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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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Tepeneu N, Krafka K, Bogovic M, Weber-Eibel J, Hausegger K, Pranzl T, Penicka D, Fasching G. Successful staged management of long gap esophageal atresia. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2022. [DOI: 10.1016/j.epsc.2022.102419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Jensen AR, McDuffie LA, Groh EM, Rescorla FJ. Outcomes for Correction of Long-Gap Esophageal Atresia: A 22-Year Experience. J Surg Res 2020; 251:47-52. [DOI: 10.1016/j.jss.2020.01.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 11/20/2019] [Accepted: 01/25/2020] [Indexed: 12/29/2022]
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Bothara VP, Singh GP, Kureel SN. A Novel Technique for Prevention of Gastroesophageal Reflux in Staged Repair of Long Gap Esophageal Atresia with Tracheoesophageal Fistula. J Indian Assoc Pediatr Surg 2020; 25:34-37. [PMID: 31896897 PMCID: PMC6910044 DOI: 10.4103/jiaps.jiaps_239_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Revised: 01/26/2019] [Accepted: 03/12/2019] [Indexed: 11/11/2022] Open
Abstract
Aim: The objective of the study is to report a novel technique of preventing gastroesophageal reflux and air leak from fistula to stomach in patients of tracheoesophageal fistula with long gap atresia, to buy time for the staged procedure. Methods: Seven patients of tracheoesophageal fistula with upper pouch of esophagus at 2nd thoracic vertebra were selected for the staged procedure. Weight ranged from 1.7 to 1.8 kg. During the 1st stage surgery for gastrostomy, midline strip of linea alba attached to xiphoid process was harvested and slinged around the gastroesophageal junction, along with right cervical esophagostomy. After radio-nuclear scan, the demonstration of abolition of gastroesophageal reflux, gastrostomy feed was started. The 2nd stage surgery performed after 6 weeks, included mobilization of esophagostomy, release of sling, thoracotomy, and tension-free esophageal anastomosis. Outcome measurement includes (1) prevention of air leak from esophagus into the stomach, (2) abolition of gastroesophageal reflux, (3) ability to start gastrostomy feeds, and (4) reversal of occlusion after release of the sling. Results: The placement of linea alba sling and elevation of gastroesophageal junction, abolished air leak from fistula to stomach in all. Radio nuclear scan demonstrated abolition of gastroesophageal reflux in 6 with weight gain after gastrostomy feeding. One patient expired due to sepsis. One patient underwent final repair with reversal of occlusion with release of the sling. Conclusion: Using a sling of the linea alba around the cardioesophageal junction, prevents gastroesophageal reflux and escape of air from esophagus into the stomach, gives time to improve the respiratory and nutritional status of the patient, for a subsequent safer delayed primary anastomosis.
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Affiliation(s)
- Vipul Prakash Bothara
- Department of Paediatric Surgery, King George's Medical University, Lucknow, Uttar Pradesh, India
| | - Gyan Prakash Singh
- Department of Anaesthesiology, King George's Medical University, Lucknow, Uttar Pradesh, India
| | - Shiv Narain Kureel
- Department of Paediatric Surgery, King George's Medical University, Lucknow, Uttar Pradesh, India
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Stadil T, Koivusalo A, Svensson JF, Jönsson L, Lilja HE, Thorup JM, Sæter T, Stenström P, Qvist N. Surgical treatment and major complications Within the first year of life in newborns with long-gap esophageal atresia gross type A and B - a systematic review. J Pediatr Surg 2019; 54:2242-2249. [PMID: 31350044 DOI: 10.1016/j.jpedsurg.2019.06.017] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Revised: 04/16/2019] [Accepted: 06/21/2019] [Indexed: 01/22/2023]
Abstract
BACKGROUND The surgical repair of long-gap esophageal atresia (LGEA) is still a challenge and there is no consensus on the preferred method of reconstruction. We performed a systematic review of the surgical treatment of LGEA Gross type A and B with the primary aim to compare the postoperative complications related to the different methods within the first postoperative year. METHODS Systematic literature review on the surgical repair of LGEA Gross type A and B within the first year of life published from January 01, 1996 to November 01, 2016. RESULTS We included 57 articles involving a total of 326 patients of whom 289 had a Gross type A LGEA. Delayed primary anastomosis (DPA) was the most applied surgical method (68.4%) in both types, followed by gastric pull-up (GPU) (8.3%). Anastomotic stricture (53.7%), gastro-esophageal reflux (GER) (32.2%) and anastomotic leakage (22.7%) were the most common postoperative complications, with stricture and GER occurring more often after DPA (61.9% and 40.8% respectively) compared to other methods (p < 0.001). CONCLUSION The majority of patients in this review were managed by DPA and postoperative complications were common despite the surgical method, with anastomotic stricture and GER being most common after DPA. LEVEL OF EVIDENCE Systematic review of case series and case reports with no comparison group (level IV).
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Affiliation(s)
- Tatjana Stadil
- Surgical Department A, Odense University Hospital, Odense, Denmark.
| | - Antti Koivusalo
- Dept. of Pediatric Surgery, Children's Hospital, University of Helsinki, Helsinki, Finland.
| | - Jan F Svensson
- Department of Pediatric Surgery, Karolinska University Hospital and Department of Women's and Children's Health, Karolinska Intitutet, Stockholm, Sweden.
| | - Linus Jönsson
- Department of Pediatric Surgery, Queen Silvia Children's Hospital, Gothenburg, Sweden.
| | - Helene Engstrand Lilja
- Department of Pediatric Surgery, Children's Hospital and Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden.
| | - Jørgen Mogens Thorup
- Dept. of Pediatric Surgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.
| | - Thorstein Sæter
- Dept. of Pediatric Surgery, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway.
| | - Pernilla Stenström
- Dept. of Pediatrics, Children's Hospital, Lund University, Lund, Sweden..
| | - Niels Qvist
- Surgical Department A, Odense University Hospital, Odense, Denmark.
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Slater BJ, Borobia P, Lovvorn HN, Raees MA, Bass KD, Almond S, Hoover JD, Kumar T, Zaritzky M. Use of Magnets as a Minimally Invasive Approach for Anastomosis in Esophageal Atresia: Long-Term Outcomes. J Laparoendosc Adv Surg Tech A 2019; 29:1202-1206. [PMID: 31524560 DOI: 10.1089/lap.2019.0199] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Introduction: The majority of esophageal atresia (EA) patients undergo surgical repair soon after birth. However, factors due to patient characteristics, esophageal length, or surgical complications can limit the ability to obtain esophageal continuity. A number of techniques have been described to treat these patients with "long-gap" EA. Magnets are a nonsurgical alternative for esophageal anastomosis. The purpose of this study was to report long-term outcomes for the use of magnets in EA. Materials and Methods: Between July 2001 and December 2017, 13 patients underwent placement of a magnetic catheter-based system under fluoroscopic guidance at six institutions. Daily chest radiographs were obtained until there was union of the magnets. Magnets were then removed and replaced with an oro- or nasogastric tube. Complications and outcomes were recorded. The average length of follow-up was 9.3 years (range 1.42-17.75). Results: A total of 85% of the patients had type A, pure EA, and 15% had type C with previous fistula ligation. The average length of time to achieve anastomosis was 6.3 days (range 3-13). No anastomotic leaks occurred, and all of the patients had an expected esophageal stenosis that required dilation given the 10F coupling surface of the magnets (average 9.8, range 3-22). Six patients (46%) had retrievable esophageal stents, and two underwent surgery; yet all maintained their native esophagus without interposition. A total of 92% were on full oral feeds at the time of follow-up. Conclusion: The use of magnets for treatment of long-gap EA is safe and feasible and accomplished good long-term outcomes. The main complication was esophageal stricture, although all patients maintained their native esophagus. A prospective observational study is currently enrolling patients to evaluate the safety and benefit of a catheter-based magnetic device for EA.
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Affiliation(s)
- Bethany J Slater
- Department of Pediatric Surgery, University of Chicago, Chicago, Illinois
| | - Paula Borobia
- Department of Pediatric of Gastroenterology, Hospital de Niños, de La Plata, Argentina
| | - Harold N Lovvorn
- Department of Pediatric Surgery, Monroe Carell, Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
| | - Muhammad A Raees
- Department of Pediatric Surgery, Monroe Carell, Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
| | - Kathryn D Bass
- Department of Pediatric Surgery, Oishei Children's Hospital, Buffalo, New York
| | - Stephen Almond
- Department of Pediatric Surgery, Driscoll Children's Hospital, Corpus Christi, Texas
| | | | | | - Mario Zaritzky
- Department of Radiology, University of Chicago, Chicago, Illinois
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Afridi F, Shorter N, Vaughan R, Neptune S, Singh S. Primary repair of long gap esophageal atresia in a neonate employing circular myotomy on upper pouch and a novel hemicircular myotomy on the distal pouch. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2019. [DOI: 10.1016/j.epsc.2019.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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Baird R, Lal DR, Ricca RL, Diefenbach KA, Downard CD, Shelton J, Sømme S, Grabowski J, Oyetunji TA, Williams RF, Jancelewicz T, Dasgupta R, Arthur LG, Kawaguchi AL, Guner YS, Gosain A, Gates RL, Sola JE, Kelley-Quon LI, St Peter SD, Goldin A. Management of long gap esophageal atresia: A systematic review and evidence-based guidelines from the APSA Outcomes and Evidence Based Practice Committee. J Pediatr Surg 2019; 54:675-687. [PMID: 30853248 DOI: 10.1016/j.jpedsurg.2018.12.019] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Revised: 11/17/2018] [Accepted: 12/26/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Treatment of the neonate with long gap esophageal atresia (LGEA) is one of the most challenging scenarios facing pediatric surgeons today. Contributing to this challenge is the variability in case definition, multiple approaches to management, and heterogeneity of the reported outcomes. This necessitates a clear summary of existing evidence and delineation of treatment controversies. METHODS The American Pediatric Surgical Association Outcomes and Evidence Based Practice Committee drafted four consensus-based questions regarding LGEA. These questions concerned the definition and determination of LGEA, the optimal method of surgical management, expected long-term outcomes, and novel therapeutic techniques. A comprehensive search strategy was crafted and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were utilized to identify, review and report salient articles. RESULTS More than 3000 publications were reviewed, with 178 influencing final recommendations. In total, 18 recommendations are provided, primarily based on level 4-5 evidence. These recommendations provide detailed descriptions of the definition of LGEA, treatment techniques, outcomes and future directions of research. CONCLUSIONS Evidence supporting best practices for LGEA is currently low quality. This review provides best recommendations based on a critical evaluation of the available literature. Based on the lack of strong evidence, prospective and comparative research is clearly needed. TYPE OF STUDY Treatment study, prognosis study and study of diagnostic test. LEVEL OF EVIDENCE Level II-V.
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Affiliation(s)
- Robert Baird
- Department of Pediatric General and Thoracic Surgery, BC Children's Hospital, University of British Columbia, 4480 Oak, Vancouver V6H3V4, British Columbia.
| | - Dave R Lal
- Division of Pediatric Surgery, Department of Surgery, Medical College of Wisconsin
| | - Robert L Ricca
- Division of Pediatric Surgery, Naval Medical Center, Portsmouth, Virginia
| | - Karen A Diefenbach
- Department of Pediatric Surgery, Nationwide Children's Hospital, The Ohio State University, Columbus, OH
| | - Cynthia D Downard
- Hiram C. Polk Jr, MD Department of Surgery, University of Louisville, Louisville, KY
| | - Julia Shelton
- University of Iowa Stead Family Children's Hospital, Iowa City, IA
| | - Stig Sømme
- Division of Pediatric Surgery, Children's Hospital Colorado, University of Colorado, Aurora, CO
| | - Julia Grabowski
- Division of Pediatric Surgery, Department of Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Tolulope A Oyetunji
- Department of Surgery, Children's Mercy Kansas City, University of Missouri-Kansas City School of Medicine, Kansas City, MO
| | - Regan F Williams
- Division of Pediatric Surgery, Le Bonheur Children's Hospital, Memphis, TN
| | - Tim Jancelewicz
- Division of Pediatric Surgery, Le Bonheur Children's Hospital, Memphis, TN
| | - Roshni Dasgupta
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH
| | - L Grier Arthur
- Division of General, Thoracic, and Minimally Invasive Surgery, St. Christopher's Hospital for Children, Drexel University, Philadelphia, PA
| | - Akemi L Kawaguchi
- Department of Pediatric Surgery, University of Texas Health Science Center at Houston, Houston, TX
| | - Yigit S Guner
- Department of Surgery University of California Irvine and Division of Pediatric Surgery Children's Hospital of Orange County
| | - Ankush Gosain
- Division of Pediatric Surgery, Department of Surgery, University of Tennessee Health Science Center, Children's Foundation Research Institute, Le Bonheur Children's Hospital, Memphis, TN
| | - Robert L Gates
- Clinical University of South Carolina-Greenville, Division of Pediatric Surgery, Greenville, SC
| | - Juan E Sola
- Division of Pediatric Surgery, University of Miami Miller School of Medicine, Miami, FL
| | - Lorraine I Kelley-Quon
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Shawn D St Peter
- Children's Mercy Hospital, 2401 Gillham Rd, Kansas City, MO 64108
| | - Adam Goldin
- Department of Pediatric General and Thoracic Surgery, Seattle Children's Hospital, Seattle, WA
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Beger B, Beger O. A new esophageal elongation technique for long-gap esophageal atresia: in vitro comparison of myotomy techniques. Esophagus 2019; 16:93-97. [PMID: 30099640 DOI: 10.1007/s10388-018-0636-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2018] [Accepted: 08/07/2018] [Indexed: 02/03/2023]
Abstract
BACKGROUND Complications such as stricture, leakage, recurrent tracheoesophageal fistula and mucosal pouch are commonly seen in myotomy techniques used for long-gap esophageal atresia (LGEA) treatments. Therefore, we think that there is a clear need for other techniques which would enable us to create more robust and longer esophagus in such cases. In this study, we reviewed multiple V-myotomy (VM) technique and the differences of the said technique with Livaditis circular myotomy (LM) and Kimura spiral myotomy (KM) techniques using literature as an aid. METHODS 21 esophagus samples from 21 male lambs aged 12 months were used in vitro for the study. All esophageal samples were matched to have a length of 120 mm. Samples were divided into 3 groups of 7 and VM, LM and KM techniques were used in each group, respectively. Post-op esophagus lengths, elongation amount with each incision and perforation pressures were measured. RESULTS Post-op esophageal lengths were measured as 227, 210 and 200 mm for VM, LM and KM, respectively. Elongation amount per incision was measured as 5.1, 4 and 3.34 mm, again in previous order of VM, LM, and KM. Finally, perforation pressure following VM, LM, and KM was measured as 460, 400, and 410 mmHg. CONCLUSION VM was found to significantly increase total esophagus length and elongation per incision over LM and KM. In addition, VM was also shown to have a higher perforation pressure. Although in vivo live animal studies are required, we can say that VM can be used to create longer and robust esophagus.
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Affiliation(s)
- Burhan Beger
- Department of Pediatric Surgery, Van Yüzüncü Yıl University Faculty of Medicine, Van, Turkey
| | - Orhan Beger
- Department of Anatomy, Mersin University Faculty of Medicine, Ciftlikkoy Campus, 33343, Mersin, Turkey.
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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: 8] [Impact Index Per Article: 1.1] [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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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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12
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Abstract
Neonatal surgery is recognized as an independent discipline in general surgery, requiring the expertise of pediatric surgeons to optimize outcomes in infants with surgical conditions. Survival following neonatal surgery has improved dramatically in the past 60 years. Improvements in pediatric surgical outcomes are in part attributable to improved understanding of neonatal physiology, specialized pediatric anesthesia, neonatal critical care including sophisticated cardiopulmonary support, utilization of parenteral nutrition and adjustments in fluid management, refinement of surgical technique, and advances in surgical technology including minimally invasive options. Nevertheless, short and long-term complications following neonatal surgery continue to have profound and sometimes lasting effects on individual patients, families, and society.
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Affiliation(s)
- Mauricio A Escobar
- Pediatric Surgery, Mary Bridge Children׳s Hospital, PO Box 5299, MS: 311-W3-SUR, 311 South, Tacoma, Washington 98415-0299.
| | - Michael G Caty
- Section of Pediatric Surgery, Department of Surgery, Yale-New Haven Children׳s Hospital, New Haven, Connecticut
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13
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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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Uygun I, Zeytun H, Otcu S. Immediate primary anastomosis for isolated oesophageal atresia: A single-centre experience. Afr J Paediatr Surg 2015; 12:273-9. [PMID: 26712295 PMCID: PMC4955473 DOI: 10.4103/0189-6725.172572] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Isolated oesophageal atresia without tracheo-oesophageal fistula represents a major challenge for most paediatric surgeons. Here, we present our experience with six neonates with isolated oesophageal atresia who successfully underwent immediate primary anastomosis using multiple Livaditis circular myotomy. MATERIALS AND METHODS All six neonates were gross type A isolated oesophageal atresia (6%), from among 102 neonates with oesophageal atresia, treated between January 2009 and December 2013. Five neonates were female; one was male. The mean birth weight was 2300 (range 1700-3100) g. RESULTS All six neonates successfully underwent immediate primary anastomosis using multiple myotomies (mean 3; range 2-4) within 10 (median 3) days after birth. The gap under traction ranged from 6 to 7 cm. One neonate died of a major cardiac anomaly. Another neonate was lost to follow-up after being well for 3 months. Three anastomotic strictures were treated with balloon dilatation, and four anastomotic leaks were treated conservatively. The mean duration of follow-up was 33 months. CONCLUSIONS To treat isolated oesophageal atresia, an immediate primary anastomosis can be achieved using multiple myotomies. Although, this approach is associated with high complication rates, as are other similar approaches, these complications can be overcome.
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Affiliation(s)
- Ibrahim Uygun
- Department of Paediatric Surgery, Medical Faculty, Dicle University, 21280 Diyarbakir, Turkey
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Abstract
BACKGROUND The diagnosis of long gap esophageal atresia (LGEA) may preclude immediate primary anastomosis. We reviewed our experience with this entity for a period of 10 years. METHODS A retrospective review was undertaken of the medical records of all patients managed for esophageal atresia (EA)/tracheoesophageal fistula (TEF) during the period from 1991 to 2001 at the Children's Hospital at Westmead, Sydney, Australia. Esophageal atresia was defined as long gap when primary repair was considered technically impossible by the surgeon. Also, a questionnaire was sent to all the general pediatric surgeons in Australia to explore their attitude toward LGEA management. RESULTS One hundred three patients with EA were managed for that period, 17 (16%) of them were defined as LGEA, with mean gap of 5 cm (SD, 1cm). Eight patients (47%) had TEF. Sixteen patients had gastrostomy tube (GT) insertion at a mean age of 4 days. Six patients had esophagostomy at a mean age of 27 days. Thirteen patients had EA repair at a mean age of 146 days. Four patients died before repair and 2 after repair secondary to associated anomalies. Fifty percent of Australian Pediatric Surgeons (APS) responded to the questionnaire. Forty percent defined LGEA as a gap more than 3 to 4 vertebral bodies, whereas 24% considered the absence of TEF as an indication of LGEA. Fifty-six percent of APS will measure the gap on preoperative chest x-rays, and 80% will assess the gap at thoracotomy for ligation of TEF. Ninety-two will measure the gap by inserting a bougie into the upper pouch and into the lower esophagus via the GT. If LGEA was diagnosed, all APS will perform GT with delayed repair. Seventy-two percent of APS will attempt delayed primary repair within 3 to 6 months of age. Seventy-six percent will perform hiatal dissection, and 48% will use upper pouch myotomies. Forty-eight percent will perform gastric pull up, and 32% will use gastric tube for esophageal replacement. CONCLUSIONS Long gap esophageal atresia represents a surgical challenge. Mortality rate is high secondary to associated anomalies. There is no consensus among APS regarding the definition of LGEA. In general, the consensus of APS would be that the preservation of the patient's own esophagus should be attempted before considering the use of an esophageal replacement.
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Affiliation(s)
- Saud Al-Shanafey
- Department of Surgery, The Children's Hospital at Westmead, Sydney, Australia.
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16
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Lopes MF, Botelho MF. Midterm follow-up of esophageal anastomosis for esophageal atresia repair: long-gap versus non-long-gap. Dis Esophagus 2007; 20:428-35. [PMID: 17760658 DOI: 10.1111/j.1442-2050.2007.00691.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Current approaches to the repair of long-gap esophageal atresia (EA) favor esophageal anastomosis. This investigation provides a midterm follow-up of long-gap EA with a primary repair to determine whether this procedure affects symptom severity and whether symptom severity may predict worsening of dysmotility. Fifteen children at least 1-year post primary repair were divided into group 1 (long-gap) and group 2 (non-long-gap). The severity of their symptoms was graded using a questionnaire focused on their eating habits and gastroesophageal motor dysfunction symptoms. Esophageal transit time and gastric emptying were assessed by scintigraphy and used to grade esophagogastric dysmotility. At midterm follow-up the majority of patients in both groups were asymptomatic (66% in group 1 vs 77.7% in group 2; P > 0.05). Esophagogastric dysmotility grades for group 1 were more severe than for group 2 (median 2.5, range from 1 to 4 vs median 1, range from 1 to 2, respectively; P > 0.05). We found no relationship between the severity of the symptoms and the presence or severity of esophagogastric dysmotility. At midterm follow-up in patients with long-gap atresia that underwent primary repair, this study showed scintigraphic evidence of silent and serious esophagogastric dysmotility in symptom-free or minimally symptomatic children. It may therefore be unreliable to use symptoms in assessing the severity of esophagogastric dysmotility, since both groups showed similar clinical findings but different scintigraphic findings.
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Affiliation(s)
- M F Lopes
- Department of Pediatric Surgery, Pediatric Hospital of Coimbra, 3000 Coimbra, Portugal.
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17
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Villegas-Alvarez F, Olvera-Durán J, Rodríguez-Aranda E, Carmona-Mancilla A, Vigueras-Villaseñor RM, Méndez-Ramírez I. Esophageal anastomotic failure: an experimental study. Arch Med Res 2004; 34:171-5. [PMID: 14567395 DOI: 10.1016/s0188-4409(03)00028-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Postsurgical complications in patients with esophageal atresia have remained unchanged during the last three decades. This study was aimed at investigating certain risk factors for small-sized esophageal anastomosis and to assess the probable relationship between esophageal length and body weight in rabbit. METHODS Six groups of 10 adult rabbits were subjected to section or 1-cm segmental resection of thoracic esophagus followed by end-to-end anastomosis. Approximation strength of esophageal ends was measured. Three different suture materials were used, and three different surgeons carried out procedures. Observed morbidity was recorded, as well as leakage or stenosis frequency in suture line. Esophageal length and body weight of nonresected rabbits were measured. RESULTS Fifteen leakages were observed in suture line; there were no differences in relative risk between groups with and without resection, or in ratio of this complication among surgeons; nonetheless, a greater number of leakages (p < 0.05) was observed at higher tension. There were no differences in magnitude of stenosis among surgeons, tension degree, or suture material used. Quadratic association was found between length of thoracic esophagus and body weight in nonresected rabbits. CONCLUSIONS Rabbit esophagus is a suitable model to assess early surgical complications but not for late complications. Among three assessed factors, increased tension in patients with segmental deficit was the most significant factor in development of anastomotic leakage. Existence of nonlineal correlation between esophageal length and body weight in rabbit showed that resection of 1 cm of esophagus represented a different weight-dependent segmental deficit, which increased as weight decreased.
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Affiliation(s)
- Fernando Villegas-Alvarez
- Laboratorio de Cirugía Experimental, Edificio de Investigación Dr. Joaquin Cravioto, Instituto Nacional de Pediatría, Secretaría de Salud, Mexico City, Mexico.
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18
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Abstract
Reoperative esophageal surgery can be a very challenging endeavor. Preoperative evaluation, planning and preparation are essential to optimize results. A general reoperative approach and the range of reconstructive options are outlined. Management of specific problems is discussed including stricture, recurrent gastroesophageal reflux, recurrent tracheoesophageal fistula, esophageal interposition, and recurrent achalasia.
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Affiliation(s)
- Craig W Lillehei
- Department of Surgery, Children's Hospital Boston, 300 Longwood Avenue, Boston, MA 02115, USA
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19
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Giacomoni MA, Tresoldi M, Zamana C, Giacomoni A. Circular myotomy of the distal esophageal stump for long gap esophageal atresia. J Pediatr Surg 2001; 36:855-7. [PMID: 11381411 DOI: 10.1053/jpsu.2001.23953] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE The aim of this work is to report the utility of the distal esophageal stump's circular myotomy in case of a long gap esophageal atresia repair. METHODS Between 1972 and 1999 the authors treated 192 patients who had esophageal atresia (EA). Among them, 6 patients with EA long gap underwent both a distal and proximal stump circular myotomy. Five cases were Gross type C, and 1 case was Gross type A. The gap (average 4.5 cm) did not permit a simple and direct end-to-end anastomosis. RESULTS One patient died 6 days after the operation because of a cardiac malformation. There was no mucosal tear during the myotomies or any anastomotic stricture later. Five patients survived. Three of them needed an antireflux procedure (60% of surviving patients). None of the 5 patients showed any mucosal outpouching, and their esophageal motility and swallowing were not different clinically compared with the patients who underwent an EA repair without a myotomy. CONCLUSIONS Distal circular myotomy is a very useful, however, delicate, procedure that can help solve the problem given by long gap EA. It is mandatory not to tear the mucosa during the myotomy to avoid the shortening of the stump caused by its repair, which would lead to an increase in the size of the gap. J Pediatr Surg 36:855-857.
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Affiliation(s)
- M A Giacomoni
- Istituti Clinici di Perfezionamento, Dipartimento di Chirurgia, Unitá operativa di Chirurgia Pediatrica, Milano, Italy
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20
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Tannuri U, Tannuri AC, Fukutaki MF, de Oliveira MS, Muoio VM, Massaguer AA. Effects of circular myotomy on the healing of esophageal suture anastomosis: an experimental study. REVISTA DO HOSPITAL DAS CLINICAS 1999; 54:9-16. [PMID: 10488595 DOI: 10.1590/s0041-87811999000100003] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
For esophageal reconstruction in newborns with esophageal atresia, esophageal reunion with an end-to-end anastomosis is the ideal procedure, although it may result in leaks and strictures due to tension on the suture line, mainly in cases with a wide gap between the ends. Circular myotomy (Livaditis' procedure) is the best method to elongate the proximal esophageal pouch and reduce anastomotic tension. This experimental investigation in dogs was undertaken to attempt to verify that circular myotomy decreases the anastomotic leak rate in newborns with wide gap esophageal atresia, and to analyze whether the technique promotes morphologic changes in the anastomotic scar. A pilot study demonstrated that it is necessary to resect more than 8 cm (40% of the total esophageal length) in order to obtain high leak rates. In the experimental project, such resection was performed in dogs divided into two groups (control group, anastomosis only, and experimental group, anastomosis plus circular myotomy in the proximal esophageal segment). The animals were killed in the 14th postoperative day, submitted to autopsy, and were evaluated as to the presence of leaks and strictures, as well as to the features (macroscopic and microscopic aspects) of the anastomosis. Leak rates were the same in both groups. Morphometric analysis revealed that in animals in the experimental group, the anastomotic scar was thinner than the control animals, and the isolated muscular manchette distal to the site of myotomy was replaced by fibrous tissue. Correspondingly, a decreased number of newly formed small vessels were noted in the experimental animals, compared to control animals. We concluded that circular myotomy does not decrease the incidence of anastomotic leaks, and it also promotes deleterious changes in anastomotic healing.
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Affiliation(s)
- U Tannuri
- Pediatric Surgery Laboratory (LIM-30), University of São Paulo Medical School, Brazil
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