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Daboos M, Abdelmaboud M, Hussein M, Salama A, Elshamy A. Azygos vein preservation revisited: impact on early outcomes after repair of esophageal atresia/tracheoesophageal fistula in newborns. Updates Surg 2023; 75:2305-2311. [PMID: 37945968 PMCID: PMC10710382 DOI: 10.1007/s13304-023-01684-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Accepted: 10/25/2023] [Indexed: 11/12/2023]
Abstract
Since the first successful repair of esophageal atresia/tracheoesophageal fistula (EA-TEF) was performed approximately 8 decades ago, surgeons have made considerable technical advances in solving intraoperative surgical challenges and reducing postoperative complications. According to some surgeons, preserving the Azygos vein makes this modification attractive. This study aimed to evaluate the benefits of preserving the Azygos vein during surgery for esophageal atresia with tracheoesophageal fistula and to highlight its advantages in reducing anastomotic leak, stricture, and other postoperative outcomes. This prospective comparative series was conducted between April 2020 and April 2023. The study included all newborns with EA-TEF eligible for primary repair. Patients were randomized to either Group A or B. Group A underwent Azygos vein preservation, whereas the remaining patients (Group B) underwent Azygos vein disconnection. Sixty-four patients were included in this study. Thirty-two patients (Group A) underwent Azygos vein preservation during EA-TEF repair, and the remaining thirty-two patients (Group B) underwent Azygos vein ligation and disconnection. Both groups were comparable in terms of demographics, clinical data, and operative findings (P > 0.05). Pneumonitis occurred in 4 patients in Group A and 16 patients in Group B. Anastomotic leaks occurred in two (6.2%) patients in Group A and six (18.7%) patients in Group B. There were two deaths in Group A and six deaths in Group B, with a significant difference between the two groups (P = 0.0485). Preserving the Azygos vein during esophageal atresia repair reduces the occurrence of postoperative pneumonia, leakage, and stenosis, and decreases postoperative mortality. Therefore, we declare that this modification is a significant and valuable addition to the current surgical procedures.
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Affiliation(s)
- Mohammad Daboos
- Department of Pediatric Surgery, Al-Azhar University, Al-Houssain University Hospital, Darrasa, Cairo, Egypt
| | - Mohamed Abdelmaboud
- Department of Pediatric Surgery, Al-Azhar University, Al-Houssain University Hospital, Darrasa, Cairo, Egypt.
| | - Mohamed Hussein
- Department of Pediatric Surgery, Al-Azhar University, Al-Houssain University Hospital, Darrasa, Cairo, Egypt
| | - Ahmed Salama
- Department of Pediatric Surgery, Al-Azhar University, Al-Houssain University Hospital, Darrasa, Cairo, Egypt
| | - Ahmed Elshamy
- Pediatric Surgery Unit, Department of Surgery, Al-Azhar University, Assuit, Egypt
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Wang C, Zheng J, Ma X. Azygos vein preservation is feasible and beneficial in esophageal atresia with tracheoesophageal fistula: A meta-analysis of randomized controlled trials. Front Pediatr 2022; 10:965275. [PMID: 35967577 PMCID: PMC9366511 DOI: 10.3389/fped.2022.965275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 07/08/2022] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Esophageal atresia (EA) with tracheoesophageal fistula (TEF) is a common congenital anomaly. It is still unknown whether azygos vein preservation will increase the difficulty or time of operation and reduce the quality of anastomosis. Thus, we conducted this meta-analysis to explore the puzzle. METHODS Two researchers independently searched the databases. Randomized controlled trials were included if these studies applied thoracotomy to perform operations and compared the outcomes in patients with EA/TEF between azygos vein preservation groups and azygos vein ligation groups. The Jadad score was used to assess the quality of the included studies. Statistical heterogeneity was evaluated using the I 2 value. A fixed or random-effect model was applied regarding the I 2 value. RESULTS Four studies involving 286 patients were included. The pooled estimates indicated that preservation of the azygos vein decreased the incidence of anatomic leakage with a pooled risk ratio (RR) of 0.54 (95% CI 0.29-0.99, P = 0.05) and mortality with an RR of 0.51 (95% CI 0.29-0.90; P = 0.02). Preservation of the azygos vein might not require a longer operative time than ligation of the azygos vein. CONCLUSIONS This research certifies that preservation of the azygos vein is able to reduce the prevalence of anastomotic leakage and mortality.
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Affiliation(s)
- Chuan Wang
- Department of Pediatric Surgery, West China Hospital of Sichuan University, Chengdu, China
| | - Junkai Zheng
- Department of Pediatric Surgery, West China Hospital of Sichuan University, Chengdu, China
| | - Xue Ma
- Department of Pediatric Surgery, West China Hospital of Sichuan University, Chengdu, China
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Korang SK, Hildorf S, Oehlenschlaeger J, Smithers CJ, Jakobsen JC, Lausten-Thomsen U. Preservation of the azygos vein versus ligation of the azygos vein during primary surgical repair of congenital esophageal atresia. Hippokratia 2021. [DOI: 10.1002/14651858.cd014889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Steven Kwasi Korang
- Copenhagen Trial Unit, Centre for Clinical Intervention Research; The Capital Region of Denmark, Rigshospitalet, Copenhagen University Hospital; Copenhagen Denmark
| | - Simone Hildorf
- Department of Pediatric Surgery; Rigshospitalet, Copenhagen University Hospital; Copenhagen Denmark
| | - Jacob Oehlenschlaeger
- Department of Pediatric Surgery; Rigshospitalet, Copenhagen University Hospital; Copenhagen Denmark
| | | | - Janus C Jakobsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research; The Capital Region of Denmark, Rigshospitalet, Copenhagen University Hospital; Copenhagen Denmark
- Department of Regional Health Research, The Faculty of Health Sciences; University of Southern Denmark; Odense Denmark
| | - Ulrik Lausten-Thomsen
- Neonatal Intensive Care Unit; Copenhagen University Hospital, Rigshospitalet; Copenhagen Denmark
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The effect of azygos vein preservation on postoperative complications after esophageal atresia repair: Results from the Turkish Esophageal Atresia Registry. J Pediatr Surg 2021; 56:1940-1943. [PMID: 33353739 DOI: 10.1016/j.jpedsurg.2020.12.008] [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: 10/19/2020] [Revised: 11/12/2020] [Accepted: 12/06/2020] [Indexed: 11/20/2022]
Abstract
AIM Preservation of the azygos vein (AV) maintains normal venous drainage of the mediastinum and decreases postoperative congestion. The modification of esophageal atresia (EA) repair by preserving AV may prevent postoperative complications and may lead to better outcomes. The data from the Turkish Esophageal Atresia Registry (TEAR) were evaluated to define the effect of AV preservation on postoperative complications of patients with EA. METHODS Data from TEAR for a period of five years were evaluated. Patients were enrolled into two groups according to the preservation of AV. Patients with divided (DAV) and preserved AV (PAV) were evaluated for demographic and operative features and postoperative complications for the first year of life. The DAV and PAV groups were compared according to the postoperative complications, such as fistula recanalization, symptomatic strictures, anastomotic leaks, total number of esophageal dilatations, and anti-reflux surgery. In addition, respiratory problems, which required treatment, were compared between groups. RESULTS Among 502 registered patients; the data from 315 patients with the information of AV ligation were included. The male female ratio of DAV (n = 271) and PAV (n = 44) groups were 150:121 and 21:23, respectively (p > 0.05). The mean body weight, height, gestational age, and associated anomalies were similar in both groups (p > 0.05). The esophageal repair with thoracotomy was significantly higher in DAV group, when compared to the PAV group (p < 0.05). The rates of primary anastomosis and tensioned anastomosis were similar in both groups (p > 0.05). There was no difference between DAV and PAV groups for anastomotic leaks, symptomatic anastomotic strictures, fistula recanalization, and the requirement for anti-reflux surgery (p > 0.05). The rate of respiratory problems, which required treatment, was significantly higher in the DAV group (p < 0.05) CONCLUSION: The data in the TEAR demonstrated that preserving the AV during EA repair led to no significant advantage on postoperative complications, with exception of respiratory problems. AV should be preserved as much as possible to maintain a normal mediastinal anatomy and to avoid respiratory complications.
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Kainth D, Anand S, Singh A, Bajpai M. Impact of preservation of the azygos vein during surgical repair of esophageal atresia-tracheoesophageal fistula (EA-TEF): a systematic review and meta-analysis. Pediatr Surg Int 2021; 37:983-989. [PMID: 33907863 DOI: 10.1007/s00383-021-04913-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/20/2021] [Indexed: 10/21/2022]
Abstract
Esophageal atresia-tracheoesophageal fistula (EA-TEF) is one of the common congenital anomalies occurring in newborns. Over the last eight decades, various technical modifications have been proposed in the surgical repair of EA-TEF. Preservation of azygos vein is one such modification that has gained considerable attention. However, a consensus statement regarding the superiority of its preservation over its division is lacking. We aim to compare the outcomes of surgery between the two groups of newborns, i.e., those undergoing repair with and without azygos vein preservation, in terms of its complications. The authors systematically searched the databases PubMed, EMBASE, Web of Science, and Scopus through December 2020. The incidence of anastomotic complications and chest infection was compared among the two groups of newborns, i.e., those undergoing surgical repair with (group A) and without azygos vein preservation (group B). Statistical analysis was performed using a fixed-effects model, and pooled risk ratio (RR) and heterogeneity (I2) were calculated. The methodological quality of the studies was assessed using the Downs and Black scale. Six comparative studies, consisting of a total of 671 newborns, were included in the meta-analysis. As compared to group B, newborns belonging to group A showed a significantly lower incidence of pneumonitis in the postoperative period (RR 0.31; 95% CI 0.17-0.57, p = 0.0001). However, no significant difference in the incidence of anastomotic complications including anastomotic leak (RR 0.73; 95% CI 0.48-1.12, p = 0.15) and stricture (RR 0.63; 95% CI 0.36-1.09, p = 0.10) was observed between the two groups. The average Downs and Black scale scores ranged from 20 to 24. The risk of bias was low (n = 1) and moderate (n = 5) in the included studies. Kappa statistics showed a value of 0.902 (p < 0.001), highlighting an almost perfect agreement among the two observers. The present meta-analysis revealed the superiority of surgical repair of EA-TEF performed with preservation of azygos vein in terms of the incidence of postoperative chest infection. However, no significant difference in the occurrence of anastomotic leak and stricture was observed between the two groups. The level of evidence of the published comparative studies is limited. Therefore, well designed, randomized controlled trial utilizing a standardized operative approach on a larger sample-size needs to be conducted for optimal comparison between the two approaches.
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Affiliation(s)
- Deepika Kainth
- Division of Neonatology, Department of Pediatrics, AIIMS, New Delhi, India
| | - Sachit Anand
- Department of Pediatric Surgery, Kokilaben Dhirubhai Ambani Hospital, Andheri West, Mumbai, 400053, India.
| | - Apoorv Singh
- Department of Pediatric Surgery, AIIMS, New Delhi, India
| | - Minu Bajpai
- Department of Pediatric Surgery, AIIMS, New Delhi, India
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Li H, Lin J, Zhang H, Wu B, Chen Y, He H, Zhou L, Gong L, Chen G, Wang M, Lin W. A propensity score matching study of the short-term efficacy of azygos arch-sparing McKeown minimally invasive esophagectomy. J Gastrointest Oncol 2021; 12:28-37. [PMID: 33708422 DOI: 10.21037/jgo-21-14] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Background To evaluate the short-term efficacy of azygos arch-sparing McKeown minimally invasive esophagectomy (McKeown-MIE). Methods We retrospectively analyzed the clinical data of 221 patients with thoracic esophageal squamous cell carcinoma who underwent McKeown-MIE at the Department of Thoracic Surgery of Gaozhou People's Hospital from August 1, 2017 to September 30, 2019. According to whether the azygos arch was preserved or not, the patients were assigned to one of two groups: the preservation group (40 cases) and the ligation group (181 cases). Within 3 months of the operation, the perioperative outcomes and the postoperative short-term efficacy of the two groups were compared. Results After propensity score (PS) matching, 40 pairs of patients were matched successfully. Between the two groups, there were no statistical difference in intraoperative blood loss, the number of lymph nodes dissected, thoracic drainage duration, fasting time, postoperative hospital stay time, and major postoperative complications (P>0.05). Compared with the ligation group, patients in the preservation group had a shorter intensive care unit (ICU) stay time, a shorter operative time, a lower volume of postoperative thoracic drainage (both the first 3 days and overall) following surgery, a tubular stomach that had a smaller caliber, and a lower incidence of tubular gastric malpositioning (P<0.05). Conclusions Preserving the azygos arch during a McKeown-MIE is safe and feasible. Doing so, not only effectively restricts the expansion of the gastric conduit, leading to a lower incidence of malpositioning, but also dramatically reduces postoperative thoracic drainage, and ICU stay time.
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Affiliation(s)
- Hui Li
- Department of Thoracic Surgery, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Jiongzhen Lin
- Department of Thoracic Surgery, Gaozhou People's Hospital, Guangdong Esophageal Cancer Institute Gaozhou Branch, Gaozhou, China
| | - Hai Zhang
- Department of Thoracic Surgery, Gaozhou People's Hospital, Guangdong Esophageal Cancer Institute Gaozhou Branch, Gaozhou, China
| | - Bomeng Wu
- Department of Thoracic Surgery, Gaozhou People's Hospital, Guangdong Esophageal Cancer Institute Gaozhou Branch, Gaozhou, China
| | - Ying Chen
- Department of Thoracic Surgery, Gaozhou People's Hospital, Guangdong Esophageal Cancer Institute Gaozhou Branch, Gaozhou, China
| | - Haiquan He
- Department of Thoracic Surgery, Gaozhou People's Hospital, Guangdong Esophageal Cancer Institute Gaozhou Branch, Gaozhou, China
| | - Linrong Zhou
- Department of Thoracic Surgery, Gaozhou People's Hospital, Guangdong Esophageal Cancer Institute Gaozhou Branch, Gaozhou, China
| | - Lanjuan Gong
- Department of Thoracic Surgery, Gaozhou People's Hospital, Guangdong Esophageal Cancer Institute Gaozhou Branch, Gaozhou, China
| | - Gang Chen
- Department of Thoracic Surgery, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Maosheng Wang
- Department of Thoracic Surgery, Gaozhou People's Hospital, Guangdong Esophageal Cancer Institute Gaozhou Branch, Gaozhou, China
| | - Wanli Lin
- Department of Thoracic Surgery, Gaozhou People's Hospital, Guangdong Esophageal Cancer Institute Gaozhou Branch, Gaozhou, China
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Fujiwara N, Sato H, Miyawaki Y, Ito M, Aoyama J, Ito S, Oya S, Watanabe K, Sugita H, Sakuramoto S. Effect of azygos arch preservation during thoracoscopic esophagectomy on facilitation of postoperative refilling. Langenbecks Arch Surg 2020; 405:1079-1089. [PMID: 32986133 DOI: 10.1007/s00423-020-01994-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Accepted: 09/22/2020] [Indexed: 11/29/2022]
Abstract
PURPOSE In esophageal cancer surgery, the significance of preserving the azygos arch during thoracoscopic esophagectomy remains unknown. To determine the significance, we examined the difference in postoperative courses between patients who underwent an azygos arch-preserving technique and patients whose azygos arch had been dissected. METHODS We retrospectively analyzed 119 patients with esophageal cancer who underwent thoracoscopic esophagectomy from January 2017 to December 2019. Statistical tests, including univariate or multivariate analyses and propensity score-matched analysis, were performed focusing on changes in fluid balance caused by the preservation of the azygos arch. RESULTS The azygos arch was preserved in 65 patients and dissected in 54 patients. Urine output on postoperative day 2 was higher, and the IN-OUT balance on postoperative day 2 or accumulated IN-OUT balance up to postoperative day 2 tended to be lower in the azygos arch-preserving group than in the dissected group. The azygos arch-preserving technique did not affect the number of dissected mediastinal lymph nodes. CONCLUSION The azygos arch-preserving technique during thoracoscopic esophagectomy facilitated postoperative refilling and avoided postoperative fluid excess. This technique might be a novel minimally invasive option for an otherwise highly invasive esophageal cancer surgery.
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Affiliation(s)
- Naoto Fujiwara
- Department of Gastroenterological Surgery, Saitama Medical University, International Medical Center, 1397-1 Yamane, Hidaka-shi, Saitama, 350-1298, Japan.
| | - Hiroshi Sato
- Department of Gastroenterological Surgery, Saitama Medical University, International Medical Center, 1397-1 Yamane, Hidaka-shi, Saitama, 350-1298, Japan
| | - Yutaka Miyawaki
- Department of Gastroenterological Surgery, Saitama Medical University, International Medical Center, 1397-1 Yamane, Hidaka-shi, Saitama, 350-1298, Japan
| | - Misato Ito
- Department of Gastroenterological Surgery, Saitama Medical University, International Medical Center, 1397-1 Yamane, Hidaka-shi, Saitama, 350-1298, Japan
| | - Junya Aoyama
- Department of Gastroenterological Surgery, Saitama Medical University, International Medical Center, 1397-1 Yamane, Hidaka-shi, Saitama, 350-1298, Japan
| | - Sunao Ito
- Department of Gastroenterological Surgery, Saitama Medical University, International Medical Center, 1397-1 Yamane, Hidaka-shi, Saitama, 350-1298, Japan
| | - Shuichiro Oya
- Department of Gastroenterological Surgery, Saitama Medical University, International Medical Center, 1397-1 Yamane, Hidaka-shi, Saitama, 350-1298, Japan
| | - Kenji Watanabe
- Department of Gastroenterological Surgery, Saitama Medical University, International Medical Center, 1397-1 Yamane, Hidaka-shi, Saitama, 350-1298, Japan
| | - Hirofumi Sugita
- Department of Gastroenterological Surgery, Saitama Medical University, International Medical Center, 1397-1 Yamane, Hidaka-shi, Saitama, 350-1298, Japan
| | - Shinichi Sakuramoto
- Department of Gastroenterological Surgery, Saitama Medical University, International Medical Center, 1397-1 Yamane, Hidaka-shi, Saitama, 350-1298, Japan
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Thoracoscopic Repair of Esophageal Atresia With Distal Tracheoesophageal Fistula (Type C): Systematic Review. Surg Laparosc Endosc Percutan Tech 2020; 30:388-393. [DOI: 10.1097/sle.0000000000000832] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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