Oslo, Norway.
| | - Ragnhild Emblem
- Dept. of Gastric and Pediatric Surgery, Oslo University Hospital, Rikshospitalet and Ullevål, Oslo, Norway.
| | - Jan F Svensson
- Department of Pediatric Surgery, Karolinska University Hospital and Department of Women's and Children's Health, Karolinska Institute, Stockholm, Sweden.
| | - Henrik Ehrén
- Department of Pediatric Surgery, Karolinska University Hospital and Department of Women's and Children's Health, Karolinska Institute, Stockholm, Sweden.
| | - Linus Jönsson
- Department of Pediatric Surgery, Queen Silvia Children's Hospital, Gothenburg, Sweden.
| | - Jakob Bäckstrand
- 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.
| | - Felipe Donoso
- 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.
| | - Lars Rasmussen
- Surgical Department A, Odense University Hospital, Odense, Denmark.
| | - Rikke Neess Pedersen
- Hans Christian Andersen Children's Hospital, Odense University Hospital, Odense, Denmark.
| | - Pernilla Stenström
- Dept. of Pediatrics, Children's Hospital, Lund University, Lund, Sweden.
| | - Einar Arnbjörnsson
- Dept. of Pediatrics, Children's Hospital, Lund University, Lund, Sweden.
| | | | - Niels Qvist
- Surgical Department A, Odense University Hospital, Odense, Denmark; Hans Christian Andersen Children's Hospital, Odense University Hospital, Odense, Denmark; OPEN, Odense Patient data Explorative Network, Odense University Hospital, Odense, Denmark.
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Post-operative paralysis and elective ventilation reduces anastomotic complications in esophageal atresia: a systematic review and meta-analysis. Pediatr Surg Int 2019; 35:87-95. [PMID: 30415438 DOI: 10.1007/s00383-018-4379-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/18/2018] [Indexed: 02/03/2023]
Abstract
AIM OF STUDY The repair of esophageal atresia (EA) carries an increased risk of anastomotic leak and stricture formation, especially in patients with anastomotic tension. To minimize this risk, pediatric surgeons perform elective post-operative muscle paralysis, positive-pressure ventilation, and head flexion (PVF) to reduce movement and tension at the anastomosis. We systematically reviewed and analyzed the effect of post-operative PVF on reducing anastomotic complications. METHODS Embase, MEDLINE, Web of Science, and PubMed databases were used to conduct searches. Articles reporting pediatric EA undergoing primary anastomosis, anastomotic complications, and comparisons between patients who received post-operative PVF to those who did not were included. Odds ratios (OR) for all post-operative anastomotic complications were calculated using random effects modelling. MAIN RESULTS Three of the 2268 papers retrieved met inclusion criteria (all retrospective cohort studies). There were no randomized controlled trials. Post-operative PVF showed a significant reduction in anastomotic leak (OR 0.07; 95% CI 0.01-0.35) when compared to no PVF. Stricture formation was not statistically different between groups. Potential sources of bias include patient allocation. CONCLUSIONS Based on available data, our analysis indicates PVF may reduce anastomotic post-operative leak. To confirm these results, a prospective study with clearer definitions of treatment allocation should be performed.
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Rothenberg SS. Thoracoscopic management of non-type C esophageal atresia and tracheoesophageal atresia. J Pediatr Surg 2017; 53:S0022-3468(17)30647-4. [PMID: 29092772 DOI: 10.1016/j.jpedsurg.2017.10.025] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2017] [Accepted: 10/05/2017] [Indexed: 01/02/2023]
Abstract
PURPOSE This study evaluates the results of thoracoscopic management of complex, non-type C, EA and TEF in infants. METHODS From March 2000 to February 2017, 23 patients were treated for Type A N=13, Type B N=4, and Type E N=6. Patients diagnosed with EA had G-tube feeds for a period of 4-9weeks. All procedures were performed thoracoscopically. EA gaps were between 4 and 7 1/2 vertebral bodies. RESULTS All surgeries were completed thoracoscopically. Average operative time was 95min for Type A, 115min for Type B, and 50min for Type E. Two patients with long gaps had small leaks which resolved with conservative management. One patient with an H-type was re-intubated causing a partial disruption of the tracheal repair. This required thoracoscopic re-exploration with repair and placement of an intercostal muscle flap. No patient has any clinical evidence of fused ribs, chest wall asymmetry, shoulder girdle weakness, or winged scapula. CONCLUSION Thoracoscopic repair of complex EA and TEF is safe and effective. The excellent visualization of the thoracic inlet allows for extensive mobilization creating sufficient length for long gaps and safely managing high fistulas. This may limit injury to adjacent structures and avoid a neck incision and chest wall deformity. LEVEL OF EVIDENCE IV.
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Long-term outcomes of oesophageal atresia without or with proximal tracheooesophageal fistula - Gross types A and B. J Pediatr Surg 2017; 52:1571-1575. [PMID: 28499713 DOI: 10.1016/j.jpedsurg.2017.04.021] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Revised: 03/24/2017] [Accepted: 04/27/2017] [Indexed: 01/28/2023]
Abstract
PURPOSE Because of an extended gap between esophageal pouches a variety of methods are employed to treat oesophageal atresia (OA) without (type A) or with (type B) proximal tracheooesophageal fistula. This retrospective observational study describes their single centre long-term outcomes from 1947 to 2014. METHODS Of 693 patients treated for OA 68 (9.7%) had type A (n=58, 8.3%) or B (n=10, 1.4%). Hospital records were reviewed. Main outcome measures were survival and oral intake. RESULTS Nine (13%) patients had early and 10 (15%) delayed primary anastomosis, 30 (44%) underwent reconstruction including colonic interposition (n=13), reversed gastric tube (n=11) and jejunum interposition (n=6), whereas19 (28%) had died without a definite repair. Median follow up was 35 (interquartile range, 7.4-40) years. Thirty-one (63%) of 49 patients with definitive repair survived long term. Survival was 22% for early and 80% for delayed primary anastomosis, 57% for colon interposition, 82% for gastric tube and 84% for jejunum interposition. Gastrooesophageal reflux was most common after gastric tube (80%), dysphagia after colon interposition (50%), and 3 (60%) of 5 survivors with jejunum interposition had permanent feeding ostomy because of neurological disorder. Endoscopic follow-up disclosed no oesophageal cancer or dysplasia. Repair in the most recent patients from 1985 to 2014 (n=14) included delayed primary anastomosis (n=7), jejunum interposition (n=6) and gastric tube (n=1) with 93% long-term survival. CONCLUSION Morbidity among long-term survivors of type A or B OA is high. With modern management survival is, however, excellent and patients without neurological disorder achieve full oral intake either after primary anastomosis or reconstruction. LEVELS OF EVIDENCE IV.
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Abstract
PURPOSE Surgical techniques for esophageal replacement (ER) in children include colon interposition, gastric tube, gastric transposition, and jejunal interposition. This review evaluates the merits and demerits of each. METHOD Surgical techniques, complications, and outcome of ER are reviewed over last seven decades. RESULTS Colon interposition is the time-tested procedure with minimal and less serious complications. Long-term complications include reflux, halitosis, colonic segment dilatation, and anastomotic stricture, sometimes requiring surgical interventions especially for dilatation and reflux. Gastric tube is technically more risky, and associated with early serious complications like prolonged leak in neck or mediastinum, graft necrosis, and ischemia leading to stricture of the tube. Long-term results are good. Gastric transposition is much simpler, can be performed in emergency and in newborns. It involves a single anastomosis in the neck. Post-operative complications include gastric stasis, bile reflux, restricted growth, and decreased pulmonary functional capacity. Jejunal interposition has not been used extensively due to short mesentery but long-term results are good in expert hands. CONCLUSION Colon is the most preferred and safest organ for ER. Stomach is a vascular and muscular organ with lower risk of ischemia. Gastric tube is a demanding technique. Jejunum or ileum is alternative for redo cases.
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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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van der Zee DC, Bagolan P, Faure C, Gottrand F, Jennings R, Laberge JM, Martinez Ferro MH, Parmentier B, Sfeir R, Teague W. Position Paper of INoEA Working Group on Long-Gap Esophageal Atresia: For Better Care. Front Pediatr 2017; 5:63. [PMID: 28409148 PMCID: PMC5374143 DOI: 10.3389/fped.2017.00063] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Accepted: 03/15/2017] [Indexed: 11/22/2022] Open
Abstract
INoEA is the International Network of Esophageal Atresia and consists of a broad spectrum of pediatric specialties and patient societies. The working group on long-gap esophageal atresia (LGEA) set out to develop guidelines regarding the definition of LGEA, the best diagnostic and treatment strategies, and highlight the necessity of experience and communication in the management of these challenging patients. Review of the literature and expert discussion concluded that LGEA should be defined as any esophageal atresia (EA) that has no intra-abdominal air, realizing that this defines EA with no distal tracheoesophageal fistula (TEF). LGEA is considerably more complex than EA with distal TEFs and should be referred to a center of expertise. The first choice is to preserve the native esophagus and pursue primary repair, delayed primary anastomosis, or traction/growth techniques to achieve anastomosis. A cervical esophagostomy should be avoided if possible. Only if primary anastomosis is not possible, replacement techniques should be used. Jejunal interposition is proposed as the best option among the major EA centers. In light of the infrequent occurrence of LGEA and the technically demanding techniques involved to achieve esophageal continuity, it is strongly advised to develop regional or national centers of expertise for the management and follow-up of these very complex patients.
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Affiliation(s)
| | - Pietro Bagolan
- Department of Medical and Surgical Neonatology, Newborn Surgery Unit, Bambino Gesù Children's Hospital-Research Institute Rome, Rome, Italy
| | - Christophe Faure
- Department of Pediatrics, Université de Montréal, Montreal, QC, Canada
| | | | - Russell Jennings
- Department of Pediatric Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | | | | | - Benoît Parmentier
- Department of Pediatric Surgery, Robert Debré University Hospital, APHP, Paris, France
| | - Rony Sfeir
- Department of Surgery, Jeanne de Flandre Hospital, Lille, France
| | - Warwick Teague
- Department of Pediatric Surgery, The Royal Children's Hospital, Melbourne, VIC, Australia
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Okuyama H, Tazuke Y, Uenoa T, Yamanaka H, Takama Y, Saka R, Nara K, Usui N. Long-term morbidity in adolescents and young adults with surgically treated esophageal atresia. Surg Today 2016; 47:872-876. [PMID: 28028638 DOI: 10.1007/s00595-016-1462-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Accepted: 11/04/2016] [Indexed: 12/28/2022]
Abstract
PURPOSE To investigate the long-term morbidity of surgically treated esophageal atresia (EA) in adolescents and young adults and establish whether these long-term morbidities are affected by the type of EA. PATIENTS AND METHODS We reviewed the medical records, including backgrounds and associated conditions, of 69 long-term survivors of EA, aged >15 years. The long-term morbidities included neurodevelopmental abnormality, nutritional impairment (short height <-2SD, low BMI <18.5), subjective symptoms, and musculoskeletal deformities. Comparisons of the results were made between Gross A-type EA (n = 6) and Gross C-type EA (n = 63). RESULTS All patients underwent esophageal anastomosis without esophageal replacement. Cardiac anomalies and long gap were present in 26 and 18%, respectively. Esophageal dilatation, fundoplication, and aortopexy were performed in 40, 34, and 18%, respectively. The incidence of long gap and esophageal stenosis was higher in Gross A-type EA than in Gross C-type EA. The long-term morbidities included neurodevelopmental abnormality (13%), nutritional impairment (62%: as short height in 34% and as low BMI in 46%), subjective symptoms (14%), and musculoskeletal deformities (59%). There were no differences in the long-term morbidities between Gross A and Gross C. CONCLUSIONS The incidence of the long-term morbidities is high in adolescents and young adults, regardless of the type of EA. Early detection of morbidity is important to improve the long-term outcomes of EA.
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Affiliation(s)
- Hiroomi Okuyama
- Department of Pediatric Surgery, Osaka University Graduate School of Medicine, 2-2, Yamadaoka, Suita, Osaka, 565-0871, Japan.
| | - Yuko Tazuke
- Department of Pediatric Surgery, Osaka University Graduate School of Medicine, 2-2, Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Takehisa Uenoa
- Department of Pediatric Surgery, Osaka University Graduate School of Medicine, 2-2, Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Hiroaki Yamanaka
- Department of Pediatric Surgery, Osaka University Graduate School of Medicine, 2-2, Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Yuichi Takama
- Department of Pediatric Surgery, Osaka University Graduate School of Medicine, 2-2, Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Ryuta Saka
- Department of Pediatric Surgery, Osaka University Graduate School of Medicine, 2-2, Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Keigo Nara
- Department of Pediatric Surgery, Osaka Medical Center and Research Institute for Maternal and Child Health, 840 Murodocho, Izumi, Osaka, 594-1101, Japan
| | - Noriaki Usui
- Department of Pediatric Surgery, Osaka Medical Center and Research Institute for Maternal and Child Health, 840 Murodocho, Izumi, Osaka, 594-1101, Japan
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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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