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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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Dingemann C, Eaton S, Aksnes G, Bagolan P, Cross KM, De Coppi P, Fruithof J, Gamba P, Goldschmidt I, Gottrand F, Pirr S, Rasmussen L, Sfeir R, Slater G, Suominen J, Svensson JF, Thorup JM, Tytgat SHAJ, van der Zee DC, Wessel L, Widenmann-Grolig A, Wijnen R, Zetterquist W, Ure BM. ERNICA Consensus Conference on the Management of Patients with Long-Gap Esophageal Atresia: Perioperative, Surgical, and Long-Term Management. Eur J Pediatr Surg 2021; 31:214-225. [PMID: 32668485 DOI: 10.1055/s-0040-1713932] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Evidence supporting best practice for long-gap esophageal atresia is limited. The European Reference Network for Rare Inherited Congenital Anomalies (ERNICA) organized a consensus conference on the management of patients with long-gap esophageal atresia based on expert opinion referring to the latest literature aiming to provide clear and uniform statements in this respect. MATERIALS AND METHODS Twenty-four ERNICA representatives from nine European countries participated. The conference was prepared by item generation, item prioritization by online survey, formulation of a final list containing items on perioperative, surgical, and long-term management, and literature review. The 2-day conference was held in Berlin in November 2019. Anonymous voting was conducted via an internet-based system using a 1 to 9 scale. Consensus was defined as ≥75% of those voting scoring 6 to 9. RESULTS Ninety-seven items were generated. Complete consensus (100%) was achieved on 56 items (58%), e.g., avoidance of a cervical esophagostomy, promotion of sham feeding, details of delayed anastomosis, thoracoscopic pouch mobilization and placement of traction sutures as novel technique, replacement techniques, and follow-up. Consensus ≥75% was achieved on 90 items (93%), e.g., definition of long gap, routine pyloroplasty in gastric transposition, and avoidance of preoperative bougienage to enable delayed anastomosis. Nineteen items (20%), e.g., methods of gap measurement were discussed controversially (range 1-9). CONCLUSION This is the first consensus conference on the perioperative, surgical, and long-term management of patients with long-gap esophageal atresia. Substantial statements regarding esophageal reconstruction or replacement and follow-up were formulated which may contribute to improve patient care.
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Affiliation(s)
- Carmen Dingemann
- Department of Pediatric Surgery, Hannover Medical School, Hannover, Germany
| | - Simon Eaton
- NIHR Biomedical Research Centre at UCLH, Developmental Biology and Cancer Programme, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Gunnar Aksnes
- Department of Pediatric Surgery, Oslo University Hospital, Oslo, Norway
| | - Pietro Bagolan
- Department of Medical and Surgical Neonatology, Research Institute, Bambino Gesù Children's Hospital, Rome, Italy
| | - Kate M Cross
- Department of Neonatal and Paediatric Surgery, Great Ormond Street Hospital for Children, London, United Kingdom
| | - Paolo De Coppi
- NIHR Biomedical Research Centre at UCLH, Developmental Biology and Cancer Programme, UCL Great Ormond Street Institute of Child Health, London, United Kingdom.,Department of Neonatal and Paediatric Surgery, Great Ormond Street Hospital for Children, London, United Kingdom
| | - JoAnne Fruithof
- Esophageal Atresia and Tracheo-Esophageal Fistula Support Federation and VOKS, Lichtenvoorde, The Netherlands
| | | | - Imeke Goldschmidt
- Department of Pediatric Gastroenterology and Hepatology, Hannover Medical School, Hannover, Germany
| | - Frederic Gottrand
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Reference Center for Rare Esophageal Diseases, CHU Lille, University of Lille, Lille, France
| | - Sabine Pirr
- Department of Pediatric Pulmonology, Allergology and Neonatology, Hannover Medical School, Hannover, Germany
| | - Lars Rasmussen
- Department of Pediatric Surgery, Odense University Hospital, Odense, Denmark
| | - Rony Sfeir
- Department of Pediatric Surgery, Reference Center for Rare Esophageal Diseases, CHU Lille, University of Lille, Lille, France
| | - Graham Slater
- Esophageal Atresia and Tracheo-Esophageal Fistula Support Federation and TOFS, Nottingham, United Kingdom
| | - Janne Suominen
- Department of Pediatric Surgery, University of Helsinki, Helsinki, Finland
| | - Jan F Svensson
- Department of Pediatric Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Joergen M Thorup
- Department of Pediatric Surgery, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Stefaan H A J Tytgat
- Department of Pediatric Surgery, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
| | - David C van der Zee
- Department of Pediatric Surgery, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Lucas Wessel
- Department of Pediatirc Surgery, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Anke Widenmann-Grolig
- Esophageal Atresia and Tracheo-Esophageal Fistula Support Federation and KEKS, Stuttgart, Germany
| | - René Wijnen
- Department of Pediatric Surgery, Erasmus MC, Rotterdam, The Netherlands
| | - Wilhelm Zetterquist
- Department of Woman and Child Health, Karolinska University Hospital, Stockholm, Sweden
| | - Benno M Ure
- Department of Pediatric Surgery, Hannover Medical School, Hannover, Germany
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Abstract
The management of long-gap esophageal atresia remains challenging with limited consensus on the definition, evaluation, and surgical approach to treatment. Efforts to preserve the native esophagus have been successful with delayed primary anastomosis and tension-based esophageal growth induction processes. Esophageal replacement is necessary in a minority of cases, with the conduit of choice and patient outcomes largely dependent on institutional expertise. Given the complexity of this patient population with significant morbidity, treatment and long-term follow-up are best done in multidisciplinary esophageal and airway treatment centers.
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Affiliation(s)
- Hester F Shieh
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, 300 Longwood Ave, Fegan 3, Boston, MA 02115
| | - Russell W Jennings
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, 300 Longwood Ave, Fegan 3, Boston, MA 02115.
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Abstract
This article focuses on esophageal replacement as a surgical option for pediatric patients with end-stage esophageal disease. While it is obvious that the patient׳s own esophagus is the best esophagus, persisting with attempts to retain a native esophagus with no function and at all costs are futile and usually detrimental to the overall well-being of the child. In such cases, the esophagus should be abandoned, and the appropriate esophageal replacement is chosen for definitive reconstruction. We review the various types of conduits used for esophageal replacement and discuss the unique advantages and disadvantages that are relevant for clinical decision-making.
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Affiliation(s)
- Shaun M Kunisaki
- Section of Pediatric Surgery, Department of Surgery, C.S. Mott Children׳s Hospital, University of Michigan Medical School, 1540 E. Hospital Dr, SPC 4211, Ann Arbor, Michigan.
| | - Arnold G Coran
- Section of Pediatric Surgery, Department of Surgery, C.S. Mott Children׳s Hospital, University of Michigan Medical School, 1540 E. Hospital Dr, SPC 4211, Ann Arbor, Michigan
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Abstract
Although most patients with esophageal atresia (EA) and tracheo-esophageal fistula (TEF) may benefit from "standard" management, which is deferred emergency surgery, some may present unexpected elements that change this paradigm. Birth weight, associated anomalies, and long gap can influence the therapeutic schedule of the patients with EA/TEF and can make their treatment tricky. As a consequence, detailed information on these aspects gives the power to develop a decision-making process as correct as possible. In this article, we will review the most important factors influencing the treatment of patients with EA/TEF and will share our experience on the diagnostic and therapeutic tips that may provide pivotal help in the management of such patients.
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Affiliation(s)
- Andrea Conforti
- Neonatal Surgery Unit, Department of Medical and Surgical Neonatology, Bambino Gesù Children Hospital - Research Institute, Piazza S. Onofrio 4, 00165 Rome, Italy
| | - Francesco Morini
- Neonatal Surgery Unit, Department of Medical and Surgical Neonatology, Bambino Gesù Children Hospital - Research Institute, Piazza S. Onofrio 4, 00165 Rome, Italy
| | - Pietro Bagolan
- Neonatal Surgery Unit, Department of Medical and Surgical Neonatology, Bambino Gesù Children Hospital - Research Institute, Piazza S. Onofrio 4, 00165 Rome, Italy.
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Bagolan P, Valfrè L, Morini F, Conforti A. Long-gap esophageal atresia: traction-growth and anastomosis - before and beyond. Dis Esophagus 2013; 26:372-9. [PMID: 23679026 DOI: 10.1111/dote.12050] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Long-gap esophageal atresia (LGEA) is still a major surgical challenge. Options for esophageal reconstruction include the use of native esophagus or esophageal replacement with stomach, colon, or small intestine. Nonetheless, there is a consensus among most pediatric surgeons that the preservation of the native esophagus is associated with better postoperative outcomes. Thus, every effort should be made to conserve the native esophagus. The present study is aimed at critically reporting our experience focused on a standardized protocol based on the preoperative assessment of the gap in all cases and reviewing the present literature because no consensus is available regarding many aspects of LGEA (from definition to treatment). All newborn infants treated since 1995 for esophageal atresia (EA), regardless of type, were included in the present study. Identification of LGEA patients (gap ≥3 vertebral bodies) was performed based on preoperative esophageal gap measurement. The selected patients were grouped based on EA type (A/B vs. C/D) and whether they were referred from an outside institution or not. Postoperative outcome was compared. Statistical analysis was performed with the Fisher's exact test and Mann-Whitney test as appropriate, with P < 0.05 considered statistically significant. Two hundred and nineteen patients have been consecutively treated between 1995 and 2012 with the following EA subtypes: type: A 25 (11.4%); B 6 (2.7%); C 182 (83.1%); D 3 (1.4%); E 3 (1.4%). Fifty-seven patients (26%) were classified as LGEA: type A-B, 31 (54.4%); type C-D, 26 (45.6%). Twenty seven (47%) of these patients were referred after at least one failed attempt at esophageal correction: type A-B, 15 (55%); type C-D, 12 (45%). Only one patient ultimately required esophageal substitution, with an overall survival rate of 94%. A standardized perioperative protocol enhances the possibility of preserving the native esophagus in cases of LGEA. Gap measurement can be accurately defined before surgery in all patients with EA. Esophageal anastomosis (either immediate or delayed repair) is almost always feasible; esophageal substitution should only be considered after a rigorous attempt at achieving end-to-end esophageal anastomosis.
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Affiliation(s)
- P Bagolan
- Department of Medical and Surgical Neonatology, Bambino Gesu' Research Children's Hospital, 00165 Rome, Italy.
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