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Hall NJ, Kitteringham L, Ron O, Stedman F, Stanton M, Wheeler R, Jones C, Smyth R, Keys C. A Minimally Interventional Approach to Oesophageal Atresia Repair With Early Enteral Feeding is Safe, Optimises Neonatal Outcomes, and Reduces Resource use. J Pediatr Surg 2024; 59:6-9. [PMID: 37867045 DOI: 10.1016/j.jpedsurg.2023.09.026] [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: 08/26/2023] [Accepted: 09/07/2023] [Indexed: 10/24/2023]
Abstract
PURPOSE Recent series of newborn Oesophageal Atresia (OA) repair continue to report widespread use of chest drains, gastrostomy, routine contrast studies and parenteral nutrition (PN) despite evidence suggesting these are superfluous. We report outcomes using a minimally interventional approach to post-operative recovery. METHODS Ethically approved (15/WA/0153), single-centre, retrospective case-note review of consecutive infants with OA 2000-2022. Infants with OA and distal trache-oesophageal fistula undergoing primary oesophageal anastomosis at initial surgery were included (including those with comorbidities such as duodenal atresia, anorectal malformation and cardiac lesions). Our practice includes routine use of a trans-anastomotic tube (TAT), no routine chest drain nor gastrostomy, early enteral and oral feeding, no routine PN and no routine contrast study. Data are median (IQR). RESULTS Of total 186 cases of OA treated during the time period, 157 met the inclusion criteria of which 2 were excluded as casenotes unavailable. TAT was used in 150 infants. A chest drain was required in 13 (8%) and two infants had a neonatal gastrostomy. Enteral feeds were started on postoperative day 2 (2-3), full enteral feeds established by day 4 (4-6) and oral feeds started on day 5 (4-8). PN was required in 15%. Median postoperative length of stay was 10 days (8-17). Progress was quicker in term infants than preterm. One infant died of cardiac disease prior to neonatal discharge. Two planned post-operative contrast studies were performed (surgeon preference) and a further 7 due to clinical suspicion of anastomotic leak. Contrast study was therefore avoided in 94%. There were 2 anastomotic leaks; both presented clinically at day 4 and day 8 after oral feeds had been started. CONCLUSION Our minimally interventional approach is safe. It facilitates prompt recovery with lower resource use, reduced demand on nursing staff, reduced radiation burden, and early discharge home compared to published series without adversely affecting outcomes. LEVEL OF EVIDENCE Level 4.
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Affiliation(s)
- Nigel J Hall
- University Surgery Unit, Faculty of Medicine, University of Southampton, Southampton, UK; Department of Paediatric Surgery and Urology, Southampton Children's Hospital, Southampton, UK.
| | - Lara Kitteringham
- Department of Paediatric Surgery and Urology, Southampton Children's Hospital, Southampton, UK
| | - Ori Ron
- Department of Paediatric Surgery and Urology, Southampton Children's Hospital, Southampton, UK
| | - Francesca Stedman
- Department of Paediatric Surgery and Urology, Southampton Children's Hospital, Southampton, UK
| | - Michael Stanton
- Department of Paediatric Surgery and Urology, Southampton Children's Hospital, Southampton, UK
| | - Robert Wheeler
- Department of Paediatric Surgery and Urology, Southampton Children's Hospital, Southampton, UK
| | - Ceri Jones
- Department of Paediatric Surgery and Urology, Southampton Children's Hospital, Southampton, UK
| | - Rachel Smyth
- Department of Paediatric Surgery and Urology, Southampton Children's Hospital, Southampton, UK
| | - Charles Keys
- Department of Paediatric Surgery and Urology, Southampton Children's Hospital, Southampton, UK
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Wyllie T, Folaranmi E, Sekaran P, Watkins WJ, Chakraborty M. Prophylactic Acid-suppression Medication to Prevent Anastomotic Strictures After Oesophageal Atresia Surgery: A Systematic Review and Meta-analysis. J Pediatr Surg 2023; 58:1954-1962. [PMID: 37355433 DOI: 10.1016/j.jpedsurg.2023.05.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 05/15/2023] [Accepted: 05/26/2023] [Indexed: 06/26/2023]
Abstract
BACKGROUND Anastomotic stricture is a common postoperative complication of oesophageal atresia ± tracheoesophageal fistula (OA/TOF) repair. Acid gastro-oesophageal reflux disease (GORD) is considered to be a factor in stricture formation and acid suppression medication is recommended post-operatively in consensus guidance. We aimed to investigate whether patients who were treated prophylactically with acid suppression medication had a reduced incidence of strictures compared to those who did not receive it. METHODS A systematic review of studies was performed, searching multiple databases without language or date restrictions. Multiple reviewers independently assessed study eligibility and literature quality. The primary outcome was anastomotic stricture formation, with secondary outcomes of GORD, anastomotic leak, and oesophagitis. Meta-analysis was performed using a random effects model, and the results were expressed as an odds ratio (OR) with 95% confidence intervals (CI). RESULTS No randomised studies on the topic were identified. Twelve observational studies were included in the analysis with ten reporting the primary outcome. The quality assessment showed a high risk of bias in several papers, predominantly due to non-objective methods of assessment of oesophageal stricture and the non-prospective, non-randomised nature of the studies. Overall, 1395 patients were evaluated, of which 753 received acid suppression medication. Meta-analysis revealed a trend towards increased odds of anastomotic strictures in infants receiving prophylactic medication, but this was not statistically significant (OR 1.33; 95% CI 0.92, 1.92). No significant differences were found in secondary outcomes. CONCLUSIONS This meta-analysis found no evidence of a statistically significant link between the prophylactic prescribing of acid suppression medication and the risk of developing anastomotic stricture after OA repair. The literature in this area is limited to observational studies and a randomised controlled trial is recommended to explore this question. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Thomas Wyllie
- Regional Neonatal Intensive Care Unit, University Hospital of Wales, Cardiff, UK
| | - Eniola Folaranmi
- Department of Paediatric Surgery, University Hospital of Wales, Cardiff, UK
| | - Prabhu Sekaran
- Department of Paediatric Surgery, University Hospital of Wales, Cardiff, UK
| | - W John Watkins
- Division of Infection and Immunity, School of Medicine, Cardiff University, Cardiff, UK
| | - Mallinath Chakraborty
- Regional Neonatal Intensive Care Unit, University Hospital of Wales, Cardiff, UK; Centre for Medical Education, School of Medicine, Cardiff University, Cardiff, UK.
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Nakagawa Y, Uchida H, Hinoki A, Shirota C, Sumida W, Makita S, Yokota K, Amano H, Yasui A, Kato D, Gohda Y, Maeda T. Refractory esophageal anastomotic stricture after esophageal atresia surgery improved with retrograde balloon dilatation through gastrostomy followed by laparoscopic fundoplication: a case report. Surg Case Rep 2023; 9:169. [PMID: 37737524 PMCID: PMC10516835 DOI: 10.1186/s40792-023-01754-0] [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: 06/23/2023] [Accepted: 09/17/2023] [Indexed: 09/23/2023] Open
Abstract
BACKGROUND An esophageal anastomotic stricture (EAS) after an esophageal atresia surgery occurs in approximately 4-60% of the cases, and its first-line therapy includes balloon dilatation. Oral balloon dilatation cannot be performed in some EAS cases; conversely, even if dilatation is possible, these strictures recur in some cases, necessitating a surgical procedure for repairing the stenosis. However, these procedures are invasive and have short- and long-term complications. If an EAS recurs repeatedly after multiple balloon dilations, gastroesophageal reflux disease (GERD) may be the underlying cause. A fundoplication procedure may be effective for treating a refractory EAS, as in the present case. CASE PRESENTATION A neonatal patient with type D esophageal atresia underwent thoracoscopic esophago-esophageal anastomosis at the age of 1 day, and her postoperative course was uneventful. Thereafter, the patient underwent gastrostomy for poor oral intake at the age of 3 months. After gastrostomy, the patient presented with a complete obstructive EAS. Balloon dilatation via the oral route was attempted; however, a guidewire could not be inserted into the EAS site. Hence, retrograde balloon dilatation via gastrostomy was performed successfully. However, the EAS recurred easily thereafter, and laparoscopic anti-reflux surgery was performed to prevent GERD. The anti-reflux surgery cured the otherwise refractory EAS and prevented its recurrence. CONCLUSIONS Retrograde balloon dilatation is another treatment option for an EAS. When an EAS recurs soon after dilatation, the patient must be evaluated for GERD; if severe GERD is observed, an appropriate anti-reflux surgery is required before dilating the EAS.
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Affiliation(s)
- Yoichi Nakagawa
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan
| | - Hiroo Uchida
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan.
| | - Akinari Hinoki
- Department of Rare/Intractable Cancer Analysis Research, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan
| | - Chiyoe Shirota
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan
| | - Wataru Sumida
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan
| | - Satoshi Makita
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan
| | - Kazuki Yokota
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan
| | - Hizuru Amano
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan
| | - Akihiro Yasui
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan
| | - Daiki Kato
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan
| | - Yousuke Gohda
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan
| | - Takuya Maeda
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan
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Marquart JP, Bowder AN, Bence CM, St Peter SD, Gadepalli SK, Sato TT, Szabo A, Minneci PC, Hirschl RB, Rymeski BA, Downard CD, Markel TA, Deans KJ, Fallat ME, Fraser JD, Grabowski JE, Helmrath MA, Kabre RD, Kohler JE, Landman MP, Lawrence AE, Leys CM, Mak GZ, Port E, Saito J, Silverberg J, Slidell MB, Wright TN, Lal DR. Thoracoscopy versus thoracotomy for esophageal atresia and tracheoesophageal fistula: Outcomes from the Midwest Pediatric Surgery Consortium. J Pediatr Surg 2023; 58:27-33. [PMID: 36283849 DOI: 10.1016/j.jpedsurg.2022.09.015] [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: 08/26/2022] [Accepted: 09/16/2022] [Indexed: 01/07/2023]
Abstract
BACKGROUND/PURPOSE Controversy persists regarding the ideal surgical approach for repair of esophageal atresia with tracheoesophageal fistula (EA/TEF). We examined complications and outcomes of infants undergoing thoracoscopy and thoracotomy for repair of Type C EA/TEF using propensity score-based overlap weights to minimize the effects of selection bias. METHODS Secondary analysis of two databases from multicenter retrospective and prospective studies examining outcomes of infants with proximal EA and distal TEF who underwent repair at 11 institutions was performed based on surgical approach. Regression analysis using propensity score-based overlap weights was utilized to evaluate outcomes of patients undergoing thoracotomy or thoracoscopy for Type C EA/TEF repair. RESULTS Of 504 patients included, 448 (89%) underwent thoracotomy and 56 (11%) thoracoscopy. Patients undergoing thoracoscopy were more likely to be full term (37.9 vs. 36.3 weeks estimated gestational age, p < 0.001), have a higher weight at operative repair (2.9 vs. 2.6 kg, p < 0.001), and less likely to have congenital heart disease (16% vs. 39%, p < 0.001). Postoperative stricture rate did not differ by approach, 29 (52%) thoracoscopy and 198 (44%) thoracotomy (p = 0.42). Similarly, there was no significant difference in time from surgery to stricture formation (p > 0.26). Regression analysis using propensity score-based overlap weighting found no significant difference in the odds of vocal cord paresis or paralysis (OR 1.087 p = 0.885), odds of anastomotic leak (OR 1.683 p = 0.123), the hazard of time to anastomotic stricture (HR 1.204 p = 0.378), or the number of dilations (IRR 1.182 p = 0.519) between thoracoscopy and thoracotomy. CONCLUSION Infants undergoing thoracoscopic repair of Type C EA/TEF are more commonly full term, with higher weight at repair, and without congenital heart disease as compared to infants repaired via thoracotomy. Utilizing propensity score-based overlap weighting to minimize the effects of selection bias, we found no significant difference in complications based on surgical approach. However, our study may be underpowered to detect such outcome differences owing to the small number of infants undergoing thoracoscopic repair. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- John P Marquart
- Division of Pediatric Surgery, Department of Surgery, Medical College of Wisconsin, 999 N 92nd St, Suite 320, Milwaukee, WI 53226, USA.
| | - Alexis N Bowder
- Division of Pediatric Surgery, Department of Surgery, Medical College of Wisconsin, 999 N 92nd St, Suite 320, Milwaukee, WI 53226, USA
| | - Christina M Bence
- Division of Pediatric Surgery, Department of Surgery, Medical College of Wisconsin, 999 N 92nd St, Suite 320, Milwaukee, WI 53226, USA
| | - Shawn D St Peter
- Division of Pediatric Surgery, Department of Surgery, Children's Mercy Hospital, 2401 Gillham Rd, Kansas City, MO 64108, USA
| | - Samir K Gadepalli
- Section of Pediatric Surgery, Department of Surgery, University of Michigan, 1500 E. Medical Center Dr, Ann Arbor, MI 48109, USA
| | - Thomas T Sato
- Division of Pediatric Surgery, Department of Surgery, Medical College of Wisconsin, 999 N 92nd St, Suite 320, Milwaukee, WI 53226, USA
| | - Aniko Szabo
- Division of Pediatric Surgery, Department of Surgery, Medical College of Wisconsin, 999 N 92nd St, Suite 320, Milwaukee, WI 53226, USA
| | - Peter C Minneci
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute and Department of Surgery, Nationwide Children's Hospital, 700 Children's Dr, Columbus, OH 43206, USA
| | - Ronald B Hirschl
- Section of Pediatric Surgery, Department of Surgery, University of Michigan, 1500 E. Medical Center Dr, Ann Arbor, MI 48109, USA
| | - Beth A Rymeski
- Department of Pediatric Surgery, Cincinnati Children's Hospital, 3333 Burnet Ave, ML 2023, Cincinnati, OH 45229, USA
| | - Cynthia D Downard
- Department of Surgery, Division of Pediatric Surgery, University of Louisville School of Medicine, 530 S. Jackson St, Louisville, KY 40202, USA
| | - Troy A Markel
- Division of Pediatric Surgery, Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr, Emerson Hall, Indianapolis, IN 46202, USA
| | - Katherine J Deans
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute and Department of Surgery, Nationwide Children's Hospital, 700 Children's Dr, Columbus, OH 43206, USA
| | - Mary E Fallat
- Department of Surgery, Division of Pediatric Surgery, University of Louisville School of Medicine, 530 S. Jackson St, Louisville, KY 40202, USA
| | - Jason D Fraser
- Division of Pediatric Surgery, Department of Surgery, Children's Mercy Hospital, 2401 Gillham Rd, Kansas City, MO 64108, USA
| | - Julia E Grabowski
- Division of Pediatric Surgery, Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, 225 E. Chicago Ave, Chicago, IL 60611, USA
| | - Michael A Helmrath
- Department of Pediatric Surgery, Cincinnati Children's Hospital, 3333 Burnet Ave, ML 2023, Cincinnati, OH 45229, USA
| | - Rashmi D Kabre
- Division of Pediatric Surgery, Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, 225 E. Chicago Ave, Chicago, IL 60611, USA
| | - Jonathan E Kohler
- Division of Pediatric Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, 600 Highland Ave, Madison, WI 53792, USA
| | - Matthew P Landman
- Division of Pediatric Surgery, Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr, Emerson Hall, Indianapolis, IN 46202, USA
| | - Amy E Lawrence
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute and Department of Surgery, Nationwide Children's Hospital, 700 Children's Dr, Columbus, OH 43206, USA
| | - Charles M Leys
- Division of Pediatric Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, 600 Highland Ave, Madison, WI 53792, USA
| | - Grace Z Mak
- The University of Chicago Medicine, Comer Children's Hospital, Chicago, IL, USA
| | - Elissa Port
- Division of Pediatric Surgery, Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, 225 E. Chicago Ave, Chicago, IL 60611, USA
| | - Jacqueline Saito
- Division of Pediatric Surgery, Department of Surgery, Washington University School of Medicine, Suite 5S40-Campus Box 8235, One Children's Place, St. Louis, MO 63110, USA
| | - Jared Silverberg
- Section of Pediatric Surgery, Department of Surgery, University of Michigan, 1500 E. Medical Center Dr, Ann Arbor, MI 48109, USA
| | - Mark B Slidell
- The University of Chicago Medicine, Comer Children's Hospital, Chicago, IL, USA
| | - Tiffany N Wright
- Department of Surgery, Division of Pediatric Surgery, University of Louisville School of Medicine, 530 S. Jackson St, Louisville, KY 40202, USA
| | - Dave R Lal
- Division of Pediatric Surgery, Department of Surgery, Medical College of Wisconsin, 999 N 92nd St, Suite 320, Milwaukee, WI 53226, USA
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