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van Hal AFRL, Vlot J, van Rosmalen J, Wijnen RMH, van Gils-Frijters APJM, Gischler SJ, Staals LM, IJsselstijn H, Rietman AB. Minimally invasive surgical approach in children treated for oesophageal atresia is associated with attention problems at school age: a prospective cohort study. Eur J Pediatr 2024; 183:2131-2140. [PMID: 38363392 PMCID: PMC11035457 DOI: 10.1007/s00431-024-05449-y] [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: 11/15/2023] [Revised: 01/11/2024] [Accepted: 01/21/2024] [Indexed: 02/17/2024]
Abstract
The long-term neurodevelopment of children born with oesophageal atresia (OA) is unclear. Therefore, we assessed the neurocognitive domains and their predictors. Patients born with OA between February 2006 and December 2014, who were routinely seen at eight years as part of a structured prospective longitudinal follow-up program, were included. Main outcome measures were need for school support, performance in various neurocognitive domains and potential predictors of neurocognitive problems. We analysed data of 65 children with a mean (SD) age of 8.1 (0.2) years, of whom 89% with OA type C. Thirty-five (54%) surgical corrections were minimally invasive; the median (interquartile range) duration of exposure to anaesthetics in the first 24 months was 398 (296 - 710) minutes. Forty-four (68%) attended regular education without extra support and intelligence was within normal range (99-108). More than 50% had z-scores ≤ -2 on one or more neurocognitive domains, of which attention was the most frequently affected domain. The speed on the sustained attention task was significantly below normal (z-score -1.48 (2.12), p < .001), as was fluctuation of sustained attention (z-score -3.19 (3.80), p < .001). The minimally invasive approach and a lower socio-economic status (both p = 0.006) proved significant predictors for sustained attention problems in multivariable analyses. Conclusion: Children who undergo minimally invasive surgery for OA correction are at risk for sustained attention problems at school age. Future studies unravelling the effects of perioperative events on neurodevelopment should lead to optimal surgical, anaesthesiological, and intensive care management in the neonatal period. What is Known: • School-aged children born with oesophageal atresia have normal intelligence but problems with sustained attention at eight years. What is New: • Oesophageal atresia patients, who undergo minimally invasive surgery or who have a background of lower socioeconomic status are at serious risk for sustained attention problems at school age. • Moreover, those who have been intubated for a longer period are at risk for stronger fluctuations in sustained attention.
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Affiliation(s)
- Anne-Fleur R L van Hal
- Department of Paediatric Surgery, Erasmus Medical Centre Sophia Children's Hospital, Rotterdam, the Netherlands.
| | - John Vlot
- Department of Paediatric Surgery, Erasmus Medical Centre Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Joost van Rosmalen
- Department of Biostatistics, Erasmus Medical Centre, Rotterdam, the Netherlands
- Department of Epidemiology, Erasmus Medical Centre, Rotterdam, the Netherlands
| | - René M H Wijnen
- Department of Paediatric Surgery, Erasmus Medical Centre Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Annabel P J M van Gils-Frijters
- Department of Paediatric Surgery, Erasmus Medical Centre Sophia Children's Hospital, Rotterdam, the Netherlands
- Department of Child and Adolescent Psychiatry/Psychology, Erasmus Medical Centre Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Saskia J Gischler
- Department of Paediatric Surgery, Erasmus Medical Centre Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Lonneke M Staals
- Department of Anaesthesiology, Erasmus Medical Centre Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Hanneke IJsselstijn
- Department of Paediatric Surgery, Erasmus Medical Centre Sophia Children's Hospital, Rotterdam, the Netherlands
| | - André B Rietman
- Department of Paediatric Surgery, Erasmus Medical Centre Sophia Children's Hospital, Rotterdam, the Netherlands
- Department of Child and Adolescent Psychiatry/Psychology, Erasmus Medical Centre Sophia Children's Hospital, Rotterdam, the Netherlands
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Wang D, Zhao Y, Zhang Y, Hua K, Gu Y, Li S, Liao J, Yang S, Yang T, Zhao J, Huang J. Diagnose and treatment for Type D congenital esophageal atresia with tracheoesophageal fistula. Pediatr Investig 2024; 8:37-43. [PMID: 38516136 PMCID: PMC10951482 DOI: 10.1002/ped4.12410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 12/05/2023] [Indexed: 03/23/2024] Open
Abstract
Importance Type D esophageal atresia (EA) with tracheoesophageal fistula (TEF) is characterized by EA with both proximal and distal TEFs. It is a rare congenital anomaly with a very low incidence. Objective To investigate diagnostic and treatment strategies for this rare condition. Methods We retrospectively reviewed the clinicopathological features of patients with EA/TEF treated at our institution between January 2007 and September 2021. Results Among 386 patients with EA/TEF, 14 (3.6%) had type D EA/TEF. Only two patients were diagnosed with proximal TEF preoperatively. Seven patients were diagnosed intraoperatively. Five patients were missed for diagnosis during the initial surgery but was later confirmed by bronchoscopy. During the neonatal period, seven patients underwent a one-stage repair of proximal and distal TEF via thoracoscopy or thoracotomy. Due to missed diagnosis and other reasons, the other 7 patients underwent two-stage surgery for repair of the proximal TEF, including cervical incision and thoracoscopy. Ten of the 14 patients experienced postoperative complications including anastomotic leakage, pneumothorax, esophageal stricture, and recurrence. Patients who underwent one-stage repair of distal and proximal TEF during the neonatal period showed a higher incidence of anastomotic leak (4/7). In contrast, only one of seven patients with two-stage repair of the proximal TEF developed an anastomotic leak. Interpretation Type D EA/TEF is a rare condition, and proximal TEFs are easily missed. Bronchoscopy may aim to diagnose and determine the correct surgical approach. A cervical approach may be more suitable for repairing the proximal TEF.
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Affiliation(s)
- Dingding Wang
- Department of Neonatal SurgeryBeijing Children's Hospital, Capital Medical University, National Center for Children's HealthBeijingChina
| | - Yong Zhao
- Department of Neonatal SurgeryBeijing Children's Hospital, Capital Medical University, National Center for Children's HealthBeijingChina
| | - Yanan Zhang
- Department of Neonatal SurgeryBeijing Children's Hospital, Capital Medical University, National Center for Children's HealthBeijingChina
| | - Kaiyun Hua
- Department of Neonatal SurgeryBeijing Children's Hospital, Capital Medical University, National Center for Children's HealthBeijingChina
| | - Yichao Gu
- Department of Neonatal SurgeryBeijing Children's Hospital, Capital Medical University, National Center for Children's HealthBeijingChina
| | - Shuangshuang Li
- Department of Neonatal SurgeryBeijing Children's Hospital, Capital Medical University, National Center for Children's HealthBeijingChina
| | - Junmin Liao
- Department of Neonatal SurgeryBeijing Children's Hospital, Capital Medical University, National Center for Children's HealthBeijingChina
| | - Shen Yang
- Department of Neonatal SurgeryBeijing Children's Hospital, Capital Medical University, National Center for Children's HealthBeijingChina
| | - Ting Yang
- Department of Neonatal SurgeryBeijing Children's Hospital, Capital Medical University, National Center for Children's HealthBeijingChina
| | - Jiawei Zhao
- Department of Neonatal SurgeryBeijing Children's Hospital, Capital Medical University, National Center for Children's HealthBeijingChina
| | - Jinshi Huang
- Department of Neonatal SurgeryBeijing Children's Hospital, Capital Medical University, National Center for Children's HealthBeijingChina
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Shieh HF, Hamilton TE, Manfredi MA, Ngo PD, Wilsey MJ, Yasuda JL, Zendejas B, Smithers CJ. Evolution of left-sided thoracoscopic approach for long gap esophageal atresia repair. J Pediatr Surg 2023; 58:629-632. [PMID: 36707264 DOI: 10.1016/j.jpedsurg.2022.12.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 12/12/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Left-sided repair for long gap esophageal atresia (LGEA) has been described for patients with a large leftward upper pouch, no thoracic tracheoesophageal fistula (TEF) nor tracheobronchomalacia (TBM), or as salvage plan after prior failed right-sided repair. We describe our experience with left-sided MIS traction induced growth process. METHODS We retrospectively reviewed patients who underwent Foker process for LGEA at two institutions between December 2016 and November 2021. Patient characteristics, surgical techniques, and outcomes were reviewed. RESULTS 71 patients underwent Foker process. Of 34 MIS cases, 28 patients (82%) underwent left-sided repair (median gap length 5 cm) at median age 4 months with median 3 (range 2-8) operations and median 13.5 (IQR 11-21) days on traction until esophageal anastomosis. 9 patients (32%) underwent completely MIS approach, whereas 5 patients (18%) converted to open at first operation and 14 patients (50%) converted to open later in the traction process. Traction was internal in 68%, external in 11%, and combination in 21%. Median follow-up was 15.4 (IQR 7.5-31.7) months after anastomosis. 14% had anastomotic leak managed with antibiotics and/or esophageal vacuum therapy. Median number of esophageal dilations was 3.5 (range 0-13). 18% required stricture resection. 39% underwent Nissen fundoplication. None have needed esophageal replacement. CONCLUSIONS For multiple reasons including the tendency of both esophageal pouches to have a leftward bias, less tracheal compression by upper pouch, and clean field of surgery for reoperative cases, we now more commonly use left-sided approach for MIS LGEA repair compared to right side, regardless of left aortic arch. LEVEL OF EVIDENCE Level IV Treatment Study.
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Affiliation(s)
- Hester F Shieh
- Department of Surgery, Johns Hopkins All Children's Hospital, 501 6th Ave S, St. Petersburg, FL 33701, United States.
| | - Thomas E Hamilton
- Department of Surgery, Boston Children's Hospital, 300 Longwood Ave, Boston, MA 02115, United States
| | - Michael A Manfredi
- Department of Gastroenterology, Boston Children's Hospital, 300 Longwood Ave, Boston, MA 02115, United States
| | - Peter D Ngo
- Department of Gastroenterology, Boston Children's Hospital, 300 Longwood Ave, Boston, MA 02115, United States
| | - Michael J Wilsey
- Department of Gastroenterology, Johns Hopkins All Children's Hospital, 501 6th Ave S, St. Petersburg, FL 33701, United States
| | - Jessica L Yasuda
- Department of Gastroenterology, Boston Children's Hospital, 300 Longwood Ave, Boston, MA 02115, United States
| | - Benjamin Zendejas
- Department of Surgery, Boston Children's Hospital, 300 Longwood Ave, Boston, MA 02115, United States
| | - C Jason Smithers
- Department of Surgery, Johns Hopkins All Children's Hospital, 501 6th Ave S, St. Petersburg, FL 33701, United States
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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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Gutierrez RS, Guelfand M, Balbontin PV. Congenital and acquired tracheoesophageal fistulas in children. Semin Pediatr Surg 2021; 30:151060. [PMID: 34172208 DOI: 10.1016/j.sempedsurg.2021.151060] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Tracheoesophageal fistulas (TEF) are an anomalous communication between airway and esophagus. There are several types of TEF. Congenital are mainly associated to an esophageal atresia. The type III or C, in which the upper segment of the esophagus ends in a blind pouch and there is distal tracheoesophageal fistula above the carina, accounts for 85% of esophageal atresias. The other are extremely infrequent. H-type or N-type TEF, classified as type 5 or E, is an uncommon variant and accounts for less than 4%. Recurrent TEF is a serious complication after first surgery of esophageal atresia and TEF. The rate of recurrence of TEF is estimated between 3-15%. The treatment is a challenge with a high rate of recurrence after surgery. Classical symptoms of RTEF include coughing especially after drinking, abdominal distension, repeated cyanosis, and respiratory infections. In the case of H-type fistula the symptoms are similar but appear during the first month of life. In this chapter we presented the management and alternative treatments of the congenital and acquired TEF.
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Affiliation(s)
- Rocío S Gutierrez
- Department of Pediatric Surgery and Urology, University Hospital Arnau de Vilanova, Lleida, Spain.
| | - Miguel Guelfand
- Division of Pediatric Surgery, Exequiel Gonzalez Cortes Children´s Hospital, Clinica Las Condes Medical Center, Santiago, Chile
| | - Patricio Varela Balbontin
- Division of Pediatric Surgery, Luis Calvo Mackenna Children´s Hospital, University of Chile, Clinica Las Condes Medical Center, Santiago, Chile
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Sampat K, Losty PD. Diagnostic and management strategies for congenital H-type tracheoesophageal fistula: a systematic review. Pediatr Surg Int 2021; 37:539-547. [PMID: 33474597 PMCID: PMC8026411 DOI: 10.1007/s00383-020-04853-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/29/2020] [Indexed: 01/10/2023]
Abstract
BACKGROUND H type tracheoesophageal fistula (H-TEF) is a rare congenital anomaly. Management may be complicated by late diagnosis and variation(s) in the therapeutic strategy. A systematic review of published studies explores the utility of diagnostic studies, operations and postoperative complications. METHODS Medline and PubMed database(s) were searched for ALL studies reporting H-TEF during 1997-2020. Using PRISMA methodology, manuscripts were screened for eligibility and reporting. RESULTS Forty-seven eligible studies were analysed. Primary diagnosis varied widely with surgeons performing oesophagography and trachea-bronchoscopy. Preoperative localisation techniques included fluoroscopy, guidewire placement and catheterisation. A cervical approach (209 of 272 cases), as well as thoracotomy, thoracoscopy and endoscopic fistula ligation, were all described. Morbidity included fistula recurrence (1.7%), leak (2%), tracheomalacia (3.4%) and respiratory sequelae (1%). The major adverse complication in all studies was vocal cord palsy secondary to laryngeal nerve injury (18.5%) yet strikingly few centres routinely reported undertaking vocal cord screening pre or postoperatively. CONCLUSION This study shows that paediatric surgeons record low volume activity with H type tracheoesophageal fistula. Variation(s) in clinical practice are widely evident. Laryngeal nerve injury and its subsequent management warrant special consideration. Care pathways may offset attendant morbidity and define 'best practice.'
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Affiliation(s)
- Keerthika Sampat
- Department of Paediatric Surgery, Alder Hey Childrens’ Hospital, Liverpool, UK
| | - Paul D. Losty
- Department of Paediatric Surgery, Alder Hey Childrens’ Hospital, Liverpool, UK ,Institute of Child Health, School of Health And Life Science, University of Liverpool, Liverpool, UK
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Kulshrestha S, Kulshrestha M, Tewari V, Chaturvedi N, Goyal A, Sharma RK, Sarkar D, Tandon JN, Katyal V. Conservative Management of Major Anastomotic Leaks Occurring after Primary Repair in Esophageal Atresia with Fistula: Role of Extrapleural Approach. J Indian Assoc Pediatr Surg 2020; 25:155-162. [PMID: 32581443 PMCID: PMC7302468 DOI: 10.4103/jiaps.jiaps_73_19] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 09/28/2019] [Accepted: 11/23/2019] [Indexed: 11/08/2022] Open
Abstract
Aims: We are reporting single-institution's experience regarding the role of conservative management in 38 cases of minor and major anastomotic leaks [AL] occurring after primary surgery of esophageal atresia [EA] with tracheo-esophageal fistula [TEF] during last 17 years between 2000 and 2017. In this retrospective review, we are sharing our experience and protocol of management of AL with more emphasis to evaluate: (a) role of conservative treatment in major AL (b) role of extra-pleural approach in enhancing the success rate in conservative treatment in major AL (c) to define the criteria for major & minor leaks and (d) to evaluate the role of ventilation in primary EA surgery to control AL. Methods: All these cases were operated through extra-pleural approach and out of total 203 cases, 38[18.7%] developed anastomotic leaks. In 29 of the 38 cases [14.3%], leak was minor and in 9 cases [4.4%] the leak was a major one. All these cases of leaks were managed conservatively. Results: All cases of major and minor leaks showed spontaneous healing except one case of minor leak that died before healing due to major cardiac anomaly. For minor leaks, average healing time was 9.5 days while for major leaks it was 17.4 days. Overall mortality was 14.8% and there was no mortality directly attributable to major or minor leak. During follow up, the incidence of stricture was 40% in cases having anastomotic leaks, while in cases without a leak, the incidence of stricture was 23.3%. These all cases of stricture responded to regular dilatations. Conclusion: We believe in cases of major AL, where primary repair is done by EP approach, a conservative treatment should be the treatment of choice. With this conservative approach of management of major AL, we not only save the native esophagus, the best conduit, but there is also less morbidity and mortality.
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Affiliation(s)
- Sanjay Kulshrestha
- Division of Pediatric Surgery, Sarkar Hospital for Women and Children, Agra, Uttar Pradesh, India
| | - Meeta Kulshrestha
- Division of Pediatric Surgery, Sarkar Hospital for Women and Children, Agra, Uttar Pradesh, India
| | - Vinay Tewari
- Division of Anesthesiology, Sarkar Hospital for Women and Children, Agra, Uttar Pradesh, India
| | - Nikhil Chaturvedi
- Department of Pediatrics, Sarkar Hospital for Women and Children, Agra, Uttar Pradesh, India
| | - Atul Goyal
- Department of Pediatrics, Sarkar Hospital for Women and Children, Agra, Uttar Pradesh, India
| | - Ram Kshitij Sharma
- Department of Pediatrics, Sarkar Hospital for Women and Children, Agra, Uttar Pradesh, India
| | - Debashish Sarkar
- Department of Obstetrics and Gynecology, Sarkar Hospital for Women and Children, Agra, Uttar Pradesh, India
| | | | - Vijay Katyal
- Department of Pediatrics, Sarkar Hospital for Women and Children, Agra, Uttar Pradesh, India
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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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Cano Novillo I, Aneiros Castro B, García Vázquez A, De Miguel Moya M. Thoracoscopic recurrent tracheo-oesophageal fistula repair with mini endostapler: promising solution. BMJ Case Rep 2019; 12:12/5/e229365. [PMID: 31151978 DOI: 10.1136/bcr-2019-229365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Recurrent tracheo-oesophageal fistula (TOF) is a common complication in children who underwent oesophageal atresia repair. The traditional surgical approach performed either by thoracotomy or cervicotomy is associated with a high rate of morbidity, mortality and new recurrence. In the last decades, endoscopic techniques have emerged as the minimally invasive alternative. However, it seems that the optimal treatment is still unknown. We present a patient with a recurrent TOF who underwent thoracoscopic closure using a 5.8 mm endostapler. The patient was extubated at the end of the procedure, and he started feeding the day after surgery. At 15 months of follow-up, he is asymptomatic. Thoracoscopic closure of TOF using endostaplers seems to be a safe alternative with some possible benefits compared with traditional and endoscopic approach.
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