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Yalcin S, Bhatia AM, He Z, Wulkan ML. Short- and Long-Term Outcomes of Thoracoscopic and Open Repair For Esophageal Atresia and Tracheoesophageal Fistula. J Pediatr Surg 2024:161662. [PMID: 39218728 DOI: 10.1016/j.jpedsurg.2024.08.002] [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: 04/30/2024] [Revised: 08/01/2024] [Accepted: 08/02/2024] [Indexed: 09/04/2024]
Abstract
BACKGROUND The aim was to evaluate short- and long-term outcomes for thoracoscopic repair of EA/TEF and compare with open repair. METHODS Patients who underwent EA/TEF repair during 2000-2020 were evaluated retrospectively. Patients with delayed repair were excluded. Demographic, operative, outcome data was collected. Outcomes were compared using Wilcoxon-rank sum tests for continuous, Chi-squared/Fisher's exact tests for categorical data. RESULTS There were 104 patients with primary repair, 49 (47.1%) underwent thoracoscopic repair per surgeon's choice. Type C accounted for 101 (97.1%) of the cases. Gestational age and birth weight were higher in the thoracoscopy group (p = 0.001). The rate of ≥3 VACTERL anomalies was higher in the OR group (p = 0.016). Operative time, rate of anastomotic leak, time to first oral feeding were similar (p > 0.05). Thoracoscopy group had decreased length of ventilation (p = 0.026) and length of stay (p = 0.029). The incidence of anastomotic stricture was higher in the thoracoscopy group (p = 0.012). Recurrent TEF was one case in each group. Rates of tube feeding at discharge and in first year were similar (p > 0.05), rate in third year was decreased (p = 0.032) in the thoracoscopy group. Rates of anti-reflux medication in first and third years, and fundoplication rate were similar (p > 0.05). CONCLUSIONS Many of the short- and long-term outcomes are comparable between thoracoscopic and open repair of EA/TEF. Length of ventilation, length of stay are decreased in the thoracoscopy group. Anastomotic stricture is higher, the need for long-term tube feeding is lower after thoracoscopic repair. Although these results could be affected by selection bias, they are still promising for advancing thoracoscopic repair of EA/TEF safely and efficiently. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Sule Yalcin
- Division of Pediatric Surgery, Department of Surgery, Emory University, School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Amina M Bhatia
- Division of Pediatric Surgery, Department of Surgery, Emory University, School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Zhulin He
- Department of Pediatrics, Biostatistics Core, Emory University School of Medicine, Atlanta, GA, USA
| | - Mark L Wulkan
- Division of Pediatric Surgery, Department of Surgery, Emory University, School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA; Department of Surgery, Akron Children's Hospital, Akron, OH, USA.
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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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Izadi S, Smithers J, Shieh HF, Demehri FR, Mohammed S, Hamilton TE, Zendejas B. The History and Legacy of the Foker Process for the Treatment of Long Gap Esophageal Atresia. J Pediatr Surg 2024; 59:1222-1227. [PMID: 38184432 DOI: 10.1016/j.jpedsurg.2023.12.020] [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: 10/16/2023] [Revised: 12/13/2023] [Accepted: 12/17/2023] [Indexed: 01/08/2024]
Abstract
Historically, children afflicted with long gap esophageal atresia (LGEA) had few options, either esophageal replacement or a life of gastrostomy feeds. In 1997, John Foker from Minnesota revolutionized the treatment of LGEA. His new procedure focused on "traction-induced growth" when the proximal and distal esophageal segments were too far apart for primary repair. Foker's approach involved placement of pledgeted sutures on both esophageal pouches connected to an externalized traction system which could be serially tightened, allowing for tension-induced esophageal growth and a delayed primary repair. Despite its potential, the Foker process was received with criticism and disbelief, and to this day, controversy remains regarding its mechanism of action - esophageal growth versus stretch. Nonetheless, early adopters such as Rusty Jennings of Boston embraced Foker's central principle that "one's own esophagus is best" and was instrumental to the implementation and rise in popularity of the Foker process. The downstream effects of this emphasis on esophageal preservation would uncover the need for a focused yet multidisciplinary approach to the many challenges that EA children face beyond "just the esophagus", leading to the first Esophageal and Airway Treatment Center for children. Consequently, the development of new techniques for the multidimensional care of the LGEA child evolved such as the posterior tracheopexy for associated tracheomalacia, the supercharged jejunal interposition, as well as minimally invasive internalized esophageal traction systems. We recognize the work of Foker and Jennings as key catalysts of an era of esophageal preservation and multidisciplinary care of children with EA.
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Affiliation(s)
- Shawn Izadi
- Department of Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Jason Smithers
- Department of Surgery, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
| | - Hester F Shieh
- Department of Surgery, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
| | - Farokh R Demehri
- Department of Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Somala Mohammed
- Department of Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Thomas E Hamilton
- Division of General, Thoracic and Fetal Surgery, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
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Zhang N, Wu W, Zhuang Y, Wang W, Pan W, Wang J. Experience in the treatment of long-gap esophageal atresia by intraluminal esophageal stretching elongation. Front Pediatr 2024; 12:1367935. [PMID: 38523834 PMCID: PMC10957633 DOI: 10.3389/fped.2024.1367935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 02/27/2024] [Indexed: 03/26/2024] Open
Abstract
Objective To summarize the experience with intraluminal esophageal stretching elongation (ILESE) in the successful treatment of long-gap esophageal atresia (LGEA) at a single center. Methods Clinical data of 68 neonates who underwent LGEA between February 2015 and January 2022 were retrospectively analyzed. Four patients died of multiple associated severe malformations and did not undergo ILESE. Esophageal anastomosis was successfully performed in 60 cases (93.75%) and failed in 4 cases (6.25%) treated with ILESE. The ILESE techniques, esophageal reconstruction, results, postoperative complications, and follow-up treatment were analyzed. Results The beginning time of performing ILESE preoperation was 53.4 ± 39.4 days after birth, and the age of esophageal reconstruction was 122.2 ± 70.3 days after birth in 60 cases. The gap length of proximal and distal esophageal segments which were evaluated the first time at admission was 4.8 ± 1.3 vertebral bodies, whereas the gap before anastomosis was -0.46 ± 0.90 vertebral bodies. Among the patients with esophageal primary-anastomosis, 55 received thoracoscopic surgery, and 5 underwent thoracotomy in the early stage. Of the 60 children with ILESE, 58 underwent end-to-end esophagostomy, of which 17 cases were combined with circular esophagotomy (livaditis), and 2 cases of esophageal lengthening were combined with the reversal of the ligulate loop of the proximal esophagus (flap). Overall, 59 cases were cured (98.3%), and 1 patient died of respiratory failure postoperatively. All patients were followed up for 7-96 months. Postoperative anastomotic leakage occurred in 16 patients (27.6%), all of whom were successfully treated conservatively. Anastomotic stenosis occurred in 49 cases (83.1%), all of which were successfully managed by non-surgical treatment, including 12.7 ± 9.3 times of esophageal balloon dilatation and 2 cases of stent dilatation. Gastroesophageal reflux occurred in 44 patients (74.6%), including associated or acquired esophageal hiatal hernia in 22 patients, and Nissen fundoplication was performed in 17 patients. Conclusions ILESE is an effective method for prolonging the proximal and distal esophagus of the LGEA to reconstruct esophageal continuity using its esophageal tissue, with an efficacy rate of 93.75%. Postoperative anastomotic stricture and gastroesophageal reflux are common and require long-term, standardized follow-up and treatment.
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Affiliation(s)
- Ning Zhang
- Department of Pediatric Surgery, Children’s Hospital of Soochow University, Suzhou, Jiangsu, China
- Department of Pediatric Surgery, The Affiliated Xuzhou Children’s Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, China
| | - Wenjie Wu
- Department of Pediatric Surgery, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yujia Zhuang
- Department of Pediatric Surgery, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Weipeng Wang
- Department of Pediatric Surgery, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Weihua Pan
- Department of Pediatric Surgery, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jun Wang
- Department of Pediatric Surgery, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Zhang M, Huang J, Jin Z, Zhang X, Zhou Y, Chi S, Rong L, Zhang Y, Cao G, Li S, Tang ST. Comparison of robotic versus thoracoscopic repair for congenital esophageal atresia: a propensity score matching analysis. Int J Surg 2024; 110:891-901. [PMID: 37983822 PMCID: PMC10871573 DOI: 10.1097/js9.0000000000000889] [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: 08/11/2023] [Accepted: 10/25/2023] [Indexed: 11/22/2023]
Abstract
BACKGROUND Despite the rapid advancement of robotic surgery across various surgical domains, only cases of robotic repair (RR) for neonates with esophageal atresia (EA) have been reported. Comprehensive studies comparing RR and thoracoscopic repair (TR) are lacking. The authors aimed to compare the safety and efficacy of RR and TR for EA. METHODS A retrospective multicenter study was conducted on 155 EA neonates undergoing RR (79 patients) or TR (76 patients) between August 2020 and February 2023 using propensity score matching. Asymmetric port distribution and step-trocar insertion techniques were applied during RR. Demographics and surgical outcomes were compared. RESULTS After matching, 63 patients (out of 79) in RR group and 63 patients (out of 76) in TR group were included. There were no significant differences in short-term outcomes between two groups, except for longer total operative time (173.81 vs. 160.54 min; P <0.001) and shorter anastomotic time (29.52 vs. 40.21 min; P <0.001) in RR group. Compared with TR group, the RR group had older age at surgery (8.00 vs. 3.00 days; P <0.001), but a comparable pneumonia rate. More importantly, the incidence of anastomotic leakage (4.76 vs. 19.05%, P =0.013), anastomotic stricture (15.87 vs. 31.74%, P =0.036) within 1 year postoperatively, and unplanned readmission (32.26 vs. 60.00%, P =0.030) within 2 years postoperatively were lower in RR group than in TR group. CONCLUSIONS RR is a technically safe and effective option for EA patients. This approach delays the age of surgery without increasing respiratory complication rates while reducing the incidence of postoperative anastomotic complications and unplanned readmission.
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Affiliation(s)
- Mengxin Zhang
- Department of Pediatric Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan
| | - Jinshi Huang
- Department of Neonatal Surgery, Beijing Children’s Hospital, Capital Medical University, National Center for Children’s Health, Beijing
| | - Zhu Jin
- Provincial Key Laboratory of Research in Structure Birth Defect Disease and Department of Pediatric Surgery, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, People’s Republic of China
| | - Xi Zhang
- Department of Pediatric Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan
| | - Ying Zhou
- Department of Pediatric Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan
| | - Shuiqing Chi
- Department of Pediatric Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan
| | - Liying Rong
- Department of Pediatric Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan
| | - Yang Zhang
- Department of Pediatric Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan
| | - Guoqing Cao
- Department of Pediatric Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan
| | - Shuai Li
- Department of Pediatric Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan
| | - Shao-tao Tang
- Department of Pediatric Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan
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Ishimaru T, Shinjo D, Fujiogi M, Michihata N, Morita K, Hayashi K, Tachimori H, Kawashima H, Fujishiro J, Yasunaga H. Risk factors for postoperative anastomotic leakage after repair of esophageal atresia: a retrospective nationwide database study. Surg Today 2023; 53:1269-1274. [PMID: 37017869 DOI: 10.1007/s00595-023-02682-0] [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: 01/31/2023] [Accepted: 03/10/2023] [Indexed: 04/06/2023]
Abstract
PURPOSE Postoperative anastomotic leakage is the most frequent short-term complication of esophageal atresia repair in neonates. We conducted this study using a nationwide surgical database in Japan to identify the risk factors for anastomotic leakage in neonates undergoing esophageal atresia repair. METHODS Neonates diagnosed with esophageal atresia between 2015 and 2019 were identified in the National Clinical Database. Postoperative anastomotic leakage was compared among patients to identify the potential risk factors, using univariate analysis. Multivariable logistic regression analysis included sex, gestational age, thoracoscopic repair, staged repair, and procedure time as independent variables. RESULTS We identified 667 patients, with an overall leakage incidence of 7.8% (n = 52). Anastomotic leakage was more likely in patients who underwent staged repairs than in those who did not (21.2% vs. 5.2%, respectively) and in patients with a procedure time > 3.5 h than in those with a procedure time < 3.5 h (12.6% vs. 3.0%, respectively; p < 0.001). Multivariable logistic regression analysis identified staged repair (odds ratio [OR] 4.89, 95% confidence interval [CI] 2.22-10.16, p < 0.001) and a longer procedure time (OR 4.65, 95% CI 2.38-9.95, p < 0.001) as risk factors associated with postoperative leakage. CONCLUSION Staged procedures and long operative times are associated with postoperative anastomotic leakage, suggesting that leakage is more likely after complex esophageal atresia repair and that such patients require refined treatment strategies.
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Affiliation(s)
- Tetsuya Ishimaru
- Department of Pediatric Surgery, Saitama Children's Medical Center, 1-2 Shintoshin, Chuo-Ku, Saitama, 330-8777, Japan.
| | - Daisuke Shinjo
- Department of Health Policy and Informatics, Tokyo Medical and Dental University Graduate School, Tokyo, Japan
- Department of Healthcare Quality Assessment, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Michimasa Fujiogi
- Department of Surgical Specialties, Division of Surgery, National Center for Child Health and Development, Tokyo, Japan
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Nobuaki Michihata
- Department of Health Services Research, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kaori Morita
- Department of Pediatric Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kentaro Hayashi
- Department of Pediatric Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hisateru Tachimori
- Department of Healthcare Quality Assessment, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
- Endowed Course for Health System Innovation, Keio University School of Medicine, Tokyo, Japan
| | - Hiroshi Kawashima
- Department of Pediatric Surgery, Saitama Children's Medical Center, 1-2 Shintoshin, Chuo-Ku, Saitama, 330-8777, Japan
| | - Jun Fujishiro
- Department of Pediatric Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
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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: 2] [Impact Index Per Article: 2.0] [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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Zou C, Dong J, Xu G, Xia R, Xiao Y, Li M, Li B, Li B, Zhou C. Thoracoscopic Versus Open Repair for Oesophageal Atresia: A Retrospective Cohort Study of 359 Patients at a Single Center. J Pediatr Surg 2023; 58:2069-2074. [PMID: 37321938 DOI: 10.1016/j.jpedsurg.2023.05.002] [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: 01/21/2023] [Revised: 03/26/2023] [Accepted: 05/03/2023] [Indexed: 06/17/2023]
Abstract
BACKGROUND This study aimed to define the effectiveness of thoracoscopic versus open repair of gross type C oesophageal atresia (EA) based on the experience of a single centre over a decade. METHODS This retrospective cohort study included patients who were admitted to Hunan Children's Hospital between January, 2010 and December, 2021 and underwent repair surgery for type C EA. RESULTS A total of 359 patients underwent type C EA repair during the study period, of which 142 were completed via an open approach and 217 were attempted via a thoracoscopic approach (seven converted to open surgery). There were no differences in the demographics or comorbidities between the patients of thoracoscopy and thoracotomy (open repair) groups. The median operating time was 109 [90, 133] min in the thoracoscopic surgery group, which was slightly shorter than that in the open repair group (115 [102, 128] min, p = 0.059). Anastomotic leakage occurred in 41 (18.9%) and 35 (24.6%) infants in the thoracoscopic and open surgery groups, respectively (p = 0.241). Thirteen patients (3.6%) died in the hospital without significant differences in the repair approach. With a median follow-up of 23.7 months, 38 (13.6%) participants had one or more anastomotic strictures requiring dilatation, without significant differences in the repair approach (p = 0.994). CONCLUSIONS Thoracoscopic repair of congenital EA is safe, and has perioperative and medium-term outcomes similar to those of open surgery. This technique is recommended only in hospitals with experienced teams of endoscopic paediatric surgeons and anaesthesiologists.
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Affiliation(s)
- Chanjuan Zou
- 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
| | - Guang Xu
- Department of Fetal & Neonatal Surgery, Hunan Children's Hospital, Changsha, 410007, China
| | - Renpeng Xia
- 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
| | - Ming Li
- Department of Fetal & Neonatal Surgery, Hunan Children's Hospital, Changsha, 410007, China
| | - Bo Li
- 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
| | - Chonggao Zhou
- Department of Fetal & Neonatal Surgery, Hunan Children's Hospital, Changsha, 410007, China.
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Koga H, Miyano G, Ochi T, Seo S, Miyake Y, Yazaki Y, Lane GJ, Kataoka K, Nishimura K, Yamataka A. Intraoperative Bronchoscopic Inspection Facilitates Thoracoscopic Repair of Esophageal Atresia with Tracheoesophageal Fistula. J Laparoendosc Adv Surg Tech A 2023; 33:291-295. [PMID: 36735541 DOI: 10.1089/lap.2022.0141] [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: 02/04/2023] Open
Abstract
Aim: The value of intraoperative bronchoscopic inspection (IBI) for accurate confirmation of the location and distance between the distal tracheoesophageal fistula (TEF) and the proximal blind end of the esophagus (GAP) was evaluated in Type C esophageal atresia (EA)+TEF. Methods: IBI involved inserting the tip of a bronchoscope into the TEF and a nasogastric tube into the blind end of the EA and measuring GAP with fluoroscopy. EA+TEF patients (n = 23) treated thoracoscopically between 2007 and 2020 were classified according to IBI as IBI+ (n = 16) and IBI- (n = 7) to compare demographics, operative time, and time taken for TEF division. Results: Demographics were similar. Mean time for TEF division (15.4 ± 4.6 minutes for IBI+ versus 38.6 ± 20.9 minutes for IBI-; p < .05) and mean operative time (215.3 ± 48.9 minutes for IBI+ versus 286.4 ± 51.7 minutes for IBI+; p < .05) were significantly shorter. Mean GAP measured radiographically was 0.5 cm (range: 0-1.2 cm); mean GAP measured with IBI was 0.9 cm (range: 0-2.2 cm). Postoperative complications were 3 anastomotic leakages (1/16 in IBI+ and 2/7 in IBI-) that resolved without surgery and 8 strictures (3/16 in IBI+ and 5/7 in IBI-) treated by dilatation. Conclusions: IBI was effective for measuring GAP and is recommended for improving the efficiency of thoracoscopic repair.
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Affiliation(s)
- Hiroyuki Koga
- Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Go Miyano
- Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Takanori Ochi
- Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Shogo Seo
- Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Yuichiro Miyake
- Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Yuta Yazaki
- Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Geoffrey J Lane
- Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Kumi Kataoka
- Department of Anesthesiology and Pain Medicine, Juntendo University School of Medicine, Tokyo, Japan
| | - Kinya Nishimura
- Department of Anesthesiology and Pain Medicine, Juntendo University School of Medicine, Tokyo, Japan
| | - Atsuyuki Yamataka
- Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, Tokyo, Japan
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10
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Patkowski D. Thoracoscopic approach for oesophageal atresia: A real game changer? J Pediatr Surg 2023; 58:204-208. [PMID: 36402593 DOI: 10.1016/j.jpedsurg.2022.10.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 10/11/2022] [Indexed: 11/15/2022]
Abstract
Almost 23 years have passed since the first thoracoscopic procedure was done. However, according to the recent study in USA, only 16% of newborns with oesophageal atresia and distal tracheooesophageal fistula are managed by thoracoscopic approach with a very high 53% conversion rate. The aim of presentation based on experience of one paediatric surgery centre is to prove that thoracoscopic approach for this malformation is a powerful tool with a potential to change the current results. It requires considerable experience that comes only from the high number of operated cases. The technique is one amongst the many others means which taken together may really help to improve the results. Thus, the question of centralisation for special rare congenital malformations comes back to mind. Is it rational to operate on only 2 or 3 cases a year in a single centre, or is it the time for centralisation and close co-operation, as has been done with biliary atresia treatment in the UK? LEVEL OF EVIDENCE: III.
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Affiliation(s)
- Dariusz Patkowski
- Pediatric Surgery and Urology Department, Wroclaw Medical University, Borowska 213, Wroclaw 50-556, Poland.
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11
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Friedmacher F. Delayed primary anastomosis for repair of long-gap esophageal atresia: technique revisited. Pediatr Surg Int 2022; 39:40. [PMID: 36482208 PMCID: PMC9732069 DOI: 10.1007/s00383-022-05317-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/22/2022] [Indexed: 12/13/2022]
Abstract
The operative management of patients born with long-gap esophageal atresia (LGEA) remains a major challenge for most pediatric surgeons, due to the rarity and complex nature of this malformation. In LGEA, the distance between the proximal and distal esophageal end is too wide, making a primary anastomosis often impossible. Still, every effort should be made to preserve the native esophagus as no other conduit can replace its function in transporting food from the oral cavity to the stomach satisfactorily. In 1981, Puri et al. observed that in newborns with LGEA spontaneous growth and hypertrophy of the two segments occur at a rate faster than overall somatic growth in the absence of any form of mechanical stretching, traction or bouginage. They further noted that maximal natural growth arises in the first 8-12 weeks of life, stimulated by the swallowing reflex and reflux of gastric contents into the lower esophageal pouch. Since then, creation of an initial gastrostomy and continuous suction of the upper esophageal pouch followed by delayed primary anastomosis at approximately 3 months of age has been widely accepted as the preferred treatment option in most LGEA cases, generally providing good functional results. The current article offers a comprehensive update on the various aspects and challenges of this technique including initial preoperative management and subsequent gap assessment, while also discussing potential postoperative complications and long-term outcome.
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Affiliation(s)
- Florian Friedmacher
- Department of Pediatric Surgery, University Hospital Frankfurt, Goethe University Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany
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12
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Shu B, Feng X, Martynov I, Lacher M, Mayer S. Pediatric Minimally Invasive Surgery-A Bibliometric Study on 30 Years of Research Activity. CHILDREN (BASEL, SWITZERLAND) 2022; 9:children9081264. [PMID: 36010154 PMCID: PMC9406539 DOI: 10.3390/children9081264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 08/15/2022] [Accepted: 08/16/2022] [Indexed: 11/23/2022]
Abstract
Background: Pediatric minimally invasive surgery (MIS) is a standard technique worldwide. We aimed to analyze the research activity in this field. Methods: Articles on pediatric MIS (1991−2020) were analyzed from the Web of Science™ for the total number of publications, citations, journals, and impact factors (IF). Of these, the 50 most cited publications were evaluated in detail and classified according to the level of evidence (i.e., study design) and topic (i.e., surgical procedure). Results: In total, 4464 publications and 53,111 citations from 684 journals on pediatric MIS were identified. The 50 most cited papers were published from 32 institutions in the USA/Canada (n = 28), Europe (n = 19), and Asia (n = 3) in 12 journals. Four authors (USA/Europe) contributed to 26% of the 50 most cited papers as first/senior author. Hot topics were laparoscopic pyeloplasty (n = 9), inguinal hernia repair (n = 7), appendectomy, and pyloromyotomy (n = 4 each). The majority of publications were retrospective studies (n = 33) and case reports (n = 6) (IF 5.2 ± 3.2; impact index 16.5 ± 6.4; citations 125 ± 39.4). They were cited as often as articles with high evidence levels (meta-analyses, n = 2; randomized controlled trials, n = 7; prospective studies, n = 2) (IF 12.9 ± 22.5; impact index 14.0 ± 6.5; citations 125 ± 34.7; p > 0.05). Conclusions: Publications on laparoscopic pyeloplasty, inguinal hernia repair, appendectomy, and pyloromyotomy are cited most often in pediatric MIS. However, the relevant number of studies with strong evidence for the advantages of MIS in pediatric surgery is missing.
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13
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Telementoring in Minimally Invasive Esophageal Atresia Repair: Results of a Case-Control Study and Lessons Learned from the TIC-PEA Study (Telemedical Interdisciplinary Care for Patients with Esophageal Atresia). CHILDREN 2022; 9:children9030387. [PMID: 35327759 PMCID: PMC8947504 DOI: 10.3390/children9030387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 03/04/2022] [Accepted: 03/07/2022] [Indexed: 12/02/2022]
Abstract
Minimally invasive esophageal atresia (EA) repair is deemed one of the most demanding procedures in pediatric surgery. Open repair is considered the gold standard and learning opportunities for minimally invasive repairs remain scarce. “Telemedical Interdisciplinary Care for Patients with Esophageal Atresia (TIC-PEA)” offers free access to an interdisciplinary network of experts for telemedical consultation (telementoring). The aim of this study was to determine the frequency of minimally invasive surgery (MIS) in TIC-PEA patients compared to the general population. TIC-PEA patients were matched and compared to controls regarding the use of MIS, patient characteristics, and complications. Patients (n = 31) were included at a mean age of 62.8 days (95%-CI: 41.4–84.3, 77% after the primary esophageal repair). The odds-ratio to have MIS was 4.03 (95%-confidence interval: 0.79–20.55) for esophageal anastomosis and 4.60 (95%-confidence interval: 0.87–24.22) for tracheoesophageal fistula-repair in the TIC-PEA group. Telementoring offered the chance to select the ideal candidate for MIS, plan the procedure, and review intraoperative images and videos with the expert. Telementoring as offered is ideal to promote MIS for EA and helps to address the individual learning curve. In order to maximize benefits, patients need to be included prior to the first esophageal procedure.
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14
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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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15
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Kennedy AA, Hart CK, de Alarcon A, Putnam PE, von Allmen D, Lehenbauer D, Bryant R, Torres-Silva C, Rutter MJ. Slide Tracheoplasty for Repair of Complex Tracheoesophageal Fistulas. Laryngoscope 2021; 132:1542-1547. [PMID: 34338338 DOI: 10.1002/lary.29785] [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: 05/04/2021] [Revised: 07/09/2021] [Accepted: 07/20/2021] [Indexed: 11/07/2022]
Abstract
OBJECTIVES/HYPOTHESIS Repair of large, recurrent, and complex tracheoesophageal fistulas (TEFs) is challenging and numerous different surgical approaches exist. These various techniques each carry a set of risks and possible complications such as fistula recurrence, tracheal stenosis or pouches, esophageal stenosis, and recurrent laryngeal nerve injury. Slide tracheoplasty is a reconstructive technique successfully used in many different airway pathologies, including TEF repair. This study examines the success, limits, and complications related to slide tracheoplasty for repair of complex TEFs. STUDY DESIGN Retrospective chart review. METHODS Patients undergoing TEF repair using a cervical or thoracic approach slide tracheoplasty, at a single institution, between July 2008 and December 2019 were retrospectively reviewed. Demographic data, comorbidities, TEF etiology and surgical history, slide tracheoplasty details and outcomes, and postoperative complication data were examined using descriptive statistics. RESULTS Twenty-six patients underwent 27 slide tracheoplasties for TEF (20 cervical approaches, 7 thoracic approaches) with a mean age of 5.2 years (IQR 0.7-7.6) at time of surgery. The most common TEF etiologies included congenital (n = 13), tracheostomy tube erosion (n = 5), and button battery ingestion (n = 4). Fistulas ranged in size from <0.5 mm to 4 cm and 59% had previous endoscopic or open repairs. There were two TEF recurrences (7.4%), one of which was successfully revised and the other which was treated with stent placement. Postoperative complications included dehiscence (3.7%), unilateral vocal fold paralysis (3.7%), and mild tracheal stenosis (18.5%). CONCLUSIONS Slide tracheoplasty is an effective surgical technique for treating complex congenital and acquired TEFs with lower rates of complications when compared to other techniques. LEVEL OF EVIDENCE IV Laryngoscope, 2021.
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Affiliation(s)
- Aimee A Kennedy
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, U.S.A
| | - Catherine K Hart
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, U.S.A.,Department of Otolaryngology Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, U.S.A.,Aerodigestive and Esophageal Center, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, U.S.A
| | - Alessandro de Alarcon
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, U.S.A.,Department of Otolaryngology Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, U.S.A.,Aerodigestive and Esophageal Center, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, U.S.A
| | - Philip E Putnam
- Aerodigestive and Esophageal Center, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, U.S.A.,Division of Gastroenterology, Nutrition and Hepatology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, U.S.A
| | - Daniel von Allmen
- Aerodigestive and Esophageal Center, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, U.S.A.,Department of Pediatric Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, U.S.A
| | - David Lehenbauer
- Department of Cardiothoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, U.S.A.,Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, U.S.A
| | - Roosevelt Bryant
- Department of Thoracic and Cardiovascular Surgery, Phoenix Children's Hospital, Phoenix, Arizona, U.S.A
| | - Cherie Torres-Silva
- Aerodigestive and Esophageal Center, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, U.S.A.,Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, U.S.A
| | - Michael J Rutter
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, U.S.A.,Department of Otolaryngology Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, U.S.A.,Aerodigestive and Esophageal Center, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, U.S.A
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16
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Bowder AN, Lal DR. Advances in the Surgical Management of Esophageal Atresia. Adv Pediatr 2021; 68:245-259. [PMID: 34243856 DOI: 10.1016/j.yapd.2021.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Alexis N Bowder
- Division of Pediatric Surgery, Department of Surgery, Medical College of Wisconsin, 999 North 92nd Street, Suite 320, Milwaukee, WI 53226, USA
| | - Dave R Lal
- Division of Pediatric Surgery, Department of Surgery, Medical College of Wisconsin, 999 North 92nd Street, Suite 320, Milwaukee, WI 53226, USA.
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17
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Feng X, Martynov I, Suttkus A, Lacher M, Mayer S. Publication Trends and Global Collaborations on Esophageal Atresia Research: A Bibliometric Study. Eur J Pediatr Surg 2021; 31:164-171. [PMID: 32146714 DOI: 10.1055/s-0040-1702223] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Research on esophageal atresia (EA) has been heavily published over the past decades. Herein, we aimed to study the quantity and quality as well as key topics in EA research with regards to global collaborations among countries and authors. MATERIALS AND METHODS Publications on EA from 1945 to 2018 were extracted from the Web of Science core collection database. Productivity (quantity) was assessed by the number of publications. Quality was estimated from the number of citations, citation rate per item and year, h-index, and impact index. Collaborative networks were evaluated using VOSviewer. All measures were analyzed for countries, authors, and journals. The 10 most cited original articles between 1969 and 2018 in 5-year intervals (n = 100) were manually screened to assess the key points of EA research. RESULTS A total of 2,170 publications from 85 countries published in 388 journals were identified yielding 26,755 citations, both significantly increasing over time (p < 0.001). The most productive countries and authors also accounted for high-quality publications and benefited from an active global network. The most productive journals derived from the field of pediatric surgery but accounted only for one-third of EA papers. The best cited journals were unspecific for pediatric surgery. Long-term outcome remained the most important topic in EA research, followed by surgical techniques, epidemiology, associated anomalies, perioperative complications, and postnatal management. In contrast, basic science was underrepresented. CONCLUSION Over the past seven decades, EA publications increased tremendously. Productiveness and quality benefited from global networking. Long-term outcome remains the key interest of EA research.
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Affiliation(s)
- Xiaoyan Feng
- Department of Pediatric Surgery, Leipzig University, Leipzig, Sachsen, Germany
| | - Illya Martynov
- Department of Pediatric Surgery, Leipzig University, Leipzig, Sachsen, Germany
| | - Anne Suttkus
- Department of Pediatric Surgery, Leipzig University, Leipzig, Sachsen, Germany
| | - Martin Lacher
- Department of Pediatric Surgery, Leipzig University, Leipzig, Sachsen, Germany
| | - Steffi Mayer
- Department of Pediatric Surgery, Leipzig University, Leipzig, Sachsen, Germany
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18
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Thakkar H, Mullassery DM, Giuliani S, Blackburn S, Cross K, Curry J, De Coppi P. Thoracoscopic oesophageal atresia/tracheo-oesophageal fistula (OA/TOF) repair is associated with a higher stricture rate: a single institution’s experience. Pediatr Surg Int 2021; 37:397-401. [PMID: 33550454 PMCID: PMC7900027 DOI: 10.1007/s00383-020-04829-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/30/2020] [Indexed: 12/24/2022]
Abstract
PURPOSE Thoracoscopic OA/TOF repair was first described in 1999. Currently, less than 10% of surgeons routinely employ minimally access surgery. Our primary aim was to review our immediate-, early- and long-term outcomes with this technique compared with the open approach. METHODS A retrospective review of all patients undergoing primary OA/TOF (Type C) repair at our institution from 2009 was conducted. Outcome measures included length of surgery, conversion rate from thoracoscopy, early complications such as anastomotic leak and post-operative complications such as anastomotic strictures needing dilatations. Fisher's exact and Kruskal-Wallis tests were used for statistical analysis. RESULTS 95 patients in total underwent OA/TOF repair during the study period of which 61 (64%) were completed via an open approach. 34 were attempted thoracoscopically of which 11 (33%) were converted. There was only one clinically significant anastomotic leak in our series that took place in the thoracoscopic group. We identified a significantly higher stricture rate in our thoracoscopic cohort (72%) versus open surgery (43%, P < 0.05). However, the median number of dilations (3) performed was not significantly different between the groups. There was one recurrent fistula in the thoracoscopic converted to open group. Our median follow-up was 60 months across the groups. CONCLUSION In our experience, the clinically significant leak rate for both open and thoracoscopic repair as well as recurrent fistula is much lower than has been reported in the literature. We do not routinely perform contrast studies and are, thus, reporting clinically significant leaks only. The use of post-operative neck flexion, ventilation and paralysis is likely to be protective towards a leak. Thoracoscopic OA/TOF repair is associated with a higher stricture rate compared with open surgery; however, these strictures respond to a similar number of dilatations and are no more refractory. Larger, multicentre studies may be useful to investigate these finding further.
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Affiliation(s)
- H Thakkar
- Department of Specialist Neonatal and Paediatric Surgery, Great Ormond Street Hospital, London, UK
| | - D M Mullassery
- Department of Specialist Neonatal and Paediatric Surgery, Great Ormond Street Hospital, London, UK
| | - S Giuliani
- Department of Specialist Neonatal and Paediatric Surgery, Great Ormond Street Hospital, London, UK
| | - S Blackburn
- Department of Specialist Neonatal and Paediatric Surgery, Great Ormond Street Hospital, London, UK
| | - K Cross
- Department of Specialist Neonatal and Paediatric Surgery, Great Ormond Street Hospital, London, UK
| | - J Curry
- Department of Specialist Neonatal and Paediatric Surgery, Great Ormond Street Hospital, London, UK
| | - Paolo De Coppi
- Department of Specialist Neonatal and Paediatric Surgery, Great Ormond Street Hospital, London, UK.
- Stem Cells and Regenerative Medicine Section, Department of Paediatric Surgery, UCL Great Ormond Street Institute of Child Health, 30 Guilford Street, Holborn, London, WC1N 1EH, UK.
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19
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Safa N, Wei S, Saran N, Guadagno E, Laberge JM, Emil S. Musculoskeletal deformities after thoracic surgery in children: An observational long-term follow-up study. J Pediatr Surg 2021; 56:136-141. [PMID: 33168178 DOI: 10.1016/j.jpedsurg.2020.09.024] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 09/22/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE This study reports the incidence, severity, and predictors of musculoskeletal deformities (MD), including scoliosis and chest wall anomalies, following thoracic procedures in children. METHODS Children younger than 14 years who had thoracic surgery between 1997 and 2012 and had no other predispositions to MD, underwent longitudinal follow-ups with dedicated musculoskeletal examination performed in an esophageal atresia, orthopedic, or research clinic. Incidence of MD was calculated, and logistic regression methods were used to determine independent predictors, including sex, gestational age, age at procedure, serratus anterior muscle division, and chest tube placement. RESULTS The study cohort consisted of 104 patients followed for a median of 10.8 years (range 3-21). A total of 56 MD developed in 41 patients (39%), including scapular winging (24; 23%), scoliosis (17; 16%), and chest wall anomalies (15; 14%). The majority of MD were subclinical, with only 8 patients [8% (6 thoracotomies, 2 thoracoscopies)] requiring intervention. Among patients who underwent thoracotomies (93, 89%), serratus anterior muscle division was the only significant predictor of the development of MD [OR 8.9; 95% CI 2.8-32.6]. CONCLUSION Musculoskeletal deformities develop in a significant proportion of children following thoracic surgery, but most are subclinical. A muscle-sparing technique decreases the incidence of these deformities. TYPE OF STUDY Prospective Cohort Study. LEVEL OF EVIDENCE Level II.
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Affiliation(s)
- Nadia Safa
- Harvey E, Beardmore Division of Pediatric Surgery, The Montreal Children's Hospital, McGill University Health Centre, 1001 Décarie Boulevard, Montréal, QC, H4A 3J1, Canada
| | - Sunny Wei
- Harvey E, Beardmore Division of Pediatric Surgery, The Montreal Children's Hospital, McGill University Health Centre, 1001 Décarie Boulevard, Montréal, QC, H4A 3J1, Canada
| | - Neil Saran
- Division of Pediatric Orthopedic Surgery, The Montreal Children's Hospital, McGill University Health Centre, 1001 Décarie Boulevard, Montréal, QC, H4A 3J1, Canada; Chest Wall Anomalies Center, Shriners Hospital for Children, Canada, 1003 Décarie Boulevard, Montreal, QC, H4A 3J1, Canada
| | - Elena Guadagno
- Harvey E, Beardmore Division of Pediatric Surgery, The Montreal Children's Hospital, McGill University Health Centre, 1001 Décarie Boulevard, Montréal, QC, H4A 3J1, Canada
| | - Jean-Martin Laberge
- Harvey E, Beardmore Division of Pediatric Surgery, The Montreal Children's Hospital, McGill University Health Centre, 1001 Décarie Boulevard, Montréal, QC, H4A 3J1, Canada; Chest Wall Anomalies Center, Shriners Hospital for Children, Canada, 1003 Décarie Boulevard, Montreal, QC, H4A 3J1, Canada
| | - Sherif Emil
- Harvey E, Beardmore Division of Pediatric Surgery, The Montreal Children's Hospital, McGill University Health Centre, 1001 Décarie Boulevard, Montréal, QC, H4A 3J1, Canada; Chest Wall Anomalies Center, Shriners Hospital for Children, Canada, 1003 Décarie Boulevard, Montreal, QC, H4A 3J1, Canada.
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20
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Marinho AS, Saxena AK. Thoracoscopic Esophageal Atresia Repair: Outcomes Analysis Between Primary and Staged Procedures. Surg Laparosc Endosc Percutan Tech 2020; 31:363-367. [PMID: 33394975 DOI: 10.1097/sle.0000000000000895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 11/10/2020] [Indexed: 11/25/2022]
Abstract
PURPOSE Thoracoscopic repair of esophageal atresia (EA) is analyzed in this systematic review that compares outcomes between primary and staged repairs. MATERIALS AND METHODS PubMed/Embase databases were reviewed for articles on thoracoscopic repair of EA, and articles were selected for primary and staged repairs. Descriptive statistics were used to analyze the quantitative parts of the study. RESULTS Thirty-six articles identified between 1999 and 2019 met the inclusion criteria and offered 776 patients for this analysis. Primary repairs were performed in n=703 and staged repairs in n=73. Comparative analysis showed that esophageal anastomosis was performed using absorbable suture in 88% primary and 78% staged repairs. Anastomotic leak rates were comparable between primary n=65/696 (9%) and staged repairs n=8/73 (11%). The re-fistulation rate was 2% in primary and 1% in staged repairs. There was no difference between suture material and re-fistulation (P>0.05; NS). In primary repairs, nonabsorbable sutures were found to be associated with more leaks than absorbable sutures (P<0.05*). The conversion rate was similar between 2 approaches; primary n=49/680 (7%) and staged n=6/73 (8%); P>0.05. No significant differences were found in the rate of anastomosis strictures between primary n=135/703 (19%) and staged repair n=21/73 (29%); P>0.05. The overall mortality was n=20/703 (3%) in primary and n=1/73 (1%) in staged repairs; P>0.05. CONCLUSIONS Successful thoracoscopic primary- and staged-EA repairs have been reported with low rate of complications. Outcomes between primary and staged repairs do not show significant differences with regards to re-fistulation, anastomotic leaks, conversion rates, and mortality.
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Affiliation(s)
- Ana S Marinho
- Department of Pediatric Surgery, Chelsea Children's Hospital, Chelsea and Westminster NHS Foundation Trust, Imperial College London, London, UK
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21
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Advances and Trends in Pediatric Minimally Invasive Surgery. J Clin Med 2020; 9:jcm9123999. [PMID: 33321836 PMCID: PMC7764454 DOI: 10.3390/jcm9123999] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 11/28/2020] [Accepted: 12/03/2020] [Indexed: 12/11/2022] Open
Abstract
As many meta-analyses comparing pediatric minimally invasive to open surgery can be found in the literature, the aim of this review is to summarize the current state of minimally invasive pediatric surgery and specifically focus on the trends and developments which we expect in the upcoming years. Print and electronic databases were systematically searched for specific keywords, and cross-link searches with references found in the literature were added. Full-text articles were obtained, and eligibility criteria were applied independently. Pediatric minimally invasive surgery is a wide field, ranging from minimally invasive fetal surgery over microlaparoscopy in newborns to robotic surgery in adolescents. New techniques and devices, like natural orifice transluminal endoscopic surgery (NOTES), single-incision and endoscopic surgery, as well as the artificial uterus as a backup for surgery in preterm fetuses, all contribute to the development of less invasive procedures for children. In spite of all promising technical developments which will definitely change the way pediatric surgeons will perform minimally invasive procedures in the upcoming years, one must bear in mind that only hard data of prospective randomized controlled and double-blind trials can validate whether these techniques and devices really improve the surgical outcome of our patients.
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22
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Elhattab A, Ali L, Rousseau V, Clermidi P, Michelet D, Farnoux C, Lapillonne A, Aly KAE, Sarnacki S, Bonnard A, Khen-Dunlop N. Thoracoscopy Versus Thoracotomy in the Repair of Esophageal Atresia with Distal Tracheoesophageal Fistula. J Laparoendosc Adv Surg Tech A 2020; 30:1289-1294. [DOI: 10.1089/lap.2020.0642] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Ahmad Elhattab
- Department of Pediatric Surgery, AP-HP, Hopital Necker-Enfants Malades, Paris, France
- Department of Pediatric Surgery, Mansoura University Children's Hospital, Mansoura, Egypt
| | - Liza Ali
- Department of Pediatric Surgery and AP-HP, Hopital Robert Debre, Paris, France
| | - Veronique Rousseau
- Department of Pediatric Surgery, AP-HP, Hopital Necker-Enfants Malades, Paris, France
| | - Pauline Clermidi
- Department of Pediatric Surgery, AP-HP, Hopital Necker-Enfants Malades, Paris, France
- Department of Pediatric Surgery, Mansoura University Children's Hospital, Mansoura, Egypt
| | - Daphné Michelet
- Department of Anesthesia, AP-HP, Hopital Robert Debre, Paris, France
| | - Caroline Farnoux
- Department of Pediatric Surgery and AP-HP, Hopital Robert Debre, Paris, France
| | - Alexandre Lapillonne
- Neonatal Care Unit, AP-HP, Hopital Necker-Enfants Malades, Paris, France
- Université de Paris, Paris, France
| | - Kamal Abdel-Elah Aly
- Department of Pediatric Surgery, Mansoura University Children's Hospital, Mansoura, Egypt
| | - Sabine Sarnacki
- Department of Pediatric Surgery, AP-HP, Hopital Necker-Enfants Malades, Paris, France
- Université de Paris, Paris, France
| | - Arnaud Bonnard
- Department of Pediatric Surgery and AP-HP, Hopital Robert Debre, Paris, France
- Université de Paris, Paris, France
| | - Naziha Khen-Dunlop
- Department of Pediatric Surgery, AP-HP, Hopital Necker-Enfants Malades, Paris, France
- Université de Paris, Paris, France
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Kim W, Son J, Lee S, Seo JM. The learning curve for thoracoscopic repair of esophageal atresia with distal tracheoesophageal fistula: A cumulative sum analysis. J Pediatr Surg 2020; 55:2527-2530. [PMID: 32646663 DOI: 10.1016/j.jpedsurg.2020.06.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 05/26/2020] [Accepted: 06/05/2020] [Indexed: 01/11/2023]
Abstract
BACKGROUND Thoracoscopic repair of esophageal atresia with tracheoesophageal fistula (EA/TEF) remains technically challenging due to the rarity of these procedures. The aim of this study is to report our experience with thoracoscopic repair of type C EA/TEF and to evaluate the learning curve based upon the surgeon's skill level. METHODS We retrospectively reviewed data of thoracoscopic EA/TEF repair performed in our center between October 2008 and May 2019. The learning curve was evaluated using the cumulative sum (CUSUM) method based on operative time. RESULTS Of the 50 consecutive cases evaluated, the mean birth weight was 2634 ± 608 g and the median age at operation was 3 days (range, 1-29 days). The mean operation time was 144 ± 65 min. Anastomosis leakage occurred in 3 cases (6%) and strictures requiring balloon dilatations occurred in 16 cases (32%). The CUSUM analysis evaluated a learning curve of approximately 10 cases of thoracoscopic type C EA/TEF repair. A lower gestational age was associated with longer operation time. CONCLUSIONS Thoracoscopic repair of type C EA/TEF is a feasible and safe procedure. The number of procedures required to achieve a stable learning curve was 10. The learning phase may be shortened by adequate set-up under the supervision of an expert endoscopic surgeon. TYPE OF STUDY Retrospective Comparative Treatment Study. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Wontae Kim
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Joonhyuk Son
- Department of Pediatric Surgery, Hanyang University College of Medicine, Seoul, Republic of Korea
| | - Sanghoon Lee
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
| | - Jeong-Meen Seo
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
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Bindi E, Torino G, Noviello C, Simonini A, Torre M, D'Agostino R, Cobellis G. Recurrent tracheoesophageal fistula secondary to clips migration after thoracoscopic esophageal atresia repair. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2020. [DOI: 10.1016/j.epsc.2020.101651] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Fernandes E, Kusel A, Evans S, Houghton J, Hamill JK. Is thoracoscopic esophageal atresia repair safe in the presence of cardiac anomalies? J Pediatr Surg 2020; 55:1511-1515. [PMID: 32253017 DOI: 10.1016/j.jpedsurg.2020.03.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2019] [Revised: 03/03/2020] [Accepted: 03/12/2020] [Indexed: 12/25/2022]
Abstract
BACKGROUND Esophageal atresia (EA) is often associated with congenital heart disease (CHD). Repair of EA by the thoracoscopic approach places physiological stress on a newborn with CHD. This paper reviews the outcomes of infants with CHD who had undergone thoracoscopic EA repair, comparing their outcomes to those without CHD. METHODS This was a review of infants who underwent thoracoscopic EA repair from 2009 to 2017 at one institution. Operative time and outcomes were analyzed in relation to CHD status. RESULTS Twenty five infants underwent thoracoscopic EA repair during the study period. Seventeen (68%) had associated anomalies of whom 9 (36%) had cardiac anomalies. The mean operative time was 217 min. There was no difference in operative time between CHD and non-CHD cases (estimate 20 min longer operative time in the presence of a cardiac anomaly [95% CI -20 to 57]). Two cases were converted to open thoracotomy; both were non-CHD. There was no difference in the time to feeding, time in intensive care unit or time in hospital between CHD and non-CHD cases. Five patients developed an anastomotic leak (two CHD and three non-CHD) of which two were clinical; all were managed conservatively. There was no case of recurrent fistula. CONCLUSIONS This pilot study did not find evidence that thoracoscopic EA repair compromised outcomes in children with congenital heart disease. A prospective multicenter study with long-term follow-up is recommended to confirm whether thoracoscopic repair in CHD is truly equivalent to the open operation. TYPE OF STUDY Therapeutic. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Erika Fernandes
- Department of Paediatric Surgery, Starship Children's Hospital, Auckland, New Zealand
| | - Amanda Kusel
- Department of Paediatric Surgery, Starship Children's Hospital, Auckland, New Zealand
| | - Stephen Evans
- Department of Paediatric Surgery, Starship Children's Hospital, Auckland, New Zealand
| | - James Houghton
- Department of Anaesthesia, Starship Children's Hospital, Auckland, New Zealand
| | - James K Hamill
- Department of Paediatric Surgery, Starship Children's Hospital, Auckland, New Zealand.
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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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27
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Sidler M, Wong ZH, Eaton S, Ahmad N, Ong M, Morsi A, Rees CM, Giuliani S, Blackburn S, Curry JI, Cross KM, De Coppi P. Insufflation in minimally invasive surgery: Is there any advantage in staying low? J Pediatr Surg 2020; 55:1356-1362. [PMID: 32102738 DOI: 10.1016/j.jpedsurg.2019.11.026] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Revised: 11/27/2019] [Accepted: 11/30/2019] [Indexed: 10/25/2022]
Abstract
AIM Minimally invasive repair of esophageal atresia with tracheoesophageal fistula (EA/TEF) and congenital diaphragmatic hernia (CDH) is feasible and confers benefits compared to thoracotomy or laparotomy. However, carbon dioxide (CO2) insufflation can lead to hypercapnia and acidosis. We sought to determine the effect of lower insufflation pressures on patients' surrogate markers for CO2 absorption - arterial partial pressure of CO2 (PaCO2), end tidal CO2 (EtCO2) and pH. METHODS Single center retrospective review, including neonates without major cardiac anomaly. Selected patients formed 2 groups: Historical pressure (HP) group and low pressure (LP) group. We reported on the patients' preoperative characteristics that potentially confound the degree of CO2 absorption or elimination. Outcome measures were perioperative PaCO2, EtCO2, arterial pH and anesthetic time. RESULTS 30 patients underwent minimally invasive surgery for CDH and 24 patients for EA/TEF with similar distribution within the HP and LP group. For CDH patients as well as for EA/TEF patients, there were no significant differences in their preoperative characteristics or surgery duration comparing HP and LP groups. With a decrease in insufflation pressure in CDH patients, there were a significant decrease (p = 0.002) in peak PaCO2 and an improvement in nadir pH (p = 0.01). For the EA/TEF patients, the decrease in insufflation pressure was associated with a significant decrease (p = 0.03) in peak EtCO2. Considering all 54 patients, we found EtCO2 to be highly significantly inversely correlated with pH and positively correlated with intraoperative PaCO2 (p < 0.001). Baseline Hb was inversely correlated with mean EtCO2 (p < 0.001). CONCLUSION With lower insufflation pressures, CDH patients had significantly improved hypercapnia and acidosis, while EA/TEF patients had significantly reduced EtCO2. EtCO2 was correlated with acidosis and hypercapnia. TYPE OF STUDY Retrospective case control study. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Martin Sidler
- Specialist Neonatal and Paediatric Surgery, Great Ormond Street Hospital, Paediatric Surgery, London, United Kingdom; Stem Cell and Regenerative Medicine Section, DBC, University College London, Great Ormond Institute of Child Health, London, United Kingdom
| | - Zeng Hao Wong
- Specialist Neonatal and Paediatric Surgery, Great Ormond Street Hospital, Paediatric Surgery, London, United Kingdom
| | - Simon Eaton
- Stem Cell and Regenerative Medicine Section, DBC, University College London, Great Ormond Institute of Child Health, London, United Kingdom
| | - Nargis Ahmad
- Paediatric Anaesthesia, Great Ormond Street Hospital, London, United Kingdom
| | - Meydene Ong
- Specialist Neonatal and Paediatric Surgery, Great Ormond Street Hospital, Paediatric Surgery, London, United Kingdom
| | - Ahmed Morsi
- Specialist Neonatal and Paediatric Surgery, Great Ormond Street Hospital, Paediatric Surgery, London, United Kingdom
| | - Clare M Rees
- Specialist Neonatal and Paediatric Surgery, Great Ormond Street Hospital, Paediatric Surgery, London, United Kingdom
| | - Stefano Giuliani
- Specialist Neonatal and Paediatric Surgery, Great Ormond Street Hospital, Paediatric Surgery, London, United Kingdom
| | - Simon Blackburn
- Specialist Neonatal and Paediatric Surgery, Great Ormond Street Hospital, Paediatric Surgery, London, United Kingdom
| | - Joseph I Curry
- Specialist Neonatal and Paediatric Surgery, Great Ormond Street Hospital, Paediatric Surgery, London, United Kingdom
| | - Kate M Cross
- Specialist Neonatal and Paediatric Surgery, Great Ormond Street Hospital, Paediatric Surgery, London, United Kingdom
| | - Paolo De Coppi
- Specialist Neonatal and Paediatric Surgery, Great Ormond Street Hospital, Paediatric Surgery, London, United Kingdom; Stem Cell and Regenerative Medicine Section, DBC, University College London, Great Ormond Institute of Child Health, London, United Kingdom.
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Son J, Jang Y, Kim W, Lee S, Jeong JS, Lee SK, Seo JM. Thoracoscopic repair of esophageal atresia with distal tracheoesophageal fistula: is it a safe procedure in infants weighing less than 2000 g? Surg Endosc 2020; 35:1597-1601. [PMID: 32323019 PMCID: PMC7222104 DOI: 10.1007/s00464-020-07538-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Accepted: 03/31/2020] [Indexed: 11/28/2022]
Abstract
Background Since Rothenberg first performed thoracoscopic repair for esophageal atresia with distal tracheoesophageal fistula (EA/TEF) successfully in 2000, thoracoscopic repair has achieved status as a routine procedure worldwide. Previously, an international multicenter study reported that this procedure was not inferior to conventional open surgery. However, thoracoscopic surgery is a highly difficult operation for surgeons and anesthesiologists; as a result, the safety and efficacy of the surgery is still under debate. Considering these circumstances, the purpose of this study was to analyze the results of single-center thoracoscopic surgery and to compare the outcomes relative to the patient’s weight at the time of surgery. Methods We retrospectively analyzed patients with EA/TEF who underwent thoracoscopic surgery in a single center between October 2008 and February 2017. Results In total, 41 cases of thoracoscopic repair of EA/TEF were performed. Upon subgrouping by over and under 2000 g of body weight at the time of operation, 34 were found to be over 2000 g and seven were under 2000 g. Intraoperative factors and events were not significantly different between the two groups. Additionally, most of the postoperative outcomes, including the rate of postoperative leakage and strictures, showed no difference. On the other hand, the under 2000 g group had more gastroesophageal reflux requiring fundoplication than did the heavier group (P = 0.04). Conclusions The results of this center’s thoracoscopic repair of EA/TEF were not inferior to other centers’ outcomes. Additionally, the intraoperative and postoperative outcomes were similar despite differences in weight at operation. Therefore, thoracoscopic repair might be a feasible surgical option for infants weighing less than 2000 g when performed by a surgeon and anesthesiologist team who are experienced in pediatric thoracoscopic surgery.
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Affiliation(s)
- Joonhyuk Son
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-Ro, Gangnam-Gu, Seoul, 06351, Korea
| | - Yerang Jang
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-Ro, Gangnam-Gu, Seoul, 06351, Korea
| | - Wontae Kim
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-Ro, Gangnam-Gu, Seoul, 06351, Korea
| | - Sanghoon Lee
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-Ro, Gangnam-Gu, Seoul, 06351, Korea
| | - Ji Seon Jeong
- Department of Anesthesiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Suk-Koo Lee
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-Ro, Gangnam-Gu, Seoul, 06351, Korea
| | - Jeong-Meen Seo
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-Ro, Gangnam-Gu, Seoul, 06351, Korea.
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Elbarbary MM, Shalaby A, Elseoudi M, Seleim HM, Ragab M, Fares AE, Khairy D, Wishahy AMK, Alkonaiesy RM, Eltagy G, Bahaaeldin K. Outcome of thoracoscopic repair of type-C esophageal atresia: a single-center experience from North Africa. Dis Esophagus 2020; 33:doaa001. [PMID: 32052010 DOI: 10.1093/dote/doaa001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 12/16/2019] [Accepted: 01/06/2020] [Indexed: 12/11/2022]
Abstract
Thoracoscopic repair of esophageal atresia is gaining popularity worldwide attributable to availability and advances in minimally invasive instruments. In this report, we presented our experience with thoracoscopic esophageal atresia/tracheoesophageal fistula (EA/TEF) repair in our tertiary care institute. A prospective study on short-gap type-C EA/TEF was conducted at Cairo University Specialized Pediatric Hospital between April 2016 and 2018. Excluded were cases with birth weight < 1500 gm, inability to stabilize physiologic parameters, or major cardiac anomalies. The technique was standardized in all cases and was carried out by operating team concerned with minimally invasive surgery at our facility. Primary outcome evaluated was successful primary anastomosis. Secondary outcomes included operative time, conversion rate, anastomotic leakage, recurrent fistula, postoperative stricture, and time till discharge. Over the inclusion period of this study, 136 cases of EA/TEF were admitted at our surgical NICU. Thoracoscopic repair was attempted in 76 cases. In total, 30 cases were pure atresia/long gap type-C atresia and were excluded from the study. Remaining 46 cases met the inclusion criteria and were enrolled in the study. Mean age at operation was 8.7 days (range 2-32), and mean weight was 2.6 Kg (range 1.8-3.6). Apart from five cases (10.8%) converted to thoracotomy, the mean operative time was 108.3 minutes (range 80-122 minute). A tension-free primary anastomosis was possible in all thoracoscopically managed cases (n = 41) cases. Survival rate was 85.4% (n = 35). Anastomotic leakage occurred in seven patients (17%). Conservative management was successful in two cases, while esophagostomy and gastrostomy were judged necessary in the other for five. Anastomotic stricture developed in five cases (16.6%) of the 30 surviving patients who kept their native esophagus. Despite the fact that good mid-term presented results may be due to patient selection bias, thoracoscopic approach proved to be feasible for management of short-gap EA/TEF. Authors of this report believe that thoracoscopy should gain wider acceptance and pediatric surgeons should strive to adopt this procedure.
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Affiliation(s)
- Mohamed M Elbarbary
- Pediatric Surgical Department, Cairo University Specialized Pediatric Hospital, Cairo, Egypt
| | - Aly Shalaby
- Pediatric Surgical Department, Cairo University Specialized Pediatric Hospital, Cairo, Egypt
| | - Mohamed Elseoudi
- Pediatric Surgical Department, Cairo University Specialized Pediatric Hospital, Cairo, Egypt
| | - Hamed M Seleim
- Pediatric Surgical Department, Tanta University Hospital, Tanta, Egypt
| | - Moutaz Ragab
- Pediatric Surgical Department, Cairo University Specialized Pediatric Hospital, Cairo, Egypt
| | - Ahmed E Fares
- Pediatric Surgical Department, Fayoum University Hospitals, Fayoum, Egypt
| | - Dalia Khairy
- Pediatric Surgical Department, Cairo University Specialized Pediatric Hospital, Cairo, Egypt
| | - Ahmed M K Wishahy
- Pediatric Surgical Department, Cairo University Specialized Pediatric Hospital, Cairo, Egypt
| | - Ramy M Alkonaiesy
- Pediatric Surgical Department, Cairo University Specialized Pediatric Hospital, Cairo, Egypt
| | - Gamal Eltagy
- Pediatric Surgical Department, Cairo University Specialized Pediatric Hospital, Cairo, Egypt
| | - Khaled Bahaaeldin
- Pediatric Surgical Department, Cairo University Specialized Pediatric Hospital, Cairo, Egypt
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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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Chiarenza SF, Bleve C, Zolpi E, Costa L, Mazzotta MR, Novek S, Bonato R, Conighi ML. The Use of Endoclips in Thoracoscopic Correction of Esophageal Atresia: Advantages or Complications? J Laparoendosc Adv Surg Tech A 2019; 29:976-980. [DOI: 10.1089/lap.2018.0388] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Salvatore Fabio Chiarenza
- Department of Pediatric Surgery and Pediatric Minimally Invasive Surgery and New Technologies, San Bortolo Hospital, Vicenza, Italy
| | - Cosimo Bleve
- Department of Pediatric Surgery and Pediatric Minimally Invasive Surgery and New Technologies, San Bortolo Hospital, Vicenza, Italy
| | - Elisa Zolpi
- Department of Pediatric Surgery and Pediatric Minimally Invasive Surgery and New Technologies, San Bortolo Hospital, Vicenza, Italy
| | - Lorenzo Costa
- Department of Pediatric Surgery and Pediatric Minimally Invasive Surgery and New Technologies, San Bortolo Hospital, Vicenza, Italy
| | | | - Steven Novek
- Department of Pediatric Surgery and Pediatric Minimally Invasive Surgery and New Technologies, San Bortolo Hospital, Vicenza, Italy
| | - Raffaele Bonato
- Department of Anesthesia, San Bortolo Hospital, Vicenza, Italy
| | - Maria Luisa Conighi
- Department of Pediatric Surgery and Pediatric Minimally Invasive Surgery and New Technologies, San Bortolo Hospital, Vicenza, Italy
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Aguilera-Pujabet M, Gahete JAM, Guillén G, López-Fernández S, Martin-Giménez MP, Lloret J, López M. Management of neonates with right-sided aortic arch and esophageal atresia: International survey on IPEG AND ESPES members´ experience. J Pediatr Surg 2018; 53:1923-1927. [PMID: 29241961 DOI: 10.1016/j.jpedsurg.2017.11.051] [Citation(s) in RCA: 6] [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: 08/14/2017] [Revised: 11/07/2017] [Accepted: 11/12/2017] [Indexed: 11/20/2022]
Abstract
AIM The optimum surgical approach of neonates with right-sided aortic arch (RAA) and esophageal atresia (EA)/tracheoesophageal fistula (TEF) is still an unsolved question. In order to propose an operative algorithm in the era of endoscopic surgery, we performed an international survey to know the current practice between pediatric endoscopic surgeons. Two of the most important societies in endoscopic pediatric surgery were queried: the International Pediatric Endosurgery Group (IPEG) and the European Society of Paediatric Endoscopic Surgeons (ESPES). MATERIALS AND METHODS During December 2016, an anonymous online-based survey was sent to all IPEG and ESPES members, collecting data regarding perioperative management and surgical repair of EA/TEF with RAA. RESULTS 144 surgeons from 23 countries completed the questionnaire. 69.2% of respondents were IPEG members, 30.8% were ESPES members. 71.5% of members who answered the survey had more than 10years of surgical experience. A preoperative echocardiography was almost uniformly performed (93.1%). 31.9% of the surveyed surgeons had never treated an EA/TEF with RAA. The remaining 98 surveyed surgeons had managed 279 cases of EA/TEF with RAA. Thoracotomy was considered the preferred approach for 54.2% of the surgeons, and 51.9% chose a right-sided approach. When RAA was an intraoperative finding, 76% would perform a contralateral thoracotomy if difficulties arose. Thoracoscopy was preferred by 45.8% of surgeons. If RAA was suspected preoperatively, 63.1% preferred to attempt a left-sided thoracoscopy and only 24.2% would change their approach to a thoracotomy. If RAA was an intraoperative finding and a safe surgical repair could not be achieved through right-sided thoracoscopy, 51.5% of them chose to perform a left sided thoracoscopy, rather than convert to thoracotomy. CONCLUSIONS Preoperative echocardiography performed by experienced examiners helps in surgical planning. Preoperative diagnosis of RAA should not discourage thoracoscopic repair, which is increasingly becoming more popular for the correction of EA/TEF. In case of an unexpected intraoperative diagnosis of RAA or operative difficulties when approaching through the right side, thoracoscopy offers a less aggressive approach. LEVEL OF EVIDENCE V.
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Affiliation(s)
- Monserrat Aguilera-Pujabet
- Department of Pediatric Surgery and Urology, Neonatal Surgical Unit, Universitat Autònoma de Barcelona, University Hospital of Vall d'Hebron, Barcelona, Spain
| | - Jose Andres Molino Gahete
- Department of Pediatric Surgery and Urology, Neonatal Surgical Unit, Universitat Autònoma de Barcelona, University Hospital of Vall d'Hebron, Barcelona, Spain
| | - Gabriela Guillén
- Department of Pediatric Surgery and Urology, Neonatal Surgical Unit, Universitat Autònoma de Barcelona, University Hospital of Vall d'Hebron, Barcelona, Spain
| | - Sergio López-Fernández
- Department of Pediatric Surgery and Urology, Neonatal Surgical Unit, Universitat Autònoma de Barcelona, University Hospital of Vall d'Hebron, Barcelona, Spain
| | - Marta Patricia Martin-Giménez
- Department of Pediatric Surgery and Urology, Neonatal Surgical Unit, Universitat Autònoma de Barcelona, University Hospital of Vall d'Hebron, Barcelona, Spain
| | - Josep Lloret
- Department of Pediatric Surgery and Urology, Neonatal Surgical Unit, Universitat Autònoma de Barcelona, University Hospital of Vall d'Hebron, Barcelona, Spain
| | - Manuel López
- Department of Pediatric Surgery and Urology, Neonatal Surgical Unit, Universitat Autònoma de Barcelona, University Hospital of Vall d'Hebron, Barcelona, Spain.
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The Visionaries, the Virtuosos, and the History of Congenital Esophageal Atresia Surgery. Ann Thorac Surg 2018; 106:305-308. [PMID: 29614258 DOI: 10.1016/j.athoracsur.2018.02.069] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Accepted: 02/14/2018] [Indexed: 11/24/2022]
Abstract
The year 2018 marks the 130th anniversary of the first known surgical attempt at correction of esophageal atresia, performed by Charles Steele. But before the first successful procedure happened, many other surgeons undertook heroic attempts to save newborns and infants with this defect. Two hundred seventy-one years passed from the first description of the defect to the first surgery survivor. This paper presents a fascinating history of these milestones in pediatric surgery and of its pioneers whose creativity, mastery, and fantasy created a basis of congenital esophageal atresia surgery.
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Wei S, Saran N, Emil S. Musculoskeletal deformities following neonatal thoracotomy: long-term follow-up of an esophageal atresia cohort. J Pediatr Surg 2017; 52:1898-1903. [PMID: 28958717 DOI: 10.1016/j.jpedsurg.2017.08.062] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Accepted: 08/28/2017] [Indexed: 11/24/2022]
Abstract
BACKGROUND Musculoskeletal deformities (MD), including scoliosis and chest wall anomalies, are potential long-term complications of neonatal thoracotomies. METHODS We studied the incidence of MD in patients who underwent open repair of esophageal atresia between 1997 and 2012, had no other predisposition to MD, and subsequently received longitudinal follow-up in a multidisciplinary esophageal atresia clinic. Detailed chest wall and musculoskeletal exams were performed at each visit. Incident rate and incident rate ratios were used to determine the incidence of deformities. Logistic regression methods were used to test the effect of independent variables including sex, gestational age, muscle division, number of thoracotomies, and operative complications on the occurrence of MD. RESULTS The study cohort consisted of 52 patients followed for a median of 8 (range 1-19) years. MD developed in 13 (25%), with an incident rate of 2.92 per 100 child-years. Division of the serratus anterior was associated with a significantly higher probability of developing MD (log-rank p=.0237) and was also a strong predictor of the same [OR 8.6 (95% CI 1.8-42.1)] after adjusting for possible confounders. CONCLUSIONS Musculoskeletal deformities develop in a significant proportion of neonates following thoracotomy. A muscle-sparing technique decreases the incidence of these deformities. TYPE OF STUDY Prospective Cohort Study. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Sunny Wei
- Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Neil Saran
- Division of Pediatric Orthopaedics, The Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada; Chest Wall Anomalies Center, Shriners Hospital for Children, Canada, Montreal, Quebec, Canada
| | - Sherif Emil
- Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada; Chest Wall Anomalies Center, Shriners Hospital for Children, Canada, Montreal, Quebec, Canada.
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Rothenberg SS. Thoracoscopic management of non-type C esophageal atresia and tracheoesophageal atresia. J Pediatr Surg 2017; 53:S0022-3468(17)30647-4. [PMID: 29092772 DOI: 10.1016/j.jpedsurg.2017.10.025] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2017] [Accepted: 10/05/2017] [Indexed: 01/02/2023]
Abstract
PURPOSE This study evaluates the results of thoracoscopic management of complex, non-type C, EA and TEF in infants. METHODS From March 2000 to February 2017, 23 patients were treated for Type A N=13, Type B N=4, and Type E N=6. Patients diagnosed with EA had G-tube feeds for a period of 4-9weeks. All procedures were performed thoracoscopically. EA gaps were between 4 and 7 1/2 vertebral bodies. RESULTS All surgeries were completed thoracoscopically. Average operative time was 95min for Type A, 115min for Type B, and 50min for Type E. Two patients with long gaps had small leaks which resolved with conservative management. One patient with an H-type was re-intubated causing a partial disruption of the tracheal repair. This required thoracoscopic re-exploration with repair and placement of an intercostal muscle flap. No patient has any clinical evidence of fused ribs, chest wall asymmetry, shoulder girdle weakness, or winged scapula. CONCLUSION Thoracoscopic repair of complex EA and TEF is safe and effective. The excellent visualization of the thoracic inlet allows for extensive mobilization creating sufficient length for long gaps and safely managing high fistulas. This may limit injury to adjacent structures and avoid a neck incision and chest wall deformity. LEVEL OF EVIDENCE IV.
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36
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Abstract
This review centers on the thoracoscopic management of esophageal atresia (EA) and distal tracheoesophageal fistula (TEF). The first thoracoscopic repair of EA was performed by Rothenberg and Lobe in Berlin in 1999 just prior to an IPEG meeting. Since that time, the largest report describing the use of thoracoscopy for EA/TEF repair came in 2005 with a multi-national, multi-institutional retrospective review from six institutions around the world. The outcomes reported were quite good and very comparable to large series of open operations that had been previously reported. This review will describe a single surgeon's technique for thoracoscopic repair of EA/TEF. In addition, further controversies regarding the usefulness of preoperative bronchoscopy, ligation of the distal TEF, and type of suture used for the esophageal anastomosis will also be discussed. Finally, there is a discussion on the advantages and disadvantages of the thoracoscopic approach.
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Affiliation(s)
- George W Holcomb
- Department of Surgery, Children's Mercy Hospital, Kansas City, MO, USA.
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37
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Abstract
Paediatric endoscopic surgery is greatly indebted to Karl Storz for developing paediatric endoscopic instruments. In more recent years, there is an increasing interest in endoscopic surgery in neonates. Now more complex procedures are being performed, although it will take another generation before these will be more generally applied. One of the key factors to success is training. More sophisticated training models are becoming available, allowing practicing in a safe environment before putting the procedure to practice. A key question in performing complex procedures is whether such procedures should not be concentrated into centres of expertise. Finally, a critical appraisal is warranted in regard to safety of surgery in neonates, as they fail to have cerebral autoregulation. As endoscopy may add additional risk factors, close monitoring is obligatory. LEVEL OF EVIDENCE V.
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Affiliation(s)
- David C van der Zee
- Department of Pediatric Surgery, University Medical Center Utrecht, Wilhelmina Children's Hospital, KE 04.140.5, P.O. Box 85090, 3508AB Utrecht, The Netherlands.
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38
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Yang YF, Dong R, Zheng C, Jin Z, Chen G, Huang YL, Zheng S. Outcomes of thoracoscopy versus thoracotomy for esophageal atresia with tracheoesophageal fistula repair: A PRISMA-compliant systematic review and meta-analysis. Medicine (Baltimore) 2016; 95:e4428. [PMID: 27472740 PMCID: PMC5265877 DOI: 10.1097/md.0000000000004428] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND A thoracoscopic approach for repair of esophageal atresia (EA) with tracheoesophageal fistula (TEF) has become a standard procedure in many pediatric surgical centers. However, whether thoracotomy or thoracoscopy offer advantages in terms of surgical outcomes is not known. METHODS To evaluate the efficacy and safety of thoracoscopic repair (TR) versus conventional open repair (COR) for EA with TEF.PubMed, Cochrane Library, and EMBASE were searched to identify relevant literature until 2016.Studies comparing surgical outcomes of patients undergoing TR versus COR for EA with TEF were reviewed.The quality of each included study was assessed using the Newcastle-Ottawa scale score. A fixed or random-effect model was applied depending on heterogeneity tests. RESULTS Eight observational clinical studies involving 452 patients were included in this meta-analysis. The meta-analysis of 2 major postoperative complications (leaks and strictures) did not show significant differences between TR and COR. Overall estimates of the odds ratio (OR) of TR versus COR for leaks and strictures were: 1.57 (95% confidence interval [CI], 0.77-3.20; P = 0.22) and 0.90 (95% CI, 0.27-2.97; P = 0.86), respectively. However, meta-analysis of operation time (OR = 19.59, 95% CI = 0.77-38.40, P = 0.04), timing of extubation (OR = -2.50, 95% CI = -3.39 to -1.62, P < 0.001), time to 1st oral feeding (OR = -2.58, 95% CI = -3.79 to -1.36, P < 0.001), and duration of hospital stay (OR = -10.76, 95% CI = -16.39 to -5.12, P < 0.001) showed significant differences.No randomized controlled trial was included, and most studies had small sample sizes and were based on retrospective analysis. CONCLUSION TR and COR show a similar complication rates of leaks and strictures for EA/TEF repair. Although associated with a longer operative time, TR has the advantages of an earlier time to extubation and 1st oral feeding, and shorter hospital stay.
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Affiliation(s)
| | | | | | | | | | | | - Shan Zheng
- Department of Pediatric Surgery, Children's Hospital of Fudan University, and Key Laboratory of Neonatal Disease, Ministry of Health, Shanghai, China
- Correspondence: Shan Zheng, Department of Pediatric Surgery, Children's Hospital of Fudan University, and Key Laboratory of Neonatal Disease, Ministry of Health, 399 Wan Yuan Road, Shanghai 201102, China (e-mail: )
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39
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Abstract
There have been major advances in the surgery for oesophageal atresia (OA) and tracheo-oesophageal fistula(TOF) with survival now exceeding 90%. The standard open approach to OA and distal TOF has been well described and essentially unchanged for the last 60 years. Improved survival in recent decades is most attributable to advances in neonatal anaesthesia and perioperative care. Recent surgical advances include the use of thoracoscopic surgery for the repair of OA/TOF and in some centres isolated OA, thereby minimising the long term musculo-skeletal morbidity associated with open surgery. The introduction of growth induction by external traction (Foker procedure) for the treatment of long-gap OA has provided an important tool enabling increased preservation of the native oesophagus. Despite this, long-gap OA still poses a number of challenges, and oesophageal replacement still may be required in some cases.
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Zani A, Cobellis G, Wolinska J, Chiu PPL, Pierro A. Preservation of native esophagus in infants with pure esophageal atresia has good long-term outcomes despite significant postoperative morbidity. Pediatr Surg Int 2016; 32:113-7. [PMID: 26520653 DOI: 10.1007/s00383-015-3821-x] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/09/2015] [Indexed: 01/28/2023]
Abstract
PURPOSE To evaluate long-term outcomes of pure esophageal atresia (EA) repair with preservation of native esophagus. METHODS Infants with pure EA treated at our institution (2000-2010) and with minimum 5-year follow-up were reviewed (REB:1000046653). Data analysed included demographics, management and outcomes and are reported as mean ± SD/median (range). RESULTS Of 185 infants with EA, 12 (7 %) had pure EA (gestational age: 36 ± 2.4 weeks, birth weight: 2353 ± 675 g). Ten had associated anomalies, including trisomy-21 (n = 2) and duodenal atresia (n = 1). SURGERY 1 patient (short gap) underwent primary thoracoscopic anastomosis, 11 had gastrostomy (Stamm, n = 5; image-guided, n = 6) as initial procedure. At definitive repair (age: 128 ± 91 days; weight 5.5 ± 2.3 kg): ten had primary anastomosis and 1 had Collis gastroplasty. No patient had esophageal replacement surgery. OUTCOMES three patients had gastrostomy dehiscence requiring re-operation. At post-operative esophagram, seven had anastomotic leak successfully treated conservatively. Seven patients developed strictures requiring balloon dilatations (median two dilatations, range 1-10), six received antireflux surgery. At 7-year follow-up (range 5-15 years), all patients had the gastrostomy closed and were on full oral feeds. CONCLUSIONS The management of pure EA continues to be challenging. The preservation of native esophagus is possible with significant morbidity. The long-term outcomes are favourable.
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Affiliation(s)
- Augusto Zani
- Division of General and Thoracic Surgery, Physiology and Experimental Medicine Program, The Hospital for Sick Children, 1526-555 University Ave, Toronto, ON, M5G 1X8, Canada
| | - Giovanni Cobellis
- Division of General and Thoracic Surgery, Physiology and Experimental Medicine Program, The Hospital for Sick Children, 1526-555 University Ave, Toronto, ON, M5G 1X8, Canada
| | - Justyna Wolinska
- Division of General and Thoracic Surgery, Physiology and Experimental Medicine Program, The Hospital for Sick Children, 1526-555 University Ave, Toronto, ON, M5G 1X8, Canada
| | - Priscilla P L Chiu
- Division of General and Thoracic Surgery, Physiology and Experimental Medicine Program, The Hospital for Sick Children, 1526-555 University Ave, Toronto, ON, M5G 1X8, Canada
| | - Agostino Pierro
- Division of General and Thoracic Surgery, Physiology and Experimental Medicine Program, The Hospital for Sick Children, 1526-555 University Ave, Toronto, ON, M5G 1X8, Canada. .,University of Toronto, Toronto, Canada.
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41
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Fonte J, Barroso C, Lamas-Pinheiro R, Silva AR, Correia-Pinto J. Anatomic Thoracoscopic Repair of Esophageal Atresia. Front Pediatr 2016; 4:142. [PMID: 28119903 PMCID: PMC5220117 DOI: 10.3389/fped.2016.00142] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Accepted: 12/19/2016] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The thoracoscopic approach to repair esophageal atresia (EA) with tracheoesophageal fistula (TEF) provides excellent view, allowing the most skillful surgeons to spare the azygos vein by performing the esophageal anastomosis over (on the right side) the azygos vein. Seeking the most anatomic repair, we started to perform the esophageal anastomosis underneath (on the left side) the azygos vein: anatomic thoracoscopic repair of esophageal atresia (ATREA). We aim to compare results of ATREA with the classic thoracoscopic repair. METHODS During the last 4 years, in our center, all infants with EA with distal TEF were operated by thoracoscopy sparing the azygos vein. According to the surgical technique, two groups were created: Group A-treated with ATREA and Group B-treated with classic thoracoscopic repair over (on the right side) the azygos vein. We retrospectively collected data regarding features of the newborn (gestational age, gender, karyotype changes, associated anomalies, birth weight), surgery (operative technique, operative time, and surgical complications), hospitalization (duration of mechanical ventilation, thoracic drainage, time for the first feeding, time of admission, and early complications) and follow-up [tracheomalacia, gastroesophageal reflux disease (GERD), anastomotic stricture, recurrence of fistula]. RESULTS Group A had seven newborns and Group B had four newborns. There were no statistically significant differences between both groups concerning the evaluated variables on surgery, hospitalization, and follow-up. Nevertheless, in Group A, there was an infant with a right aortic arch where ATREA was particularly useful as it avoided that the azygos vein and the aortic arch were left compressed in between the esophagus and trachea. Postoperatively, one patient of Group B had a major anastomotic leak with empyema requiring surgical re-intervention. During follow-up, anastomotic stricture requiring esophageal dilation occurred with similar rates in both groups. In Group B, one patient had severe and symptomatic tracheomalacia requiring aortopexy and severe GERD requiring fundoplication. No patients developed recurrent fistula. CONCLUSION The ATREA is feasible in the great majority of patients with EA with TEF without compromising long-term results and might be particularly useful for those infants with malformations of the cardiac venous return vessels and/or major aortic malformations.
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Affiliation(s)
- Joana Fonte
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal; ICVS/3B's - PT Government Associate Laboratory, Braga/Guimarães, Portugal; Department of Pediatric Surgery, Hospital de Braga, Braga, Portugal
| | - Catarina Barroso
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal; ICVS/3B's - PT Government Associate Laboratory, Braga/Guimarães, Portugal; Department of Pediatric Surgery, Hospital de Braga, Braga, Portugal
| | - Ruben Lamas-Pinheiro
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal; ICVS/3B's - PT Government Associate Laboratory, Braga/Guimarães, Portugal; Department of Pediatric Surgery, Hospital de Braga, Braga, Portugal
| | - Ana R Silva
- Department of Pediatric Surgery, Hospital de Braga , Braga , Portugal
| | - Jorge Correia-Pinto
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal; ICVS/3B's - PT Government Associate Laboratory, Braga/Guimarães, Portugal; Department of Pediatric Surgery, Hospital de Braga, Braga, Portugal
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42
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Woo S, Lau S, Yoo E, Shaul D, Sydorak R. Thoracoscopic versus open repair of tracheoesophageal fistulas and rates of vocal cord paresis. J Pediatr Surg 2015; 50:2016-8. [PMID: 26392058 DOI: 10.1016/j.jpedsurg.2015.08.021] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Accepted: 08/24/2015] [Indexed: 11/26/2022]
Abstract
BACKGROUND/PURPOSE The purpose of this study was to investigate the rates of vocal cord paresis/paralysis (VCP) in patients treated for esophageal atresia (EA) with and without fistula performed thoracoscopically versus open. METHODS A retrospective review of EA cases performed from 2008 to 2014 in an integrated health care system was performed. RESULTS A total of 31 cases of EA were performed by 6 surgeons at 4 different institutions. Seventeen cases were performed thoracoscopically, whereas 14 cases were performed open. In the thoracoscopic group, the average gestational age (weeks) of the patient was significantly higher 38.3 vs. 35.2 (p=0.016) as well as the average birth weight (grams) 2843 vs. 2079 (p=0.005). There was no difference in the postoperative length of stay, rates of anastomotic stricture, leak, or tracheomalacia. There were 10 cases of vocal cord paresis, 9 from the thoracoscopic group and one from the open group (p=0.007). Of the 10 cases of VCP, 6 were unilateral (left sided) and 4 were bilateral. Of the 10 cases, 6 resolved, 2 resulted in permanent paralysis, and 2 are currently still being evaluated. CONCLUSIONS Thoracoscopic repair of EA appears to have higher rates of VCP. The results are thought to be from thoracoscopic dissection of the esophagus high into the thoracic inlet.
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Affiliation(s)
- Sunee Woo
- Department of Surgery, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA, USA
| | - Stanley Lau
- Department of Surgery, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA, USA
| | - Edward Yoo
- Department of Surgery, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA, USA
| | - Donald Shaul
- Department of Surgery, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA, USA
| | - Roman Sydorak
- Department of Surgery, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA, USA.
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Rothenberg SS, Flake AW. Experience with Thoracoscopic Repair of Long Gap Esophageal Atresia in Neonates. J Laparoendosc Adv Surg Tech A 2015; 25:932-5. [PMID: 26485521 DOI: 10.1089/lap.2015.0124] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION This report evaluates the results of a two-surgeon experience with thoracoscopic repair in patients with long gap esophageal atresia (EA). MATERIALS AND METHODS From March 2000 to February 2015, 14 consecutive patients with pure EA were repaired thoracoscopically. The gap length was then evaluated by contrast gastrostomy tube study. Patients were operated on between 4 to 8 weeks of age. Patient weights ranged from 2.6 to 3.8 kg. The longest gap was 7½ vertebral bodies. Dissection was carried well up into the thoracic inlet on the upper pouch and down to the esophageal hiatus on the lower pouch. A 15th patient was not referred until 3 months of age. RESULTS All 15 procedures were completed successfully thoracoscopically. Operative times ranged from 60 to 135 minutes. There were two leaks; both resolved with conservative therapy. Feeds were started on Day 5 in all other patients. Six of 13 patients required dilations (one to nine), and 8 required a Nissen fundoplication for severe reflux. All patients are currently on full oral feeds. No patient has any evidence of chest wall asymmetry, winged scapula, or clinically significant scoliosis. CONCLUSIONS Thoracoscopic repair of long gap EA has proven to be an effective and safe technique when performed in the first 2 months of life. The improved visualization and access to the upper pouch and lower pouches allow for maximal mobilization. The results are superior to those of documented open series and avoid the morbidity of repeated operations in the neonatal period.
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Affiliation(s)
- Steven S Rothenberg
- 1 The Rocky Mountain Hospital for Children , Denver, Colorado.,2 Columbia University College of Physicians and Surgeons , New York, New York
| | - Alan W Flake
- 3 The Children's Hospital of Philadelphia , Philadelphia, Pennsylvania
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Davenport M, Rothenberg SS, Crabbe DCG, Wulkan ML. The great debate: open or thoracoscopic repair for oesophageal atresia or diaphragmatic hernia. J Pediatr Surg 2015; 50:240-6. [PMID: 25638610 DOI: 10.1016/j.jpedsurg.2014.11.008] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2014] [Accepted: 11/02/2014] [Indexed: 10/24/2022]
Abstract
Controversy exists over the best method and technique of repair of oesophageal atresia and diaphragmatic hernia. Open surgical repairs have a long established history of over 60 years of experience. Set against this has been a series of successful thoracoscopic repairs of both congenital anomalies reported over the past decade. This review was based upon a four-handed debate on the merits and weaknesses of the two contrasting surgical philosophies and reviews existing literature, techniques, complications, and importantly outcome and results.
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Affiliation(s)
- Mark Davenport
- Department of Paediatric Surgery, Kings College Hospital, London, UK.
| | - Steven S Rothenberg
- 2055 High St Suite 370, Rocky Mountain Hospital For Children, Denver, CO, USA.
| | - David C G Crabbe
- Department of Paediatric Surgery, Leeds General Infirmary, Leeds, UK.
| | - Mark L Wulkan
- Emory University School of Medicine/Children's Healthcare of Atlanta, Atlanta, GA, USA.
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45
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Okuyama H, Koga H, Ishimaru T, Kawashima H, Yamataka A, Urushihara N, Segawa O, Uchida H, Iwanaka T. Current Practice and Outcomes of Thoracoscopic Esophageal Atresia and Tracheoesophageal Fistula Repair: A Multi-institutional Analysis in Japan. J Laparoendosc Adv Surg Tech A 2015; 25:441-4. [PMID: 25594776 DOI: 10.1089/lap.2014.0250] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND In order to better understand the current practice and outcomes of thoracoscopic repair of esophageal atresia (EA)/tracheoesophageal fistula (TEF), a multi-institutional analysis was conducted among seven Japanese institutes. MATERIALS AND METHODS A survey was sent to the seven institutes regarding the surgical technique, postoperative management, and outcomes of thoracoscopic repair of EA/TEF. RESULTS The operation was uniformly performed via an intrapleural approach in the 0-45° prone position. The TEF was occluded with suture ligature in four (57.1%) institutes and clips in the remaining three (42.9%) institutes. Anastomosis was performed using the extracorporeal knot-tying technique in four institutes and the intracorporeal technique in three institutes. Patients were routinely left intubated and paralyzed for 3-7 days postoperatively in four institutes. In total, 58 patients underwent thoracoscopic repair of EA/TEF. Fifty-two (89.7%) of the patients underwent successful thoracoscopic repair. Six (10.3%) operations were converted to open thoracotomy because of a long gap (n=4), right aortic arch (n=1), and intraoperative instability (n=1). The body weight at operation ranged from 1.2 to 4.6 kg, and the operative time ranged from 115 to 428 minutes. There were no major intraoperative complications. Eleven patients (19.0%) suffered from anastomotic leakage. Twenty-eight patients (48.3%) developed anastomotic stricture. One patient died during the postoperative period because of an unrelated disease. Recurrent TEF developed in three patients (5.2%). Thirteen patients (22.4%) later required fundoplication. CONCLUSIONS The outcome of thoracoscopic repair of EA/TEF was comparable to that of the open procedure. As considerable variability was observed among the seven institutes with respect to the surgical technique and management, standardizing the surgical management may improve the outcome.
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Affiliation(s)
- Hiroomi Okuyama
- 1 Department of Pediatric Surgery, Osaka University Graduate School of Medicine , Suita, Osaka, Japan
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46
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Abstract
In the 50 years since the first edition of this journal, operative paediatric surgery has undergone radical change. Many of the most common instruments are unchanged, both as a testament to their utility and in recognition of past surgeons remembered eponymously. Surrounding that basic core of instruments, theatre has changed radically as new tools and techniques have arisen. Surgeons have come down from their pedestals, recognising surgery as a team sport rather than a solo performance. More than half of the current paediatric surgical trainees are women, a higher proportion than in any other craft group of the Royal Australasian College of Surgeons. The appearance, and rapid development, of laparoscopy is to many observers the most notable change in surgery over the last 50 years. Placed in its context though, it is simply the most prominent example of a frameshift in surgical thinking. The patient as a whole is now the focus, rather than just the disease. Recent developments are as much about minimising harm to normal tissues as they are about extirpating pathology. As a surgical maxim, 'Primum non nocere' is even more in evidence in 2015 than it was in 1965.
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Affiliation(s)
- Craig A McBride
- Department of Paediatric Surgery, Stuart Pegg Paediatric Burns Centre, Royal Children's Hospital, Brisbane, Queensland, Australia; Centre for Children's Burns and Trauma Research, Queensland Children's Medical Research Institute, University of Queensland, Brisbane, Queensland, Australia
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47
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Lee S, Lee SK, Seo JM. Thoracoscopic repair of esophageal atresia with tracheoesophageal fistula: overcoming the learning curve. J Pediatr Surg 2014; 49:1570-2. [PMID: 25475795 DOI: 10.1016/j.jpedsurg.2014.04.016] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2014] [Revised: 03/11/2014] [Accepted: 04/27/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND/PURPOSE We describe our initial experience of thoracoscopic esophageal atresia with distal tracheoesophageal fistula (EA/TEF) repair. METHODS Twenty-three consecutive cases of thoracoscopic repair of EA/TEF were performed between October 2008 and March 2013. The medical records of 22 patients were retrospectively reviewed, excluding one case of early postoperative mortality. RESULTS The study period was divided into two sections: from 2008 to 2011 (13 cases) and from 2012 to 2013 (9 cases). Patient characteristics did not differ between the two study periods. Mean operation time was significantly shorter in period 2 compared to period 1 (p<0.01). There was one case that was converted to open repair via thoracotomy during period 1. Anastomosis leakage was seen in two cases during period 1, while no cases of leakage were encountered in period 2. Ten of 13 cases (76.9 %) in period 1 had clinically significant esophageal strictures requiring one or more sessions of balloon dilatations. No cases of esophageal strictures were seen in period 2 (p<0.01). CONCLUSIONS When the initial learning curve was endured, surgical outcomes of thoracoscopic repair of EA/TEF were superior to the outcomes of earlier cases, and comparable to past experiences with open thoracotomy.
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Affiliation(s)
- Sanghoon Lee
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Suk-Koo Lee
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jeong-Meen Seo
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
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48
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Thoracoscopic repair of esophageal atresia and tracheo-esophageal fistula in neonates: the current state of the art. Pediatr Surg Int 2014; 30:979-85. [PMID: 25169923 DOI: 10.1007/s00383-014-3586-7] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/12/2014] [Indexed: 10/24/2022]
Abstract
The first thoracoscopic esophageal atresia with tracheo-esophageal fistula (EATEF) repair was performed in March of 2000. This report evaluates the results and evolution of the technique over the last decade. Thoracoscopic esophageal atresia repair has proven to be an effective and safe technique. Initial experience resulted in a higher stricture rate but this improved with experience and changes in technique over the last decade. The outcomes are similar to or superior to that of an open thoracotomy and avoid the musculoskeletal morbidity associated with that technique.
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49
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Yamoto M, Urusihara N, Fukumoto K, Miyano G, Nouso H, Morita K, Miyake H, Kaneshiro M. Thoracoscopic versus open repair of esophageal atresia with tracheoesophageal fistula at a single institution. Pediatr Surg Int 2014; 30:883-7. [PMID: 25052256 DOI: 10.1007/s00383-014-3554-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/15/2014] [Indexed: 11/30/2022]
Abstract
PURPOSE The potential benefits of thoracoscopic repair (TR) of esophageal atresia and tracheoesophageal fistula (EA/TEF) in newborns are still unclear. Our aim was to define the criteria, perioperative outcome after undergoing TR versus open repair (OR) for EA/TEF. PATIENTS AND METHODS A retrospective chart review was conducted of 36 consecutive neonates who underwent EA/TEF repair between 2001 and 2012 in Shizuoka Children's Hospital. Patients in this study were birth weight >2,000 g, and did not have severe cardiac malformations or chromosomal aberrations. Of the 26 newborns who met the selection criteria, 11 patients underwent attempts at TR compared to 15 patients who underwent OR. All cases were followed 1 year after operation at least. RESULTS All 11 TR were successfully completed. There were no significant differences between intra- and perioperative complications in the two groups. Intraoperative EtCO2 and arterial blood gases were not significantly different between the two groups. We did not found eating disorder, respiratory disorder, and failure of growth in all cases. CONCLUSION In our study, the thoracoscopic approach appeared to be favorable and safe for EA/TEF repair in carefully selected patients.
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Affiliation(s)
- Masaya Yamoto
- Department of Pediatric Surgery, Shizuoka Children's Hospital, 860 Urushiyama, Aoi-ku, Shizuoka, 420-8660, Japan,
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50
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Thoracoscopic repair of esophageal atresia with distal tracheoesophageal fistula and a proximal type-H tracheoesophageal fistula. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2014. [DOI: 10.1016/j.epsc.2014.04.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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