The outcome of conservative treatment for anastomotic leakage after surgical repair of esophageal atresia

Clinical Signs as a Guide for Esophagram After Esophageal Atresia/Tracheoesophageal Fistula Repair

INTRODUCTION

Esophageal atresia/tracheoesophageal fistula (EA/TEF) is a congenital malformation that occurs in about 1 in 2500-4000 live births. After surgical repair, despite the lack of evidence supporting the routine use of postoperative esophagram, most surgeons report obtaining an esophagram prior to enteral feeding. We hypothesized that abnormal indicators in vital signs, drain characteristics, and chest radiograph (CXR) could be used to screen for anastomotic leak, thus reducing the need for a routine esophagram.

METHODS

A single institution, retrospective chart review of all patients born with EA with or without TEF between 2009 and 2022 was performed. Vital signs, postoperative CXR, chest drain characteristics, and esophagram results were analyzed for patients who underwent repair.

RESULTS

Forty-five patients who underwent EA/TEF repair were included in the study, and 40 patients had routine esophagram. Out of the twenty-two patients who had at least one abnormal indicator, 14 (64%) had an anastomotic leak. Seventeen patients (43%) had the absence of abnormalities of all three indicators, and none of these patients had an anastomotic leak (100% negative predictive value). Moreover, changes in drain characteristics and vital signs together presented high sensitivity (87.5%), specificity (90%), and negative predictive value (94%).

CONCLUSIONS

In the absence of abnormalities in vital signs, CXR, and drain characteristics in patients undergoing EA/TEF repair, routine esophagram can be safely avoided prior to enteral feeding. Abnormalities in drain characteristics and vital signs together were highly sensitive and specific for anastomotic leak, thus potentially eliminating the need for routine CXR and thereby minimizing radiation exposure and cost.

Anastomotic leaks and the relationship with anastomotic strictures after esophageal atresia surgery; effects of patient characteristics

BACKGROUND

This study aimed to evaluate the link between anastomotic leaks (AL) and anastomotic strictures (AS) after esophageal atresia surgery and the influence of patient demographics.

MATERIALS AND METHODS

The clinical data of neonates who underwent surgical repair for esophageal atresia were retrospectively reviewed. The results of AL treatment and the relationship with AS, also the effects of patient characteristics were examined with logistic regression analysis.

RESULTS

Primary repair was performed on 122 of 125 patients who underwent surgery for esophageal atresia. AL occurred in 25 patients and 21 were treated non-operatively. While 4 patients were re-operated, AL recurred in 3 and led to the death of one. There was no correlation between the development of AL and sex or the presence of additional anomalies. The gestational age and birth weight of patients with AL were significantly higher than those of patients without. AS developed in 45 patients. The mean gestational age was significantly higher in patients who developed AS (p < .001). While the development of AS was significantly higher in patients with AL (p = .001), the number of dilatation sessions needed was also significantly higher in these patients (p = .026). Complications related to anastomosis were less common in patients whose gestational age was ≤33 weeks.

CONCLUSION

Non-operative treatment remains effective for AL after esophageal atresia surgery. AL increases the risk of developing AS and significantly increases the number of dilatation sessions needed. Anastomotic complications are less common in patients with lower gestational age.NOVEL ASPECTSGestational age and birth weight were found to be significantly higher in patients with anastomotic leaks than in those without and fewer anastomotic complications were encountered in patients whose gestational age was ≤ 33 weeks.Anastomotic stricture development was significantly higher in patients with anastomotic leaks and the number of dilatation sessions needed for treatment was also significantly higher in these patients.

Primary repair of esophageal atresia Gross type C via thoracoscopic magnetic compression anastomosis: A case report

BACKGROUND

Esophageal atresia (EA) is a life-threatening congenital malformation in newborns, and the traditional repair approaches pose technical challenges and are extremely invasive. Therefore, surgeons have been actively investigating new minimally invasive techniques to address this issue. Magnetic compression anastomosis has been reported in several studies for its potential in repairing EA. In this paper, the primary repair of EA with magnetic compression anastomosis under thoracoscopy was reported.

CASE SUMMARY

A full-term male weighing 3500 g was diagnosed with EA Gross type C. The magnetic devices used in this procedure consisted of two magnetic rings and several catheters. Tracheoesophageal fistula ligation and two purse strings were performed. The magnetic compression anastomosis was then completed thoracoscopically. After the primary repair, no additional operation was conducted. A patent anastomosis was observed on the 15^th day postoperatively, and the magnets were removed on the 23^rd day. No leakage existed when the transoral feeding started.

CONCLUSION

Thoracoscopic magnetic compression anastomosis may be a promising minimally invasive approach for repairing EA.

The cause of dysphagia in patients with esophageal atresia: a systematic review and meta-analysis

PURPOSE

Dysphagia is the most common symptom in patients with esophageal atresia (EA) of all ages. There is no study addressing the direct relation between dysphagia and surgical results. Therefore, a systematic review was performed to define the relationship between surgical complications and dysphagia in patients with EA.

METHODS

The systematic review was drafted under PRISMA guidelines. Systematic literature search was performed for the period 2000 (Jan) to 2019 (Dec)-20 years-in the databases: MEDLINE, EMBASE, and PubMed. Statistical analysis was performed using Comprehensive Meta-Analysis Version 3.0 software.

RESULTS

Among 767 articles, 486 abstracts were screened for the inclusion criteria. The full-texts of 64 articles were assessed for eligibility. The sub-group analysis could be performed in 4 articles for anastomotic strictures. Heterogeneity was calculated by I² statistic as 18,487 and pooled odds ratio was measured under the fixed effect model (Q = 3.68; P = 0.298, I² = 18,487). There was no significant relationship with an odds ratio of 1.37 between anastomotic stricture (AS) and dysphagia (95% CI 0.631-2.973, p = 0.426). There was no publication bias for the data (Begg's test, p = 0.496; Egger's tests, p = 0.335).

CONCLUSION

This meta-analysis did not reveal a significant relationship between AS and dysphagia in children with EA. Since many other factors contribute to dysphagia, comprehensive variable information such as detailed standardized registry systems for rare diseases for pooling analysis is needed regarding other potential factors including surgical complications.

Esophageal Perforation into the Pericardium in a 3-Year-Old Child with Esophageal Stricture: A Rare Complication Following Esophageal Dilatation

Perforation of the esophagus during dilatation is a rare complication that might cause mortality. We present the report of a 3-year-old girl who was diagnosed with B cell acute lymphoblastic leukemia at 17 months of age. She experienced a complicated clinical course after chemotherapy was initiated, which included mucositis and acute pericarditis. She later developed an acquired esophageal stricture and tracheoesophageal fistula, which were managed with resection and primary anastomosis when she was in remission. Postoperatively, the patient developed a leak, which was treated conservatively. She subsequently developed a stricture that was treated successfully. On the fourth dilatation attempt and after she was sent home, she presented with persistent vomiting and low-grade fever and became vitally unstable on the same day, after stabilization, upper gastroenterology contrast revealed contrast filling the pericardium. She was managed conservatively with close observation and serial echocardiograms and then discharged home on day 18 in good condition after complete resolution of the pericardial effusion.

Azygos vein preservation is feasible and beneficial in esophageal atresia with tracheoesophageal fistula: A meta-analysis of randomized controlled trials

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.

Successful management of anastomotic leakage with endoscopic fibrin glue injection after primary repair of pure oesophageal atresia

Anastomotic leakage (AL) occurs in 15% of cases of primary repair of oesophageal atresia. Urgent surgery is indicated in cases of complete anastomotic separation or severe mediastinitis. Otherwise, conservative management including keeping the patient nil per os (NPO), feeding via transanastomotic tube and prolonged parenteral nutrition, has been widely accepted as it can avoid multiple surgeries in neonates and allow oesophageal continuity to be preserved. However, complications relating to prolonged feeding tube use are common downsides to this approach and the negative impact of prolonged NPO on mastication and swallowing function cannot be ignored.In this case report, a novel approach for the treatment of AL with fibrin glue is reported, following primary repair of oesophageal atresia. It was endoscopically injected into the leakage site to enhance healing and early closure. This procedure was safely performed and achieved early establishment of oral feeding.

Association of clinical factors with postoperative complications of esophageal atresia

BACKGROUND

Esophageal atresia (EA) with or without tracheoesophageal fistula (TEF) remains one of the most common gastrointestinal neonatal malformations. Even though postoperative management is standardized, it differs between hospitals and disease-associated clinical factors that may play a role in outcome have not yet been assessed in detail.

METHODS

In this monocentric retrospective study, data of 43 patients with EA between 2010 and 2018 were analyzed. Analysis includes assessment of the clinical background, surgical technique, postoperative management including application of continuous muscle relaxation (CMR), influence of coagulation parameters such as factor XIII and incidence of complications.

RESULTS

21 patients (49%) were preterm infants with birth weights between 490 and 2840 g (median 1893 g). Only 35% (n = 15) presented without any concomitant malformations. Within the entire study population, representing Vogt II, IIIb and IIIc, we observed an association between the development of a postoperative pneumothorax and anastomotic failure (AF) (p = 0.0013). Furthermore, pneumothorax was associated with anastomotic stenosis (AS) in Vogt IIIb patients (p = 0.0129). CMR (applied since March 2017 in 7 patients in an attempt to prevent anastomotic problems due to high complication rates) and coagulation factor XIII did not significantly correlate with postoperative outcome.

CONCLUSION

Appearance of pneumothorax was correlated with postoperative complications. These children should be monitored carefully in closer scheduled gastroenterological follow-up esophago-gastro-duodenoscopies. CMR and factor XIII substitution did not reduce anastomotic leakage but should be tested within an enlarged study population.

Risk Factors and Reasons for Treatment Abandonment for Patients With Esophageal Atresia: A Study From a Tertiary Care Hospital in Beijing, China

Background: This study aims to identify the risk factors and reasons for treatment abandonment for patients with esophageal atresia (EA) in a tertiary care hospital in China. Methods: A retrospective study was conducted on 360 patients with EA admitted to Beijing Children's Hospital between January 1, 2007 and June 1, 2020. Medical records for treatment abandonment and non-treatment abandonment patients were compared. Univariate and multivariate logistic regression analyses were conducted to identify potential risk factors for treatment abandonment. Results: After the diagnosis of EA, parents of 107 patients refused surgical repair and discharged against medical advice, and 253 patients underwent surgical repair. Among these 253 patients, parents of 59 patients abandoned treatment after surgery; 52 patients were discharged in an unstable condition, and parents of seven patients abandoned resuscitation leading to death in the hospital. By comparing clinical characteristics between treatment abandonment before surgery (n = 107) and non-treatment abandonment (n = 253) groups, we found that mother's parity >1, unplanned admission to intensive care unit before surgery, associated anomalies, and Gross type A/B were significant independent risk factors for treatment abandonment before surgery. Furthermore, birth weight <2,545 g, being discharged from neonatal center/intensive care unit and other departments, unplanned admission to intensive care unit after surgery, operative time >133 min, admission before 2016, pneumothorax, and anastomotic leakage were significant independent risk factors for treatment abandonment after surgery. The reasons for treatment abandonment included financial difficulties, multiple malformations with poor prognosis, belief of incurability and concerns about the prognosis of the diseases, postoperative complications, and extensive length of intensive care unit stay. Conclusions: Treatment abandonment of children with EA/TEF is still a common and serious problem in China. This study showed that EA/TEF patients in critical conditions, with associated anomalies, Gross type A/B, and who had occurrence of complications had high-risk for treatment abandonment.

The influence of prematurity on neonatal surgical morbidity and mortality

BACKGROUND

As survival rates amongst premature infants have improved, prematurity remains a leading contributor to neonatal surgical morbidity and mortality. This study aims to better assess the influence of prematurity on surgical outcomes.

METHODS

The NSQIP-Pediatric database was used to compare outcomes between preterm and term infants undergoing surgical repair of select congenital anomalies from 2012 to 2017. Prematurity was categorized as extremely preterm (EP) (<29 weeks), very preterm (VP) (29-32 weeks), moderate to late preterm (MLP) (33-36 weeks), and term (≥37 weeks). Significance was determined using Chi-square tests, Fisher exact tests and adjusted logistic regression analysis.

RESULTS

4852 infants were identified with 45 (0.9%) EP, 211 (4.3%) VP, 1492 (30.8%) MLP, and 3104 (64.0%) term. Compared to term, preterm infants have increased odds of surgical morbidity (EP Odds Ratio (OR) 3.2 95% Confidence Interval (CI) 1.6-6.4, VP OR 1.2 95%CI 0.9-1.7, and MLP OR 1.2 95%CI 1.0-1.4). 30-day mortality decreased as neonatal age increased from 22.2% EP to 2.9% term (p < 0.001). Premature populations had higher rates of sepsis, pneumonia, bleeding requiring transfusion and 30-day mortality.

CONCLUSIONS

Prematurity increases morbidity and mortality amongst neonates undergoing surgery. Risk-adjustment for prematurity is needed and premature infants may have unique quality improvement targets.

LEVEL OF EVIDENCE

Level III.

The burden of esophageal dilatations following repair of esophageal atresia

AIM

To describe the burden of esophageal dilatations in patients following esophageal atresia (EA) repair.

METHOD

A retrospective review was performed at The Royal Children's Hospital, Melbourne, of all neonates undergoing operative repair for EA over a 17-year period (1999-2015). Stricture was defined by radiological and/or intra-operative findings of narrowing at the esophageal anastomosis. Data recorded included EA type, perinatal details, operative approach, esophageal anastomosis outcome, dilatation requirement, and survival. Key endpoints were anastomotic leakage and tension, esophageal dilatation technique, dilatation frequency, fundoplication, and complications.

RESULTS

During the study period, 287 newborn EA patients were admitted, of which 258 underwent operative repair and survived to primary discharge. Excluding 11 patients with isolated tracheoesophageal fistula, 247 patients were included in the final analysis. Intra-operative anastomotic tension was documented in 41/247 (16.6%), anastomotic leak occurred in 48/247 (19.4%), and fundoplication was performed in 37/247 (15.0%). Dilatations were performed in 149/247 (60.3%). Techniques included bougie-alone (92/149, 61.7%), combination of bougie and balloon (51/149, 34.2%), and balloon-alone (6/149, 4.0%). These patients underwent 1128 dilatations; median number of dilatations per patient was 4 (interquartile range 2-8). Long-gap EA and anastomotic tension were risk factors (p < 0.01) for multiple dilatations. Complications occurred in 13/1128 (1.2%) dilatation episodes: 11/13 esophageal perforation, 2/13 clinically significant aspiration. Perforations were rare events in both balloon (6/287, 2.1%) and bougie dilatations (4/841, 0.5%); one patient had a perforation from guidewire insertion.

CONCLUSIONS

Esophageal dilatation occurred in a majority of EA patients. Long-gap EA was associated with an increased burden of esophageal dilatation. Perforations were rare events in balloon and bougie dilatations.

TYPE OF STUDY

Original article - retrospective review.

LEVEL OF EVIDENCE

II.

Am I out of control? The application of statistical process control charts to children's surgery

AIMS

To illustrate the construction of statistical control charts and show their potential application to analysis of outcomes in children's surgery.

PATIENTS AND METHODS

Two datasets recording outcomes following esophageal atresia repair and intestinal resection for Crohn's disease maintained by the author were used to construct four types of charts. The effects of altering the target signal, the alarm signal and the limits are illustrated. The dilemmas in choice of target rate are described. Simulated data illustrate the advantages over hypothesis testing.

RESULTS

The charts show the author's institutional leak rate for esophageal atresia repair may be within acceptable limits, but that this is dependent on the target set. The desirable target is contentious. The leak rate for anastomoses following intestinal resection for Crohn's disease leak is also within acceptable limits when compared to published experience, but may be deteriorating. The charts are able to detect deteriorating levels of performance well before hypothesis testing would suggest a systematic problem with outcomes.

CONCLUSIONS

Statistical process control charts can provide surgeons with early warning of systematic poor performance. They are robust to volume-outcome influences, since the outcome is tested sequentially after each procedure or patient. They have application in a specialty with low frequencies of operations such as children's surgery.

TYPE OF STUDY

Diagnostic test.

LEVEL OF EVIDENCE

Level II.

Early Management of Esophageal Leak in Esophageal Atresia: Changing Paradigms

Introduction: A leak at the esophageal anastomosis can occur in 10%-20% of cases of esophageal atresia (EA). Thoracoscopic repair is trans-pleural, with the potential development of an empyema. Standard treatment of an anastomotic leak in a stable patient is often nonoperative, which can lead to prolonged parenteral nutrition and hospitalization. Our objective is to show that early thoracoscopic redo anastomosis management is safe and feasible. Materials and Methods: Retrospective study of a case series of four infants, diagnosed with EA and treated with early thoracoscopic esophageal leak repair between 2013 and 2018. Variables analyzed included age, weight, type of EA, day of leak, surgical approach, time to start feeding, surgical complications, and follow-up. Results: Three patients were type III, and one was type I originally repaired with a thoracoscopic approach. Leaking of the anastomosis was found the second postoperative day in one patient, third day in two patients, and the fifth day in the last one. All were confirmed with an esophagogram. All patients were operated in the first 24 hours after diagnosis by the thoracoscopic approach. The site of leak was found and re-sutured. Patients started feeding between the third and fourth day through a transanastomotic tube, starting oral feeding at the seventh day after an esophagogram did not show a leak. No complications were found. Mean time to complete oral feeding was 10 days. Two patients needed esophageal dilations. Mean time of follow-up has been 33 months. Conclusion: Early thoracoscopic repair of an anastomotic leak can be considered an alternative to the standard nonsurgical management. The early re-suture of the area of leak is a change in paradigm, but it offers the benefits of preservation of the native esophagus, early resumption of enteral feedings, and a shorter length of parental nutrition and hospitalization. Level of Evidence: IV.

The Value of Thoracic Lavage in the Treatment of Anastomotic Leakage After Surgery for Type III Esophageal Atresia

Background

The aim of this study was to define whether the addition of thoracic lavage to chest drainage was more efficient than the use of chest drainage alone in the treatment for anastomotic leaks in type III esophageal atresia.

Material/Methods

The clinical data of 42 patients with anastomotic leakage treated with the addition of thoracic lavage from January 2012 to March 2019 in our hospital were analyzed retrospectively. The clinical data of 50 patients with anastomotic leakage treated without thoracic lavage from March 1999 to December 2011 in our hospital were selected as controls.

Results

The duration of fistula healing, mechanical ventilation, hospitalization in intensive care unit, and gastric tube intubation in the thoracic lavage group were significantly shorter than those in the non-lavage group. The cost of hospitalization and the incidence of severe pneumonia were significantly lower in the thoracic lavage group than in the non-lavage group. The diameter of the anastomotic opening after anastomotic fistula healing was wider in the thoracic lavage group than in the non-lavage group.

Conclusions

The technique of thoracic lavage is simple, economical and convenient and can effectively promote the healing of anastomotic fistulas, accelerate postoperative recovery in children and reduce the cost of treatment.

Clinical Analysis of Azygos Vein Preservation Under Thoracoscope in the Operation of Type III Esophageal Atresia

Purpose: The aim of this study was to investigate the clinical effectiveness of azygos vein preservation when using a thoracoscope in the operation for type III esophageal atresia for children. Materials and Methods: We retrospectively analyzed the clinical data of 34 patients (group B) who underwent the thoracoscopic operation of type III esophageal atresia with azygos vein preservation from January 2017 to April 2018. The clinical data of 36 patients (group A) who underwent the thoracoscopic operation of type III esophageal atresia with azygos vein mutilation from April 2015 to December 2016 were selected as a control group. Results: All patients were successfully operated on. There was no significant difference in the operation time, amount of bleeding, mechanical ventilation time, and intensive care time between the azygos vein mutilation group and azygos vein preservation group. Compared with the operation severing the azygos vein, preservation of azygos vein has obvious advantages in postoperative hospitalization time, the incidence of anastomotic leakage (P < .05). The follow-up results for 1 year after the operation showed that the incidence of anastomotic stricture with preservation of azygos vein was significantly lower than that with azygos vein transection (P < .05). Conclusions: The thoracoscopic operation of type III esophageal atresia with azygos vein preservation can not only improve the edema of esophageal tissue around the esophagus, but also reduce the occurrence of esophageal anastomotic leakage and accelerate the postoperative recovery of children, and it has the same safety as the operation with azygos vein mutilation.

Experimental fortification of intestinal anastomoses with nanofibrous materials in a large animal model

Anastomotic leakage is a severe complication in gastrointestinal surgery. It is often a reason for reoperation together with intestinal passage blockage due to formation of peritoneal adhesions. Different materials as local prevention of these complications have been studied, none of which are nowadays routinely used in clinical practice. Nanofabrics created proved to promote healing with their structure similar to extracellular matrix. We decided to study their impact on anastomotic healing and formation of peritoneal adhesions. We performed an experiment on 24 piglets. We constructed 3 hand sutured end-to-end anastomoses on the small intestine of each pig. We covered the anastomoses with a sheet of polycaprolactone nanomaterial in the first experimental group, with a sheet of copolymer of polylactic acid with polycaprolactone in the second one and no fortifying material was used in the Control group. The animals were sacrificed after 3 weeks of observation. Clinical, biochemical and macroscopic signs of anastomotic leakage or intestinal obstruction were monitored, the quality of the scar tissue was assessed histologically, and a newly developed scoring system was employed to evaluate the presence of adhesions. The material is easy to manipulate with. There was no mortality or major morbidity in our groups. No statistical difference was found inbetween the groups in the matter of level of peritoneal adhesions or the quality of the anastomoses. We created a new adhesion scoring system. The material appears to be safe however needs to be studied further to prove its' positive effects.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Respiratory Morbidity in Children with Repaired Congenital Esophageal Atresia with or without Tracheoesophageal Fistula

Congenital esophageal atresia with or without tracheoesophageal fistula (CEA ± TEF) is a relatively common malformation that occurs in 1 of 2500–4500 live births. Despite the refinement of surgical techniques, a considerable proportion of children experience short- and long-term respiratory complications, which can significantly affect their health through adulthood. This review focuses on the underlying mechanisms and clinical presentation of respiratory morbidity in children with repaired CEA ± TEF. The reasons for the short-term pulmonary impairments are multifactorial and related to the surgical complications, such as anastomotic leaks, stenosis, and recurrence of fistula. Long-term respiratory morbidity is grouped into four categories according to the body section or function mainly involved: upper respiratory tract, lower respiratory tract, gastrointestinal tract, and aspiration and dysphagia. The reasons for the persistence of respiratory morbidity to adulthood are not univocal. The malformation itself, the acquired damage after the surgical repair, various co-morbidities, and the recurrence of lower respiratory tract infections at an early age can contribute to pulmonary impairment. Nevertheless, other conditions, including smoking habits and, in particular, atopy can play a role in the recurrence of infections. In conclusion, our manuscript shows that most children born with CEA ± TEF survive into adulthood, but many comorbidities, mainly esophageal and respiratory issues, may persist. The pulmonary impairment involves many underlying mechanisms, which begin in the first years of life. Therefore, early detection and management of pulmonary morbidity may be important to prevent impairment in pulmonary function and serious long-term complications. To obtain a successful outcome, it is fundamental to ensure a standardized follow-up that must continue until adulthood.

Management of recurrent tracheoesophageal fistula after esophageal atresia and follow-up

Recurrent tracheoesophageal fistula (rTEF) is a complex complication after the repair of esophageal atresia (EA) and remains a challenge because of difficulties in preoperative management and the substantial rates of mortality and morbidity after reoperation. By reviewing a single institution's experience in the management of rTEF and assessing the outcome, we aimed to provide an optimal approach for managing rTEF and to evaluate growth and feeding problems after reoperations. The medical records of 35 patients with rTEF treated at a single institution from June 2012 to December 2015 were reviewed, and follow-up data were collected from all survivors. The diagnosis of rTEF was made using a modified esophagram in 32 of 35 patients. Before reoperation, all patients received continuous aspiration to prevent reflux and aspiration pneumonia by placing two nasogastric tubes at the level of the fistula and into the stomach, and they received enteral nutrition through a jejunal feeding tube. Thirty-five patients received a total of 41 reoperations, including 12 operations of fistula resection, 28 reanastomosis, and 1 esophageal replacement. The incidence of postoperative anastomotic leak (AL), anastomotic stricture (AS), and repeat recurrences was 40.0%, 17.1%, and 11.4%, respectively. The mortality rate was 8.6%. All survivors achieved full oral intake. Mid-term follow-up (median of 18 months) revealed that 7 (21.9%) presented prolonged meal time, 6 (18.8%) had feeding refusal, 8 (25.0%) experienced coughing during feeding, and 7 (21.9%) had vomiting during feeding. According to the growth data, 5 survivors (15.6%) presented with growth retardation, including stunting (n = 1), wasting (n = 2), and underweight (n = 2). The modified esophagram is an effective and reliable method for diagnosing rTEF. Optimized preoperative management and surgical techniques lead to a satisfactory outcome. Nevertheless, nutritional evaluation and feeding guidance by a nutritionist after reoperation are recommended.

Magnetic Compression Stricturoplasty For Treatment of Refractory Esophageal Strictures in Children: Technique and Lessons Learned

INTRODUCTION

Esophageal stricture is the most common complication following repair of esophageal atresia (EA). In general, these strictures are successfully managed using endoscopic techniques including bougie and balloon dilation, stenting, and chemotherapeutic agent application. If these techniques are unsuccessful, patients require segmental esophageal resection and reanastomosis or esophageal replacement. Magnetic compression anastomosis has been described in children. Herein we report our experience with magnetic compression stricturoplasty to treat refractory strictures after EA repair.

METHODS

We reviewed our experience using magnets to treat refractory strictures in 2 patients. Both patients failed multiple standard interventions. Because of near complete esophageal obstruction, both patients were candidates for esophageal replacement or segmental resection/anastamosis. In both patients, we applied neodymium-iron-boron magnets using fluoroscopic and endoscopic guidance.

RESULTS

The magnets were successfully positioned in both cases. Magnets were left in place for 7 and 10 days allowing for gradual compression stricturoplasty/anastamosis. Upon removal of the magnets, recanalization was visualized endoscopically and self-expanding stents were placed. There were no leaks or significant early complications. By 31 months post-magnetic stricturoplasty, both patients achieved durable esophageal patency without dysphagia.

CONCLUSION

Magnetic stricturoplasty was successful at establishing early patency of the esophagus in 2 patients with recalcitrant EA strictures. Fundamental knowledge of magnetism was critical in configuring magnet arrays for surgery. In both cases, early follow-up is promising. Further follow-up will define the long-term success of this technique.

Anastomotic Strictures after Esophageal Atresia Repair: Incidence, Investigations, and Management, Including Treatment of Refractory and Recurrent Strictures

Improved surgical techniques, as well as preoperative and postoperative care, have dramatically changed survival of children with esophageal atresia (EA) over the last decades. Nowadays, we are increasingly seeing EA patients experiencing significant short- and long-term gastrointestinal morbidities. Anastomotic stricture (AS) is the most common complication following operative repair. An esophageal stricture is defined as an intrinsic luminal narrowing in a clinically symptomatic patient, but no symptoms are sensitive or specific enough to diagnose an AS. This review aims to provide a comprehensive view of AS in EA children. Given the lack of evidence-based data, we critically analyzed significant studies on children and adults, including comments on benign strictures with other etiologies. Despite there is no consensus about the goal of the luminal diameter based on the patient's age, esophageal contrast study, and/or endoscopy are recommended to assess the degree of the narrowing. A high variability in incidence of ASs is reported in literature, depending on different definitions of AS and on a great number of pre-, intra-, and postoperative risk factor influencing the anastomosis outcome. The presence of a long gap between the two esophageal ends, with consequent anastomotic tension, is determinant for stricture formation and its response to treatment. The cornerstone of treatment is endoscopic dilation, whose primary aims are to achieve symptom relief, allow age-appropriate capacity for oral feeding, and reduce the risk of pulmonary aspiration. No clear advantage of either balloon or bougie dilator has been demonstrated; therefore, the choice is based on operator experience and comfort with the equipment. Retrospective evidences suggest that selective dilatations (performed only in symptomatic patients) results in significantly less number of dilatation sessions than routine dilations (performed to prevent symptoms) with equal long-term outcomes. The response to dilation treatment is variable, and some patients may experience recurrent and refractory ASs. Adjunctive treatments have been used, including local injection of steroids, topical application of mitomycin C, and esophageal stenting, but long-term studies are needed to prove their efficacy and safety. Stricture resection or esophageal replacement with an interposition graft remains options for AS refractory to conservative treatments.

Outcome and management in infants with esophageal atresia - A single centre observational study

BACKGROUND/PURPOSE

A successful outcome in the repair of esophageal atresia (EA) is associated with a high quality pediatric surgical centre, however there are several controversies regarding the optimal management. The aim of this study was to investigate the outcome and management EA in a single pediatric surgical centre.

METHODS

Medical records of infants with repaired EA from 1994 to 2013 were reviewed.

RESULTS

129 infants were included. Median follow-up was 5.3 (range 0.1-21) years. Overall survival was 94.6%, incidences of anastomotic leakage 7.0%, recurrent fistula 4.6% and anastomotic stricture 53.5% (36.2% within first year). In long gap EA (n=13), delayed primary anastomosis was performed in 9 (69.2%), gastric tube in 3 (23.1%) and gastric transposition in one (7.7%) infants. The incidences of anastomotic leakage and stricture in long gap EA were, 23.1% and 69.2%, respectively. Peroperative tracheobronchoscopy and postoperative esophagography were implemented as a routine during the study-period, but chest drains were routinely abandoned.

CONCLUSION

The outcome in this study is fully comparable with recent international reports showing a low mortality but a significant morbidity, especially considering anastomotic strictures and LGEA. Multicenter EA registry with long-term follow up may help to establish best management of EA.

Surgical management of oesophageal atresia

There have been major advances in the surgery for oesophageal atresia (OA) and tracheo-oesophageal fistula(TOF) with survival now exceeding 90%. The standard open approach to OA and distal TOF has been well described and essentially unchanged for the last 60 years. Improved survival in recent decades is most attributable to advances in neonatal anaesthesia and perioperative care. Recent surgical advances include the use of thoracoscopic surgery for the repair of OA/TOF and in some centres isolated OA, thereby minimising the long term musculo-skeletal morbidity associated with open surgery. The introduction of growth induction by external traction (Foker procedure) for the treatment of long-gap OA has provided an important tool enabling increased preservation of the native oesophagus. Despite this, long-gap OA still poses a number of challenges, and oesophageal replacement still may be required in some cases.

Motility, digestive and nutritional problems in Esophageal Atresia

Esophageal atresia (EA) with or without tracheoesophageal fistula (TEF) is a rare congenital malformation. Digestive and nutritional problems remain frequent in children with EA both in early infancy and at long-term follow-up. These patients are at major risk of presenting with gastroesophageal reflux and its complications, such as anastomotic strictures. Esophageal dysmotility is constant, and can have important consequences on feeding and nutritional status. Patients with EA need a systematic follow-up with a multidisciplinary team.

Role of feeding jejunostomy in major anastomotic disruptions in esophageal atresia: A pilot study

Aims:

To investigate the role of feeding jejunostomy (FJ) in patients of esophageal atresia with anastomotic leak (AL) to decrease the degree of gastroesophageal reflux (GER) and its effect on anastomotic healing.

Materials and Methods:

Twenty neonates, with major AL and severe GER after primary repair were managed with decompressing gastrostomy and transgastric FJ and analyzed prospectively.

Results:

Male to female ratio was 1.7:1. Mean birth weight was 2.2 kg. Anastomotic gap ranged from 0 to 4 cm. The amount of leak was more than 20% of nasogastric feeds. Gastrostomy and FJ was done on an average of the 12^th postoperative day, after observing the general condition, chest tube output, lung expansion, and ventilatory requirement. There was a drastic reduction in chest tube output and lung expanded in all patients. Average hospital stay was 36 days (8-80 days). Sixty percentage patients were discharged successfully on FJ. Esophagogram demonstrated healing and leak free patency after an average of 1.5 months. GER was noted in seven patients, four developed stricture, and one had pseudodiverticulum in follow-up.

Conclusion:

Decompressing gastrostomy and FJ can be an alternative to managing major ALs. It helps in healing of anastomotic dehiscence and in preserving the native esophagus.

Reoperation for anastomotic complications of esophageal atresia and tracheoesophageal fistula

BACKGROUND/PURPOSE

The purpose of the study was to review our experience in the re-operative management of anastomotic complications (ACs) following primary repair of esophageal atresia (EA) and tracheoesophageal fistula (TEF) and to assess the outcomes after reoperation.

METHODS

We retrospectively reviewed 21 EA patients who underwent reoperation from 2005 to 2014. Clinical features, reasons for reoperation, diagnosis of ACs, re-operative procedures and outcomes, as well as long-term follow-up of reoperation were analyzed.

RESULTS

Reoperation occurred in 16 recurrent TEF (RTEF) cases (76.2%), 4 severe anastomotic strictures (AS), and 1 anastomotic leakage (AL) cases (19% and 4.8%, respectively). All of AS and AL were confirmed by esophagography. RTEF were confirmed by esophagoscopy and bronchoscopy. All of the cases underwent reoperation successfully. The average operative time and length of post-operative hospital stay were 2.7 ± 0.8 hours and 15.4 ± 3.3 days, respectively. The mortality rate was 4.8%. All of the cases were followed up from 1 to 107 months after reoperation. No patients experienced respiratory or feeding issues. No severe postoperative complications were shown in all re-operative cases.

CONCLUSIONS

ACs including severe AS and AL as well as RTEF are the significant indications for reoperation after EA repair. The reoperation was effective to treat multiple anastomotic complications.

The Esophageal Anastomotic Stricture Index (EASI) for the management of esophageal atresia

BACKGROUND

Anastomotic stricture is the most common complication following repair of esophageal atresia. An Esophageal Anastomotic Stricture Index (EASI) based on the postoperative esophagram may identify patients at high risk of stricture formation.

METHODS

Digital images of early postoperative esophagrams of patients undergoing EA repair from 2005 to 2013 were assessed. Demographics and outcomes including dilations were prospectively collected. Upper (U-EASI) and lower (L-EASI) pouch ratios were generated using stricture diameter divided by maximal respective pouch diameter. Score performances were evaluated with area under the receiver operator curves (AUC) and the Fisher's exact test for single and multiple (>3) dilatations. Interrater agreement was evaluated using the intraclass correlation coefficient (ICC).

RESULTS

Forty-five patients had esophagrams analyzed; 28 (62%) required dilatation and 19 received >3 (42%). U-EASI and L-EASI ratios ranged from 0.17 to 0.70, with L-EASI outperforming the U-EASI as follows: L-EASI AUC: 0.66 for a single dilatation, 0.65 for >3 dilatations; U-EASI AUC: 0.56 for a single dilatation, 0.67 for >3 dilatations. All patients with an L-EASI ratio of ≤0.30 (n=8) required multiple esophageal dilatations, p=0.0006. The interrater ICC was 0.87.

CONCLUSION

The EASI is a simple, reproducible tool to predict the development and severity of anastomotic stricture after esophageal atresia repair and can direct postoperative surveillance.

Anastomotic strictures and endoscopic dilatations following esophageal atresia repair

PURPOSE

To identify risk factors that can predict prevalence of anastomotic strictures (AS) following esophageal atresia (EA) repair.

METHODS

Of 46 consecutive patients with EA managed at our institution between 2004 and 2012, 35 underwent esophageal anastomosis and were included in this retrospective longitudinal study. Routine endoscopy was performed 1 month after surgical repair. According to stricture index (SI), endoscopically calculated as SI = (D - d)/D, where D is the diameter of the esophageal pouch and d the stricture diameter, population was divided into Group 1, SI ≤ 0.1 (no evidence of stricture); Group 2, 0.3 > SI > 0.1 (mild stricture); Group 3, SI ≥ 0.3 (high-grade stricture). Trends of subsequent endoscopic esophageal dilatations were compared between the groups using Wilcoxon-Mann-Whitney or Pearson's tests. Cox regression analysis was performed to estimate the hazard ratio.

RESULTS

Gastro-esophageal reflux disease (P = 0.04), tension on the anastomosis (P = 0.02) and long-gap form (P = 0.008) have an increased risk of developing AS. SI at 1 month after surgery correlates with the average number of future dilatations: Group 2 and 3 compared to Group 1 required more dilatations (hazard ratio 2.291 and 12.765).

CONCLUSION

AS remain frequent complications of esophageal surgery, especially in specific subgroups of patients. SI at 1 month after surgery could already predict the severity of the stricture and the need for subsequent endoscopic esophageal dilatations.

Oesophageal atresia associated with congenital oesophageal stenosis

Congenital esophageal stenosis (CES) is associated with oesophageal atresia and tracheoesophageal fistula (EA-TEF). Tracheobronchial (cartilaginous) rests are typically found within the area of stenosis. The authors present a case report of EA-TEF associated with CES and present a modification of a novel technique to facilitate the management of CES. The impact of gastro-oesophageal reflux disease is discussed in this unique entity. Finally, the literature is reviewed for this unique entity.

Modern outcomes of oesophageal atresia: single centre experience over the last twenty years

AIM OF THE STUDY

The aim of this study was assessment of the contemporary outcomes of oesophageal atresia (OA) in a national paediatric surgical centre.

PATIENTS AND METHODS

A review of the hospital records of all patients who underwent repair of oesophageal atresia (OA) in our institute between 1991 and 2011 was performed.

RESULTS

The study included 130 consecutive infants with OA: types A (n=4, 3%), B (n=2, 2%), C (n=110, 85%), D (n=5, 4%), and E (n=9, 7%). Median follow-up was 8.8 (range 0.1-21) years. Twenty-nine (22%) infants had cardiac and 76 (58%) other anomalies, and seventeen (13%) had a long-gap OA. The final repair was primary (n =113, 87%) or delayed (n=3) end-to-end anastomosis, oesophageal replacement (n=8) (6%) with gastric tube (n=4) or with jejunum interposition (n=4), and closure of the trachea-oesophageal fistula (Type E, n=9). Oesophageal continuity was achieved in all patients. Overall mortality was 3/130 (2%) and caused by gastric perforation (n=1), prolonged apnoeic spell (n =1), and food asphyxiation (n=1). Oral feeds were achieved in 121 (94%) children. Eight (6%) children remain dependent on feeding ostomy. Long-gap OA was a major predictor of post-repair complications.

CONCLUSION

The modern outcome for infants with OA is characterized by an extremely low hospital mortality and satisfactory oesophageal function, enabling full oral feeds in the vast majority of children.