Current progress in neonatal surgery

A scoping review of the post-discharge care needs of babies requiring surgery in the first year of life

Congenital anomalies are among the leading causes of under-5 mortality, predominantly impacting low- and middle-income countries (LMICs). A particularly vulnerable group are babies with congenital disorders requiring surgery in their first year. Addressing this is crucial to meet SDG-3, necessitating targeted efforts. Post-discharge, these infants have various care needs provided by caregivers, yet literature on these needs is scant. Our scoping review aimed to identify the complex care needs of babies post-surgery for critical congenital cardiac conditions and non-cardiac conditions. Employing the Joanna Briggs Institute's methodological framework for scoping reviews we searched Pubmed, EMBASE, CINAHL, PsychINFO, and Web of Science databases. Search terms included i) specific congenital conditions (informed by the literature and surgeons in the field), ii) post-discharge care, and iii) newborns/infants. English papers published between 2002-2022 were included. Findings were summarised using a narrative synthesis. Searches yielded a total of 10,278 papers, with 40 meeting inclusion criteria. 80% of studies were conducted in High-Income Countries (HICs). Complex care needs were shared between cardiac and non-cardiac congenital conditions. Major themes identified included 1. Monitoring, 2. Feeding, and 3. Specific care needs. Sub-themes included monitoring (oxygen, weight, oral intake), additional supervision, general feeding, assistive feeding, condition-specific practices e.g., stoma care, and general care. The post-discharge period poses a challenge for caregivers of babies requiring surgery within the first year of life. This is particularly the case for caregivers in LMICs where access to surgical care is challenging and imposes a financial burden. Parents need to be prepared to manage feeding, monitoring, and specific care needs for their infants before hospital discharge and require subsequent support in the community. Despite the burden of congenital anomalies occurring in LMICs, most of the literature is HIC-based. More research of this nature is essential to guide families caring for their infants post-surgical care.

Acute kidney injury post-abdominal surgery in infants: implications for prevention and management

Acute kidney injury (AKI) is common in critically ill infants and is associated with long-term sequelae including hypertension and chronic kidney disease. The etiology of AKI in infants is multifactorial. There is robust literature highlighting the risk of AKI after cardiothoracic surgery in infants. However, risk factors and outcomes for AKI in infants after abdominal surgery remains limited. This article reviews the epidemiology and association of abdominal surgery with postoperative AKI and suggests methods for AKI management and prevention. Postoperative AKI may result from hemodynamic shifts, hypoxia, exposure to nephrotoxic medications, and inflammation. Infants in the intensive care unit after intraabdominal surgeries have a unique set of risk factors that predispose them to AKI development. Prematurity, sepsis, prolonged operation time, emergent nature of the procedure, and diagnosis of necrotizing enterocolitis increase risk of AKI after intrabdominal surgeries. Prevention, early diagnosis, and management of AKI post-abdominal surgery is imperative to clinical practice. Close monitoring of urine output, serum creatinine, and fluid status is necessary in infants after abdominal surgery. A recent study suggests elevated levels of a urinary biomarker, neutrophil gelatinase-associated lipocalin (NGAL), 24 h after an abdominal procedure may improve early prediction of AKI. Identification of risk factors, avoidance of nephrotoxic medications, careful fluid balance, early detection of AKI, and maintenance of hemodynamic stability is imperative to potentially prevent and/or mitigate AKI.

Epidemiologic and clinical characteristics of selected congenital anomalies at the largest Bosnian pediatric surgery tertiary center

Congenital anomalies (CA) are any abnormality present at birth, either structural or functional, that may potentially affect an infant's health, development, and/or survival. There is a paucity of studies on clinical characteristics and outcomes of CA in Bosnia and Herzegovina, mainly due to the lack of a nationwide congenital malformations monitoring system. A 5-year hospital-based study was conducted to determine the prevalence at birth and clinical characteristics of selected major CA in Sarajevo Canton, Bosnia and Herzegovina. Ninety-one CA were observed from 2012 to 2016 (the overall prevalence was 39.6 cases/10,000 live births). The mean age of neonates at diagnosis was 3 days. The gastrointestinal tract was the most commonly affected system (76.9%), with esophageal atresia (EA) being the most frequent (17.6% of all CA). Major CA were more prevalent among preterm infants than term infants (P = .001), particularly in males (61.5% vs. 38.5%; P = .028; M:F ratio was 1.59). Multiple CA were seen in 37.4% of neonates. The overall mortality rate of neonates was 11%, and the median length of hospital stay was 19.8 days. Our study revealed the distribution and clinical patterns of common major CA in the largest tertiary care facility in Bosnia and Herzegovina. It also confirmed a relatively high mortality rate, which requires further efforts to improve the quality of neonatal care in the country.

Predictors of Early Mortality in Esophageal Atresia: A 12-year Cohort Study in Tehran, Iran

Background: Esophageal atresia and tracheoesophageal fistula (EA/TEF) is a known correctable anomaly of the esophagus, and its prognosis depends on multiple factors. Studies investigating the EA/TEF post-operative outcomes among the Iranian population are limited to small sample sizes, and the current prevalence of coexisting anomalies and predictors of poor prognosis in the Iranian population is still unclear. Objectives: This study aimed to investigate the predictors of in-hospital mortality in neonates with EA/TEF at our center within a 12-year period. Methods: In this retrospective cohort study, we investigated neonates with EA/TEF admitted/referred to a tertiary referral center in Tehran, Iran, from March 2008 to April 2020. Neonates with chromosomal anomalies or age > 10 days at operation date were excluded. Baseline characteristics, associated anomalies, type of EA, and transmission distance were compared in the study population. We followed the neonates for incurring in-hospital mortality. Results: We included 233 neonates in the final analysis. The mean age at operation was 3.1 ± 1.7 days, and 111 (47.6%) cases were female. The most common EA type was type C (proximal esophageal atresia with distal fistula), with a prevalence of 94.4%. In this cohort, 23 (9.9%) cases had vertebral anomalies, anal atresia, cardiovascular malformations, trachea-esophageal fistula, renal and limb anomalies (VACTERL) association, and 29 (12.4%) cases died during the in-hospital course. Moreover, neonates with lower birth weight, gestational birth weight < 37 weeks, other coexisting anomalies, cardiovascular defects, and non-VACTERL anomalies were at higher risk of in-hospital mortality. In contrast, EA types and transmission distance did not increase the mortality risk. Furthermore, we measured a cut-off value of < 2575.0 g for birth weight to predict in-hospital mortality with 65.5% sensitivity and 61.3% specificity. Conclusions: Lower birth weight, prematurity (< 37 weeks), and coexisting anomalies, especially cardiovascular defects, were associated with an increased risk of in-hospital mortality in neonates after EA/TEF repair surgery.

Sepsis Screening of Neonatal Abdominal Surgery and Its Outcomes

Aim

The aim of this study was to evaluate the early indicators of sepsis (sepsis screening) and their statistical correlation with sepsis in neonatal abdominal surgery.

Materials and Methods

A prospective observational study was performed on thirty consecutive neonate cases aged between 0 and 28 days with surgical abdomen at the Paediatric Surgery Department, ABVIMS and Dr. Ram Manohar Lohia Hospital, New Delhi. The study duration was 18 months. Septic screening was done in all neonates on day 0, 1, 3, 7, and 14 days of surgery with serum procalcitonin, C-reactive protein, total leukocyte count, immature/total neutrophil ratio, and microerythrocyte sedimentation rate. A septic screening-positive patient (three or more positive parameters out of five) was correlated with sepsis and analysis was done.

Results

A total of 30 neonates of abdominal surgical cases were included consequently, out of which 56.7% (n = 17) were male and 43.3% (n = 13) were female. Maximum cases were of congenital diaphragmatic hernia 20% (n = 6) and then anorectal malformation 16.7% (n = 5). About 70% of neonates were sepsis screening positive. Fifty percentage of neonates were diagnosed to have sepsis on the clinical or laboratory findings, so sensitivity and specificity of sepsis screening were 93.33% and 40%, respectively. There was total 30% mortality in this study.

Conclusion

Sepsis screening is an early marker of sepsis, which can be used to help in early detection of neonatal surgical sepsis and timely intervention that can lead to decrease mortality and morbidity in neonatal surgery.

Co-occurring non-omphalocele and non-gastroschisis anomalies among cases with congenital omphalocele and gastroschisis

The pathogenesis of omphalocele and gastroschisis is not obvious. Their etiology is disputed. The prevalence and the types of anomalies co-occurring with omphalocele and gastroschisis are variable in the different series published. The aim of this study was to estimate the frequency and the types of co-occurring anomalies in cases with gastroschisis and omphalocele. This study was performed in a well-described population of 387,067 consecutive births between 1979 and 2007. Hundred-one cases with omphalocele were registered (2.61 per 10,000), 75 (74.3%) had co-occurring anomalies comprising chromosomal anomalies (28 cases, 27.7%, including 18 trisomy 18), non-chromosomal syndromes (16 cases, 15.8%, including 3 cases with Beckwith-Wiedemann syndrome, 2 cases with the OEIS sequence, and one case with the Pentalogy of Cantrell complex), and 31 cases, 30.7% with MCA (multiple congenital anomalies). The most common MCA were musculoskeletal (23.5%), urogenital (20.4%), cardiovascular (15.1%), and central nervous (9.1%). Seventy-one cases of gastroschisis were ascertained (1.83 per 10,000). However, the prevalence increased during the study period. The frequency was highest in the mothers 15-19 years old. Sixteen out of the 71 cases with gastroschisis, (22.5%) had co-occurring anomalies including 11 cases of MCA and 5 cases with syndromes. To conclude, the frequency and the types of anomalies co-occurring with omphalocele and gastroschisis are peculiar. Therefore, cases with gastroschisis and omphalocele need to be screened for co-occurring anomalies.

Risk factors of early mortality after neonatal surgery in Tunisia

BACKGROUND

Research concerning factors of death after neonatal surgery is scarce. Insight into mortality might improve perioperative care. This study aimed to identify predictive factors of mortality after neonatal surgery in a low income country (LIC).

METHODS

Charts of all newborn patients who underwent surgical procedures under general anesthesia during the neonatal period in our department of pediatric surgery between January 2010 and December 2017 were reviewed. We used univariate and multivariate analysis to evaluate perioperative variables potentially predictive of early postoperative mortality.

RESULTS

One hundred eighty-two cases were included in the study: 41 newborns (28.6%) were premature (<37 weeks of gestation) and 52 (22.5%) weighed less than 2.5 kg. The most commonly diagnosed conditions were esophageal atresia (24%) and bowel obstruction (19%). Forty-four patients (24%) died during hospitalization. The highest rate of mortality was observed for congenital diaphragmatic hernia. Univariate analysis showed that perinatal predictive variables of mortality were prematurity, low birth weight, the necessity of preoperative intubation, and duration of surgery more than 2 h. Logistic regression showed three independent risk factors, which are the duration of surgery, low birth weight and the necessity of preoperative intubation.

CONCLUSION

The overall mortality in infants undergoing neonatal surgery is still high in LICs. Knowledge of independent risk factors of early mortality may help clinicians to more adequately manage the high-risk population.

TYPE OF THE STUDY

Clinical research paper.

LEVEL OF EVIDENCE

III.

Tracheoesophageal fistula in the developing world: are we ready for thoracoscopic repair?

PURPOSE

Tracheoesophageal fistula (TEF) is a bellwether for a country's ability to care for sick newborns. We aim to review the existing literature from low- and middle-income countries in regard to management of those newborns and the possible approaches to improve their outcomes.

METHODS

A review of the existing English literature was conducted with the aim of assessing challenges faced by providers in LMIC in terms of diagnostic, preoperative, operative and post-operative care for TEF patients. We also review the limited literature for performing thoracoscopic repair in the developing world context and suggest methods for introduction of advanced thoracoscopic procedures including techniques for providing anesthesia to these challenging babies.

RESULTS

While outcomes related to technique from LMIC are comparable to the developed world, rates of secondary complications like sepsis and pneumonia are higher. In many areas, repairs are conducted in a staged fashion with minimal utilization of thoracoscopic approach. The paucity of resources creates strain on intraoperative and post-operative management.

CONCLUSION

Clearly, not all developing world contexts are ready to attempt thoracoscopic repair but we outline suggestions for assessing the existing capabilities and a stepwise gradual implementation of advanced thoracoscopy when appropriate.

Regenerative medicine using stem cells from human exfoliated deciduous teeth (SHED): a promising new treatment in pediatric surgery

Stem cells from human exfoliated deciduous teeth (SHEDs), being a type of mesenchymal stem cell, are an ideal cell source for regenerative medicine. They have minimal risk of oncogenesis, high proliferative capacity, high multipotency, and immunosuppressive ability. Stem cell transplantation using SHED has been found to have an anti-fibrotic effect on liver fibrosis in mice. SHED transplantation and the bio 3D printer, which can create scaffold-free 3-D images of the liver and diaphragm, provide a new innovative treatment modality for intractable pediatric surgical diseases such as biliary atresia and diaphragmatic hernia.

A Pilot Study on Neonatal Surgical Mortality: A Multivariable Analysis of Predictors of Mortality in a Resource-Limited Setting

Purpose:

The aim of this research is to study the predictors of neonatal surgical mortality (NSM)-defined as in-hospital death or death within 30 days of neonatal surgery.

Materials and Methods:

All neonates operated over the study period of 18 months were included to evaluate NSM. The evaluated preoperative and intraoperative variables were birth weight, gestation age, age at presentation, associated anomalies, site and duration of surgery, intraoperative blood loss, and temperature after surgery. Assessed postoperative variables included the need for vasopressors, postoperative ventilation, sepsis, reoperations, and time taken to achieve full enteral nutrition. Univariate and multivariate logistic regression was applied to find the predictors of mortality.

Results:

Based on patient's final outcome, patients were divided into two groups (Group 1-survival, n = 100 and Group 2-mortality, n = 50). Incidence of NSM in this series was 33.33%. Factors identified as predictors of NSM were duration of surgery >120 min (P = 0.007, odds ratio [OR]: 9.76), need for prolonged ventilation (P = 0.037, OR: 5.77), requirement of high dose of vasopressors (P = 0.003, OR: 25.65) and reoperations (P = 0.031, OR: 7.16 (1.20–42.81).

Conclusion:

NSM was largely dependent on intraoperative stress factors and postoperative care. Neonatal surgery has a negligible margin of error and warrants expertize to minimize the duration of surgery and complications requiring reoperations. Based on our observations, we suggest a risk stratification score for neonatal surgery.

Clinical factors associated with in-hospital death in pediatric surgical patients admitted to the neonatal intensive care unit: a 15-year single tertiary center experience

BACKGROUND/PURPOSE

The purpose of this study was to explore clinical characteristics and primary surgical diagnoses associated with in-hospital death in pediatric surgical patients admitted to the neonatal intensive care unit (NICU) of a tertiary hospital.

METHODS

This retrospective study includes all patients admitted to our NICU for pediatric surgical diseases between January 2001 and December 2015. Univariate and multivariate binary logistic regression were performed to assess independent factors associated with in-hospital death.

RESULTS

A total of 440 cases were included and 334 (83.5%) patients underwent one or more surgeries. Thirty six patients (8.2%) died while hospitalized in the NICU. The 5 most common surgical diagnoses were intestinal atresia/stenosis, anorectal malformation, congenital diaphragmatic hernia (CDH), esophageal atresia, and urinary system disorder. Necrotizing enterocolitis (NEC) had the highest mortality rate. Using logistic regression, in-hospital death was predicted by extremely low birth weight (ELBW) (odds ratio (OR)=6.594; P=0.006), CDH (OR=13.954; P<0.001), and NEC (OR=8.991; P=0.049).

CONCLUSIONS

This study describes CDH, NEC, and ELBW are independent predictive factors associated with in-hospital death of pediatric surgical patients in our NICU. Novel approaches for those conditions are required to improve the survival.

TYPE OF STUDY

Prognostic LEVELS OF EVIDENCE: II.

Isolated tracheoesophageal fistula versus esophageal atresia - Early morbidity and short-term outcome. A single institution series

PURPOSE

We compared the postnatal course, morbidity and early results after repair for cases of isolated or "pure" TEF with those for cases of esophageal atresia (EA) with distal tracheoesophageal fistula (TEF).

METHODS

Twenty-four consecutive infants were divided into two groups: isolated TEF [TEF group] (n = 5) and EA with distal TEF [EA group] (n = 19).

RESULTS

A high rate of prematurity (29%) and major cardiac and other surgically-relevant malformations (0.8 vs. 0.7 per infant) was found in both groups. The median age at surgery was 8 days for the TEF group vs. 1 day for the EA group (p < 0.01). Most infants of both cohorts had stable acid-base and respiratory parameters at admission. Generally, tracheoscopy provided valuable information regarding the position of the TEF. Surgery for isolated TEF was performed via right cervicotomy in 4 cases and via thoracotomy in one. Postoperative thoracostomy tubes were inserted in 3 cases and one emergency gastrostomy was created for acute gastric overextension (exclusively in patients with EA). The duration of postoperative mechanical ventilation (49 vs. 113 h, p = 0.045) and the median length of stay in the pediatric surgery unit (10 vs. 20.5 days, p = 0.003) were shorter for the isolated TEF group. Four EA patients experienced severe events. Total mortality was 8% (0 out of 5 with TEF vs. 2 out of 19 with EA).

CONCLUSION

Developmental delay and a high rate of morbidity were found in both groups. More complex surgery increased perioperative morbidity in cases of EA. With early recognition of isolated TEF, a less complicated course can be expected in comparison with esophageal atresia.

Twenty-year trends in neonatal surgery based on a nationwide Japanese surveillance program

AIM

To discuss the chronological changes observed in a national survey of neonatal surgery in Japan performed every 5 years by the Committee in the Japanese Society of Pediatric Surgeons.

METHODS

We analyzed the data obtained for 20 years from 1993 to 2013 and herein report the chronological changes.

RESULTS

The number of summarized cases was least in 1993, with 2806 cases, and subsequently increased to 3753 cases in 2013. The mortality rate among the patients with maternal transport linearly decreased (p = 0.0386). Although the proportion of extremely low birth weight infants linearly increased (p = 0.0014), with an annual rate of +0.39 %, the mortality rate linearly decreased (p = 0.0010), with an annual rate of -1.68 %. Moreover, the overall mortality rate linearly decreased (p = 0.0002), with an annual rate of -0.26 %. Most diseases were observed to exhibit a decline in the mortality rate with the same trend as overall mortality. The decline in the mortality rate was most robust with respect to congenital diaphragmatic hernia (CDH). The mortality rates, except for that of CDH, omphalocele, esophageal atresia, and intestinal perforation, declined to 5 % or lower by 2013.

CONCLUSIONS

The present findings may be the result of remarkable progress in perinatal management.

Early mortality after neonatal surgery: analysis of risk factors in an optimized health care system for the surgical newborn

OBJECTIVE

Anesthetic and operative interventions in neonates remain hazardous procedures, given the vulnerability of the patients in this pediatric population. The aim was to determine the preoperative and intraoperative factors associated with 30-day post-operative mortality and describe mortality outcomes following neonatal surgery under general anesthesia in our center.

METHODS

Infants less than 28 days of age who underwent general anesthesia for surgery during an 11-year period (2000 - 2010) in our tertiary care pediatric center were retrospectively identified using the pediatric intensive care unit database. Multiple logistic regression was used to identify independent preoperative and intraoperative factors associated with 30-day post-operative mortality.

RESULTS

Of the 437 infants in the study (median gestational age at birth 37 weeks, median birth weight 2,760 grams), 28 (6.4%) patients died before hospital discharge. Of these, 22 patients died within the first post-operative month. Logistic regression analysis showed increased odds of 30-day post-operative mortality among patients who presented American Society of Anesthesiologists physical status (ASA) score 3 or above (odds ratio 19.268; 95%CI 2.523 - 147.132) and surgery for necrotizing enterocolitis/gastrointestinal perforation (OR 5.291; 95%CI 1.962 - 14.266), compared to those who did not.

CONCLUSION

The overall in-hospital mortality of 6.4% is within the prevalence reported for developed countries. Establishing ASA score 3 or above and necrotizing enterocolitis/gastrointestinal perforation as independent risk factors for early mortality in neonatal surgery may help clinicians to more adequately manage this high risk population.

The utility of muscle sparing axillar skin crease incision for pediatric thoracic surgery

BACKGROUND

Posterolateral or standard axillar incisions for the pediatric thoracic surgery are occasionally associated with poor motor as well as cosmetic results, including chest deformities and large surgical scars. A muscle sparing axillar skin crease incision (MSASCI) was initially proposed by Bianchi et al. (in J Pediatr Surg 33:1798-1800, 1998) followed by Kalman and Verebely (in Eur J Pediatr Surg 12:226-229, 2002) resulting in satisfactory cosmetics. However, they performed operations through the third or fourth intercostals space (ICS), therefore the target organs were restricted in the upper two-thirds of the thoracic cavity.

PATIENTS AND METHODS

Thoracic surgeries were performed using MSASCI in 27 patients (1-day to 9-year old). There were ten patients with esophageal atresia, seven with congenital cystic adenomatoid malformation, five with pulmonary sequestration, two with mediastinal neuroblastoma, two with right diaphragmatic hernia, and one with pulmonary hypertension. A thoracotomy was performed through the appropriate ICS (from third to eighth).

RESULTS

In all patients, the expected procedures, including pulmonary lower lobectomy, were successfully performed by MSASCI throughout the thoracic cavity. A good operational field was easily obtained in neonates and infants. Most of the patients achieved excellent motor and aesthetic outcomes.

CONCLUSIONS

MSASCI may become the standard approach for the thoracic surgery for small children.

Surgical intervention strategies for pediatric ovarian tumors: experience with 60 cases at one institution

PURPOSE

The aim of this study was to assess the surgical intervention strategies for pediatric ovarian tumors.

METHODS

The clinical features and treatment were analyzed for 60 children with ovarian tumors treated at our institution between 2000 and 2010.

RESULTS

Twenty-one of the 60 patients were prenatally diagnosed neonatal cases with cystic lesions. Of the 21 neonates, surgery included ultrasound-guided aspiration in 14 cases, salpingo-oophorectomy by umbilical crease incision in 6 cases with torsions, and cystectomy with ovarian preservation in one case with torsion. The mean age of the other 39 patients was 9.3 years. For 31 of these patients with benign lesions, surgery included tumor resection with ovarian preservation after aspiration of the cystic lesion through a modified Rocky Davis incision in 21 cases containing 3 torsion cases, and salpingo-oophorectomy in 10 cases, including 8 torsion cases. A salpingo-oophorectomy was performed for all eight of the patients with malignant tumors, including borderline lesions of mucinous or serous cyst adenoma, and postoperative chemotherapy was administered for two yolk sac tumors and one dysgerminoma. Only one case demonstrating a yolk sac tumor with lung metastasis at initial diagnosis died of disease after recurrence.

CONCLUSIONS

The majority of pediatric ovarian tumors were benign disease, and the patients with malignant lesions had a good prognosis. In neonatal cases, an umbilical crease incision approach is feasible and provides excellent cosmesis. We recommend tumor resection with ovarian preservation through a minimally invasive approach (modified Rocky Davis incision) as the first line treatment for older pediatric patients with ovarian tumors other than those preoperatively diagnosed as malignant.

The role of surgery in the treatment of neuroblastoma

The role of surgery varies greatly according to the clinical condition of the patients with neuroblastoma. A surgical resection is the mainstay of treatment for a localized tumor. However, in the era of intense chemotherapy associated with hematopoietic stem cell plant rescue, surgical resections are recommended without sacrificing the kidney or major vessels. Tumor biology further defines the necessity of supportive chemotherapy or radiation after surgical resection. The presence of diverse terminology concerning the range of resection may impose some confusion in the understanding of the previous papers. Therefore, the definition of a surgical resection was initially stated. In high-risk patients, the advantages of surgery for a patient's survival seem to be limited. This article reviews the efficacy of surgical resections in different clinical situations for a better understanding of the meaning of surgery in the treatment of neuroblastoma. The results of surgical resections are summarized according to the International Neuroblastoma Staging System. Finally, the long-term results regarding the strategy-related survival of the patients in the Niigata tumor board are briefly introduced.

Gastric tube-pericardial fistula: a remote complication of esophageal replacement for long gap esophageal atresia

Several short and long-term complications of esophageal replacement have been described in the literature. We report the case of a gastric tube-pericardial fistula occurring 20 years after initial repair of long gap esophageal atresia with a reversed gastric tube.

Esophageal atresia repair with thoracotomy: the Cincinnati contemporary experience

Esophageal atresia/tracheoesophageal fistula (EA/TEF) repair using an open muscle-sparing thoracotomy has been the standard approach used in our institution. Whereas perioperative mortality is now very uncommon, short- and long-term morbidity is very common in these patients. However, the complexity of the esophageal anatomy and significant comorbidities appear to be important contributors to significant complications in these patients. At least 30% of the EA/TEF patients required esophageal dilatations for anastomotic stricture; this increased to 50% for patients with pure EA. Gastroesophageal reflux requiring an antireflux procedure was performed 23% of the time for EA/TEF and 30% for EA patients. In addition, there were a few complications, such as winging of the scapula and scoliosis, that were attributed in part to the utilization of a nonmuscle-sparing thoracotomy. The standard muscle-sparing thoracotomy remains a very versatile and useful approach to repairing esophageal atresia, and it is the standard for repairing more complex anatomical variants. The self-reported long-term quality of life in these patients is very good, except for a few individuals with protracted feeding disorders and severe dysphagia.