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Daboos M, Abdelmaboud M, Hussein M, Salama A, Elshamy A. Azygos vein preservation revisited: impact on early outcomes after repair of esophageal atresia/tracheoesophageal fistula in newborns. Updates Surg 2023; 75:2305-2311. [PMID: 37945968 PMCID: PMC10710382 DOI: 10.1007/s13304-023-01684-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Accepted: 10/25/2023] [Indexed: 11/12/2023]
Abstract
Since the first successful repair of esophageal atresia/tracheoesophageal fistula (EA-TEF) was performed approximately 8 decades ago, surgeons have made considerable technical advances in solving intraoperative surgical challenges and reducing postoperative complications. According to some surgeons, preserving the Azygos vein makes this modification attractive. This study aimed to evaluate the benefits of preserving the Azygos vein during surgery for esophageal atresia with tracheoesophageal fistula and to highlight its advantages in reducing anastomotic leak, stricture, and other postoperative outcomes. This prospective comparative series was conducted between April 2020 and April 2023. The study included all newborns with EA-TEF eligible for primary repair. Patients were randomized to either Group A or B. Group A underwent Azygos vein preservation, whereas the remaining patients (Group B) underwent Azygos vein disconnection. Sixty-four patients were included in this study. Thirty-two patients (Group A) underwent Azygos vein preservation during EA-TEF repair, and the remaining thirty-two patients (Group B) underwent Azygos vein ligation and disconnection. Both groups were comparable in terms of demographics, clinical data, and operative findings (P > 0.05). Pneumonitis occurred in 4 patients in Group A and 16 patients in Group B. Anastomotic leaks occurred in two (6.2%) patients in Group A and six (18.7%) patients in Group B. There were two deaths in Group A and six deaths in Group B, with a significant difference between the two groups (P = 0.0485). Preserving the Azygos vein during esophageal atresia repair reduces the occurrence of postoperative pneumonia, leakage, and stenosis, and decreases postoperative mortality. Therefore, we declare that this modification is a significant and valuable addition to the current surgical procedures.
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Affiliation(s)
- Mohammad Daboos
- Department of Pediatric Surgery, Al-Azhar University, Al-Houssain University Hospital, Darrasa, Cairo, Egypt
| | - Mohamed Abdelmaboud
- Department of Pediatric Surgery, Al-Azhar University, Al-Houssain University Hospital, Darrasa, Cairo, Egypt.
| | - Mohamed Hussein
- Department of Pediatric Surgery, Al-Azhar University, Al-Houssain University Hospital, Darrasa, Cairo, Egypt
| | - Ahmed Salama
- Department of Pediatric Surgery, Al-Azhar University, Al-Houssain University Hospital, Darrasa, Cairo, Egypt
| | - Ahmed Elshamy
- Pediatric Surgery Unit, Department of Surgery, Al-Azhar University, Assuit, Egypt
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Chakraborty P, Roy S, Mandal KC, Halder PK, Jana G, Paul K. Esophageal Atresia and Tracheoesophageal Fistula: A Retrospective Review from a Tertiary Care Institute. JOURNAL OF THE WEST AFRICAN COLLEGE OF SURGEONS 2022; 12:30-36. [PMID: 36388731 PMCID: PMC9641742 DOI: 10.4103/jwas.jwas_100_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 07/01/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND A survey of neonates with esophageal atresia and tracheoesophageal fistula (EA ± TEF) to determine additional factors responsible for poor surgical outcomes in our institution where employing an improved standard of care can ameliorate the outcome. MATERIALS AND METHODS We carried out a retrospective review of 54 neonates, who underwent surgical repair of EA± TEF over a 5-year period. We collected data regarding the patients' demographics, perioperative findings, records of neonatal intensive care, and ascertained the effects of gender, gestational age, birth weight, age at operation, type of anomaly, coexisting major anomalies, preoperative inotrope therapy, and duration of postoperative ventilation on the surgical outcome. RESULTS The mortality rate was 51.9%, out of which, 42.8% of neonates succumbed to ventilator-associated conditions. Age at the time of surgery, gestational age, preoperative inotrope support, presence of coexisting anomalies, and duration of postoperative ventilation were determined as the significant variables predicting mortality(P < 0.05). The area under the Receiver Operating Curve showed the duration of postoperative ventilation as the best indicator of mortality. The Logistic regression model (χ2 = 11.204, P = 0.019) with the above-mentioned variables showed that neonates who were operated before 2.5 days and who required <74.5 hours of postoperative ventilation were 3.91 and 48.30 times more likely to survive respectively, than their counterparts. CONCLUSION A delay in surgery due to delayed diagnosis and or delayed transportation to tertiary centres and prolonged ventilatory support have an additional detrimental effect on the surgical outcomes of EA ± TEF.
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Affiliation(s)
- Partha Chakraborty
- Department of Pediatric Surgery, R. G. Kar Medical College, Kolkata, West Bengal, India
| | - Sourav Roy
- Department of Pediatric Surgery, R. G. Kar Medical College, Kolkata, West Bengal, India
| | - Kartik Chandra Mandal
- Department of Pediatric Surgery, Dr. B. C. Roy, Post Graduate Institute of Pediatric Sciences (PGIPS), Kolkata, West Bengal, India
| | - Pankaj Kumar Halder
- Department of Pediatric Surgery, R. G. Kar Medical College, Kolkata, West Bengal, India
| | - Gunadhar Jana
- Department of Anesthesiology, K. P. C. Medical College, Jadavpur, Kolkata, West Bengal, India
| | - Kallol Paul
- Department of Pediatric Medicine, College of Medicine and Sagore Dutta Hospital, Kolkata, West Bengal, India
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Wang C, Zheng J, Ma X. Azygos vein preservation is feasible and beneficial in esophageal atresia with tracheoesophageal fistula: A meta-analysis of randomized controlled trials. Front Pediatr 2022; 10:965275. [PMID: 35967577 PMCID: PMC9366511 DOI: 10.3389/fped.2022.965275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 07/08/2022] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Esophageal atresia (EA) with tracheoesophageal fistula (TEF) is a common congenital anomaly. It is still unknown whether azygos vein preservation will increase the difficulty or time of operation and reduce the quality of anastomosis. Thus, we conducted this meta-analysis to explore the puzzle. METHODS Two researchers independently searched the databases. Randomized controlled trials were included if these studies applied thoracotomy to perform operations and compared the outcomes in patients with EA/TEF between azygos vein preservation groups and azygos vein ligation groups. The Jadad score was used to assess the quality of the included studies. Statistical heterogeneity was evaluated using the I 2 value. A fixed or random-effect model was applied regarding the I 2 value. RESULTS Four studies involving 286 patients were included. The pooled estimates indicated that preservation of the azygos vein decreased the incidence of anatomic leakage with a pooled risk ratio (RR) of 0.54 (95% CI 0.29-0.99, P = 0.05) and mortality with an RR of 0.51 (95% CI 0.29-0.90; P = 0.02). Preservation of the azygos vein might not require a longer operative time than ligation of the azygos vein. CONCLUSIONS This research certifies that preservation of the azygos vein is able to reduce the prevalence of anastomotic leakage and mortality.
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Affiliation(s)
- Chuan Wang
- Department of Pediatric Surgery, West China Hospital of Sichuan University, Chengdu, China
| | - Junkai Zheng
- Department of Pediatric Surgery, West China Hospital of Sichuan University, Chengdu, China
| | - Xue Ma
- Department of Pediatric Surgery, West China Hospital of Sichuan University, Chengdu, China
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The effect of azygos vein preservation on postoperative complications after esophageal atresia repair: Results from the Turkish Esophageal Atresia Registry. J Pediatr Surg 2021; 56:1940-1943. [PMID: 33353739 DOI: 10.1016/j.jpedsurg.2020.12.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 11/12/2020] [Accepted: 12/06/2020] [Indexed: 11/20/2022]
Abstract
AIM Preservation of the azygos vein (AV) maintains normal venous drainage of the mediastinum and decreases postoperative congestion. The modification of esophageal atresia (EA) repair by preserving AV may prevent postoperative complications and may lead to better outcomes. The data from the Turkish Esophageal Atresia Registry (TEAR) were evaluated to define the effect of AV preservation on postoperative complications of patients with EA. METHODS Data from TEAR for a period of five years were evaluated. Patients were enrolled into two groups according to the preservation of AV. Patients with divided (DAV) and preserved AV (PAV) were evaluated for demographic and operative features and postoperative complications for the first year of life. The DAV and PAV groups were compared according to the postoperative complications, such as fistula recanalization, symptomatic strictures, anastomotic leaks, total number of esophageal dilatations, and anti-reflux surgery. In addition, respiratory problems, which required treatment, were compared between groups. RESULTS Among 502 registered patients; the data from 315 patients with the information of AV ligation were included. The male female ratio of DAV (n = 271) and PAV (n = 44) groups were 150:121 and 21:23, respectively (p > 0.05). The mean body weight, height, gestational age, and associated anomalies were similar in both groups (p > 0.05). The esophageal repair with thoracotomy was significantly higher in DAV group, when compared to the PAV group (p < 0.05). The rates of primary anastomosis and tensioned anastomosis were similar in both groups (p > 0.05). There was no difference between DAV and PAV groups for anastomotic leaks, symptomatic anastomotic strictures, fistula recanalization, and the requirement for anti-reflux surgery (p > 0.05). The rate of respiratory problems, which required treatment, was significantly higher in the DAV group (p < 0.05) CONCLUSION: The data in the TEAR demonstrated that preserving the AV during EA repair led to no significant advantage on postoperative complications, with exception of respiratory problems. AV should be preserved as much as possible to maintain a normal mediastinal anatomy and to avoid respiratory complications.
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Kainth D, Anand S, Singh A, Bajpai M. Impact of preservation of the azygos vein during surgical repair of esophageal atresia-tracheoesophageal fistula (EA-TEF): a systematic review and meta-analysis. Pediatr Surg Int 2021; 37:983-989. [PMID: 33907863 DOI: 10.1007/s00383-021-04913-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/20/2021] [Indexed: 10/21/2022]
Abstract
Esophageal atresia-tracheoesophageal fistula (EA-TEF) is one of the common congenital anomalies occurring in newborns. Over the last eight decades, various technical modifications have been proposed in the surgical repair of EA-TEF. Preservation of azygos vein is one such modification that has gained considerable attention. However, a consensus statement regarding the superiority of its preservation over its division is lacking. We aim to compare the outcomes of surgery between the two groups of newborns, i.e., those undergoing repair with and without azygos vein preservation, in terms of its complications. The authors systematically searched the databases PubMed, EMBASE, Web of Science, and Scopus through December 2020. The incidence of anastomotic complications and chest infection was compared among the two groups of newborns, i.e., those undergoing surgical repair with (group A) and without azygos vein preservation (group B). Statistical analysis was performed using a fixed-effects model, and pooled risk ratio (RR) and heterogeneity (I2) were calculated. The methodological quality of the studies was assessed using the Downs and Black scale. Six comparative studies, consisting of a total of 671 newborns, were included in the meta-analysis. As compared to group B, newborns belonging to group A showed a significantly lower incidence of pneumonitis in the postoperative period (RR 0.31; 95% CI 0.17-0.57, p = 0.0001). However, no significant difference in the incidence of anastomotic complications including anastomotic leak (RR 0.73; 95% CI 0.48-1.12, p = 0.15) and stricture (RR 0.63; 95% CI 0.36-1.09, p = 0.10) was observed between the two groups. The average Downs and Black scale scores ranged from 20 to 24. The risk of bias was low (n = 1) and moderate (n = 5) in the included studies. Kappa statistics showed a value of 0.902 (p < 0.001), highlighting an almost perfect agreement among the two observers. The present meta-analysis revealed the superiority of surgical repair of EA-TEF performed with preservation of azygos vein in terms of the incidence of postoperative chest infection. However, no significant difference in the occurrence of anastomotic leak and stricture was observed between the two groups. The level of evidence of the published comparative studies is limited. Therefore, well designed, randomized controlled trial utilizing a standardized operative approach on a larger sample-size needs to be conducted for optimal comparison between the two approaches.
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Affiliation(s)
- Deepika Kainth
- Division of Neonatology, Department of Pediatrics, AIIMS, New Delhi, India
| | - Sachit Anand
- Department of Pediatric Surgery, Kokilaben Dhirubhai Ambani Hospital, Andheri West, Mumbai, 400053, India.
| | - Apoorv Singh
- Department of Pediatric Surgery, AIIMS, New Delhi, India
| | - Minu Bajpai
- Department of Pediatric Surgery, AIIMS, New Delhi, India
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Abstract
Knowledge of variations of azygos and hemiazygos veins is of importance to cardiothoracic surgeons and radiologists during various surgical, radiological, and echography techniques. We report some unique variations of azygos system of veins observed during dissection classes for undergraduate medical students. The azygos vein was formed as usual by the union of right subcostal and ascending lumbar veins. The vein ascended upward and to the left to reach the midline at the level of the 9th thoracic vertebra. After ascending till 5th thoracic vertebra, it gradually inclined to the right of midline and terminated by opening into the superior vena cava at the level of the 3rd thoracic vertebra. There was no major variation in the tributaries of the azygos vein on the right side, except that the right superior intercostal vein crossed behind the azygos vein from right to left and opened into the left side of the azygos vein. Further, two anastomotic veins connected the 10th, 11th and 12th posterior intercostal veins with each other to form two anastomotic circles on the right side of 10th to 12th thoracic vertebrae. The hemiazygos vein bifurcated on the left side of the 10th thoracic vertebra and the two ends opened into the azygos vein at the level of 9th and 10th thoracic vertebrae forming a venous circle in front of the 10th thoracic vertebra. The course of accessory hemiazygos vein was noteworthy. Instead of its classic descending course, the vein ascended upward from the left side of the 8th thoracic vertebra till the 6th thoracic vertebra before opening into the azygos vein.
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Affiliation(s)
- Satheesha Nayak Badagabettu
- Department of Anatomy, Melaka Manipal Medical College (Manipal Campus), Manipal University, Manipal, Karnataka, India
| | - Prakashchandra Shetty
- Department of Anatomy, Melaka Manipal Medical College (Manipal Campus), Manipal University, Manipal, Karnataka, India
| | - Melanie Rose D'Souza
- Department of Anatomy, Melaka Manipal Medical College (Manipal Campus), Manipal University, Manipal, Karnataka, India
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