Oesophageal atresia: a simplified approach to early management

Radiation exposure in infants with oesophageal atresia and tracheo-oesophageal fistula

PURPOSE

Oesophageal atresia and tracheo-oesophageal atresia require surgical repair in early infancy. These children have significant disease-related morbidity requiring frequent radiological examinations resulting in an increased malignancy risk.

METHODS

A single-centre, retrospective review was performed of radiation exposure in children with OA/TOF born 2011-2015. Medical records were reviewed to determine the number and type of imaging studies involving ionising radiation exposure enabling the calculation of the estimated effective dose per child over the first year of life.

RESULTS

Forty-nine children were included. Each child underwent a median of 19 (IQR 11.5-35) imaging studies, which were primarily plain radiography (median = 14, IQR 7-26.5). The overall median estimated effective dose per patient was 4.7 (IQR 3.0-9.4) mSv, with the majority of radiation exposure resulting from fluoroscopic imaging (median 3.3 mSv, IQR 2.2-6.0). 'Routine' postoperative oesophagrams showed no leak in 35/36 (97%) with the remaining study showing an insignificant leak that did not alter management.

CONCLUSIONS

Careful consideration should be given to the use of imaging in OA/TOF to minimise morbidity in these vulnerable infants. Oesophagrams in children without the symptoms of anastomotic leak or stricture should be discontinued. Standardisation of monitoring protocols with regard to radiation exposure should be considered.

Challenging surgical dogma in the management of proximal esophageal atresia with distal tracheoesophageal fistula: Outcomes from the Midwest Pediatric Surgery Consortium

PURPOSE

Perioperative management of infants with esophageal atresia and tracheoesophageal fistula (EA/TEF) is frequently based on surgeon experience and dogma rather than evidence-based guidelines. This study examines whether commonly perceived important aspects of practice affect outcome in a contemporary multi-institutional cohort of patients undergoing primary repair for the most common type of esophageal atresia anomaly, proximal EA with distal TEF.

METHODS

The Midwest Pediatric Surgery Consortium conducted a multicenter, retrospective study examining selected outcomes on infants diagnosed with proximal EA with distal TEF who underwent primary repair over a 5-year period (2009-2014), with a minimum 1-year follow up, across 11 centers.

RESULTS

292 patients with proximal EA and distal TEF who underwent primary repair were reviewed. The overall mortality was 6% and was significantly associated with the presence of congenital heart disease (OR 4.82, p=0.005). Postoperative complications occurred in 181 (62%) infants, including: anastomotic stricture requiring intervention (n=127; 43%); anastomotic leak (n=54; 18%); recurrent fistula (n=15; 5%); vocal cord paralysis/paresis (n=14; 5%); and esophageal dehiscence (n=5; 2%). Placement of a transanastomotic tube was associated with an increase in esophageal stricture formation (OR 2.2, p=0.01). Acid suppression was not associated with altered rates of stricture, leak or pneumonia (all p>0.1). Placement of interposing prosthetic material between the esophageal and tracheal suture lines was associated with an increased leak rate (OR 4.7, p<0.001), but no difference in the incidence of recurrent fistula (p=0.3). Empiric postoperative antibiotics for >24h were used in 193 patients (66%) with no difference in rates of infection, shock or death when compared to antibiotic use ≤24h (all p>0.3). Hospital volume was not associated with postoperative complication rates (p>0.08). Routine postoperative esophagram obtained on day 5 resulted in no delayed/missed anastomotic leaks or a difference in anastomotic leak rate as compared to esophagrams obtained on day 7.

CONCLUSION

Morbidity after primary repair of proximal EA and distal TEF patients is substantial, and many common practices do not appear to reduce complications. Specifically, this large retrospective series does not support the use of prophylactic antibiotics beyond 24h and empiric acid suppression may not prevent complications. Use of a transanastomotic tube was associated with higher rates of stricture, and interposition of prosthetic material was associated with higher leak rates. Routine postoperative esophagram can be safely obtained on day 5 resulting in earlier initiation of oral feeds.

STUDY TYPE

Treatment study.

LEVEL OF EVIDENCE

III.

Is routine use of transanastomotic tube justified in the repair of esophageal atresia?

BACKGROUND

Transanastomotic feeding tube (TAFT) is commonly used for post-operative enteral nutrition after esophageal atresia (EA)/tracheoesophageal fistula (TEF) repairs. The purpose of this study is to analyze the therapeutic implications of avoiding a TAFT and its impact on the outcomes post-operatively.

METHODS

The medical data of 33 inpatients with EA/TEF type C repair from 2009 to 2014 were retrospectively reviewed. Patients were divided into two groups for comparison based on the usage of TAFT during the repair: TAFT- (without) and TAFT+ (with) groups, without randomization. Both groups were compared statistically for post-operative complications and outcomes.

RESULTS

Eighteen neonates were males and 15 females, with an average birth weight of 2.43±0.43 kg and a mean gestational age of 36.15 weeks. Nineteen (57.5%) in the TAFT- group and 14 (42.4%) were in the TAFT+ group. The post-operative complications, need for dilatations, duration of total parenteral nutrition (TPN) and length of hospital stay were similar in both groups. The incidence of pneumonitis was significantly higher in the TAFT+ group.

CONCLUSIONS

By avoiding a TAFT, there is no increase in complication rates nor does it entail a prolonged period of TPN. Besides, not using a TAFT may have the advantage of reducing incidence of aspiration and consequent pneumonitis.

Oesophageal atresia and tracheo-oesophageal fistula: current management strategies and complications

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.

Use of transanastomotic feeding tubes during esophageal atresia repair

PURPOSE

Esophageal atresia (EA) with tracheoesophageal fistula (TEF) type C accounts for 85% of all EA. In our center, patients were previously started on total parenteral nutrition (TPN) postoperatively and oral feedings initiated only after a contrast esophagogram. Our aim is to assess the benefit of intraoperatively placed transanastomotic feeding tubes (TAFTs).

METHODS

A 7-year retrospective review analyzed the outcomes of children with EATEF type C as they relate to the use of TAFT. Demographics, associated anomalies, operative findings, complications, duration of TPN, resumption of oral feeding, length of stay, and follow-up were examined.

RESULTS

Twenty-one patients had EATEF type C. Eleven (55%) and 9 (45%) patients were identified as nonfeeding tube (NFT) and TAFT groups, respectively. There were no differences in gestational age, birth weight, associated anomalies, and interval to operative intervention or operative time. Excluding one patient with a severe cardiac malformation in the NFT group, there were no significant differences in anastomotic leak (8% vs 22%), stenosis (36% vs 22%), TPN duration (20 days vs 12 days), and cholestasis (36% vs 11%).

CONCLUSION

Transanastomotic feeding tube may lead to shorter TPN duration and decreased cholestasis, but a larger prospective study would be required to prove these benefits and ensure that it does not increase anastomotic leaks. This could be done through an expanded Canadian Pediatric Surgery Network study.

Imaging of the Esophagus in Children

The main role of the esophagus is to facilitate passage of food from the mouth to the stomach. A number of conditions can alter esophageal structure or function including congenital anomalies, trauma, infection, and neoplasm. This article reviews the anatomy, imaging evaluation, and common problems seen in the pediatric thoracic esophagus.