Long gap esophageal atresia and esophageal replacement: moving toward a separation?

Critical Role of Pleural Wrap and Post-operative Neonatal Protocol in Long-gap Oesophageal Atresia: A Team Effort

BACKGROUND

The objectives of this study were to bring out the results of application of pleural wrap in primary repair of tracheo - esophageal fistula (TEF) with long-gap oesophageal atresia (LGEA) and also define the role of neonatologists and paediatric intensivists in post-operative management in these patients by laying down standard neonatal management protocol.

MATERIALS AND METHODS

This was a retrospective descriptive observational study conducted between March 2011 and April 2019 on 23 cases of LGEA with TEF. The study was conducted at two tertiary care paediatric surgery centres in Northern part of India wherein these newborn babies were operated by two paediatric surgeons with variable experience of 8-12 years. It also describes the neonatal management protocol used in post-operative period.

RESULTS

Out of 23 patients, 15 were boys and 8 were girls, with a mean age of 32.25 weeks and a mean birth weight of 2.02 kg. The mean hospital stay was 23.5 ± 8 days. Eleven cases had gap between 3 and 3.5 cm, 8 cases between 3.5 and 4 cm and 4 cases had gap more than 4 cm. The incidence of associated anomalies was 52%. Anastomotic leak rate was 8.69%, and 3 (13.04%) patients died in the post-operative period. All the operated patients were managed postoperatively as per strict neonatal management protocol exclusively by the team of neonatologists and neonatal intensivists.

CONCLUSION

Application of pleural wrap over anastomosis following primary repair of LGEA with TEF significantly reduced the incidence of anastomotic leak in our study. Apart from the pleural wrap, the key to successful outcome also is contributed by the little prolonged, controlled ventilation and patience and perseverance in post-operative feeds. This post-operative management protocol that has been followed by us in our study is easily reproducible and can be adopted by paediatric surgeons working alongside neonatologists as a team.

Long-gap esophageal atresia: gastric transposition or esophageal lengthening with delayed primary anastomosis? A systematic review

PURPOSE

This study aims to evaluate different surgical approaches to long-gap esophageal atresia (LGEA) with or without tracheoesophageal fistula (TEF) is unclear.

METHODS

A systematic literature review was done comparing gastric transposition versus esophageal lengthening with delayed primary anastomosis in infants with LGEA+/-TEF. The primary outcome was time to full oral feeds. Secondary outcomes were time to full enteric feeds, need for further surgery, growth, mortality, and postoperative adverse events.

RESULTS

No comparative studies were found. However, the literature was re-interrogated for non-comparative studies. Four hundred thirty-eight articles were identified and screened, and 18 met the inclusion criteria. All were case series. Forty-three infants underwent gastric transposition, and 106 had esophageal lengthening with delayed primary anastomosis. One study on gastric transposition reported time to full oral feeds, and one study in each group reported growth. Time to full enteric feeds was reported in one study in each group. 30% of infants had further surgery following gastric transposition, including hiatus hernia repair (5/43, 12%) and esophageal dilation (7/43, 16%). Following esophageal lengthening, 62/106 (58%) had anti-reflux surgery, 58/106 (55%) esophageal dilatation and 11/106 (10%) esophageal stricture resection. Anastomotic complications occurred in 13/43 (30%), gastrointestinal in 16/43 (37%), respiratory in 17/43 (40%), and nerve injury in 2/43 (5%) of the gastric transposition group. In the esophageal lengthening group, anastomotic complications occurred in 68/106 (64%), gastrointestinal in 62/106 (58%), respiratory in 6/106 (6%), and none sustained nerve injury. Each group had one death due to a cause not directly related to the surgical procedure.

CONCLUSIONS

This systematic review highlights the morbidity associated with both surgical procedures and the variety in reporting outcomes.

Outcome of long gap esophageal atresia at 6 years: A prospective case control cohort study

BACKGROUND DATA

EA is the most frequent congenital esophageal malformation. Long gap EA remains a therapeutic challenge for pediatric surgeons. A case case-control prospective study from a multi-institutional national French data base was performed to assess the outcome, at age of 1 and 6 years, of long gap esophageal atresia (EA) compared with non-long gap EA/tracheo-esophageal fistula (TEF). The secondary aim was to assess whether initial treatment (delayed primary anastomosis of native esophagus vs. esophageal replacement) influenced mortality and morbidity at ages 1 and 6 years.

METHODS

A multicentric population-based prospective study was performed and included all patients who underwent EA surgery in France from January 1, 2008 to December 31, 2010. A comparative study was performed with non-long gap EA/TEF patients. Morbidity at birth, 1 year, and 6 years was assessed.

RESULTS

Thirty-one patients with long gap EA were compared with 62 non-long gap EA/TEF patients. At age 1 year, the long gap EA group had longer parenteral nutrition support and longer hospital stay and were significantly more likely to have complications both early post-operatively and before age 1 year compared with the non-long gap EA/TEF group. At 6 years, digestive complications were more frequent in long gap compared to non-long gap EA/TEF patients. Tracheomalacia was the only respiratory complication that differed between the groups. Spine deformation was less frequent in the long gap group. There were no differences between conservative and replacement groups at ages 1 and 6 years except feeding difficulties that were more common in the native esophagus group.

CONCLUSIONS

Long gap strongly influenced digestive morbidity at age 6 years.

Delayed primary anastomosis for repair of long-gap esophageal atresia: technique revisited

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.

Post-operative ventilation strategies after surgical repair in neonates with esophageal atresia: A retrospective cohort study

BACKGROUND

Infants affected by Esophageal atresia (EA) with or without tracheoesophageal fistula (TEF) may require non-invasive ventilation (NIV) in the post-operative period after elective extubation, especially if born preterm. The aim of the paper is to evaluate the role of different ventilation strategies on anastomotic complications, specifically on anastomotic leak (AL).

MATERIALS AND METHODS

Retrospective single Institution study, including all consecutive neonates affected by EA with or without TEF in a 5-year period study (from 2014 to 2018). Only infants with a primary anastomosis were included in the study. All infants were mechanically ventilated after surgery and electively extubated after 6-7 days. The duration of invasive ventilation was decided on a case-by-case basis after surgery, based on the pre-operative esophageal gap and intraoperative findings. The need for non-invasive ventilation (NCPAP, NIPPV, and HHHFNC) after extubation and extubation failure with the need for mechanical ventilation in the post-operative period were assessed. The primary outcome evaluated was the rate of anastomotic leak.

RESULTS

102 EA/TEF infants were managed in the study period. Sixty-seven underwent primary anastomosis. Of these, 29 (43.3%) were born preterm. Patients who required ventilation (n = 32) had a significantly lower gestational age as well as birthweight (respectively p = 0.007 and p = 0.041). 4/67 patients had an AL after surgical repair, with no statistical differences among post-operative ventilation strategies.

CONCLUSION

We found no significant differences in the rate of anastomotic leak (AL) according to post-operative ventilation strategies in neonates operated on for EA/TEF.

Decellularized esophageal tubular scaffold microperforated by quantum molecular resonance technology and seeded with mesenchymal stromal cells for tissue engineering esophageal regeneration

Current surgical options for patients requiring esophageal replacement suffer from several limitations and do not assure a satisfactory quality of life. Tissue engineering techniques for the creation of customized “self-developing” esophageal substitutes, which are obtained by seeding autologous cells on artificial or natural scaffolds, allow simplifying surgical procedures and achieving good clinical outcomes. In this context, an appealing approach is based on the exploitation of decellularized tissues as biological matrices to be colonized by the appropriate cell types to regenerate the desired organs. With specific regard to the esophagus, the presence of a thick connective texture in the decellularized scaffold hampers an adequate penetration and spatial distribution of cells. In the present work, the Quantum Molecular Resonance^® (QMR) technology was used to create a regular microchannel structure inside the connective tissue of full-thickness decellularized tubular porcine esophagi to facilitate a diffuse and uniform spreading of seeded mesenchymal stromal cells within the scaffold. Esophageal samples were thoroughly characterized before and after decellularization and microperforation in terms of residual DNA content, matrix composition, structure and biomechanical features. The scaffold was seeded with mesenchymal stromal cells under dynamic conditions, to assess the ability to be repopulated before its implantation in a large animal model. At the end of the procedure, they resemble the original esophagus, preserving the characteristic multilayer composition and maintaining biomechanical properties adequate for surgery. After the sacrifice we had histological and immunohistochemical evidence of the full-thickness regeneration of the esophageal wall, resembling the native organ. These results suggest the QMR microperforated decellularized esophageal scaffold as a promising device for esophagus regeneration in patients needing esophageal substitution.

Childhood outcome after correction of long-gap esophageal atresia by thoracoscopic external traction technique

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.

[Effect of muscle relaxants on the prognosis of neonates with congenital esophageal atresia-tracheoesophageal fistula after surgery]

OBJECTIVE

To summarize the experience in the application of muscle relaxants in the perioperative period in neonates with congenital esophageal atresia-tracheoesophageal fistula (EA-TEF).

METHODS

A retrospective analysis was performed on the medical data of 58 previously untreated neonates with EA-TEF who were treated in the Neonatal Center of Beijing Children's Hospital, Capital Medical University from 2017 to 2019. The incidence rate of anastomotic leak was compared between the neonates receiving muscle relaxants for different durations after surgery (≤ 5 days and > 5 days). The correlation between the duration of postoperative use of muscle relaxants and the duration of mechanical ventilation was evaluated.

RESULTS

Among the 58 neonates with EA-TEF, 44 underwent surgery, among whom 35 with type III EA-TEF underwent thoracoscopic surgery. Among these 35 neonates, 30 (86%) received muscle relaxants after surgery, with a median duration of 4.75 days, and 6 (18%) experienced anastomotic leak. There was no significant difference in the incidence rate of anastomosis leak between the ≤ 5 days and > 5 days groups (P > 0.05). The duration of postoperative invasive mechanical ventilation was positively correlated with the duration of the use of muscle relaxants (r_s=0.548, P < 0.05).

CONCLUSIONS

Prolonged use of muscle relaxants after surgery cannot significantly reduce the incidence of anastomotic leak, but can prolong the duration of invasive mechanical ventilation in neonates with EA-TEF. Therefore, prolonged use of muscle relaxants is not recommended after surgery.

Thoracoscopy for Esophageal Diverticula After Esophageal Atresia With Tracheo-Esophageal Fistula

Background: Esophageal diverticulum (ED) is an extremely rare complication of congenital esophageal atresia (EA) with or without tracheoesophageal fistula (TEF) surgery. We aimed to investigate feasible methods for the treatment of this rare complication. Methods: We retrospectively reviewed all patients with EA/TEF at Beijing Children's Hospital from January 2015 to September 2019. The clinicopathological features of patients with ED after EA/TEF surgery were recorded. Follow-up was routinely performed after surgery until December 2020. Results: Among 198 patients with EA/TEF, ED only occurred in four patients (2.02%; one male, three female). The four patients had varying complications after the initial operation, including anastomotic leakage (3/4), esophageal stenosis (3/4), and recurrence of TEF (1/4). The main clinical symptoms of ED included recurrent pneumonia (4/4), coughing (4/4), and dysphagia (3/4). All ED cases occurred near the esophageal anastomosis. Patients' age at the time of diverticulum repair was 6.6-16.8 months. All patients underwent thoracoscopic esophageal diverticulectomy (operation time: 1.5-3.5 h). Anastomotic leakage occurred in one patient and spontaneously healed after 2 weeks. The other three patients had no peri-operative complications. All patients were routinely followed up after surgery for 14-36 months. During the follow-up period, all patients could eat orally, had good growth and weight gain, and showed no ED recurrence or anastomotic leakage on esophagogram. Conclusions: ED is a rare complication after EA/TEF surgery and is a clear indication for diverticulectomy. During the midterm follow-up, thoracoscopic esophageal diverticulectomy was safe and effective for ED after EA/TEF surgery.

Intramural Injection of Botulinum Toxin A in Surgical Treatment of a Long Gap Esophageal Atresia-Rat Model

INTRODUCTION

 Anastomosis with minimal tension is desirable in long-gap esophageal atresia. Prior studies in piglets showed that intraesophageal injection of botulinum toxin type A (BTX-A) results in significant esophageal elongation. Our aim was to determine the BTX-A dose, number of injections, and time necessary to elicit maximal response.

MATERIALS AND METHODS

 Adult male Wistar rats (n = 48) were randomly assorted into five groups. Four treatment groups received 2 or 4 U/kg of BTX-A, delivered using two or four injections, and a control group received 0.9% NaCl. Esophagus was removed 6 or 24-hours postinjection and tested ex vivo using a stretch tension device. Subsequently, an optimal dose and time following injection was used to study the effects of BTX-A on anastomotic healing in vivo. Rats (n = 12) received an intraesophageal injection of BTX-A or 0.9% NaCl, followed by resection of 0.5 cm of esophagus and end-to-end anastomosis. Rats were observed for 9 days, and esophagus was removed for gross and histological evaluation.

RESULTS

 The largest effect on elongation was recorded in the BTX-A (2 U/kg) 24 hour, four injection group. In the anastomosis study, stricture formation was observed in all animals in the control group. Absence of esophageal stricture was found in three out of four animals in the treatment group macroscopically and histologically.

CONCLUSION

 We found that BTX-A exerts a positive effect on stretch characteristics of esophageal tissue in rats at 2 U/kg via four-injection delivery and 24-hour waiting period. This study suggests that BTX-A might improve anastomotic healing.

14 Years’ experience of esophageal replacement surgeries

BACKGROUND

Esophageal replacement is a challenge to the therapeutic skills of surgeons and a technically demanding operation in the pediatric age group. Various conduits and routes have been described in the literature, each with their specific advantages and disadvantages. We carried out this retrospective study to share our experience of esophageal replacement.

METHODOLOGY

This study was conducted at the department of pediatric surgery The Children's Hospital and The Institute of Child Health, Lahore. The records of patients treated for esophageal replacement were reviewed. The patients under follow-up were called for clinical evaluation and assessed of long terms complications if any.

RESULTS

A total of 93 patients with esophageal replacement were included in the study. Esophageal replacement was done with gastric transposition in 84 cases (90%), colon interposition in 7 cases (7.5%) including one case of redo colonic interposition, and jejunal interposition in 2 cases (2%). Routes of esophageal replacement were trans-hiatal in 71 (76%), retrosternal in 13 (14%), and trans-hiatal with thoracotomy in 9 (10%) patients. Postoperatively, all of the conduits maintained viability. Wound infection was seen in 10 (11%), wound dehiscence in 5 (5%), anastomotic leak in 9 (10%), anastomotic stenosis in 12 (13%), fistula formation in 4 (4%), aortic injury 1 (1%), dumping syndrome 8 (9%), reflux 18 (19%), dysphagia 15 (16%) and death occurred in 12 patients (13%).

CONCLUSION

There are problems with esophageal replacement in developing countries. In this context, gastric conduit appeared as the best conduit for esophageal replacement, using the trans-hiatal route for replacement, in the authors' experience.

[Antenatal ultrasound prediction of esophageal atresia type]

BACKGROUND

Esophageal atresia (EA) is a rare congenital malformation of the upper aerodigestive tract, which can be diagnosed antenatally in 50-65% of cases. Postnatal management differs according to the type of EA. No studies have evaluated the correlation of antenatal ultrasound findings with the type of EA.

OBJECTIVE

The main objective is to study the association between antenatal ultrasound signs and the type of EA. The secondary objective is to study the association between postnatal morbidity and the type of EA.

METHOD

We conducted a single-center retrospective study between May 2010 and August 2019. Fetuses with suspected prenatal EA and postnatal diagnosis confirmation were included. Postnatal confirmation of EA was performed during surgery for live births and by fetopathological examination for termination of pregnancy. Prenatal signs and postnatal morbidity were compared according to the type of EA.

RESULTS

We included 15 cases of postnatally confirmed EA, including 9 type 1EA, 5 type 3EA and 1 type 4EA (11 live births and 4 terminations of pregnancy). The gestational age at diagnosis was earlier in type 1EA: 22⁺⁰ [6-21,21-24] versus 30⁺⁰ [28^+0-32⁺⁰] (P=0.03). Compared to type 3EA, type 1EA had a higher incidence of non-visible stomach bubble (89% versus 40%, P=0.09) and upper esophageal cul-de-sac dilatation (56% versus 0%, P=0.09). Neonatal morbidity in type 1EA was more severe with a longer hospital stay in neonatal intensive care.

CONCLUSION

The antenatal ultrasound signs seem to be more pronounced in case of type 1EA. Type 1EA is associated with severe morbidity compared to Type 3EA. Improving prenatal diagnosis of EA and its type allows a more accurate prognostic evaluation.

Patterns of malformation associated with esophageal atresia/tracheoesophageal fistula: A retrospective single center study

Esophageal atresia/tracheoesophageal fistula (EA/TEF) is one of the most common gastrointestinal birth defects. It can occur in isolation or in association with other birth defects or genetic syndromes. We retrospectively reviewed the EA/TEF cases evaluated at Rady Children's Hospital San Diego (San Diego, CA) between 2007 and 2016. Data were collected for 157 patients. The majority of patients (105, 66.8%) had an associated major malformation present, and 52 patients (33.1%) had isolated EA/TEF. The patients with associated malformations were distributed as follows: 16 patients (10.2%) had a known genetic syndrome (the most common being Trisomy 21 in 11 patients); six patients (3.8%) had a suspected genetic syndrome; one patient had a suspected teratogenic syndrome (diabetic embryopathy); 30 patients had VACTERL association (19.1%); 32 patients had a "partial VACTERL" association (only two VACTERL-type defects without other malformation); nine patients (5.7%) had one additional non-VACTERL-type birth defect, two patients had VACTERL-type defects plus auricular malformations; and nine patients (5.7%) were classified as "unknown syndrome." A classification of the patterns of malformation of patients with congenital EA/TEF is proposed based on reviewing the data of this relatively large and phenotypically diverse patient group.

Fixed the gap, solved the problem? Eating skills in esophageal atresia patients at 3 years

Although eating problems have been described as long-term morbidities of esophageal atresia (EA), there have been few studies exploring eating outcomes in children born with EA as primary aim. Parents of children operated on for EA in our Institution from January 2012 to January 2016, answered a telephone structured interview developed specifically to conduct the present study, assessing eating skills at 3 years of age. Clinical data were collected from children's medical records. Parents (45 mothers and 6 fathers) of 51 children (male = 34; female = 17) with a median age of 3.5 years form the object of the study. Considering eating problems, parents reported that 23 children (45%) still have episodes of choking during meals at 3 years of age, 9 (45%) of these have more than one episode a week, and 19 parents (39%) reported higher levels of anxiety during mealtimes. Forty-four children (86%) were described by their parents as able to eat alone, 32 (65%) accepted all food textures and 45 (90%) was described as curious about food (3 years). Forty-three (86%) parents let their children eat with other people. Correlations showed that weaning age was significantly associated with number of dilatations (rs = 0.35, P = 0.012), days of mechanical ventilation (rs = 0.40, P < 0.001), and presence of gastrostomy tube at discharge (rs = 0.45, P < 0.001). Chewing age resulted associated with number of dilatations (rs = 0.34, P < 0.01) and days of mechanical ventilation (rs = 0.38, P < 0.01). Presence of choking episodes was associated with curiosity about food (rs = 0.29, P < 0.05), while frequent choking episodes were associated with higher parental anxiety during mealtimes (rs = 0.45, P < 0.05). In order to prevent delay in the achievement of eating developmental milestones in children operated on of EA, we advocate a dedicated preventive intervention from birth to follow-up.

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

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).

[Erfolgreiche therapeutische endoskopisch-endoluminale Procaininstillation in eine Anastomosenregion bei chronischem Symptomkomplex nach operativer Versorgung einer angeborenen Ösophagusatresie]

Hintergrund: Wir berichten über eine 27-jährige Patientin, die nach operativem Magenhochzug bei Ösophagusatresie unter massiv einschränkenden Symptomen wie Sodbrennen, Erbrechen, Regurgitation, Übelkeit und Magenkrämpfen litt, trotz maximaler konservativer Therapie. Falldarstellung: Die Patientin erhielt im Rahmen einer Gastroskopie eine endoluminale Procaininfiltration in die narbige Anastomosenregion, woraufhin sich die klinische Symptomatik deutlich reduzierte und auch im Langzeitverlauf stabil vermindert blieb. Schlussfolgerung: Wir beschreiben die unseres Wissens nach erste endoluminale Infiltration von Procain in narbige Gewebsareale einer enteralen Anastomosenregion nach operativem Magenhochzug.

BACKGROUND

We present a 27-year-old female who, despite maximum conservative therapy, suffered from severely restricting symptoms such as heartburn, vomiting, regurgitation, nausea and stomach spasms after a gastric pull-up because of an esophageal atresia.

CASE REPORT

During a gastroscopy, an endoluminal injection of procaine in scar tissue in the area of the anastomosis was performed whereupon the symptoms diminished considerably and remained in this diminished state over a long course.

CONCLUSION

We described the first successful endoluminal injection with procaine into scar tissue after enteral anastomosis because of an esophageal atresia.

Magnetic Compression Anastomosis in Long-Gap Esophageal Atresia Gross Type A: A Case Report

Esophageal atresia (EA) Gross type A (long-gap without tracheoesophageal fistula) is a rare and a surgical challenging form of EA that constitutes ∼6% of the children born with EA. We present the seventh reported case with successful esophagoesophagostomy obtained by magnetic compression of a long-gap EA type A without thoracotomy.

Etiological heterogeneity and clinical variability in newborns with esophageal atresia

BACKGROUND

The aim of this study was to define different characteristics of infants with esophageal atresia and correlations with neonatal level of care, morbidity and mortality occurring during hospital stay.

METHODS

Charts of all newborns with esophageal atresia (EA) admitted to our University NICU between January 2003 and November 2016 were reviewed and subdivided in four groups related to different clinical presentations; EA as an isolated form (A), with a concomitant single malformation (B), as VACTERL association (C), and in the context of a syndrome or an entity of multiple congenital anomalies (D).

RESULTS

We recruited 67 infants with EA (with or without tracheoesophageal fistula), distributed in groups as follows: A 31.3%, B 16.4%, C 26.8% and D 25.3%. Type of atresia was not statistically different among different groups. Mortality was higher in groups C and D, especially if associated with congenital heart defects. In survivors, we found different auxological evolution and prognostic profiles considering duration in days of invasive mechanical ventilation and total parenteral nutrition, as well as length of stay and corrected gestational age at discharge.

CONCLUSIONS

In the context of genetic and syndromic entities, subjects with VACTERL association showed a lower mortality rate although a higher and more complex level of intensive care was noted in comparison to infants without VACTERL genetic and syndromic entities.

Comparison of outcomes of thoracoscopic primary repair of gross type C esophageal atresia performed by qualified and non-qualified surgeons

PURPOSE

Although thoracoscopic repair of esophageal atresia has become widespread, most studies are based on operations performed by expert surgeons. Therefore, the outcomes of operations performed by non-expert surgeons are not well known. The aim of this study was to compare outcomes based on operator skill level.

METHODS

We retrospectively reviewed the demographics and outcomes of patients with Gross type C esophageal atresia, who underwent primary thoracoscopic repair at our hospital between January 2014 and August 2016. Outcomes of surgeries performed by qualified surgeons, as determined by the Japanese Society for Endoscopic Surgery were compared with those of non-qualified surgeons. All operations were performed by or under the supervision of one qualified surgeon.

RESULTS

Nine operations were performed by qualified surgeons and six operations by non-qualified surgeons with >10 years of experience in surgery. None of the patients developed anastomotic leakage or recurrent tracheoesophageal fistula. However, the operative time and rate of stricture formation at the beginning of the weaning period were significantly higher in the latter group (P = 0.008 and 0.044).

CONCLUSIONS

Although supervision of experts would improve results in thoracoscopic repair of esophageal atresia, the results indicate that good skill is necessary to avoid anastomotic stricture.

Outcomes of primary gastric transposition for long-gap esophageal atresia in neonates

BACKGROUND

Gastric transposition is a relatively novel method of esophageal replacement. The purpose of this retrospective study was to assess the outcomes of long-gap esophageal atresia (LGEA) treated with esophageal replacement using primary gastric transposition in neonates.

METHODS

Between March 2008 and May 2015, 14 newborns with LGEA were treated in our hospital. They were all found to have gaps of over 3 cm at the time of the surgery and were diagnosed with LGEA. Primary gastric transposition was performed. They also underwent a gastric drainage procedure by pyloromyotomy. The nasogastric tube was removed if no anastomotic fistula was present and oral feeding was initiated. After initial recovery and discharge, the patients were evaluated with outpatient follow-ups or telephone follow-ups from 1 month after the surgery.

RESULTS

The mean age of the neonates at the time of the surgery was 32 hours (range, 4-96 h). The mean birth weight was 2550 g (range, 2100-3500 g). There were 2 deaths in this series of patients due to respiratory failure or withdrawal of treatment by the parents, with a mortality rate of 14.3%. Seven of the neonates developed unilateral or bilateral severe pneumonia. Early anastomotic leak occurred in 3 cases and anastomotic strictures occurred in 4 cases. These 4 neonates were able to eat a fairly normal diet after esophageal balloon dilation. Gastroesophageal reflux occurred in 7 of 12 cases. Feeding multiple small meals and postural support for positioning and feeding were instructed for these 7 cases. Subsequently, the symptoms alleviated and they had no additional surgical therapy. None of the neonates had delayed gastric emptying or gastric retention.

CONCLUSION

Primary gastric transposition may be a rewarding reconstructive option in the treatment of LGEA.

Long-gap esophageal atresia

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.

Oesophageal atresia with no distal tracheoesophageal fistula: Management and outcomes from a population-based cohort

PURPOSE

To describe the incidence and outcomes to one-year in infants born with oesophageal atresia (OA) with no distal tracheoesophageal fistula within a population cohort.

METHODS

A subgroup analysis of a prospective multicentre population cohort study was undertaken describing the outcomes of infants with OA and no tracheoesophageal fistula, (type A) and those with only an upper pouch fistula, (type B).

MAIN RESULTS

Twenty-one of 151 infants in the whole cohort were diagnosed with type A or B oesophageal atresia (14%). Fifteen were type A (71%) and six type B (29%). Infants with type B had a shorter gap length than those with type A: 2.5 vertebral bodies (2-3) vs. 5 (4-6) (p=0.008). All infants with type B OA underwent oesophageal anastomosis, 83% (n=5) as the primary procedure. All infants with type A, underwent staged management. Six (40%) had delayed primary anastomosis and eight required oesophageal replacement (53%). One infant died prior to reconstruction. The median time to delayed primary anastomosis in infants with type A or B OA was 82days (75-89days) (n=7). The median time to oesophageal replacement was 94days (89-147days) (n=8). Median length of stay for infants with type A or B OA from first operation to first discharge was 101days (31-123days).

CONCLUSIONS

Infants with type B OA had a shorter gap length and all were managed with oesophageal anastomosis. OA with no distal tracheoesophageal fistula is uncommon at a population level and frequently has a complex course.

LEVEL OF EVIDENCE

Rating: II.

Esophageal replacement in children: Challenges and long-term outcomes

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.

Repair of esophageal atresia with proximal fistula using endoscopic magnetic compression anastomosis (magnamosis) after staged lengthening

We describe the treatment of a patient with long-gap esophageal atresia with an upper pouch fistula, mircogastria and minimal distal esophageal remnant. After 4.5 months of feeding via gastrostomy, a proximal fistula was identified by bronchoscopy and a thoracoscopic modified Foker procedure was performed reducing the gap from approximately 7-5 cm over 2 weeks of traction. A second stage to ligate the fistula and suture approximate the proximal and distal esophagus resulted in a gap of 1.5 cm. IRB and FDA approval was then obtained for endoscopic placement of 10-French catheter mounted magnets in the proximal and distal pouches promoting a magnetic compression anastomosis (magnamosis). Magnetic coupling occurred at 4 days and after magnet removal at 13 days an esophagram demonstrated a 10 French channel without leak. Serial endoscopic balloon dilation has allowed drainage of swallowed secretions as the baby learns bottling behavior at home.

Functional residual capacity and lung clearance index in infants treated for esophageal atresia and tracheoesophageal fistula

BACKGROUND

Newborn babies with esophageal atresia/tracheoesophageal fistula (EA/TEF) are prone to respiratory tract disorders. Functional residual capacity (FRC) and lung clearance index (LCI) are commonly considered useful and sensitive tools to investigate lung function and early detecting airways diseases. The aim of the present study is to report the first series of EA/TEF infants prospectively evaluated for FRC and LCI.

METHODS

Prospective observational cohort study of all patients treated for EA/TEF. Lung volume and ventilation inhomogeneity were measured by helium gas dilution technique using an ultrasonic flow meter. Babies were studied both in assisted controlled ventilation (sedated) and in spontaneous breathing (quiet sleep). Three consecutive FRC and LCI measurements were collected for each test at three different time points: before surgery (T0), 24hours after surgery (T1) and after extubation (T2).

RESULTS

16 EA newborns were eligible for the study between December 2011 and July 2013. Three were excluded because of technical problems. At T0 FRC values were in the normal range regardless the presence of TEF but worsened afterwards at T1, with a subsequent recovering after extubation; a significant improvement after surgery was observed concerning LCI while no differences were found in tidal volume.

CONCLUSION

Helium gas dilution technique is a suitable method to measure the effect of surgery on lung physiology, even in ventilated infants with EA. The changes observed could be related to the ventilatory management and lung compression during surgical procedure.

Preservation of native esophagus in infants with pure esophageal atresia has good long-term outcomes despite significant postoperative morbidity

PURPOSE

To evaluate long-term outcomes of pure esophageal atresia (EA) repair with preservation of native esophagus.

METHODS

Infants with pure EA treated at our institution (2000-2010) and with minimum 5-year follow-up were reviewed (REB:1000046653). Data analysed included demographics, management and outcomes and are reported as mean ± SD/median (range).

RESULTS

Of 185 infants with EA, 12 (7 %) had pure EA (gestational age: 36 ± 2.4 weeks, birth weight: 2353 ± 675 g). Ten had associated anomalies, including trisomy-21 (n = 2) and duodenal atresia (n = 1).

SURGERY

1 patient (short gap) underwent primary thoracoscopic anastomosis, 11 had gastrostomy (Stamm, n = 5; image-guided, n = 6) as initial procedure. At definitive repair (age: 128 ± 91 days; weight 5.5 ± 2.3 kg): ten had primary anastomosis and 1 had Collis gastroplasty. No patient had esophageal replacement surgery.

OUTCOMES

three patients had gastrostomy dehiscence requiring re-operation. At post-operative esophagram, seven had anastomotic leak successfully treated conservatively. Seven patients developed strictures requiring balloon dilatations (median two dilatations, range 1-10), six received antireflux surgery. At 7-year follow-up (range 5-15 years), all patients had the gastrostomy closed and were on full oral feeds.

CONCLUSIONS

The management of pure EA continues to be challenging. The preservation of native esophagus is possible with significant morbidity. The long-term outcomes are favourable.

Macrophage Phenotype Is Associated With the Regenerative Response in Experimental Replacement of the Porcine Esophagus

A porcine model for bridging circumferential defects in the intrathoracic esophagus has been developed in order to improve the treatment of children born with long-gap esophageal atresia. The aim of this study was to identify factors beneficial for tissue regeneration in the bridging area in this model and to describe the histological progression 20 days after replacement with a silicone-stented Biodesign mesh. Resection of 3 cm of intrathoracic esophagus and replacement with a bridging graft was performed in six newly weaned piglets. They were fed through a gastrostomy for 10 days, and then had probe formula orally for another 10 days prior to sacrifice. Two out of six piglets had stent loss prior to sacrifice. In the four piglets with the stent in place, a tissue tube, with visible muscle in the wall, was seen at sacrifice. Histology showed that the wall of the healing area was well organized with layers of inflammatory cells, in-growing vessels, and smooth muscle cells. CD163+ macrophages was seen toward the esophageal lumen. In the animals where the stent was lost, the bridging area was narrow, and histology showed a less organized structure in the bridging area without the presence of CD163+ macrophages. This study indicates that regenerative healing was seen in the porcine esophagus 20 days after replacement of a part of the intrathoracic esophagus with a silicone-stented Biodesign mesh, if the bridging graft is retained. If the graft is lost, the inflammatory pattern changes with invasion of proinflammatory, M1 macrophages in the entire wall, which seems to redirect the healing process toward scar formation.

Immediate primary anastomosis for isolated oesophageal atresia: A single-centre experience

BACKGROUND

Isolated oesophageal atresia without tracheo-oesophageal fistula represents a major challenge for most paediatric surgeons. Here, we present our experience with six neonates with isolated oesophageal atresia who successfully underwent immediate primary anastomosis using multiple Livaditis circular myotomy.

MATERIALS AND METHODS

All six neonates were gross type A isolated oesophageal atresia (6%), from among 102 neonates with oesophageal atresia, treated between January 2009 and December 2013. Five neonates were female; one was male. The mean birth weight was 2300 (range 1700-3100) g.

RESULTS

All six neonates successfully underwent immediate primary anastomosis using multiple myotomies (mean 3; range 2-4) within 10 (median 3) days after birth. The gap under traction ranged from 6 to 7 cm. One neonate died of a major cardiac anomaly. Another neonate was lost to follow-up after being well for 3 months. Three anastomotic strictures were treated with balloon dilatation, and four anastomotic leaks were treated conservatively. The mean duration of follow-up was 33 months.

CONCLUSIONS

To treat isolated oesophageal atresia, an immediate primary anastomosis can be achieved using multiple myotomies. Although, this approach is associated with high complication rates, as are other similar approaches, these complications can be overcome.

Long-gap oesophageal atresia: comparison of delayed primary anastomosis and oesophageal replacement with gastric tube

BACKGROUND

Long-gap oesophageal atresia (LGOA) causes significant early and long-term morbidity. We conducted a retrospective 25-year review comparing outcomes of delayed primary anastomosis versus oesophageal replacement with greater curvature gastric tube.

METHODS

Records of 44 consecutive patients undergoing LGOA repair (1986-2010) were obtained from OA database with ethics approval and were analysed for complication and long-term outcomes. Analysis was conducted using Student's t-test for quantitative and Fisher exact test for qualitative data.

RESULTS

Thirty (68%) patients underwent delayed primary anastomosis and 14 (32%) had oesophageal replacement. Oesophageal replacement patients had longer gaps (mean 5.5 vertebrae, range 4-9) compared to delayed primary anastomosis (mean 3.9, range 2-6) (p=0.004), but no difference in perioperative complications (p=0.2) (Table 1). Oesophageal replacement had more long-term complications (86%) compared to delayed primary anastomosis (30%) (p=0.005). Almost all patients (>90%) experienced gastro-oesophageal reflux and 21 delayed primary anastomosis patients (70%) underwent fundoplication. 60% of delayed primary anastomosis and 64.3% of oesophageal replacement patients had continued gastrointestinal symptoms years after repair.

CONCLUSIONS

Our experience indicates that LGOA can be repaired safely using both methods, with no deaths and similar perioperative risk, but high long-term morbidity mandates long-term follow-up of these patients. Delayed primary anastomosis has a better long-term outcome compared to oesophageal replacement with gastric tube.

Difficult esophageal atresia: trick and treat

Although most patients with esophageal atresia (EA) and tracheo-esophageal fistula (TEF) may benefit from "standard" management, which is deferred emergency surgery, some may present unexpected elements that change this paradigm. Birth weight, associated anomalies, and long gap can influence the therapeutic schedule of the patients with EA/TEF and can make their treatment tricky. As a consequence, detailed information on these aspects gives the power to develop a decision-making process as correct as possible. In this article, we will review the most important factors influencing the treatment of patients with EA/TEF and will share our experience on the diagnostic and therapeutic tips that may provide pivotal help in the management of such patients.

Near infrared spectroscopy: experience on esophageal atresia infants

OBJECTIVE

Near infrared spectroscopy (NIRS) gradually became the gold standard to guide anesthetic conduction during cardiac surgery, and nowadays, it is commonly utilized to monitor cerebral oxygenation during invasive procedures. Preterm babies also benefit from this non-invasive monitoring to prevent neurological sequelae. However, few data are available on NIRS perioperative changes in newborn operated on for major non-cardiac malformations. Aim of the present study is to evaluate the usefulness of NIRS assessment during and after esophageal atresia (EA) correction and its correlation with clinical behavior.

PATIENTS AND METHODS

All patients treated for EA from May 2011 were prospectively enrolled in the study. All infants underwent "open" correction of EA and cerebral and splanchnic NIRS was applied up to 48h after surgery. Body temperature, blood pressure, pH, paSO2, paCO2, and urine output, were recorded during NIRS registration. Mann-Whitney test and 1-way ANOVA (Kruskal-Wallis and Dunn's multiple comparison tests) were used as appropriate.

RESULTS

Seventeen patients were enrolled into the study and 13 were available for the analysis. Four patients were excluded because of poor NIRS registration. Cerebral and renal NIRS values significantly decreased at 24h post-operatively (p<0.05). Interestingly, all parameters studied as possible confounders in NIRS remained stable during the study period. Urine output significantly decreased.

CONCLUSION

Our data confirmed that perioperative monitoring of tissue oxygenation during neonatal esophageal surgery is feasible. Cerebral and renal NIRS evaluation, as for cardiac patients, may guide anesthetic conduction and postoperative care. Out data suggest a newly observed hemodynamic reorganization during esophageal surgery involving renal and, probably, splanchnic blood flow redistribution, demonstrated by the observed subsequent significant post-operative transitory decrease in urinary output. Reducing the decrement in cerebral and renal NIRS values may improve, and ideally eliminate, the well-known late sequelae linked to hemodynamic changes during surgery. More studies are needed to better understand the causes of the NIRS described hemodynamic changes and, therefore, correct them.

Long-term health-related quality of life after complex and/or complicated esophageal atresia in adults and children registered in a German patient support group

BACKGROUND

Health-related quality of life (HRQoL) after esophageal atresia (EA) repair is postulated to be good. However, little is known about the long-term results after repair of complex and/or complicated EA regarding HRQoL. We investigated long-term HRQoL after delayed anastomosis, esophageal replacement, major revisions, or multiple dilatations in patients registered in a support group.

METHODS

Patients registered in the German patient support group database (KEKS) were enrolled and allocated to subgroups according to surgical treatment and age. HRQoL was evaluated using validated questionnaires (GIQLI, WHO-5, KIDSCREEN27).

RESULTS

Complete follow-up (mean 14.5 ± 9.8 years) was available for 90/92 patients. Patients were allocated to subgroups delayed anastomosis (n=28), esophageal replacement (n=27), major revisions (n=15), and multiple dilatations (n=20). Adult patients presented with impaired well-being according to WHO-score and gastrointestinal function (GIQLI). In contrast, HRQoL of children was comparable to controls in most KIDSCREEN27-dimensions. Delayed anastomosis was associated with most-favourable HRQoL. Regarding physical well-being, these children scored significantly better than controls [64.01 ± 10.40 vs. 52.36 ± 8.73;p=0.0011], children after replacement [51.40 ± 5.70;p=0.008], revisions [52.04 ± 6.97;p=0.026], and multiple dilatations [50.22 ± 9.67,p=0.04].

CONCLUSIONS

HRQoL after complex and/or complicated EA is excellent in children registered in a patient support group. In adults, disease-specific symptoms negatively affect HRQoL. Our data indicate that saving the esophagus may achieve the best HRQoL.

Dilated ureter for esophageal substitution: a preliminary experimental study in the rat

BACKGROUND

Esophageal replacement using digestive organs such as the colon, stomach, or jejunum has been used to treat long-gap esophageal atresia and caustic esophageal strictures. Nevertheless, it presents a major challenge. Here, we report a preliminary experimental study that examined the use of a free dilated ureter as an option for esophageal substitution in a transplantation rat model.

METHODS

Ten 28-week-old male donor rats underwent distal ureteral ligation for 4 weeks, and the total dilated ureters were recovered. In each of the ten recipient 20-week-old male rats, a ureter was transplanted through the mediastinum into the esophageal bed, without vascular anastomosis. All rats received cyclosporine and cotrimoxazole for 10 days. On postoperative day 10, the rats were sacrificed, and the transplanted ureters were evaluated macroscopically and histopathologically.

RESULTS

All procedures were achieved. In the early postoperative period, three transplanted rats died. Upon macroscopic evaluation, no evidence of complications was observed, and all transplanted ureters exhibited apparently good firm tissue. Histopathological examination showed a viable ureteral structure with good vascularity, low inflammation, and regenerated epithelium in all rats.

CONCLUSION

As an option for esophageal substitution, heterotopic ureteral transplantation can be performed directly into the mediastinal location of the esophagus, without vascular anastomosis in a rat model. In the future, free dilated ureters might be useful for esophageal grafting or patching in humans; however, this procedure must be validated in additional large animal models before being attempted in humans.

Comparison of outcomes according to the operation for type A esophageal atresia

Purpose

The purpose was to evaluate outcomes according to different operative strategies of type A esophageal atresia (EA).

Methods

All patients who underwent surgery for type A EA between 1980 and 2011 were included. Patients were divided into 2 groups: E-E group included patients who received esophageal end-to-end anastomosis, whereas E-G group included patients who received esophago-gastric tube anastomosis.

Results

Twenty-two patients were included. The median gestational age was 37.5 weeks. The median birth weight was 2.5 kg. Twenty-one patients underwent gastrostomy as initial procedures, and one patient underwent primary esophageal end-to-end anastomosis. The median gap between both esophageal ends was six vertebral distance (VD). Seven patients underwent primary anastomosis of the esophagus, and 14 patients underwent gastric replacement. Three patients (13.6%) had anastomotic leakage and 10 patients (45.5%) had anastomotic stenosis. Most of the patients (90.9%) had gastroesophageal reflux, but only two patients required antireflux surgery. The median VD was significantly shorter in E-E group than in E-G group (3 VD vs. 6 VD). Stenosis was significantly more often in E-E group, but there was no significant difference in leakage and reflux symptoms.

Conclusion

The treatment for type A EA can include E-E anastomosis or E-G anastomosis, depending on the length of the end-to-end interval after performing gastrostomy. Appropriate tension and blood flow in the anastomosis site are essential for preventing postoperative stenosis and leakage, and esophageal replacement with gastric tube is believed to be feasible and safe in cases where excessive tension is present.

Retrospective cohort study of long-gap oesophageal atresia

AIM

Long-gap oesophageal atresia (LGOA) remains a rare variant of a relatively common congenital malformation. Objectives of this study were to review the short-term results including survival, length of stay and post-operative complications for infants with LGOA managed at a single centre in addition to their growth and neurodevelopmental assessment.

METHODS

Retrospective review of the case notes of all infants admitted with oesophageal atresia to our institution from January 2001 to May 2011. Infants with LGOA were selected based on pre-defined criteria. Demographic and clinical variables and details of follow-up visits including developmental assessments were extracted from their case notes.

RESULTS

Of 101 infants with oesophageal atresia, 15 fulfilled the criteria for LGOA. Overall survival was 80%. Median length of stay was 83 days. Additional congenital anomalies were present in nine (60%). A fall in weight centile during hospitalisation or outpatient follow-up signifying growth failure was seen in a majority with 11 of 13 patients showing this phenomenon. Follow-up at our institution ranged from 6 months to 9 years. Developmental assessments (Bayley-III) commenced in August 2006 were available in four patients (age 5-13 months) and were abnormal in all, with particular delay in the gross motor domain.

CONCLUSIONS

Infants with LGOA spend a long time in hospital. They remain at significant risk of growth failure during hospitalisation and following discharge. There appears to be a risk of developmental delay that warrants close monitoring.

Intramural injection with botulinum toxin significantly elongates the pig esophagus

BACKGROUND/PURPOSE

Surgical treatment of long-gap esophageal atresia (LGEA) is challenging. Methods which facilitate stretching of the esophageal pouches may allow primary anastomosis. Botulinum toxin type A (BTX-A) blocks acetylcholine release in neuromuscular junctions, thereby causing muscle relaxation. We hypothesized that intramural injections with BTX-A into the esophageal wall of piglets would significantly elongate the tissue upon stretch.

METHODS

Twenty-four piglets were randomized to receive BTX-A of placebo (saline). After one hour, the esophagus was removed en bloc and tested in a stretch-tension device.

RESULTS

The mean esophageal elongation was 84% (range 83-101) in the BTX-A-group and 65% (50-78) in the control group. The mean difference between the two groups was 18%, which was significant (p < 0.001).

CONCLUSION

Intramural injections with botulinum toxin type A elongate the esophagus significantly. Clinically, this could be a potential method to achieve primary anastomosis in LGEA. Additional clinical studies are necessary to evaluate the method before it can be generally recommended.

Esophageal transplantation in the rat

PURPOSE

Esophageal replacement surgery has been used to treat long-gap esophageal atresia, caustic esophageal stricture, and esophageal avulsion. Here, we report total esophageal transplantation in rats without vascular anastomosis as an option for esophageal replacement surgery.

METHODS

Fourteen total segments of esophageal transplants were harvested from 24-week-old male Sprague-Dawley rats using a harvesting procedure. The segments were transplanted through the mediastinum in the esophageal bed of 15-week-old male Sprague-Dawley rats without adjacent vascular anastomosis using the transhiatal pull-up technique. The ends of the transplanted esophagus were ostomized using cervical and abdominal esophagostomies. An immunosuppressive-treated (IT) group (n = 7) received cyclosporine and cotrimoxazole for 10 days, while an untreated (UT) group (n = 7) received only cotrimoxazole for 10 days. On post-operative day 10, the rats were sacrificed, and the transplant and recipient esophagi were evaluated macroscopically and histopathologically.

RESULTS

All transplantations were successful and all transplanted rats survived. Upon macroscopic evaluation, no evidence of complications was observed and all transplanted esophagi in the two groups appeared to exhibit excellent firm tissue; however, mild necrosis was observed in the cervical end of the transplant in one rat in the IT group. Histopathologic examination showed a viable esophageal structure in all rats. Inflammation and muscular atrophy were lower in the IT group than in the UT group, whereas vascularity was higher in the IT group than in the UT group.

CONCLUSION

Total esophageal transplantation was performed directly without vascular anastomosis into recipients in a rat model. This procedure should be done in larger animal models before being attempted in humans.

Esophageal atresia with proximal tracheoesophageal fistula: a missed diagnosis

AIM OF THE STUDY

This retrospective study was performed to compare the relative incidence of esophageal atresia (EA) with proximal tracheoesophageal fistula (PTEF) at our institution with those reported in literature and to test the hypothesis that our higher relative incidence is caused by the routine use of tracheoscopy.

METHODS

A total of 204 children with EA were managed at our institution from 1981 to 2012. The type of EA and the diagnostic assessment were noted, and the relative incidence of PTEF was calculated. For patients managed from 1981 to 2003 (Group 1), the PTEF was diagnosed by contrast esophagogram or during surgical repair. For those born after 2004 (Group 2), the final diagnosis was made by routine rigid tracheoscopy performed preoperatively. The relative incidence of PTEF was compared between these two groups and with those reported in 15 selected published large series, encompassing 4197 patients with EA.

MAIN RESULTS

Of 204 patients with EA, 10 had PTEF, with a relative incidence of 4.9%, statistically higher than those reported in reference group (1.14%, P<0.001). The routine employ of tracheoscopy involved a higher relative incidence of PTEF (Group 2=11.11%, Group 1=3.14%, P=0.038). The age of diagnosis of PTEF was 2.8 days for children of Group 2 and 4.2 days for Group 1 (P=0.038).

CONCLUSION

The presence of the proximal TEF should be always ruled out before surgery. Routine employ of rigid tracheoscopy avoids delay of the diagnosis, improves diagnostic accuracy, and involves a higher relative incidence of proximal fistul. This procedure should be recommended in children undergoing EA repair.

Long-gap esophageal atresia: traction-growth and anastomosis - before and beyond

Long-gap esophageal atresia (LGEA) is still a major surgical challenge. Options for esophageal reconstruction include the use of native esophagus or esophageal replacement with stomach, colon, or small intestine. Nonetheless, there is a consensus among most pediatric surgeons that the preservation of the native esophagus is associated with better postoperative outcomes. Thus, every effort should be made to conserve the native esophagus. The present study is aimed at critically reporting our experience focused on a standardized protocol based on the preoperative assessment of the gap in all cases and reviewing the present literature because no consensus is available regarding many aspects of LGEA (from definition to treatment). All newborn infants treated since 1995 for esophageal atresia (EA), regardless of type, were included in the present study. Identification of LGEA patients (gap ≥3 vertebral bodies) was performed based on preoperative esophageal gap measurement. The selected patients were grouped based on EA type (A/B vs. C/D) and whether they were referred from an outside institution or not. Postoperative outcome was compared. Statistical analysis was performed with the Fisher's exact test and Mann-Whitney test as appropriate, with P < 0.05 considered statistically significant. Two hundred and nineteen patients have been consecutively treated between 1995 and 2012 with the following EA subtypes: type: A 25 (11.4%); B 6 (2.7%); C 182 (83.1%); D 3 (1.4%); E 3 (1.4%). Fifty-seven patients (26%) were classified as LGEA: type A-B, 31 (54.4%); type C-D, 26 (45.6%). Twenty seven (47%) of these patients were referred after at least one failed attempt at esophageal correction: type A-B, 15 (55%); type C-D, 12 (45%). Only one patient ultimately required esophageal substitution, with an overall survival rate of 94%. A standardized perioperative protocol enhances the possibility of preserving the native esophagus in cases of LGEA. Gap measurement can be accurately defined before surgery in all patients with EA. Esophageal anastomosis (either immediate or delayed repair) is almost always feasible; esophageal substitution should only be considered after a rigorous attempt at achieving end-to-end esophageal anastomosis.

Delayed primary anastomosis for management of long-gap esophageal atresia: a meta-analysis of complications and long-term outcome

PURPOSE

Management of newborns with long-gap esophageal atresia (LGEA) remains a challenge for pediatric surgeons. Since spontaneous growth of the esophageal segments occurs without mechanical stretching, initial gastrostomy followed by delayed primary anastomosis (DPA) comprises treatment in most LGEA patients. This meta-analysis aimed to investigate the complications and long-term outcome in patients with LGEA managed by DPA.

METHODS

A systematic literature search was conducted for relevant articles published between 1981 and 2011, and a meta-analysis of complications and long-term outcome was performed.

RESULTS

Forty-four articles presented data on 451 newborns with LGEA managed by DPA. Most common variants were pure LGEA (194/451) and LGEA with tracheoesophageal fistula (257/451). Initial gap lengths ranged from 1.9 to 7.0 cm. At the time of DPA, performed at a mean of 11.9 weeks (range 0.5-54.0), the gap had decreased to 0.5-3.0 cm. Mean follow-up was 5.5 years (range 0.5-27.0). Frequent complications were anastomotic leaks/strictures, gastroesophageal reflux (GER), esophagitis and dysphagia. Relative risk for strictures was significantly higher in patients who previously had a leak (p < 0.0001) or GER (p < 0.0001). Patients with GER also had a significantly higher risk for esophagitis (p = 0.0283) and dysphagia (p = 0.0174). The majority of patients could eat without swallowing difficulties at follow-up.

CONCLUSION

DPA provides good long-term functional results. However, the high incidence of GER and associated strictures requires early intervention to prevent feeding problems.

Current knowledge on esophageal atresia

Esophageal atresia (EA) with or without tracheoesophageal fistula (TEF) is the most common congenital anomaly of the esophagus. The improvement of survival observed over the previous two decades is multifactorial and largely attributable to advances in neonatal intensive care, neonatal anesthesia, ventilatory and nutritional support, antibiotics, early surgical intervention, surgical materials and techniques. Indeed, mortality is currently limited to those cases with coexisting severe life-threatening anomalies. The diagnosis of EA is most commonly made during the first 24 h of life but may occur either antenatally or may be delayed. The primary surgical correction for EA and TEF is the best option in the absence of severe malformations. There is no ideal replacement for the esophagus and the optimal surgical treatment for patients with long-gap EA is still controversial. The primary complications during the postoperative period are leak and stenosis of the anastomosis, gastro-esophageal reflux, esophageal dysmotility, fistula recurrence, respiratory disorders and deformities of the thoracic wall. Data regarding long-term outcomes and follow-ups are limited for patients following EA/TEF repair. The determination of the risk factors for the complicated evolution following EA/TEF repair may positively impact long-term prognoses. Much remains to be studied regarding this condition. This manuscript provides a literature review of the current knowledge regarding EA.

Current Controversies in the Surgical Treatment of Esophageal Atresia

Background and Aims:

Esophageal atresia (EA) with or without tracheo-esophageal fistula (TEF) is a rare condition that can be nowadays succesfully treated. The current interest therefore is focused on the management of the difficult cases, on thoracoscopic approach, and on some aspects of the long-term results.

Methods:

The current strategies for the difficult or impossible anastomoses in pure and long-gap EA, the introduction of thoracoscopic repair and the causes, mechanisms and management of post-operative gastro-esophageal reflux (GER) are reviewed.

Results:

Methods of esophageal elongation and multi-staged repair of pure and long-gap EA allow anastomosis but with functional results that are often poor. Esophageal replacement with colon or stomach achieves at least similar results and often requires less procedures. Thoracoscopic repair is a promising adjunct, but the difficulties for setting it as a gold-standard are pointed out. GER is a part of the disease and its surgical treatment, that is often required, is burdened by high failure rates.

Conclusions:

EA with or without TEF can be successfully treated in most cases, but a number of unsolved issues remain and the current approach to difficult cases will certainly evolve in the future.

Repair of long-gap esophageal atresia: gastric conduits may improve outcome—a 20-year single center experience

INTRODUCTION

Treatment of long-gap esophageal atresia (LEA) is a major challenge. Options for reconstruction include native esophagus, or replacement with stomach, colon, or small intestine. However, debate continues regarding the optimal conduit for esophageal replacement.

METHODS

Medical records of patients with a diagnosis of esophageal atresia during a 20-year period were reviewed.

RESULTS

Twenty-eight cases of LEA were identified. Ten patients underwent primary anastomosis either after serial pouch dilations (9/10) and/or after a lengthening procedure (2/10). Nine received colonic interpositions, and the remainder were reconstructed with a gastric tube (n = 3), or gastric interposition (n = 2). One patient died prior to repair, and two await definitive treatment. Repeat esophageal reconstruction was required in four patients because of conduit ischemia. Two ischemic events occurred in the colonic interposition group, and two in the native esophageal repairs. All patients, except one who relocated, received long-term follow-up (mean 4.2 years: range 0.5-11.5 years).

CONCLUSIONS

Surgeon's expertise and patient's anatomy should be considered when selecting an appropriate operation for LEA. Although native esophagus is generally preferred, it is associated with a high rate of stricture. Although our study has a limited by numbers, we found that patients with gastric conduits had lower complication rates and no conduit ischemia. We suggest that gastric transposition may be favored as an initial reconstructive option.

Extrathoracic esophageal elongation (Kimura's technique): a feasible option for the treatment of patients with complex esophageal atresia

AIM

The aim of this study was to evaluate the outcome of all patients who underwent an extrathoracic esophageal elongation (EEE) (Kimura's technique) and determine its role, among other surgical options, for the treatment of patients with complex esophageal atresia (EA) who have a previously created esophagostomy.

METHODS

Between March 1997 and September 2008, we performed 20 EEEs. Twelve patients were males and 8 were females. The diagnoses were type C EA (n = 12), type A EA (n = 5), type B EA (n = 2), and type D EA (n = 1). Mean age at the initiation of the EEE was 10 months (range, 3-25 months).

RESULTS

At the time of this report, 15 of the 20 patients have finished the treatment, 4 patients are still in the process of elongation, and one patient (premature, with a birth weight of 685 g) died before the final esophageal reconstruction. Of the 15 patients who finished the treatment, 12 (80%) completed it satisfactorily and 3 (20%) had to be prematurely interrupted. (In 2 patients, despite multiple attempts, the upper pouch could not be adequately elongated, and in one patient, an early perforation of the upper pouch precluded further elongations.) Of the 12 patients who completed the treatment satisfactorily, 10 (83%) are asymptomatic and exclusively on oral alimentation, whereas 2 (17%) have a pseudodiverticulum and esophageal dysmotility (requiring supplemental alimentation through a gastrostomy). Five of the 12 patients have gastroesophageal reflux (2 required a Nissen fundoplication and 3 are being treated medically).

CONCLUSIONS

We believe that the EEE is a useful surgical option for a selected group of patients with complex long-gap EA who required a primary esophagostomy and also for patients with any type of EA who developed severe complications after a primary repair and required a secondary esophagostomy. With this technique, we avoided an esophageal replacement in 80% of cases, and given that the EEE does not invalidate a later esophageal replacement, we believe that the EEE is a feasible initial option for these patients.

Pediatric gastroesophageal reflux clinical practice guidelines: joint recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN)

OBJECTIVE

To develop a North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) international consensus on the diagnosis and management of gastroesophageal reflux and gastroesophageal reflux disease in the pediatric population.

METHODS

An international panel of 9 pediatric gastroenterologists and 2 epidemiologists were selected by both societies, which developed these guidelines based on the Delphi principle. Statements were based on systematic literature searches using the best-available evidence from PubMed, Cumulative Index to Nursing and Allied Health Literature, and bibliographies. The committee convened in face-to-face meetings 3 times. Consensus was achieved for all recommendations through nominal group technique, a structured, quantitative method. Articles were evaluated using the Oxford Centre for Evidence-based Medicine Levels of Evidence. Using the Oxford Grades of Recommendation, the quality of evidence of each of the recommendations made by the committee was determined and is summarized in appendices.

RESULTS

More than 600 articles were reviewed for this work. The document provides evidence-based guidelines for the diagnosis and management of gastroesophageal reflux and gastroesophageal reflux disease in the pediatric population.

CONCLUSIONS

This document is intended to be used in daily practice for the development of future clinical practice guidelines and as a basis for clinical trials.