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Castro P, Fall F, Pace D, Mack SJ, Rothstein DH, Devin CL, Sagalow E, Linden AF, Boelig M, Asti L, Berman L. Association of Operative Approach With Postoperative Outcomes in Neonates Undergoing Surgical Repair of Esophageal Atresia and Tracheoesophageal Fistula. J Pediatr Surg 2024:S0022-3468(24)00460-3. [PMID: 39147683 DOI: 10.1016/j.jpedsurg.2024.07.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2024] [Revised: 07/15/2024] [Accepted: 07/18/2024] [Indexed: 08/17/2024]
Abstract
INTRODUCTION Minimally invasive surgery (MIS) is gaining traction as a first-line approach to repair congenital anomalies. This study aims to evaluate outcomes for neonates undergoing open versus MIS repairs for esophageal atresia/tracheoesophageal fistula (EA/TEF). METHODS In this retrospective study, neonates undergoing EA/TEF repair from 2013 to 2020 were identified using the National Surgical Quality Improvement Program-Pediatric database. Proportions of operative approach (open vs. MIS) over time were analyzed. A propensity score-matched analysis using preoperative characteristics was performed and outcomes were compared including composite morbidity and reintervention rates (overall, major [thoracoscopy, thoracotomy], and minor [chest/feeding tube placement, endoscopy]) between operative approaches. Pearson's chi-square or Fisher's exact tests were used as appropriate. RESULTS We identified 1738 neonates who underwent EA/TEF repair. MIS utilization increased over time. Pre-match, neonates undergoing open repair were more likely to be premature, lower weight, ventilator dependent, and have cardiac risk factors with higher severity. Post-match, the groups were similar and included 340 neonates per group. MIS repair was associated with longer median operative time (209 vs. 174 min, p < 0.001) and increased overall post-operative intervention rates (7.6% vs. 2.9%, p = 0.01). There were no differences in composite morbidity (24.4% vs. 25.0%, p = 0.86) outside of reintervention. CONCLUSION MIS approach for neonates with EA/TEF appears to be associated with a higher rate of reinterventions. Further studies evaluating MIS approaches for the repair of EA/TEF are needed to better define short- and long-term outcomes. TYPE OF STUDY Retrospective comparative study. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Paulo Castro
- Philadelphia College of Osteopathic Medicine, Philadelphia, PA, United States
| | - Fari Fall
- Division of Pediatric Surgery, Nemours Children's Health, Wilmington, DE, United States; Department of General Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, United States
| | - Devon Pace
- Division of Pediatric Surgery, Nemours Children's Health, Wilmington, DE, United States; Department of General Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, United States
| | - Shale J Mack
- Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, United States
| | - David H Rothstein
- Division of Pediatric Surgery, Seattle Children's Hospital, University of Washington, Seattle, WA, United States
| | - Courtney L Devin
- Division of Colorectal Surgery, Emory University School of Medicine, Atlanta, GA, United States
| | - Emily Sagalow
- Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, United States
| | - Allison F Linden
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine/Children's Healthcare of Atlanta, Atlanta, GA, United States
| | - Matthew Boelig
- Division of Pediatric Surgery, Nemours Children's Health, Wilmington, DE, United States; Department of General Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, United States
| | - Lindsey Asti
- Division of Pediatric Surgery, Nemours Children's Health, Wilmington, DE, United States
| | - Loren Berman
- Division of Pediatric Surgery, Nemours Children's Health, Wilmington, DE, United States; Department of General Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, United States.
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Davis SE, Davis C, Patel N, Kubba H, Clement WA. Long-term Airway Outcomes and Interventions in Children With Oesophageal Atresia With Tracheoesophageal Fistula: A 20-year Single Centre Observational Study. J Pediatr Surg 2024; 59:1066-1071. [PMID: 38429129 DOI: 10.1016/j.jpedsurg.2024.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 01/10/2024] [Accepted: 02/06/2024] [Indexed: 03/03/2024]
Abstract
BACKGROUND Airway anomalies, symptoms and interventions are commonly reported in children with oesophageal atresia with tracheoesophageal fistula (OA/TOF). The purpose of this study was to assess the incidence of these airway pathologies and those requiring interventions in the long-term. METHODS A retrospective case note review of all patients admitted to the Neonatal Unit at the Royal Hospital for Children, Glasgow between January 2000 and December 2015 diagnosed with OA/TOF. Included patients had a minimum of 5 years follow-up. RESULTS 121 patients were identified. 118 proceeded to OA/TOF repair. 115 patients had long-term follow-up data. Ninety-five (83%) children had one or more airway symptom recorded. Thirty-six (31%) neonates underwent airway endoscopy at the time of their initial OA/TOF repair. Forty-six (40%) children underwent airway endoscopy at a later date due to airway symptoms. Airway pathologies identified included airway malacia, thirty-two (28%), subglottic stenosis, eleven (10%), tracheal pouch, twenty-five (22%), laryngeal cleft, seven (6%) and recurrent fistula, five (4%). Airway interventions included endoscopic division of tracheal pouch, ten (9%), tracheostomy, seven (6%), aortopexy, six (5%), repair of recurrent fistula, five (4%), endoscopic repair of laryngeal cleft, three (3%) and four (3%) required open airway reconstruction for subglottic stenosis. One child (1%) remains tracheostomy dependent. CONCLUSIONS Long-term airway pathologies are common in children with OA/TOF. Many of these are remediable with surgical intervention. Clinicians should be cognisant of this and refer to Airway Services appropriately.
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Affiliation(s)
- Sandra E Davis
- Department of Paediatric Surgery, Royal Hospital for Children, Glasgow, United Kingdom.
| | - Carl Davis
- Department of Paediatric Surgery, Royal Hospital for Children, Glasgow, United Kingdom
| | - Neil Patel
- Department of Neonatology, Royal Hospital for Children, Glasgow, United Kingdom
| | - Haytham Kubba
- Department of Paediatric Otolaryngology Head and Neck Surgery, Royal Hospital for Children, Glasgow, United Kingdom
| | - W Andrew Clement
- Department of Paediatric Otolaryngology Head and Neck Surgery, Royal Hospital for Children, Glasgow, United Kingdom
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Koivusalo AI, Suominen JS, Nokso-Koivisto J, Pakarinen MP. Vocal Cord Paralysis after Repair of Esophageal Atresia. Eur J Pediatr Surg 2024; 34:50-55. [PMID: 37669755 DOI: 10.1055/s-0043-1774370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/07/2023]
Abstract
OBJECTIVE Etiology of vocal cord paralysis (VCP) and laryngeal dysfunction may be congenital or surgical trauma of recurrent and superior laryngeal nerves. We assessed the incidence, risk factors, and morbidity of VCP after repair of esophageal atresia (EA). METHODS Medical records of 201 EA patients from 2000 to 2022 were reviewed for this retrospective study. Postrepair vocal cord examination (VCE) included awake nasolaryngeal fiberoscopy by otolaryngologist or laryngoscopy under spontaneous breathing anesthesia. Before 2017, postoperative VCE was performed in symptomatic patients only and routinely after 2017. MAIN RESULTS Overall, VCE was performed on 79 (38%) patients (52 asymptomatic), whereas 122 asymptomatic patients underwent no VCE. VCP was diagnosed in 32 of 79 patients (right 12, left 10, and bilateral 10; symptomatic 25 and asymptomatic unilateral 7) corresponding with extrapolated overall VCP incidence of 16 to 24% among 201 patients including asymptomatic ones. Ten patients (bilateral VCP 8 and left VCP 2) required tracheostomy. Of 10 patients with bilateral VCP, three underwent laryngotracheal expansion surgery (left VC lateralization in one and laryngoplasty in two with acquired subglottic stenosis), three remained tracheostomy dependent, three were off tracheostomy, and one died of complications after redo esophageal reconstruction. All patients with unilateral VCP managed without tracheostomy. Cervical dissection or ostomy formation was a major risk factor of VCP. CONCLUSION Repair of EA is associated with a considerable risk of VCP and associated morbidity. Cervical EA surgery significantly increased the risk of VCP. Bilateral VCP may eventually require laryngotracheal expansion surgery.
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Affiliation(s)
- A I Koivusalo
- Department of Pediatric Surgery, New Children's Hospital, University of Helsinki, Helsinki, Finland
| | - J S Suominen
- Department of Pediatric Surgery, New Children's Hospital, University of Helsinki, Helsinki, Finland
| | - J Nokso-Koivisto
- Department of Ear, Nose, and Throat Surgery, University of Helsinki, Surgical Hospital, Helsinki, Finland
| | - M P Pakarinen
- Department of Pediatric Surgery, New Children's Hospital, University of Helsinki, Helsinki, Finland
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Meisner JW, Izadi S, Kamran A, Shieh HF, Smithers CJ, Bennett J, Demehri FR, Mohammed S, Lawlor C, Choi SS, Zendejas B. Screening for Vocal Fold Movement Impairment in Children Undergoing Esophageal and Airway Surgery. Laryngoscope 2023; 133:3564-3570. [PMID: 36892035 DOI: 10.1002/lary.30646] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 02/04/2023] [Accepted: 02/27/2023] [Indexed: 03/10/2023]
Abstract
INTRODUCTION Children undergoing cervical and/or thoracic operations are at risk for recurrent laryngeal nerve injury, resulting in vocal fold movement impairment (VFMI). Screening for VFMI is often reserved for symptomatic patients. OBJECTIVE Identify the prevalence of VFMI in screened preoperative patients prior to an at-risk operation to evaluate the value of screening all patients at-risk for VFMI, regardless of symptoms. METHODS A single center, retrospective review of all patients undergoing a preoperative flexible nasolaryngoscopy between 2017 and 2021, examining the presence of VFMI and associated symptoms. RESULTS We evaluated 297 patients with a median (IQR) age of 18 (7.8, 56.3) months and a weight of 11.3 (7.8, 17.7) kilograms. Most had a history of esophageal atresia (EA, 60%), and a prior at-risk cervical or thoracic operation (73%). Overall, 72 (24%) patients presented with VFMI (51% left, 26% right, and 22% bilateral). Of patients with VFMI, 47% did not exhibit the classic symptoms (stridor, dysphonia, and aspiration) of VFMI. Dysphonia was the most prevalent classic VFMI symptom, yet only present in 18 (25%) patients. Patients presenting with a history of at-risk surgery (OR 2.3, 95%CI 1.1, 4.8, p = 0.03), presence of a tracheostomy (OR 3.1, 95%CI 1.0, 10.0, p = 0.04), or presence of a surgical feeding tube (OR 3.1, 95%CI 1.6, 6.2, p = 0.001) were more likely to present with VFMI. CONCLUSION Routine screening for VFMI should be considered in all at-risk patients, regardless of symptoms or prior operations, particularly in those with a history of an at-risk surgery, presence of tracheostomy, or a surgical feeding tube. LEVEL OF EVIDENCE 3 Laryngoscope, 133:3564-3570, 2023.
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Affiliation(s)
- Jay W Meisner
- Department of Surgery, Boston Children's Hospital, Boston, Massachusetts, U.S.A
| | - Shawn Izadi
- Department of Surgery, Boston Children's Hospital, Boston, Massachusetts, U.S.A
| | - Ali Kamran
- Department of Surgery, Boston Children's Hospital, Boston, Massachusetts, U.S.A
| | - Hester F Shieh
- Department of Surgery, Johns Hopkins All Childrens, St Petersburg, Florida, U.S.A
| | - C Jason Smithers
- Department of Surgery, Johns Hopkins All Childrens, St Petersburg, Florida, U.S.A
| | - John Bennett
- Department of Surgery, Boston Children's Hospital, Boston, Massachusetts, U.S.A
| | - Farokh R Demehri
- Department of Surgery, Boston Children's Hospital, Boston, Massachusetts, U.S.A
| | - Somala Mohammed
- Department of Surgery, Boston Children's Hospital, Boston, Massachusetts, U.S.A
| | - Claire Lawlor
- Department of Ear, Nose and Throat Surgery, Children's National, Washington, District of Columbia, U.S.A
| | - Sukgi S Choi
- Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital, Boston, Massachusetts, U.S.A
| | - Benjamin Zendejas
- Department of Surgery, Boston Children's Hospital, Boston, Massachusetts, U.S.A
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Flaherty E, Folaranmi SE. Thoracoscopic Versus Open Repair of Esophageal Atresia: A Systematic Review of Surgical Outcomes. J Laparoendosc Adv Surg Tech A 2023; 33:1114-1120. [PMID: 37418028 DOI: 10.1089/lap.2022.0561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/08/2023] Open
Abstract
Introduction: Esophageal atresia (EA) is a rare defect in the continuity of the esophagus, with the absent portion forming an upper and lower segment. Despite both thoracoscopic and conventional open repair (OR) techniques being well established worldwide, the literature remains unclear as to the comparison of surgical outcomes and efficacy of each procedure. Aim: To conduct a systematic review to determine which technique for EA repair, thoracoscopic or open, has the better outcome. Methods: A Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) compliant literature search returned 14 full text articles for analysis of demographic information and surgical outcomes. Results: Major comorbidities were more likely in the OR group (P < .05) with all other surgical outcomes comparable between the two groups. Conclusion: Overall, this systematic review highlights that the surgical outcomes of patients undergoing thoracoscopic repair for EA are comparable with those of the conventional OR.
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Affiliation(s)
- Erin Flaherty
- School of Medicine, Cardiff University, Cardiff, United Kingdom
| | - Semiu Eniola Folaranmi
- School of Medicine, Cardiff University, Cardiff, United Kingdom
- Department of Paediatric Surgery, Children's Hospital for Wales, Cardiff, United Kingdom
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Marquart JP, Bowder AN, Bence CM, St Peter SD, Gadepalli SK, Sato TT, Szabo A, Minneci PC, Hirschl RB, Rymeski BA, Downard CD, Markel TA, Deans KJ, Fallat ME, Fraser JD, Grabowski JE, Helmrath MA, Kabre RD, Kohler JE, Landman MP, Lawrence AE, Leys CM, Mak GZ, Port E, Saito J, Silverberg J, Slidell MB, Wright TN, Lal DR. Thoracoscopy versus thoracotomy for esophageal atresia and tracheoesophageal fistula: Outcomes from the Midwest Pediatric Surgery Consortium. J Pediatr Surg 2023; 58:27-33. [PMID: 36283849 DOI: 10.1016/j.jpedsurg.2022.09.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Accepted: 09/16/2022] [Indexed: 01/07/2023]
Abstract
BACKGROUND/PURPOSE Controversy persists regarding the ideal surgical approach for repair of esophageal atresia with tracheoesophageal fistula (EA/TEF). We examined complications and outcomes of infants undergoing thoracoscopy and thoracotomy for repair of Type C EA/TEF using propensity score-based overlap weights to minimize the effects of selection bias. METHODS Secondary analysis of two databases from multicenter retrospective and prospective studies examining outcomes of infants with proximal EA and distal TEF who underwent repair at 11 institutions was performed based on surgical approach. Regression analysis using propensity score-based overlap weights was utilized to evaluate outcomes of patients undergoing thoracotomy or thoracoscopy for Type C EA/TEF repair. RESULTS Of 504 patients included, 448 (89%) underwent thoracotomy and 56 (11%) thoracoscopy. Patients undergoing thoracoscopy were more likely to be full term (37.9 vs. 36.3 weeks estimated gestational age, p < 0.001), have a higher weight at operative repair (2.9 vs. 2.6 kg, p < 0.001), and less likely to have congenital heart disease (16% vs. 39%, p < 0.001). Postoperative stricture rate did not differ by approach, 29 (52%) thoracoscopy and 198 (44%) thoracotomy (p = 0.42). Similarly, there was no significant difference in time from surgery to stricture formation (p > 0.26). Regression analysis using propensity score-based overlap weighting found no significant difference in the odds of vocal cord paresis or paralysis (OR 1.087 p = 0.885), odds of anastomotic leak (OR 1.683 p = 0.123), the hazard of time to anastomotic stricture (HR 1.204 p = 0.378), or the number of dilations (IRR 1.182 p = 0.519) between thoracoscopy and thoracotomy. CONCLUSION Infants undergoing thoracoscopic repair of Type C EA/TEF are more commonly full term, with higher weight at repair, and without congenital heart disease as compared to infants repaired via thoracotomy. Utilizing propensity score-based overlap weighting to minimize the effects of selection bias, we found no significant difference in complications based on surgical approach. However, our study may be underpowered to detect such outcome differences owing to the small number of infants undergoing thoracoscopic repair. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- John P Marquart
- Division of Pediatric Surgery, Department of Surgery, Medical College of Wisconsin, 999 N 92nd St, Suite 320, Milwaukee, WI 53226, USA.
| | - Alexis N Bowder
- Division of Pediatric Surgery, Department of Surgery, Medical College of Wisconsin, 999 N 92nd St, Suite 320, Milwaukee, WI 53226, USA
| | - Christina M Bence
- Division of Pediatric Surgery, Department of Surgery, Medical College of Wisconsin, 999 N 92nd St, Suite 320, Milwaukee, WI 53226, USA
| | - Shawn D St Peter
- Division of Pediatric Surgery, Department of Surgery, Children's Mercy Hospital, 2401 Gillham Rd, Kansas City, MO 64108, USA
| | - Samir K Gadepalli
- Section of Pediatric Surgery, Department of Surgery, University of Michigan, 1500 E. Medical Center Dr, Ann Arbor, MI 48109, USA
| | - Thomas T Sato
- Division of Pediatric Surgery, Department of Surgery, Medical College of Wisconsin, 999 N 92nd St, Suite 320, Milwaukee, WI 53226, USA
| | - Aniko Szabo
- Division of Pediatric Surgery, Department of Surgery, Medical College of Wisconsin, 999 N 92nd St, Suite 320, Milwaukee, WI 53226, USA
| | - Peter C Minneci
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute and Department of Surgery, Nationwide Children's Hospital, 700 Children's Dr, Columbus, OH 43206, USA
| | - Ronald B Hirschl
- Section of Pediatric Surgery, Department of Surgery, University of Michigan, 1500 E. Medical Center Dr, Ann Arbor, MI 48109, USA
| | - Beth A Rymeski
- Department of Pediatric Surgery, Cincinnati Children's Hospital, 3333 Burnet Ave, ML 2023, Cincinnati, OH 45229, USA
| | - Cynthia D Downard
- Department of Surgery, Division of Pediatric Surgery, University of Louisville School of Medicine, 530 S. Jackson St, Louisville, KY 40202, USA
| | - Troy A Markel
- Division of Pediatric Surgery, Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr, Emerson Hall, Indianapolis, IN 46202, USA
| | - Katherine J Deans
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute and Department of Surgery, Nationwide Children's Hospital, 700 Children's Dr, Columbus, OH 43206, USA
| | - Mary E Fallat
- Department of Surgery, Division of Pediatric Surgery, University of Louisville School of Medicine, 530 S. Jackson St, Louisville, KY 40202, USA
| | - Jason D Fraser
- Division of Pediatric Surgery, Department of Surgery, Children's Mercy Hospital, 2401 Gillham Rd, Kansas City, MO 64108, USA
| | - Julia E Grabowski
- Division of Pediatric Surgery, Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, 225 E. Chicago Ave, Chicago, IL 60611, USA
| | - Michael A Helmrath
- Department of Pediatric Surgery, Cincinnati Children's Hospital, 3333 Burnet Ave, ML 2023, Cincinnati, OH 45229, USA
| | - Rashmi D Kabre
- Division of Pediatric Surgery, Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, 225 E. Chicago Ave, Chicago, IL 60611, USA
| | - Jonathan E Kohler
- Division of Pediatric Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, 600 Highland Ave, Madison, WI 53792, USA
| | - Matthew P Landman
- Division of Pediatric Surgery, Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr, Emerson Hall, Indianapolis, IN 46202, USA
| | - Amy E Lawrence
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute and Department of Surgery, Nationwide Children's Hospital, 700 Children's Dr, Columbus, OH 43206, USA
| | - Charles M Leys
- Division of Pediatric Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, 600 Highland Ave, Madison, WI 53792, USA
| | - Grace Z Mak
- The University of Chicago Medicine, Comer Children's Hospital, Chicago, IL, USA
| | - Elissa Port
- Division of Pediatric Surgery, Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, 225 E. Chicago Ave, Chicago, IL 60611, USA
| | - Jacqueline Saito
- Division of Pediatric Surgery, Department of Surgery, Washington University School of Medicine, Suite 5S40-Campus Box 8235, One Children's Place, St. Louis, MO 63110, USA
| | - Jared Silverberg
- Section of Pediatric Surgery, Department of Surgery, University of Michigan, 1500 E. Medical Center Dr, Ann Arbor, MI 48109, USA
| | - Mark B Slidell
- The University of Chicago Medicine, Comer Children's Hospital, Chicago, IL, USA
| | - Tiffany N Wright
- Department of Surgery, Division of Pediatric Surgery, University of Louisville School of Medicine, 530 S. Jackson St, Louisville, KY 40202, USA
| | - Dave R Lal
- Division of Pediatric Surgery, Department of Surgery, Medical College of Wisconsin, 999 N 92nd St, Suite 320, Milwaukee, WI 53226, USA
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Hamed DHED, Hussein A, Magdy B, Elseoudi M, Elbarbary MM, Wishahy AMK. Post-operative bronchoscopy findings of esophageal atresia patients, initial phase of single-institute experience. ANNALS OF PEDIATRIC SURGERY 2022. [DOI: 10.1186/s43159-022-00169-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Esophageal atresia (EA) is not a rare congenital anomaly. It is usually accompanied by tracheoesophageal fistula (TEF). Respiratory morbidities are experienced in most of the survivors. Although it was believed that these symptoms tend to improve by age, permanent lung damage may continue to adulthood in some patients. We aimed to assess the respiratory tract in the follow-up period as an attempt to correlate possible findings with symptoms experienced which allowed us to pay more attention to the respiratory tract during the upcoming surgical interventions. Prospective observational study was conducted on patients presented to our institute, throughout 2018, with various degrees of refractory respiratory tract involvement, after having had their EA repaired inside or outside our institute. After exclusion of esophageal causes of these manifestations, bronchoscopy was performed to correlate the findings with the symptoms experienced by these patients. The study does not include patients repaired after 2018 as surgical modifications were performed and are still under study.
Results
Fifteen patients presented with various respiratory symptoms. Although recurrent chest infection is the commonest presentation, acute life-threatening events were reported in 5 patients. Blind-ended tracheal diverticulum was the most common finding observed in 80% of patients. About 76% of these patients were found to have tracheomalacia. Moreover, bronchoscopy was able to detect recurrent tracheoesophageal fistula in 4 patients. Vocal cords were affected in 13% of these patients.
Conclusions
Frequent respiratory symptoms in operated patients warrant careful long-term monitoring and appropriate management. Although bronchoscopy is considered a mandatory pre-repair procedure, it is a crucial tool in evaluating the survivors. It is pivotal to pay more attention to the respiratory tract to modify the surgical techniques to overcome these pitfalls.
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Association of operative approach with outcomes in neonates with esophageal atresia and tracheoesophageal fistula. J Pediatr Surg 2021; 56:2172-2179. [PMID: 33994203 DOI: 10.1016/j.jpedsurg.2021.04.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 03/17/2021] [Accepted: 04/05/2021] [Indexed: 01/04/2023]
Abstract
PURPOSE We sought to evaluate the impact of thoracoscopic repair on perioperative outcomes in infants with esophageal atresia and tracheoesophageal fistula (EA/TEF). METHODS The American College of Surgeons National Surgical Quality Improvement Program pediatric database from 2014 to 2018 was queried for all neonates who underwent operative repair of EA/TEF. Operative approach based on intention to treat was correlated with perioperative outcomes, including 30-day postoperative adverse events, in logistic regression models. RESULTS Among 855 neonates, initial thoracoscopic repair was performed in 133 (15.6%) cases. Seventy (53%) of these cases were converted to open. Those who underwent thoracoscopic repair were more likely to be full-term (p = 0.03) when compared to those in the open repair group. There were no significant differences in perioperative outcome measures based on surgical approach except for operative time (thoracoscopic: 217 min vs. open: 180 min, p<0.001). A major cardiac comorbidity (OR 1.6, 95% CI 1.2-2.1; p = 0.003) and preoperative ventilator requirement (OR 1.4, 95% CI 1.0-1.9; p = 0.034) were the only risk factors associated with adverse events. CONCLUSIONS Thoracoscopic neonatal repair of EA/TEF continues to be used sparingly, is associated with high conversion rates, and has similar perioperative outcomes when compared to open repair. LEVEL OF EVIDENCE III.
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Murray-Torres TM, Winch PD, Naguib AN, Tobias JD. Anesthesia for thoracic surgery in infants and children. Saudi J Anaesth 2021; 15:283-299. [PMID: 34764836 PMCID: PMC8579498 DOI: 10.4103/sja.sja_350_20] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 04/21/2020] [Indexed: 11/19/2022] Open
Abstract
The management of infants and children presenting for thoracic surgery poses a variety of challenges for anesthesiologists. A thorough understanding of the implications of developmental changes in cardiopulmonary anatomy and physiology, associated comorbid conditions, and the proposed surgical intervention is essential in order to provide safe and effective clinical care. This narrative review discusses the perioperative anesthetic management of pediatric patients undergoing noncardiac thoracic surgery, beginning with the preoperative assessment. The considerations for the implementation and management of one-lung ventilation (OLV) will be reviewed, and as will the anesthetic implications of different surgical procedures including bronchoscopy, mediastinoscopy, thoracotomy, and thoracoscopy. We will also discuss pediatric-specific disease processes presenting in neonates, infants, and children, with an emphasis on those with unique impact on anesthetic management.
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Affiliation(s)
- Teresa M Murray-Torres
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, Missouri, USA.,Department of Anesthesiology, St. Louis Children's Hospital, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Peter D Winch
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, Missouri, USA.,Department of Anesthesiology and Pain Medicine, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Aymen N Naguib
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, Missouri, USA.,Department of Anesthesiology and Pain Medicine, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Joseph D Tobias
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, Missouri, USA.,Department of Anesthesiology and Pain Medicine, The Ohio State University College of Medicine, Columbus, Ohio, USA
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Lawlor CM, Meisner J, Jennings RW, Zendejas B, Choi SS. Comparative Effectiveness of Recurrent Laryngeal Nerve Monitoring Techniques in Pediatric Surgery. Laryngoscope 2021; 132:889-894. [PMID: 34432299 DOI: 10.1002/lary.29837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Revised: 07/13/2021] [Accepted: 08/09/2021] [Indexed: 11/09/2022]
Abstract
OBJECTIVES/HYPOTHESIS The recurrent laryngeal nerve (RLN) is at risk during pediatric cervical, thoracic, and cardiac surgery. We aim to determine the feasibility and effectiveness of RLN monitoring techniques in all pediatric patients. STUDY DESIGN Retrospective case series. METHODS Retrospective review of patients/procedures with RLN(s) at risk and RLN monitoring at Boston Children's Hospital July 2019-October 2020. Primary outcomes: pre/postoperative vocal fold mobility by awake flexible fiberoptic laryngoscopy (FFL). RESULTS One hundred one patients (median [interquartile range, IQR] age 14.6 months [4.6-49.7 months], weight 10 kg [5.2-16.2 kg]) underwent 122 procedures with RLN(s) at risk. RLN monitoring attempted 111 cases, successful 96 (84%). Surgical indications: esophageal atresia/tracheoesophageal fistula, and tracheobronchomalacia. Sixty-two (56%) procedures in reoperative field. Median follow-up 112 days (IQR 41-230). Pre/postoperative FFL performed 84 procedures (69%), 19 new postoperative RLN injuries (16%), median age 12 months, reoperative fields 11 (18%). Prass probes: 34 cases (28 successful, 82%), 6 injuries (18%), age 12.2 (5.8-23.6) months. Dragonfly electrodes: 45 cases (37 successful, 82%), 8 injuries (18%), age 7.5 (3.8-19) months. Nerve integrity monitoring (NIM) integrated electrode endotracheal tube: 33 cases (33 successful, 100%), 5 injuries (15%), age 90 (58.8-136.7) months. Automatic periodic stimulation (APS): 16 cases, 13 successful (81%), four injuries (25%), age 7.2 (5.3-20.6) months. NIM RLN monitoring is significantly more successful than Prass, Dragonfly (95%CI -0.3 to 0.02, P = .02; and 95%CI 0.05-0.31, P = .008). Rates of injury are not different between types of RLN monitoring (P = .94), with APS use (P = .47), or with monitoring success (95%CI -0.36 to 0.09, P = .28). CONCLUSIONS RLN monitoring is feasible in pediatric patients of all ages. Although NIM type RLN monitoring success is superior, all forms offer similar rates of nerve protection. LEVEL OF EVIDENCE 3 Laryngoscope, 2021.
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Affiliation(s)
- Claire M Lawlor
- Department of Otolaryngology, Children's National Health System, Washington, District of Columbia, USA
| | - Jay Meisner
- Department of Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Russell W Jennings
- Department of Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Benjamin Zendejas
- Department of Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Sukgi S Choi
- Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital, Boston, Massachusetts, USA
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Thoracoscopic repair of congenital isolated H-type tracheoesophageal fistula. J Pediatr Surg 2021; 56:1386-1388. [PMID: 32972739 DOI: 10.1016/j.jpedsurg.2020.08.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 07/28/2020] [Accepted: 08/19/2020] [Indexed: 11/21/2022]
Abstract
BACKGROUND/PURPOSE The available literature on congenital isolated H-type tracheoesophageal fistula (TEF) is limited, and preferred approach varies among centers (cervicotomy, thoracotomy, thoracoscopy). We aimed to present one of the biggest case series of thoracoscopic approach for congenital isolated TEF and to assess the method's feasibility and outcomes. METHODS Retrospective review of thoracoscopic TEF repair experiences at 2 European university pediatric surgery centers. RESULTS 9 boys and 3 girls were involved in the study (age 5 days-4 years), 8 of them were newborns (mean birth weight 3013 g, mean gestational age 39 weeks). The most common presenting symptoms were desaturations on feeding in neonates and recurrent respiratory tract infections in older children. The diagnoses were established on contrast study and confirmed with rigid bronchoscopy. The fistulas were located at or below the thoracic inlet; the fistulas were 2 cm above the carina to half the height of the trachea. All patients underwent successful thoracoscopic TEF repair. There were no conversions. The postoperative course was uneventful in all but one who had rethoracoscopy for prolonged postoperative chylothorax. All patients had satisfactory vocal cord function. One patient required reoperation for fistula recurrence 8 months after primary surgery. CONCLUSION Thoracoscopic approach for isolated H-type TEF seems to be possible as a procedure of choice with satisfactory results and all benefits of minimally invasive procedure. LEVEL OF EVIDENCE IV (case series).
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Kiblawi R, Zoeller C, Zanini A, Ure BM, Dingemann J, Kuebler JF, Schukfeh N. Video-Assisted Thoracoscopic or Conventional Thoracic Surgery in Infants and Children: Current Evidence. Eur J Pediatr Surg 2021; 31:54-64. [PMID: 33027837 DOI: 10.1055/s-0040-1716878] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION The pros and cons of video-assisted thoracoscopic versus conventional thoracic surgery in infants and children are still under debate. We assessed reported advantages and disadvantages of video-assisted thoracoscopy in pediatric surgical procedures, as well as the evidence level of the available data. MATERIALS AND METHODS A systematic literature search was performed to identify manuscripts comparing video-assisted thoracoscopic and the respective conventional thoracic approach in classic operative indications of pediatric surgery. Outcome parameters were analyzed and graded for level of evidence (according to the Oxford Centre of Evidence-Based Medicine). RESULTS A total of 48 comparative studies reporting on 12,709 patients, 11 meta-analyses, and one pilot randomized controlled trial including 20 patients were identified. More than 15 different types of advantages for video-assisted thoracoscopic surgery were described, mostly with a level of evidence 3b or 3a. Most frequently video-assisted thoracoscopic surgery was associated with shorter hospital stay, shorter postoperative ventilation, and shorter time to chest drain removal. Mortality rate and severe complications did not differ between thoracoscopic and conventional thoracic pediatric surgery, except for congenital diaphragmatic hernia repair with a lower mortality and higher recurrence rate after thoracoscopic repair. The most frequently reported disadvantage for video-assisted thoracoscopic surgery was longer operative time. CONCLUSION The available data point toward improved recovery in pediatric video-assisted thoracoscopic surgery despite longer operative times. Further randomized controlled trials are needed to justify the widespread use of video assisted thoracoscopy in pediatric surgery.
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Affiliation(s)
- Rim Kiblawi
- Department of Pediatric Surgery, Hannover Medical School, Hannover, Niedersachsen, Germany
| | - Christoph Zoeller
- Department of Pediatric Surgery, Hannover Medical School, Hannover, Niedersachsen, Germany
| | - Andrea Zanini
- Department of Pediatric Surgery, University of Witwatersrand, Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa
| | - Benno M Ure
- Department of Pediatric Surgery, Hannover Medical School, Hannover, Niedersachsen, Germany
| | - Jens Dingemann
- Department of Pediatric Surgery, Hannover Medical School, Hannover, Niedersachsen, Germany
| | - Joachim F Kuebler
- Department of Pediatric Surgery, Hannover Medical School, Hannover, Niedersachsen, Germany
| | - Nagoud Schukfeh
- Department of Pediatric Surgery, Hannover Medical School, Hannover, Niedersachsen, Germany
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Quick ME, Giblett N, Uwiera TC, Herbert H, Vijayasekaran S. A novel approach in managing challenging tracheoesophageal fistulae. Int J Pediatr Otorhinolaryngol 2020; 138:110261. [PMID: 32798829 DOI: 10.1016/j.ijporl.2020.110261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 07/09/2020] [Accepted: 07/10/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To analyze the outcomes of an open anterior cervical approach and tospecifically describe a novel extended tracheotomy incision ("Key-hole technique") torepair H-type and other challenging tracheoesophageal fistulae (TOF) at a singletertiary pediatric center. METHOD A retrospective chart analysis of pediatric patients (0-18 years old) who had undergone repair of TOF's between January 2006 and March 2020 were reviewed. A case series of patients who had undergone open cervical utilizing three different techniques were included. Patient demographics, surgical management and post-operative surgical outcomes including complications were evaluated. RESULTS During the study period, 117 pediatric patients were diagnosed and anaged with TOFs with or without oesophageal atresia. Within this group, 12 patients (10%) had anterior open cervical repair of congenital or persisting TOFs (6 males and 6 females). Eight cases (7%) had congenital Type E (known as H-type), two had type D, one type B and one type C TOF. Median gestational age was 37 weeks (range 28-41 weeks), age of presentation ranged from 1 day old to 3 years old with 67% being diagnosed within the first month of life. At the time of definitive surgery all patients had a bronchoscopy and oesophagoscopy to confirm the diagnosis, identify the level of the fistula and place a catheter through the fistula. This cases series of open anterior cervical repair of TOFs comprised of seven (58%) patients who had primary extraluminal tracheal approach, four (33%) with extended tracheotomy incision ('Key-hole' technique) and one (9%) patient with slide tracheoplasty for recurrent type C TOF in the presence of subglottic stenosis. Eleven of the twelve patients had successful open anterior cervical repair of TOF. One patient who had primary open anterior cervical repair with the 'Key-hole' technique had recurrence managed successfully with slide tracheoplasty. There were no cases of recurrent laryngeal nerve injury. CONCLUSION This series demonstrates that open anterior cervical approach to correct TOFs is an effective and safe method in the majority of cases of congenital and acquired fistulae where there is no oesophageal atresia or the atresia is corrected (in the case of recurrent or second fistulae). We also present the outcomes of a novel surgical "Keyhole" technique to manage TOF fistulas via an extended-tracheotomy incision. We also found that slide tracheoplasty is an effective salvage operation in the case of complex recurrent fistulae.
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Affiliation(s)
- Mark E Quick
- Department of Otolaryngology, Perth Children's Hospital, Nedlands, WA, Australia.
| | - Neil Giblett
- Department of Otolaryngology, Perth Children's Hospital, Nedlands, WA, Australia
| | - Trina C Uwiera
- Division of Pediatric Surgery, Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | - Hayley Herbert
- Department of Otolaryngology, Perth Children's Hospital, Nedlands, WA, Australia
| | - Shyan Vijayasekaran
- Department of Otolaryngology, Perth Children's Hospital, Nedlands, WA, Australia; Faculty of Health and Medical Sciences, University of Western Australia, WA, Australia
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Lawlor CM, Zendejas B, Baird C, Munoz-San Julian C, Jennings RW, Choi SS. Intraoperative Recurrent Laryngeal Nerve Monitoring During Pediatric Cardiac and Thoracic Surgery: A Mini Review. Front Pediatr 2020; 8:587177. [PMID: 33330282 PMCID: PMC7728690 DOI: 10.3389/fped.2020.587177] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Accepted: 10/29/2020] [Indexed: 12/18/2022] Open
Abstract
Objective: Review techniques for intraoperative recurrent laryngeal nerve (RLN) monitoring during pediatric surgery for esophageal atresia, tracheoesophageal fistula, tracheobronchomalacia, and cardiac surgery. Summary Background Data: Literature was reviewed for reports of intraoperative recurrent laryngeal nerve monitoring in cervical, thoracic, and cardiac surgical procedures which place the RLNs at risk for injury. Methods: Review paper. Results: The RLN is at risk during pediatric surgery for esophageal atresia, tracheoesophageal fistula, tracheobronchomalacia, and cardiac surgery. Intraoperative nerve monitoring has decreased rates of RLN injury in thyroid surgery. Intraoperative RLN monitoring techniques appropriate for pediatric surgery are discussed, including endotracheal tubes with integrated surface electrodes, adhesive surface electrodes for smaller endotracheal tubes, endolaryngeal electrodes, and automatic periodic continuous intra-operative stimulation. Conclusions: Multiple techniques exist to monitor the RLN in children undergoing cervical, cardiac, and thoracic surgery. Monitoring the RLN during procedures that place the RLNs at risk may help decrease the rate of RLN injury.
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Affiliation(s)
- Claire M Lawlor
- Department of Otolaryngology, Children's National Health System, Washington, DC, United States
| | - Benjamin Zendejas
- Department of Surgery, Boston Children's Hospital, Boston, MA, United States
| | - Christopher Baird
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, MA, United States
| | - Carlos Munoz-San Julian
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA, United States
| | - Russell W Jennings
- Department of Surgery, Boston Children's Hospital, Boston, MA, United States
| | - Sukgi S Choi
- Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital, Boston, MA, United States
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Thoracoscopy vs. thoracotomy for the repair of esophageal atresia and tracheoesophageal fistula: a systematic review and meta-analysis. Pediatr Surg Int 2019; 35:1167-1184. [PMID: 31359222 DOI: 10.1007/s00383-019-04527-9] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/19/2019] [Indexed: 12/14/2022]
Abstract
Esophageal atresia (EA) and tracheoesophageal fistula (TEF) require emergency surgery in the neonatal period to prevent aspiration and respiratory compromise. Surgery was once exclusively performed via thoracotomy; however, there has been a push to correct this anomaly thoracoscopically. In this study, we compare intra- and post-operative outcomes of both techniques. A systematic review and meta-analyses was performed. A search strategy was developed in consultation with a librarian which was executed in CENTRAL, MEDLINE, and EMBASE from inception until January 2017. Two independent researchers screened eligible articles at title and abstract level. Full texts of potentially relevant articles were then screened again. Relevant data were extracted and analyzed. 48 articles were included. A meta-analysis found no statistically significant difference between thoracoscopy and thoracotomy in our primary outcome of total complication rate (OR 0.98, [0.29, 3.24], p = 0.97). Likewise, there were no statistically significant differences in anastomotic leak rates (OR 1.55, [0.72, 3.34], p = 0.26), formation of esophageal strictures following anastomoses that required one or more dilations (OR 1.92, [0.93, 3.98], p = 0.08), need for fundoplication following EA repair (OR 1.22, [0.39, 3.75], p = 0.73)-with the exception of operative time (MD 30.68, [4.35, 57.01], p = 0.02). Considering results from thoracoscopy alone, overall mortality in patients was low at 3.2% and in most cases was due to an associated anomaly rather than EA repair. Repair of EA/TEF is safe, with no statistically significant differences in morbidity when compared with an open approach.Level of evidence 3a systematic review of case-control studies.
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Abstract
Thoracoscopic repair (TR) of esophageal atresia (EA) has been performed with increasing frequency over the last two decades, with the expectation of improved outcomes by avoiding thoracotomy. To understand the current practice and outcomes of TR of EA, we reviewed the relevant literature, including 15 case series, 7 comparative studies, and 3 meta-analysis comparing TR with conventional open repair (COR). Most of the studies had a retrospective design and small numbers of patients. Although the evidence level is low because of the lack of prospective studies, this review found that TR is as safe as COR, with comparative outcomes. Moreover, there were several advantages of TR over COR, such as less blood loss and a shorter hospital stay. The long-term outcomes of TR remain unclear because of limited data. Moreover, there is a significant learning curve over the first 10-20 TRs performed. We conclude that TR of EA, when conducted by experienced surgeons, is a safe and minimally invasive alternative to COR and may yield better results than COR in appropriately selected patients.
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Vocal cord dysfunction following esophageal atresia and tracheoesophageal fistula (EA/TEF) repair. J Pediatr Surg 2019; 54:1551-1556. [PMID: 30274710 DOI: 10.1016/j.jpedsurg.2018.08.041] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Revised: 08/14/2018] [Accepted: 08/29/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND The purpose of this study was to determine risk factors and long-term outcomes in patients with esophageal atresia +/-tracheoesophageal fistula (EA/TEF) with vocal cord dysfunction (VCD) owing to recurrent laryngeal nerve (RLN) injury. METHOD A retrospective chart review was performed for EA/TEF patients repaired at our institution from 1999 to 2014 (REB #1000032265). RESULTS Of 197 patients, 22 (11.2%) were diagnosed with VCD by indirect laryngoscopy following EA/TEF repair. Aspiration was documented on video swallow study for 21 patients, and as a result, 13 required thickened feeds and 8 required gastrostomy tube feeds. Of the 16 H-type TEF patients, 8 (50%) had VCD. Following discharge, 20 (90.9%) patients with VCD eventually tolerated full feeds orally without aspiration but only 8 (36.4%) had documented recovery of vocal cord movement at long-term follow up (mean 452 days). Overall, patients with VCD were more likely to have feeding modifications, increased exposure to radiological studies, and increased frequency of Otolaryngology follow-up compared to EA/TEF patients without VCD. CONCLUSION EA/TEF patients are at risk for VCD. Clinical improvement did not always correlate with recovery of VC motion. Strategies to minimize RLN damage will improve outcomes and quality of life for EA/TEF patients. LEVEL OF EVIDENCE Level III.
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Kovesi T, Porcaro F, Petreschi F, Trozzi M, Bottero S, Cutrera R. Vocal cord paralysis appears to be an acquired lesion in children with repaired esophageal atresia/tracheoesophageal fistula. Int J Pediatr Otorhinolaryngol 2018; 112:45-47. [PMID: 30055738 DOI: 10.1016/j.ijporl.2018.06.031] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Revised: 06/13/2018] [Accepted: 06/15/2018] [Indexed: 11/19/2022]
Abstract
OBJECTIVES Determine whether vocal cord paresis or paralysis (VCP/P) following surgical repair of congenital esophageal atresia/tracheoesophageal fistula (EA/TEF) is generally a primary anomaly, or is secondary to EA/TEF repair. METHODS We carried out a retrospective study based on a recently published protocol, which included the systematic performance of a laryngo-tracheo-bronchoscopy before and after EA/TEF repair. RESULTS There were 105 patients with EA/TEF referred for multidisciplinary follow-up, between 2010 and 2015. Sixty-four of the 105 patients included in the study underwent EA/TEF repair at the referral center and had pre-operative bronchoscopy; the others had their initial surgery elsewhere. No included patient had VCP/P detected pre-operatively. Six patients (4 initially managed at the referral center) were diagnosed with VCP/P during the follow-up period (6/105, 5.7%). CONCLUSION VCP appears to be an acquired lesion in this population.
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Affiliation(s)
- Thomas Kovesi
- Division of Respirology, Children's Hospital of Eastern Ontario, 401 Smyth Rd., Ottawa, ON K1H 8L1, Canada.
| | - Federica Porcaro
- Respiratory Unit, Academic Department of Pediatrics, Bambino Gesù Children's Hospital, Piazza di Sant'Onofrio, 4, 00165 Roma, RM, Italy.
| | - Francesca Petreschi
- Respiratory Unit, Academic Department of Pediatrics, Bambino Gesù Children's Hospital, Piazza di Sant'Onofrio, 4, 00165 Roma, RM, Italy.
| | - Marilena Trozzi
- Airway Surgery Unit, Department of Pediatric Surgery, Bambino Gesù Children's Hospital, Piazza di Sant'Onofrio, 4, 00165 Roma, RM, Italy.
| | - Sergio Bottero
- Airway Surgery Unit, Department of Pediatric Surgery, Bambino Gesù Children's Hospital, Piazza di Sant'Onofrio, 4, 00165 Roma, RM, Italy.
| | - Renato Cutrera
- Respiratory Unit, Academic Department of Pediatrics, Bambino Gesù Children's Hospital, Piazza di Sant'Onofrio, 4, 00165 Roma, RM, Italy.
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Taghavi K, Stringer MD. Preoperative laryngotracheobronchoscopy in infants with esophageal atresia: why is it not routine? Pediatr Surg Int 2018; 34:3-7. [PMID: 29022107 DOI: 10.1007/s00383-017-4194-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/26/2017] [Indexed: 01/28/2023]
Abstract
The value of laryngotracheobronchoscopy (LTB) immediately prior to repair of esophageal atresia with or without tracheo-esophageal fistula is contentious. Currently, there is a wide range of opinion on the utility of this investigation which is reflected by huge variation in clinical practice. This review is a critical analysis of the arguments for and against performing routine LTB prior to esophageal atresia repair. Reserving LTB for selected cases only is potentially disadvantageous since it limits the surgeon's and anesthetist's familiarity with the procedure, equipment, and range of potential findings. There is sufficient evidence to suggest that routine preoperative LTB becomes the standard of care.
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Affiliation(s)
- Kiarash Taghavi
- Department of Paediatric Surgery, Starship Children's Hospital, Auckland, New Zealand.,Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Mark D Stringer
- Department of Paediatric Surgery, Wellington Children's Hospital, Riddiford Street, Newtown, Wellington, 6021, New Zealand. .,Department of Paediatrics and Child Health, University of Otago, Wellington, New Zealand.
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Wu Y, Kuang H, Lv T, Wu C. Comparison of clinical outcomes between open and thoracoscopic repair for esophageal atresia with tracheoesophageal fistula: a systematic review and meta-analysis. Pediatr Surg Int 2017; 33:1147-1157. [PMID: 28914345 DOI: 10.1007/s00383-017-4153-9] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/20/2017] [Indexed: 12/19/2022]
Abstract
OBJECTIVE A meta-analysis was performed for a comparison of outcomes between open repair (OR) and thoracoscopic repair (TR) for esophageal atresia with tracheoesophageal fistula (EA with TEF). METHODS Electronic databases, including PubMed, Cochrane Library, and Medline, were searched systematically for the literatures aimed mainly at comparing the therapeutic effects for EA with TEF administrated by OR and TR. Corresponding data sets were extracted and two reviewers independently assessed the methodological quality. Meta-analysis was performed with Stata 12.0. RESULTS Ten studies meeting the inclusion criteria were included, involving 447 subjects in total. It was observed that OR entailed a shorter operative time with significant statistical differences (SMD 0.604; 95% CI 0.344-0.864, P = 0). While TR was superior in two aspects: shorter length of hospital stay (SMD 0.584; 95% CI 0.214-0.953; P = 0.002) and shorter first oral feeding time (SMD 0.652; 95% CI 0.27-1.035; P = 0.001). However, meta-analyses of occurrence rate of leaks (OR, 1.747; 95% CI 0.817-3.737; P = 0.15), strictures (OR, 0.937; 95% CI 0.5-1.757; P = 0.839), pulmonary complications (OR, 1.08; 95% CI 0.21-5.44; P = 0.897), fundoplication rate of Gastroesophageal Reflux Disease (GERD) (OR, 1.642; 95% CI 0.855-3.153; P = 0.601), and blood loss (SMD 0.048; 95% CI -1.292 to 1.388; P = 0.944) showed no significant differences between OR and TR. Meta-analysis of ventilation time showed similar outcome between OR and TR (SMD 0.474; 95% CI 0.02-0.968; P = 0.06), but the result remained controversial due to estimated result changing after sensitivity analysis (SMD 0.61; 95% CI 0.16-1.07; P = 0). CONCLUSIONS Compared with OR, a longer operative time was associated within TR group, although the TR procedure could possibly reduce the length of hospital stay and first oral feeding time. Meanwhile, the occurrence rate for leaks, strictures, pulmonary complications, and the fundoplication rate of GERD, and blood loss were similar between the OR and TR groups. Estimated result of ventilation time between the two groups remained ambiguous.
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Affiliation(s)
- Yuhao Wu
- Department of Cardiothoracic Surgery, Children's Hospital of Chongqing Medical University, No. 136 Zhongshan Second Road, Yuzhong District, Chongqing, 400014, China
- Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, 400014, China
- China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing, 400014, China
- Chongqing Key Laboratory of Pediatrics, Chongqing, 400014, China
| | - Hongyu Kuang
- Department of Cardiology, Children's Hospital of Chongqing Medical University, Chongqing, 400014, China
- Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, 400014, China
- China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing, 400014, China
- Chongqing Key Laboratory of Pediatrics, Chongqing, 400014, China
| | - Tiewei Lv
- Department of Cardiology, Children's Hospital of Chongqing Medical University, Chongqing, 400014, China
- Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, 400014, China
- China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing, 400014, China
- Chongqing Key Laboratory of Pediatrics, Chongqing, 400014, China
| | - Chun Wu
- Department of Cardiothoracic Surgery, Children's Hospital of Chongqing Medical University, No. 136 Zhongshan Second Road, Yuzhong District, Chongqing, 400014, China.
- Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, 400014, China.
- China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing, 400014, China.
- Chongqing Key Laboratory of Pediatrics, Chongqing, 400014, China.
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Respiratory Morbidity in Children with Repaired Congenital Esophageal Atresia with or without Tracheoesophageal Fistula. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2017; 14:ijerph14101136. [PMID: 28953251 PMCID: PMC5664637 DOI: 10.3390/ijerph14101136] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/06/2017] [Revised: 09/21/2017] [Accepted: 09/25/2017] [Indexed: 12/19/2022]
Abstract
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.
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Cervical repair of congenital tracheoesophageal fistula: Complications lurking! J Pediatr Surg 2016; 51:1623-6. [PMID: 27372236 DOI: 10.1016/j.jpedsurg.2016.06.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Revised: 06/01/2016] [Accepted: 06/09/2016] [Indexed: 12/17/2022]
Abstract
AIM Esophageal atresia (EA) and tracheoesophageal fistula (TEF) consist of a spectrum of rare congenital abnormalities. Although EA surgical treatment is well established, the outcome of EA with proximal fistula (type B and D EA) or isolated H-type fistula (type E EA) is poorly explored. These forms of EA shared a common surgical step: the need of a cervical approach to close the fistula. Therefore, the aim of present study is to evaluate postoperative outcomes of patients treated for Gross type B-D and E EA, on regards of their cervical surgery. MATERIALS AND METHODS A retrospective case series analysis of all patients affected by type B-D and E EA, and admitted to our tertiary care center between January 2003 and December 2014 was performed. All patients underwent preoperative flexible laryngo-tracheobronchoscopy (LTBS) as part of our standardized preoperative diagnostic assessment to define the diagnosis, evaluate preoperative vocal cord motility and to cannulate the fistula when required. Fistula closure was always performed through a right cervical access. Analysis of all cases and comparison between type B-D and E EA were performed. Mann-Whitney test, Chi-squared test and unpaired t test were used as appropriate; p<0.05 was considered significant. RESULTS During the study period, 180 EA newborns were treated. Proximal or isolated TEF was found in 18 patients (10%): 7 type B, 11 type E EA. Patients affected by type B and E EA/TEF frequently present associated major malformations (27%), and major cardiac abnormalities (44%). Major postoperative complications were: vocal cord paralysis (5 patients), bilateral in 2 infants requiring tracheostomy, cerebral ischemia (1 patient), and cardiac failure (1 patient). CONCLUSION Patients affected by type B and E EA have a high rate of associated abnormalities, and risk of possible sequelae. Postoperative complications are common, with possible transient vocal cord dismotility, but in some cases persistent paralysis may require tracheostomy. Therefore, both preoperative and postoperative LTBS is highly recommended to evaluate the presence of a proximal fistula, and vocal cord motility, even in asymptomatic patients, to rule out any possible intraoperative "surprise" and any vocal cord abnormality and to possibly define its pathogenesis (congenital vs. iatrogenic).
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Abstract
Neonates and infants may need a tracheostomy for many different reasons, ranging from airway obstruction to a requirement for long term mechanical ventilator support. Here, we present the pathophysiology of the many congenital and acquired conditions that might be managed with a tracheostomy. Decisions about tracheostomy demand consideration of not only the benefits, but also the potential side-effects, which may differ in the short and long term and may be attributable to underlying conditions as well as the tracheostomy. Evaluation of potential advantages of tracheostomy will influence decisions about optimal timing. In many cases, an infant may 'graduate' from dependence on a tracheostomy and resume a natural airway, although some will require reconstructive airway surgery.
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Affiliation(s)
- Sara B DeMauro
- The Children's Hospital of Philadelphia, Philadelphia, PA, USA; The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
| | - Julie L Wei
- Nemours Children's Hospital, Orlando, FL, USA; University of Central Florida College of Medicine, Orlando, FL, USA
| | - Richard J Lin
- The Children's Hospital of Philadelphia, Philadelphia, PA, USA; The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
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