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Lee WG, Evans LL, Chen CS, Fuchs JR, Zamora IJ, Bruzoni M, Harrison MR, Muensterer OJ. Lessons Learned From the First-In-Human Compassionate Use of Connect-EA™ in Ten Patients With Esophageal Atresia. J Pediatr Surg 2024; 59:437-444. [PMID: 37838619 DOI: 10.1016/j.jpedsurg.2023.09.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 09/12/2023] [Accepted: 09/15/2023] [Indexed: 10/16/2023]
Abstract
INTRODUCTION Delayed primary repair of esophageal atresia in patients with high-risk physiologic and anatomic comorbidities remains a daunting challenge with an increased risk for peri-operative morbidity and mortality via conventional repair. The Connect-EA device facilitates the endoscopic creation of a secure esophageal anastomosis. This follow-up study reports our long-term outcomes with the novel esophageal magnetic compression anastomosis (EMCA) Connect-EA device for EA repair, as well as lessons learned from the ten first-in-human cases. We propose an algorithm to maximize the advantages of the device for EA repair. METHODS Under compassionate use approval, from June 2019 to December 2022, ten patients with prohibitive surgical or medical risk factors underwent attempted EMCA with this device. All patients underwent prior gastrostomy, tracheoesophageal fistula ligation (if necessary), and demonstrated pouch apposition prior to EMCA. RESULTS Successful device deployment and EMCA formation were achieved in nine patients (90%). Mean time to anastomosis formation was 8 days (range 5-14) and the device was retrieved endoscopically in five (56%) cases. At median follow-up of 22 months (range 4-45), seven patients (78%) are tolerating oral nutrition. Balloon dilations (median 4, range 1-11) were performed either prophylactically for radiographic asymptomatic anastomotic narrowing (n = 7, 78%) or to treat clinically-significant anastomotic narrowing (n = 2, 22%) with no ongoing dilations at 3-month follow up post-repair. CONCLUSION EMCA with the Connect-EA device is a safe and feasible minimally-invasive alterative for EA repair in high-risk surgical patients. Promising post-operative outcomes warrant further Phase I investigation. LEVEL OF EVIDENCE IV, Case series of novel operative technique without comparison group.
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Affiliation(s)
- William G Lee
- Department of Pediatric Surgery, University of California San Francisco, 550 16th Street Box 0570, San Francisco, CA 94143, USA
| | - 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
| | - 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 37232, USA
| | - Matias Bruzoni
- 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
| | - Oliver J Muensterer
- Department of Pediatric Surgery, Dr. von Hauner Children's Hospital, LMU Munich, Lindwurmstrasse 4, 80337, Munich, 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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Uecker M, Ure BM, Dingemann J. Ethical Publication Standards in Articles Reporting on Novel Surgical Methods: Analysis of Three Pediatric Surgical Journals. Eur J Pediatr Surg 2021; 31:34-39. [PMID: 32820497 DOI: 10.1055/s-0040-1715611] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
INTRODUCTION According to the Declaration of Helsinki, medical research and new therapeutic interventions involving human subjects require prior informed consent and ethical approval. In 2010, 46% of pediatric surgical publications lacked documentation of ethical approval and 84% lacked documentation of informed parental consent with lowest rates of ethical adherence found in articles concerning novel methods. The aim of this study was to investigate whether adherence to ethical standards has improved in pediatric surgical publications. MATERIALS AND METHODS All 3,093 consecutive articles published in Journal of Pediatric Surgery, European Journal of Pediatric Surgery, and Pediatric Surgery International over the last 5 years were systematically reviewed for publications describing novel surgical methods. Novel methods were defined as surgical methods not published before or not considered common practice. The publications were reviewed as to whether ethical approval and informed consent to participate was documented. RESULTS In total, 105 articles describing novel surgical methods were identified (61 Journal of Pediatric Surgery, 16 European Journal of Pediatric Surgery, and 28 Pediatric Surgery International). Authors reported on new operative techniques (62%), modified techniques (31%), or use of new materials (7%). Ethical approval was documented in 52% of the articles with almost half reporting approval for retrospective data analysis only but not the application of the novel method. Informed consent was documented in 21% of publications. Complications were reported in 48% of the studies, including recurrences and reinterventions for the unsuccessful novel methods. Two authors reported mortalities due to underlying disease, one of which failed to report prior ethical approval or informed consent. CONCLUSION Adherence to ethical publication principles in pediatric surgery has improved over the last years but is still lacking in many publications. When implementing new methods, prior ethical approval and informed consent and their documentation are mandatory, specifically in the light of potential hazard to patients.
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Affiliation(s)
- Marie Uecker
- Department of Pediatric Surgery, Medical School Hannover, Hannover, Germany
| | - Benno M Ure
- Department of Pediatric Surgery, Medical School Hannover, Hannover, Germany
| | - Jens Dingemann
- Department of Pediatric Surgery, Medical School Hannover, Hannover, Germany
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Beger B, Beger O. A new esophageal elongation technique for long-gap esophageal atresia: in vitro comparison of myotomy techniques. Esophagus 2019; 16:93-97. [PMID: 30099640 DOI: 10.1007/s10388-018-0636-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2018] [Accepted: 08/07/2018] [Indexed: 02/03/2023]
Abstract
BACKGROUND Complications such as stricture, leakage, recurrent tracheoesophageal fistula and mucosal pouch are commonly seen in myotomy techniques used for long-gap esophageal atresia (LGEA) treatments. Therefore, we think that there is a clear need for other techniques which would enable us to create more robust and longer esophagus in such cases. In this study, we reviewed multiple V-myotomy (VM) technique and the differences of the said technique with Livaditis circular myotomy (LM) and Kimura spiral myotomy (KM) techniques using literature as an aid. METHODS 21 esophagus samples from 21 male lambs aged 12 months were used in vitro for the study. All esophageal samples were matched to have a length of 120 mm. Samples were divided into 3 groups of 7 and VM, LM and KM techniques were used in each group, respectively. Post-op esophagus lengths, elongation amount with each incision and perforation pressures were measured. RESULTS Post-op esophageal lengths were measured as 227, 210 and 200 mm for VM, LM and KM, respectively. Elongation amount per incision was measured as 5.1, 4 and 3.34 mm, again in previous order of VM, LM, and KM. Finally, perforation pressure following VM, LM, and KM was measured as 460, 400, and 410 mmHg. CONCLUSION VM was found to significantly increase total esophagus length and elongation per incision over LM and KM. In addition, VM was also shown to have a higher perforation pressure. Although in vivo live animal studies are required, we can say that VM can be used to create longer and robust esophagus.
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Affiliation(s)
- Burhan Beger
- Department of Pediatric Surgery, Van Yüzüncü Yıl University Faculty of Medicine, Van, Turkey
| | - Orhan Beger
- Department of Anatomy, Mersin University Faculty of Medicine, Ciftlikkoy Campus, 33343, Mersin, Turkey.
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