1
|
van Hal AFRL, Aanen IP, Wijnen RMH, Pullens B, Vlot J. The Value of Preoperative Rigid Tracheobronchoscopy for the Diagnosis of Tracheomalacia in Oesophageal Atresia Patients. J Pediatr Surg 2024:S0022-3468(24)00415-9. [PMID: 39089893 DOI: 10.1016/j.jpedsurg.2024.07.005] [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: 04/08/2024] [Revised: 07/05/2024] [Accepted: 07/08/2024] [Indexed: 08/04/2024]
Abstract
BACKGROUND Oesophageal atresia (OA) is often accompanied by tracheomalacia (TM). The aim of this study was to evaluate its presence in OA patients during routine rigid tracheobronchoscopy (TBS) before primary correction and compare this to postoperative TBS and clinical signs of TM. METHODS This retrospective cohort study included patients born with OA between June 2013 and December 2022 who had received a TBS before OA correction and had been followed for at least twelve months. Definite TM was postoperatively diagnosed through TBS, and probable TM was defined as having symptoms of TM. RESULTS We analysed data from 79 patients, of whom 87% with OA type C. Preoperatively, TM was observed in 33 patients (42% of all patients), seven of whom had severe TM. Definite TM was observed in 21 patients (27%), of whom 15 had severe TM. Forty-one patients (52% of all patients) had developed symptoms of TM within twelve months, including harsh barking cough (n = 15), stridor and/or wheezing (n = 20), recurrent respiratory insufficiency (n = 11), or needing airway surgery (n = 7). The sensitivity of preoperative TBS for the presence of postoperative (definite and probable combined) TM is 50.0%, 95% CI [35.2-64.8], and the specificity 67.6%, 95% CI [51.7-81.1]. Clinical characteristics did not differ between the patients with or without postoperative TM. CONCLUSIONS More than half of the studied patients with OA experienced symptoms of TM. While preoperative TBS is routinely performed prior to surgical OA correction, its predictive value for the presence of postoperative TM remains limited. LEVEL OF EVIDENCE Level II. TYPE OF STUDY Study of Diagnostics Test.
Collapse
Affiliation(s)
- Anne-Fleur R L van Hal
- Department of Paediatric Surgery, Erasmus University Medical Center - Sophia Children's Hospital, Dr. Molewaterplein 40, 3015 GD Rotterdam, the Netherlands.
| | - Irene P Aanen
- Department of Paediatric Surgery, Erasmus University Medical Center - Sophia Children's Hospital, Dr. Molewaterplein 40, 3015 GD Rotterdam, the Netherlands
| | - René M H Wijnen
- Department of Paediatric Surgery, Erasmus University Medical Center - Sophia Children's Hospital, Dr. Molewaterplein 40, 3015 GD Rotterdam, the Netherlands
| | - Bas Pullens
- Department of Otorhinolaryngology and Head and Neck Surgery, Erasmus University Medical Center - Sophia Children's Hospital, Dr. Molewaterplein 40, 3015 GD Rotterdam, the Netherlands
| | - John Vlot
- Department of Paediatric Surgery, Erasmus University Medical Center - Sophia Children's Hospital, Dr. Molewaterplein 40, 3015 GD Rotterdam, the Netherlands
| |
Collapse
|
2
|
Sumida W, Yasui A, Shirota C, Makita S, Okamoto M, Ogata S, Takimoto A, Takada S, Nakagawa Y, Kato D, Gohda Y, Amano H, Guo Y, Hinoki A, Uchida H. Update on aortopexy and posterior tracheopexy for tracheomalacia in patients with esophageal atresia. Surg Today 2024; 54:211-219. [PMID: 36729255 DOI: 10.1007/s00595-023-02652-6] [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] [Received: 08/11/2022] [Accepted: 10/25/2022] [Indexed: 02/03/2023]
Abstract
Despite improving the survival after repair of esophageal atresia (EA), the morbidity of EA repair remains high. Specifically, tracheomalacia (TM) is one of the most frequent complications of EA repair. Continuous positive airway pressure is generally applied for the treatment of TM. However, surgical intervention is required against an apparent life-threatening event or inability to perform extubation for a long period. According to our review, most cases of TM showed symptom improvement after aortopexy. The ratio of the trachea's lateral and anterior-posterior diameter at the brachiocephalic artery crossing the trachea, which reflects the compression of the trachea by the brachiocephalic artery, is a good indicator of aortopexy. Our finding suggests that most TM cases associated with EA may not be caused by tracheal fragility alone, but may involve blood vessel compression. Posterior tracheopexy (PT) is also an effective treatment for TM. Recently, open or thoracoscopic PT was able to be performed simultaneously with EA repair. In many cases, aortopexy or PT is a safe and effective surgical treatment for TM with EA. Other surgical procedures, such as external stenting, should be considered for patients with diffuse-type TM for whom aortopexy and PT appear relatively ineffective.
Collapse
Affiliation(s)
- Wataru Sumida
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Akihiro Yasui
- Department of Pediatric Surgery, Anjo Kosei Hospital, Anjo, Japan
| | - Chiyoe Shirota
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Satoshi Makita
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Masamune Okamoto
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Seiya Ogata
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Aitaro Takimoto
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Shunya Takada
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Yoichi Nakagawa
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Daiki Kato
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Yousuke Gohda
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Hizuru Amano
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Yaohui Guo
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Akinari Hinoki
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Hiroo Uchida
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan.
| |
Collapse
|
3
|
Mohammed S, Kamran A, Izadi S, Visner G, Frain L, Demehri FR, Shieh HF, Jennings RW, Smithers CJ, Zendejas B. Primary Posterior Tracheopexy at Time of Esophageal Atresia Repair Significantly Reduces Respiratory Morbidity. J Pediatr Surg 2024; 59:10-17. [PMID: 37903674 DOI: 10.1016/j.jpedsurg.2023.09.028] [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: 08/28/2023] [Accepted: 09/08/2023] [Indexed: 11/01/2023]
Abstract
PURPOSE Esophageal atresia with tracheoesophageal fistula (EA/TEF) is often associated with tracheobronchomalacia (TBM), which contributes to respiratory morbidity. Posterior tracheopexy (PT) is an established technique to treat TBM that develops after EA/TEF repair. This study evaluates the impact of primary PT at the time of initial EA/TEF repair. METHODS Review of all newborn primary EA/TEF repairs (2016-2021) at two institutions. Long-gap EA and reoperative cases were excluded. Based on surgeon preference and preoperative bronchoscopy, neonates underwent primary PT (EA + PT Group) or not (EA Group). Perioperative, respiratory and nutritional outcomes within the first year of life were evaluated. RESULTS Among 63 neonates, 21 (33%) underwent PT during EA/TEF repair. Groups were similar in terms of demographics, approach, and complications. Neonates in the EA + PT Group were significantly less likely to have respiratory infections requiring hospitalization within the first year of life (0% vs 26%, p = 0.01) or blue spells (0% vs 19%, p = 0.04). Also, they demonstrated improved weight-for-age z scores at 12 months of age (0.24 vs -1.02, p < 0.001). Of the infants who did not undergo primary PT, 10 (24%) developed severe TBM symptoms and underwent tracheopexy during the first year of life, whereas no infant in the EA + PT Group needed additional airway surgery (p = 0.01). CONCLUSION Incorporation of posterior tracheopexy during newborn EA/TEF repair is associated with significantly reduced respiratory morbidity within the first year of life. LEVEL OF EVIDENCE Level III.
Collapse
Affiliation(s)
- Somala Mohammed
- Department of Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Ali Kamran
- Department of Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Shawn Izadi
- Department of Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Gary Visner
- Department of Pediatrics, Boston Children's Hospital, Boston, MA, USA
| | - Leah Frain
- Department of Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Farokh R Demehri
- Department of Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Hester F Shieh
- Department of Surgery, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
| | - Russell W Jennings
- Department of Surgery, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
| | - Charles J Smithers
- Department of Surgery, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
| | | |
Collapse
|
4
|
Zhou C, Dong J, Li B, Li M, Zou C, Xiao Y, Xu G, Li B. Effects of primary posterior tracheopexy in thoracoscopic repair of esophageal atresia. Heliyon 2023; 9:e15931. [PMID: 37215794 PMCID: PMC10195884 DOI: 10.1016/j.heliyon.2023.e15931] [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: 03/06/2023] [Revised: 04/25/2023] [Accepted: 04/27/2023] [Indexed: 05/24/2023] Open
Abstract
Background This study aimed to evaluate the effectiveness of primary posterior tracheopexy (PPT) in reducing ventilator dependence after repair of esophageal atresia (EA), and the risk of respiratory tract infections (RTI) requiring readmissions within one year. Methods This retrospective cohort study recruited patients with EA admitted to our hospital between June 2020 and December 2021. Results In the PPT group (n = 17), the time to extubation after surgery was 86.7 h for 12 patients, with one patient (8.3%) requiring repeated postoperation intubation; six-in-sixteen patients (37.5%) experience at least one RTI requiring hospitalization in one year. In the non-PPT group (n = 17), the time to extubation was 127.0 h for 14 patients, with six-in-fourteen patients (42.9%) requiring repeated intubation; twelve-in-seventeen patients (70.6%) experienced at least one RTI requiring hospitalization in one year. Conclusions Although the differences did not reach statistical significance due to limited number of participants, patients underwent PPT during EA repair had lower chance of repeated intubation and decreased risk of RTI requiring admissions within one year.
Collapse
Affiliation(s)
- Chonggao Zhou
- Department of Fetal & Neonatal Surgery, Hunan Children's Hospital, Changsha 410007, China
| | - Jie Dong
- Pediatrics Research Institute of Hunan Province, Hunan Children's Hospital, Changsha 410007, China
| | - Bo Li
- Department of Fetal & Neonatal Surgery, Hunan Children's Hospital, Changsha 410007, China
| | - Ming Li
- Department of Fetal & Neonatal Surgery, Hunan Children's Hospital, Changsha 410007, China
| | - Chanjuan Zou
- Department of Fetal & Neonatal Surgery, Hunan Children's Hospital, Changsha 410007, China
| | - Yong Xiao
- Department of Fetal & Neonatal Surgery, Hunan Children's Hospital, Changsha 410007, China
| | - Guang Xu
- Department of Fetal & Neonatal Surgery, Hunan Children's Hospital, Changsha 410007, China
| | - Bixiang Li
- Department of Fetal & Neonatal Surgery, Hunan Children's Hospital, Changsha 410007, China
| |
Collapse
|
5
|
Yasui A, Hinoki A, Amano H, Shirota C, Tainaka T, Sumida W, Yokota K, Makita S, Okamoto M, Takimoto A, Nakagawa Y, Uchida H. Thoracoscopic posterior tracheopexy during primary esophageal atresia repair ameliorate tracheomalacia in neonates: a single-center retrospective comparative cohort study. BMC Surg 2022; 22:285. [PMID: 35879691 PMCID: PMC9310495 DOI: 10.1186/s12893-022-01738-1] [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: 02/13/2022] [Accepted: 07/20/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Esophageal atresia (EA) is often associated with tracheomalacia (TM). The severity of TM symptoms varies widely, with serious cases requiring prolonged respiratory support and surgical treatment. Although we performed thoracoscopic posterior tracheopexy (TPT) during primary EA repair to prevent or reduce the symptoms of TM, few studies have investigated the safety and effectiveness of TPT during primary EA repair. Therefore, this study aimed to evaluate the safety and efficacy of TPT in neonates. METHODS We retrospectively reviewed the records of all patients diagnosed with TM who underwent primary thoracoscopic EA repair between 2013 and 2020 at the Nagoya University Hospital. Patients were divided into two groups: TPT (TPT group) and without TPT (control group). TPT has been performed in all patients with EA complicated by TM since 2020. We compared patient backgrounds, surgical outcomes, postoperative complications, and treatment efficacy. RESULTS Of the 22 patients reviewed, eight were in the TPT group and 14 were in the control group. There were no statistically significant differences in the surgical outcomes between the groups (operation time: p = 0.31; blood loss: p = 0.83; time to extubation: p = 0.30; time to start enteral feeding: p = 0.19; time to start oral feeding: p = 0.43). Conversion to open thoracotomy was not performed in any case. The median operative time required for posterior tracheopexy was 10 (8-15) min. There were no statistically significant differences in postoperative complications between the groups (chylothorax: p = 0.36; leakage: p = 1.00; stricture: p = 0.53). The respiratory dependence rate 30 days postoperative (2 [25%] vs. 11 [79%], p = 0.03) and the ratio of the lateral and anterior-posterior diameter of the trachea (LAR) were significantly lower in the TPT group (1.83 [1.66-2.78] vs. 3.59 [1.80-7.70], p = 0.01). CONCLUSIONS TPT during primary EA repair for treatment of TM significantly lowered respiratory dependence rate at 30 days postoperative without increasing the risk of postoperative complications. This study suggested that TPT could improve TM associated with EA.
Collapse
Affiliation(s)
- Akihiro Yasui
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan
| | - Akinari Hinoki
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan
| | - Hizuru Amano
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan
| | - Chiyoe Shirota
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan
| | - Takahisa Tainaka
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan
| | - Wataru Sumida
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan
| | - Kazuki Yokota
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan
| | - Satoshi Makita
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan
| | - Masamune Okamoto
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan
| | - Aitaro Takimoto
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan
| | - Yoichi Nakagawa
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan
| | - Hiroo Uchida
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan.
| |
Collapse
|
6
|
Nøhr A, Ifaoui IBR, Lauritsen TL, Hjuler T. An occult tracheal pouch causing life-threatening endotracheal tube displacements in an infant after repair of esophageal atresia with tracheoesophageal fistula. OTOLARYNGOLOGY CASE REPORTS 2021. [DOI: 10.1016/j.xocr.2021.100302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
|
7
|
Jo Svetanoff W, Zendejas B, Ngo P, Manfredi M, Hamilton TE, Jennings RW, Smithers CJ. The left-sided repair: An alternative approach for difficult esophageal atresia repair. J Pediatr Surg 2021; 56:938-943. [PMID: 33248682 DOI: 10.1016/j.jpedsurg.2020.11.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 10/27/2020] [Accepted: 11/02/2020] [Indexed: 11/15/2022]
Abstract
PURPOSE We describe a left-sided approach for long gap esophageal atresia (LGEA) repair in patients who have a large leftward upper pouch and no significant tracheomalacia, or as a salvage strategy after prior failed right-sided repairs. METHODS Retrospective review of patients who underwent repair via traction induced growth (Foker procedure [FP]) from 2014 to 2019 was performed. Surgical technique and post-operative outcomes were evaluated. RESULTS Of 47 LGEA patients, 18 (38%) were approached via the left side - 94% had a left aortic arch, and 22% had prior attempts at a right-sided anastomosis. More left-sided patients underwent minimally invasive repair (39% vs 7%, p = 0.007) and internal traction (50% vs 10%, p = 0.002) compared to right-sided patients. On multivariate analysis, internal traction was associated with a decreased length of paralysis (p<0.01); length of intubation and hospital stay were similar between groups. Anastomotic leak (17% vs 20%, p = 0.80) and stricture resection (6% vs 24%, p = 0.12) rates were similar. No left-sided FP patient required additional surgery for tracheomalacia, while six right-sided patients required intervention. CONCLUSION Left-sided FP can be considered for LGEA patients with a large leftward upper pouch or as a salvage pathway after a failed right chest approach, with similar outcomes to the right-sided approach.
Collapse
Affiliation(s)
- Wendy Jo Svetanoff
- Department of General Surgery, Boston Children's Hospital, 300 Longwood Ave, Boston, MA 02115, United States; Department of Pediatric Surgery, Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO 64108, United States
| | - Benjamin Zendejas
- Department of General Surgery, Boston Children's Hospital, 300 Longwood Ave, Boston, MA 02115, United States
| | - Peter Ngo
- Division of Gastroenterology, Hepatology, and Nutrition, Boston Children's Hospital, 300 Longwood Ave, Boston, MA 02115, United States
| | - Michael Manfredi
- Division of Gastroenterology, Hepatology, and Nutrition, Boston Children's Hospital, 300 Longwood Ave, Boston, MA 02115, United States
| | - Thomas E Hamilton
- Department of General Surgery, Boston Children's Hospital, 300 Longwood Ave, Boston, MA 02115, United States
| | - Russell W Jennings
- Department of General Surgery, Boston Children's Hospital, 300 Longwood Ave, Boston, MA 02115, United States
| | - C Jason Smithers
- Department of General Surgery, Boston Children's Hospital, 300 Longwood Ave, Boston, MA 02115, United States; Department of Surgery, Johns Hopkins All Children's Hospital, 601 5th St S, Ste306, St. Petersburg, FL 33701, United States.
| |
Collapse
|
8
|
Kamran A, Zendejas B, Meisner J, Choi SS, Munoz-San Julian C, Ngo P, Manfredi M, Yasuda JL, Smithers CJ, Hamilton TE, Jennings RW. Effect of Posterior Tracheopexy on Risk of Recurrence in Children after Recurrent Tracheo-Esophageal Fistula Repair. J Am Coll Surg 2021; 232:690-698. [PMID: 33556502 DOI: 10.1016/j.jamcollsurg.2021.01.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 01/14/2021] [Accepted: 01/14/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND A recurrent tracheo-esophageal fistula can complicate esophageal atresia and tracheo-esophageal fistula (TEF) repair in children. Therapeutic approaches and the rate of recurrence vary widely. Most reports are limited by small cohorts and short-term follow-up, and rates of re-recurrence are substantial, making it difficult to select the treatment of choice. We aimed to review our experience with the treatment of recurrent TEF using posterior tracheopexy, focusing on operative risks and long-term outcomes. STUDY DESIGN We conducted a retrospective review of patients with esophageal atresia TEF with recurrent TEF treated at 2 institutions from 2011 to 2020. We approach recurrent TEFs surgically. Once the TEF is divided and repaired, the membranous trachea is sutured to the anterior longitudinal ligament of the spine (posterior tracheopexy) and the esophagus is rotated into the right chest (rotational esophagoplasty), separating the suture lines widely. To detect re-recurrence, patients undergo endoscopic surveillance during follow-up. RESULTS Sixty-two patients with a recurrent TEF were surgically treated (posterior tracheopexy/rotational esophagoplasty) at a median age of 14 months. All had significant respiratory symptoms. On referral, 24 had earlier failed endoscopic and/or surgical attempts at repair. Twenty-nine required a concomitant esophageal anastomotic stricturoplasty or stricture resection. Postoperative morbidity included 3 esophageal leaks, and 1 transient vocal cord dysfunction. We have identified no recurrences, with a median follow-up of 2.5 years, and all symptoms have resolved. CONCLUSIONS The surgical treatment of recurrent TEFs that incorporates a posterior tracheopexy and rotational esophagoplasty is highly effective for preventing re-recurrence with low perioperative morbidity.
Collapse
Affiliation(s)
- Ali Kamran
- Departments of General Surgery, Boston Children's Hospital, Boston, MA
| | - Benjamin Zendejas
- Departments of General Surgery, Boston Children's Hospital, Boston, MA
| | - Jay Meisner
- Departments of General Surgery, Boston Children's Hospital, Boston, MA
| | - Sukgi S Choi
- Otolaryngology and Communication Enhancement, Boston Children's Hospital, Boston, MA
| | | | - Peter Ngo
- Division of Gastroenterology, Hepatology, and Nutrition, Boston Children's Hospital, Boston, MA
| | - Michael Manfredi
- Division of Gastroenterology, Hepatology, and Nutrition, Boston Children's Hospital, Boston, MA
| | - Jessica L Yasuda
- Division of Gastroenterology, Hepatology, and Nutrition, Boston Children's Hospital, Boston, MA
| | - C Jason Smithers
- Department of Surgery, Johns Hopkins All Children's Hospital, St Petersburg, FL
| | - Thomas E Hamilton
- Departments of General Surgery, Boston Children's Hospital, Boston, MA
| | | |
Collapse
|
9
|
van Tuyll van Serooskerken ES, Tytgat SHAJ, Verweij JW, Bittermann AJN, Coenraad S, Arets HGM, van der Zee DC, Lindeboom MYA. Primary Posterior Tracheopexy in Esophageal Atresia Decreases Respiratory Tract Infections. Front Pediatr 2021; 9:720618. [PMID: 34568240 PMCID: PMC8459008 DOI: 10.3389/fped.2021.720618] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 08/11/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Esophageal atresia (EA) is often accompanied by tracheomalacia (TM). TM can lead to severe respiratory complaints requiring invasive treatment. This study aims to evaluate if thoracoscopic primary posterior tracheopexy (PPT) can prevent the potential sequelae of TM in patients with EA. Methods: A cohort study including all consecutive EA patients treated between 2014 and July 2019 at the Wilhelmina Children's Hospital was conducted. Two groups were distinguished: (group 1) all EA patients born between January 2014 and December 2016 and (group 2) all EA patients born between January 2017 and July 2019, after introduction of PPT. In the latter group, PPT was performed in EA patients with moderate (33-66%) or severe (67-100%) tracheomalacia, seen during preoperative bronchoscopy. Group differences were assessed using the Fisher's exact test for bivariate variables and the Mann-Whitney U-test for continuous variables. Results: A total of 64 patients were included in this study (28 patients in group 1; 36 patients in group 2). In group 2, PPT was performed in 14 patients. Respiratory tract infections (RTIs) requiring antibiotics within the first year of life occurred significantly less in group 2 (61 vs. 25%, p = 0.004). Brief resolved unexplained events (BRUEs) seemed to diminish in group 2 compared to group 1 (39 vs. 19%, p = 0.09). Conclusion: Thoracoscopic primary posterior tracheopexy decreases the number of respiratory tract infections in EA patients. The clinical impact of reducing RTIs combined with the minimal additional operating time and safety of PPT outweighs the risk of overtreatment.
Collapse
Affiliation(s)
| | - Stefaan H A J Tytgat
- Department of Pediatric Surgery, Pediatric Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, Netherlands.,Congenital Esophageal and Airway Team Utrecht, Pediatric Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, Netherlands
| | - Johannes W Verweij
- Department of Pediatric Surgery, Pediatric Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, Netherlands.,Congenital Esophageal and Airway Team Utrecht, Pediatric Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, Netherlands
| | - Arnold J N Bittermann
- Congenital Esophageal and Airway Team Utrecht, Pediatric Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, Netherlands.,Department of Pediatric Otorhinolaryngology, Pediatric Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, Netherlands
| | - Saskia Coenraad
- Congenital Esophageal and Airway Team Utrecht, Pediatric Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, Netherlands.,Department of Pediatric Otorhinolaryngology, Pediatric Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, Netherlands
| | - Hubertus G M Arets
- Congenital Esophageal and Airway Team Utrecht, Pediatric Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, Netherlands.,Department of Pediatric Pulmonology, Pediatric Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, Netherlands
| | - David C van der Zee
- Department of Pediatric Surgery, Pediatric Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, Netherlands.,Congenital Esophageal and Airway Team Utrecht, Pediatric Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, Netherlands
| | - Maud Y A Lindeboom
- Department of Pediatric Surgery, Pediatric Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, Netherlands.,Congenital Esophageal and Airway Team Utrecht, Pediatric Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, Netherlands
| |
Collapse
|
10
|
When to consider a posterolateral descending aortopexy in addition to a posterior tracheopexy for the surgical treatment of symptomatic tracheobronchomalacia. J Pediatr Surg 2020; 55:2682-2689. [PMID: 32444171 DOI: 10.1016/j.jpedsurg.2020.04.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Revised: 03/09/2020] [Accepted: 04/23/2020] [Indexed: 11/23/2022]
Abstract
PURPOSES The descending thoracic aorta typically crosses posterior to the left mainstem bronchus (LMSB). We sought to evaluate patient factors that may lead one to consider a posterolateral descending thoracic aortopexy (PLDA) in addition to a posterior tracheopexy (PT) in the surgical treatment of symptomatic tracheobronchomalacia (TBM) that involves the LMSB. METHODS Retrospective review of patients who underwent PT with or without PLDA between 2012 and 2017. Severity and extent of TBM were assessed using dynamic tracheobronchoscopy. Aortic positioning compared to the anterior border of the spine (ABS) at the level of the left mainstem bronchus was identified on computed tomography (CT). Factors associated with performing a PLDA were evaluated with logistic regression. RESULTS Of 188 patients who underwent a PT, 70 (37%) also had a PLDA performed. On multivariate analysis, >50% LMSB compression on bronchoscopy (OR 8.06, p < 0.001), >50% of the aortic diameter anterior to the ABS (OR 2.06, p = 0.05), and more recent year of surgery (OR 1.61, p = 0.003) were associated with performing a PLDA. CONCLUSION When performing a PT, a PLDA should be considered for patients who have >50% LMSB compression on dynamic bronchoscopy, and in those with a descending thoracic aorta located >50% anterior to the ABS. LEVEL OF EVIDENCE III TYPE OF STUDY: Retrospective comparative study.
Collapse
|
11
|
Koumbourlis AC, Belessis Y, Cataletto M, Cutrera R, DeBoer E, Kazachkov M, Laberge S, Popler J, Porcaro F, Kovesi T. Care recommendations for the respiratory complications of esophageal atresia-tracheoesophageal fistula. Pediatr Pulmonol 2020; 55:2713-2729. [PMID: 32716120 DOI: 10.1002/ppul.24982] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 07/18/2020] [Accepted: 07/22/2020] [Indexed: 12/11/2022]
Abstract
Tracheoesophageal fistula (TEF) with esophageal atresia (EA) is a common congenital anomaly that is associated with significant respiratory morbidity throughout life. The objective of this document is to provide a framework for the diagnosis and management of the respiratory complications that are associated with the condition. As there are no randomized controlled studies on the subject, a group of experts used a modification of the Rand Appropriateness Method to describe the various aspects of the condition in terms of their relative importance, and to rate the available diagnostic methods and therapeutic interventions on the basis of their appropriateness and necessity. Specific recommendations were formulated and reported as Level A, B, and C based on whether they were based on "strong", "moderate" or "weak" agreement. The tracheomalacia that exists in the site of the fistula was considered the main abnormality that predisposes to all other respiratory complications due to airway collapse and impaired clearance of secretions. Aspiration due to impaired airway protection reflexes is the main underlying contributing mechanism. Flexible bronchoscopy is the main diagnostic modality, aided by imaging modalities, especially CT scans of the chest. Noninvasive positive airway pressure support, surgical techniques such as tracheopexy and rarely tracheostomy are required for the management of severe tracheomalacia. Regular long-term follow-up by a multidisciplinary team was considered imperative. Specific templates outlining the elements of the clinical respiratory evaluation according to the patients' age were also developed.
Collapse
Affiliation(s)
- Anastassios C Koumbourlis
- Division of Pulmonary & Sleep Medicine, Children's National Hospital, George Washington University School of Medicine & Health Sciences, Washington, District of Columbia
| | - Yvonne Belessis
- Department of Respiratory Medicine, Sydney Children's Hospital Randwick, Randwick, New South Wales, Australia
| | - Mary Cataletto
- Division of Pediatric Pulmonary Medicine, New York University, Winthrop University Hospital, Mineola, New York
| | - Renato Cutrera
- Academic Department of Pediatrics (DPUO), Pediatric Pulmonology & Respiratory Intermediate Care Unit, Sleep and Long Term Ventilation Unit, Pediatric Hospital "Bambino Gesù" Research Institute, Rome, Italy
| | - Emily DeBoer
- Department of Pediatrics, Section of Pulmonary and Sleep Medicine, University of Colorado Denver, Children's Hospital Colorado Breathing Institute, Aurora, Colorado
| | - Mikhail Kazachkov
- Department of Pediatric Pulmonology, Gastroesophageal, Upper Airway and Respiratory Diseases Center, New York University School of Medicine, New York, New York
| | - Sophie Laberge
- Department of Pediatrics, Division of Respiratory Medicine, Sainte-Justine University Hospital Center, Université de Montréal, Montreal, Quebec, Canada
| | - Jonathan Popler
- Division of Pediatric Pulmonology, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Federica Porcaro
- Department of Pediatrics, Pediatric Pulmonology & Respiratory Intermediate Care Unit, Sleep and Long-Term Ventilation Unit, Bambino Gesù Children's Hospital, Rome, Italy
| | - Thomas Kovesi
- Pediatrics, Division of Respirology, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Canada
| |
Collapse
|
12
|
Thoracoscopic Posterior Tracheopexy Is a Feasible and Effective Treatment for Tracheomalacia. J Laparoendosc Adv Surg Tech A 2019; 29:1228-1231. [DOI: 10.1089/lap.2019.0156] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
|
13
|
Update zur minimalinvasiven Chirurgie im Kindesalter. Monatsschr Kinderheilkd 2019. [DOI: 10.1007/s00112-019-00773-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
|
14
|
van der Zee DC, Lindeboom MYA, Tytgat SHA. Error traps and culture of safety in esophageal atresia repair. Semin Pediatr Surg 2019; 28:139-142. [PMID: 31171148 DOI: 10.1053/j.sempedsurg.2019.04.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Esophageal atresia (EA) repair has always been a source of immense professional gratification for the pediatric surgeon. In many ways, this anomaly defines the entire profession. Due to its rarity, there is an increased risk of inadvertent events occurring during correction. This article describes some of the error traps that may occur in attempting esophageal reconstruction and how they may be avoided.
Collapse
Affiliation(s)
- David C van der Zee
- Department of Pediatric Surgery, University Medical Center Utrecht, Wilhelmina Children's Hospital, Lundlaan 6, 3584 EA Utrecht, The Netherlands.
| | - Maud Y A Lindeboom
- Department of Pediatric Surgery, University Medical Center Utrecht, Wilhelmina Children's Hospital, Lundlaan 6, 3584 EA Utrecht, The Netherlands
| | - Stefaan H A Tytgat
- Department of Pediatric Surgery, University Medical Center Utrecht, Wilhelmina Children's Hospital, Lundlaan 6, 3584 EA Utrecht, The Netherlands
| |
Collapse
|
15
|
van Lennep M, Singendonk MMJ, Dall'Oglio L, Gottrand F, Krishnan U, Terheggen-Lagro SWJ, Omari TI, Benninga MA, van Wijk MP. Oesophageal atresia. Nat Rev Dis Primers 2019; 5:26. [PMID: 31000707 DOI: 10.1038/s41572-019-0077-0] [Citation(s) in RCA: 69] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Oesophageal atresia (EA) is a congenital abnormality of the oesophagus that is caused by incomplete embryonic compartmentalization of the foregut. EA commonly occurs with a tracheo-oesophageal fistula (TEF). Associated birth defects or anomalies, such as VACTERL association, trisomy 18 or 21 and CHARGE syndrome, occur in the majority of patients born with EA. Although several studies have revealed signalling pathways and genes potentially involved in the development of EA, our understanding of the pathophysiology of EA lags behind the improvements in surgical and clinical care of patients born with this anomaly. EA is treated surgically to restore the oesophageal interruption and, if present, ligate and divide the TEF. Survival is now ~90% in those born with EA with severe associated anomalies and even higher in those born with EA alone. Despite these achievements, long-term gastrointestinal and respiratory complications and comorbidities in patients born with EA are common and lead to decreased quality of life. Oesophageal motility disorders are probably ubiquitous in patients after undergoing EA repair and often underlie these complications and comorbidities. The implementation of several new diagnostic and screening tools in clinical care, including high-resolution impedance manometry, pH-multichannel intraluminal impedance testing and disease-specific quality of life questionnaires now provide better insight into these problems and may contribute to better long-term outcomes in the future.
Collapse
Affiliation(s)
- Marinde van Lennep
- Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Pediatric Gastroenterology and Nutrition, Amsterdam, The Netherlands
| | - Maartje M J Singendonk
- Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Pediatric Gastroenterology and Nutrition, Amsterdam, The Netherlands
| | - Luigi Dall'Oglio
- Digestive Endoscopy and Surgery Unit, Bambino Gesu Children's Hospital-IRCCS, Rome, Italy
| | - Fréderic Gottrand
- CHU Lille, University Lille, National Reference Center for Congenital Malformation of the Esophagus, Department of Pediatric Gastroenterology Hepatology and Nutrition, Lille, France
| | - Usha Krishnan
- Department of Paediatric Gastroenterology, Sydney Children's Hospital, Sydney, New South Wales, Australia
- Discipline of Paediatrics, School of Women's and Children's Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Suzanne W J Terheggen-Lagro
- Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Pediatric Pulmonology, Amsterdam, The Netherlands
| | - Taher I Omari
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
- Center for Neuroscience, Flinders University, Adelaide, South Australia, Australia
| | - Marc A Benninga
- Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Pediatric Gastroenterology and Nutrition, Amsterdam, The Netherlands.
| | - Michiel P van Wijk
- Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Pediatric Gastroenterology and Nutrition, Amsterdam, The Netherlands
- Emma Children's Hospital, Amsterdam UMC, Vrije Universiteit, Pediatric Gastroenterology, Amsterdam, The Netherlands
| |
Collapse
|
16
|
Polites SF, Kotagal M, Wilcox LJ, de Alarcon A, Benscoter DT, von Allmen D. Thoracoscopic posterior tracheopexy for tracheomalacia: A minimally invasive technique. J Pediatr Surg 2018; 53:2357-2360. [PMID: 30316404 DOI: 10.1016/j.jpedsurg.2018.08.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Revised: 08/14/2018] [Accepted: 08/16/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND Tracheomalacia is the most common congenital abnormality of the trachea. Posterior tracheopexy to alleviate posterior intrusion contributing to dynamic tracheal collapse has been reported using thoracotomy or median sternotomy. Here we describe the minimally invasive operative technique of thoracoscopic posterior tracheopexy with bronchoscopic guidance. OPERATIVE TECHNIQUE After preoperative computed tomography and bronchoscopy, a right thoracoscopic approach is utilized. The esophagus is mobilized and the membranous trachea is sutured to the prevertebral fascia under direct bronchoscopic visualization. Immediate improvement in tracheal collapse is noted. No major complications are reported and length of stay is short. Aortopexy may also be required to address anterior vascular compression. CONCLUSION Thoracoscopic posterior tracheopexy is safe and feasible. Further studies with more patients and longer follow-up are needed to assess durability.
Collapse
Affiliation(s)
- Stephanie F Polites
- Division of General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Meera Kotagal
- Division of General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Lyndy J Wilcox
- Department of Otolaryngology-Head and Neck Surgery, University Cincinnati, Cincinnati, Ohio
| | - Alessandro de Alarcon
- Department of Otolaryngology-Head and Neck Surgery, University Cincinnati, Cincinnati, Ohio
| | - Dan T Benscoter
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Daniel von Allmen
- Division of General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH.
| |
Collapse
|