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Zarfati A, Tambucci R, Bagolan P, Conforti A. Isoperistaltic gastric tube for long gap esophageal atresia (LGEA) in newborn, infants, and toddlers: a case-control study from a tertiary center. Front Pediatr 2023; 11:1194928. [PMID: 37260794 PMCID: PMC10228820 DOI: 10.3389/fped.2023.1194928] [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: 03/27/2023] [Accepted: 05/03/2023] [Indexed: 06/02/2023] Open
Abstract
Background Limited evidence exists about outcomes after gastric tube formation as "rescue" technique to avoid esophageal replacement in long gap esophageal atresia (LGEA). The last ERNICA Consensus Conference on the Management of LGEA has placed the techniques of gastric tubulization among the priorities for future research. Aims Evaluate personal experience with Isoperistaltic Gastric Tube (IGT) and compare its outcomes with other more popular techniques for LGEA. Methods A case-control study has been conducted. A retrospective monocentric analysis of LGEA patients (period: 2010-19) has been conducted in all consecutive IGT patients and each of these has been type matched with two cases of LGEA treated with other techniques. The follow-up (FU) considered was 24-months. Results IGT and controls showed no statistically significant differences regarding preoperative variables like sex, gestational age, birth weight, syndromes, and EA type. However, IGT patients had a significantly longer esophageal GAP under boost pressure (4.5 vertebral bodies vs. 3.6, p = 0.019) at time of surgery. The analysis showed no statistical difference among the two groups about perioperative outcomes, ICU, or overall postoperative stay. No differences have been shown between IGT and controls during the follow-up regarding GERD, esophagitis, fundoplication, dysphagia, vocal cord paralysis, stenosis, and dilatations, auxologic data, need for anastomosis revision, oral aversion, and death. Conclusions Isoperistaltic Gastric Tube is safe and effective even in LGEA patients with longer gaps, with good perioperative, post-operative and middle-term outcomes. This procedure may be considered as an alternative to avoid esophageal substitution when a primary anastomosis seems impossible for a residual gap after traction and growth techniques.
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Affiliation(s)
- Angelo Zarfati
- Department of Systems Medicine, University of Rome “Tor Vergata”, Rome, Italy
- Neonatal Surgery Unit, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | - Renato Tambucci
- Digestive Endoscopy and Surgery Unit, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | - Pietro Bagolan
- Department of Systems Medicine, University of Rome “Tor Vergata”, Rome, Italy
- Neonatal Surgery Unit, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | - Andrea Conforti
- Neonatal Surgery Unit, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
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Durakbasa CU, Mutus M, Gercel G, Fettahoglu S, Okur H. Transhiatal isoperistaltic colon interposition without cervical oesophagostomy in long-gap oesophageal atresia. Afr J Paediatr Surg 2020; 17:45-48. [PMID: 33342832 PMCID: PMC8051634 DOI: 10.4103/ajps.ajps_95_17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Oesophageal colonic interposition in oesophageal atresia (OA) patients is almost exclusively done as a staged operation with an initial oesophagostomy and gastrostomy followed by the definitive surgery months later. This study presents a series of patients in whom a cervical oesophagostomy was not performed before the substitution surgery. PATIENTS AND METHODS Records of EA patients were evaluated for those who underwent colon interposition without cervical oesophagostomy. RESULTS There were five patients: three with pure EA and two with proximal tracheo-oesophageal fistula. A delayed primary repair could not be performed because of intra-abdominally located distal pouch. The mean age at the time of definitive operation was 5.54 (±2.7) months and the mean weight was 6.24 (±1.3) kg. A right or a left colonic segment was used for interposition keeping the proximal anastomosis within the thorax. The post-operative results were quite satisfactory within a median follow-up period of 33.2 months. CONCLUSION Avoiding cervical oesophagostomy and its inherent complications and drawbacks is possible in a subset of patients with long-gap EA who underwent colonic substitution surgery. This approach may be seen as an extension of the consensus that the native oesophagus should be preserved whenever possible, because it uses the native oesophagus in its entirety.
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Affiliation(s)
- Cigdem Ulukaya Durakbasa
- Department of Pediatric Surgery, Goztepe Training and Research Hospital, Istanbul Medeniyet University, Istanbul, Turkey
| | - Murat Mutus
- Department of Pediatric Surgery, Goztepe Training and Research Hospital, Istanbul Medeniyet University, Istanbul, Turkey
| | - Gonca Gercel
- Department of Pediatric Surgery, Goztepe Training and Research Hospital, Istanbul Medeniyet University, Istanbul, Turkey
| | - Selma Fettahoglu
- Department of Pediatric Surgery, Goztepe Training and Research Hospital, Istanbul Medeniyet University, Istanbul, Turkey
| | - Hamit Okur
- Department of Pediatric Surgery, Goztepe Training and Research Hospital, Istanbul Medeniyet University, Istanbul, Turkey
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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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4
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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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5
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Liu J, Yang Y, Zheng C, Dong R, Zheng S. Surgical outcomes of different approaches to esophageal replacement in long-gap esophageal atresia: A systematic review. Medicine (Baltimore) 2017; 96:e6942. [PMID: 28538385 PMCID: PMC5457865 DOI: 10.1097/md.0000000000006942] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [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 Esophageal replacement (ER) surgery has been widely used in long-gap esophageal atresia (LGEA) over the past few decades. The most commonly used surgical approaches in many pediatric surgical centers include colon interposition (CI), gastric pull-up (GPU), jejunal interposition (JI), and gastric tube reconstruction (GTR). However, there is no systematic evidence on which is the optimal conduit for the native esophagus. The aim of this systematic review was to evaluate the short- and long-term outcomes among these 4 replacement approaches in LGEA cases based on current evidence. METHODS PubMed, Web of Science, Cochrane Library, and EMBASE were searched for relevant literature on November 18 2016. Studies on ER in LGEA were reviewed and selected according to eligibility criteria. We focused on surgical outcomes regarding to different replacement approaches, including postoperative complications and long-term follow-up. Both detailed descriptions of single studies and pooled data analysis were conducted. Data were computed by Reviewer Manager 5.3. RESULTS Twenty-three studies were included (4 comparative retrospective, 3 prospective, and 16 retrospective) with a total of 593 patients (393 LGEA, 66.3%). The number of patients with available data for analysis was 534 (90.1%), including 127 patients (98 LGEA) of GPU, 335 (223 LGEA) of CI, 45 (all LGEA) of JI, and 27 (all LGEA) of GTR. Follow-up information was provided in 15 studies. Anastomotic leak and stricture, respiratory problems, and gastroesophageal reflux were analyzed as major postoperative complications. Long-term follow-ups were concentrated on growth and feeding conditions. CONCLUSION Current evidence on short- and long-term outcomes of ER in LGEA patients was limited, and proper prospective comparative studies were lacking. This present systematic review indicates CI and GPU as comparable and favorable approaches, especially CI in the long-term outcomes. Studies on JI and GTR were limited, which need larger sample size to assess their validity and outcomes.
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Séguier-Lipszyc E, Bonnard A, Aizenfisz S, Enezian G, Maintenant J, Aigrain Y, de Lagausie P. The management of long gap esophageal atresia. J Pediatr Surg 2005; 40:1542-6. [PMID: 16226981 DOI: 10.1016/j.jpedsurg.2005.06.007] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Present management of esophageal atresia has enabled the survival rate to approach 95%. Controversy remains concerning the many options for the surgical management of long gap esophageal atresia without tracheoesophageal fistula and represents the difficulty of this pathology. In the last couple of years, we have had a nonexplained outbreak of cases of long gap esophageal atresia without tracheoesophageal fistula. This article reports our experience in the management of these children. MATERIAL AND METHODS It is a retrospective study of all cases of long gap esophageal atresia without tracheoesophageal fistula managed in our institution since 1992, focusing on the antenatal period, delivery with weight and term, the associated malformations, the initial management, and the definitive surgery. Mann-Whitney U test was used for statistical analysis. RESULTS Ten cases (8.7%) of long gap esophageal atresia according to Ladd's classification, 6 during the past 2 years, were taken in charge at Robert Debré Hospital between 1992 and 2002. There were 4 girls and 6 boys. Ten had a prenatal diagnosis of esophageal atresia. The average birth weight was 2496 g (range, 1400-3400 g) with an average term of 36.6-week gestation (range, 31.5-39.6). Delayed reconstruction was done in all children between 41 and 147 days of life (average of 102 days). Six had a direct anastomosis and 4 had a colonic esophagoplasty (3 with an esogastric disconnection during the same procedure). The average follow-up was 60 months (range, 27-133). There was 1 death owing to adenovirus infection at 5 years of age. Four children required a Nissen fundoplication for severe gastroesophageal reflux. At least, 2 children presented an anastomotic stricture which required pneumatic dilatations. CONCLUSION Treatment options for long gap esophageal atresia generally require several stages over several months. We propose, for their management, a direct anastomosis at 4 months of age whenever it is possible. If not, we use a colonic esophagoplasty with an esogastric disconnection to control the gastroesophageal reflux which is responsible for strictures and respiratory impairment and does not obstruct the aperistaltic tube.
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7
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Borgnon J, Tounian P, Auber F, Larroquet M, Boeris Clemen F, Girardet JP, Audry G. Esophageal replacement in children by an isoperistaltic gastric tube: a 12-year experience. Pediatr Surg Int 2004; 20:829-33. [PMID: 15243776 DOI: 10.1007/s00383-004-1190-y] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/23/2003] [Indexed: 10/26/2022]
Abstract
The colonic segment is the most frequently used material for replacing the esophagus in children; however, the use of a gastric tube has become a reliable alternative operation. Since 1987, we have used an isoperistaltic gastric tube to replace the esophagus in children, and we present a series of 21 patients. Indications for operation included caustic injury (nine), esophageal atresia (eight), peptic stricture (two), congenital stricture (one), and esophageal duplication (one). There was no death or necrosis of the graft during the early postoperative period. The esophagogastric anastomosis leaked in two cases, but both of them closed spontaneously. A temporary dumping syndrome was encountered in two children. Two patients had strictures of their upper anastomosis responding to dilatations. The two patients who had a pharyngogastric anastomosis developed either intractable stricture or nonfunctioning anastomosis. One of them died 9 months later from aspiration pneumonitis. At follow-up, 16 of 21 patients could accept a normal diet (13 were entirely asymptomatic, and three suffered occasional mild dysphagia). Two patients suffered significant dysphagia (one had a durable dilation of his gastric tube), and three needed a feeding jejunostomy. Acid secretion of the gastric tube was proved in nine cases. Two patients were shown to have cervical Barrett's esophagus above the anastomosis. These findings indicate the need for lifelong endoscopic follow-up for these patients.
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Affiliation(s)
- J Borgnon
- Department of Pediatric Surgery, Hôpital d'Enfants Armand Trousseau, 26 avenue du Dr. Arnold Netter, 75571 Paris cedex 12, France
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8
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McCollum MO, Rangel SJ, Blair GK, Moss RL, Smith BM, Skarsgard ED. Primary reversed gastric tube reconstruction in long gap esophageal atresia. J Pediatr Surg 2003; 38:957-62. [PMID: 12778402 DOI: 10.1016/s0022-3468(03)00133-7] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND/PURPOSE Esophageal reconstruction in long-gap esophageal atresia (EA) poses a technical challenge with several surgical options. The purpose of this study was to review the authors' experience with the reversed gastric tube (RGT) in esophageal reconstruction. METHODS This series describes 7 babies with pure EA treated at 2 centers between 1989 and 2001. Data, gathered by retrospective chart review, included clinical details of the esophageal and associated malformations, technique and timing of repair, early and late complications, and long-term follow-up. Institutional review board (IRB) approval of this study has been obtained. RESULTS Seven babies were included. Associated malformations were present in 4: trisomy 21 in 2 and imperforate anus in 2. After gastrostomy tube placement, patients were treated with gastrostomy tube feedings and continuous upper pouch suction. Median gap length was 5.5 vertebral segments (range, 3 to 9). RGT with a posterior mediastinal esophagogastric anastomosis was performed at median age of 62 days (range, 38 to 131). There were no anastomotic leaks. Three patients had strictures, one required resection. Exclusive oral nourishment was achieved in 5 patients by 6 months of age. At last follow-up (mean, 4.5 years), 6 patients were receiving oral nutrition exclusively, and all were maintaining growth curves. CONCLUSIONS In long gap EA, early esophageal reconstruction using an RGT can be performed with minimal morbidity and promising short-term results.
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Affiliation(s)
- M O McCollum
- Division of Pediatric Surgery, British Columbia's Children's Hospital, Vancouver, BC, Canada
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9
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Maksoud-Filho JG, Gonçalves MEP, Tannuri U, Maksoud JG. An exclusively intraabdominal distal esophageal segment prevents primary delayed anastomosis in children with pure esophageal atresia. J Pediatr Surg 2002; 37:1521-5. [PMID: 12407531 DOI: 10.1053/jpsu.2002.36176] [Citation(s) in RCA: 15] [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 study was to evaluate the outcome of children with pure esophageal atresia (EA) managed by the strategy of delayed primary anastomosis and to find parameters to identify which of these children will have satisfactory esophageal growth to permit a successful primary esophageal anastomosis. METHODS Sixteen children with pure EA were treated by delayed anastomosis strategy from June 1992 to May 2001 at the Instituto da Criança-University of São Paulo Medical School. The treatment consisted of creating an early feeding gastrostomy, continuous upper pouch suction, and periodic radiologic/endoscopic assessments of the gap between the superior and inferior esophageal pouches. The first assessment was done 4 weeks after the initial gastrostomy. Subsequent assessments were done, when necessary, 4 to 10 weeks after the first one. Children with the gap between the pouches corresponding to 2 vertebral bodies or less were considered for primary repair. RESULTS The waiting period ranged from 8 to 14 weeks. Five children were considered for primary repair (31.3%). All of them had an end-to-end esophageal anastomosis performed without tension. Eleven children (68.7%) did not show significant esophageal growth after the waiting period and were not considered for primary esophageal anastomosis. Eight of them (50%) showed an entirely intraabdominal distal pouch at the first assessment. CONCLUSIONS (1) Infants with an exclusively intraabdominal distal pouch at the first evaluation will not reach sufficient elongation of the pouches and should be considered early as a candidate for esophageal replacement. (2) Combined radiologic/endoscopic assessment and the measurement of the gap in terms of vertebral bodies is a practical and reliable method to predict the feasibility of primary anastomosis. (3) Using these criteria, primary anastomosis could be accomplished in less than a third of cases.
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Affiliation(s)
- João Gilberto Maksoud-Filho
- Pediatric Surgery Division, Department of Pediatric Surgery, University of São Paulo Medical School, São Paulo, Brazil
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10
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Abstract
Improvements in the diagnosis and treatment of congenital disorders have resulted in a change in surgical practice. Many conditions that formerly required corrective surgery immediately after birth are no longer surgical emergencies. Most babies with congenital anomalies that can be corrected by surgery are now stabilized and optimized before the procedure. This article focused on the more common conditions that require semi-elective or urgent surgery in the neonatal period. Salient features of each of these disorders were described. Factors unique to each of these conditions that can affect the anesthetic course of these children were discussed. Methods and techniques that may aid in the anesthetic management of these children were delineated.
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Affiliation(s)
- L M Liu
- Department of Anesthesiology, University of Medicine and Dentistry of New Jersey-New Jersey Medical School, Newark, New Jersey, USA
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11
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Abstract
Oesophageal atresia (OA) is a congenital anomaly in which the oesophagus ends in a blind upper pouch. Specialised family-centred nursing care is required for the neonate/infant with 'long-gap' OA. Goals of preoperative nursing care focus on prevention of aspiration, optimising nutrition and thus growth of the baby and supporting parents. Primary repair is delayed to enable further growth of the infant and additional oesophageal growth. Additional nursing and medical research needs to be undertaken in a number of areas relating to the management of infants with long-gap OA.
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Affiliation(s)
- A D Hawley
- Department of Surgery, Murdoch Children's Research Institute, Royal Children's Hospital, Melbourne, Australia
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12
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Aloisi AS, de Freitas S, Colombo AC, Amalfi R, Sbragia-Neto L, Bustorff-Silva JM. Lateral esophagostomy: an alternative in the initial management of long gap esophageal atresia without fistula. J Pediatr Surg 2000; 35:1827-9. [PMID: 11101747 DOI: 10.1053/jpsu.2000.19273] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The authors report an alternative method of cervical esophagostomy that was used in a child with type A esophageal atresia. This method involved performing a lateral esophagostomy in the proximal pouch, preserving its distal end, allowing the child to swallow normally, without choking, while stimulating the spontaneous growth of the proximal esophagus. As a result, the infant could be discharged home on G-tube feedings while waiting for spontaneous growth of the proximal pouch to occur. There were no episodes of aspiration during this period, and definitive reconstruction through end-to-end esophageal anastomosis was accomplished successfully at the age of 18 months. The authors consider that this alternative might increase the possibility of a definitive correction through delayed primary anastomosis of the infant's own esophagus in children with this type of malformation.
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Affiliation(s)
- A S Aloisi
- Division of Pediatric Surgery, Santa Casa de Piracicaba, University of Campinas School of Medical Sciences, Campinas, Brazil
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13
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Abstract
BACKGROUND/PURPOSE Long gap esophageal atresia may require months of preoperative management before definitive repair. When 2 recent patients prompted the authors to consider preoperative home care, no published protocol could be identified. This survey is undertaken to determine pediatric surgeons' experience with preoperative home care for long gap atresia. METHODS A total of 543 surgeons were asked if any patients with long gap atresia had been treated preoperatively at home. For patients sent home, information on nursing care, insurance issues, complications, and timing or type of repair was requested. RESULTS A total of 380 surveys (70%) were returned. A total of 165 surveys representing 348 patients were included. Forty-one of 165 surgeons (25%) treated 63 of 87 patients (72%) with long gap atresia and an intact upper pouch at home. Home nursing care was provided for 44 patients (70%): 16 (36.4%) night shift, 2 (4.5%) day shift, 3 (6.8%) 24 hour, and 23 (52.3%) intermittent care. No complications referable to preoperative home care were reported. CONCLUSIONS Significant hesitancy and practice variance exists regarding preoperative home care of patients with long gap esophageal atresia. Many surgeons are satisfied with the safety and cost effectiveness of this technique, although a prospective, multicenter trial is needed to study it in a randomized, controlled fashion.
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Affiliation(s)
- C M Hollands
- Miami Children's Hospital, Division of Pediatric Surgery, FL, USA
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14
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Davison P, Poenaru D, Kamal I. Esophageal atresia: primary repair of a rare long gap variant involving distal pouch mobilization. J Pediatr Surg 1999; 34:1881-3. [PMID: 10626882 DOI: 10.1016/s0022-3468(99)90340-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
This report describes a rare type IIIb variant of long gap pure esophageal atresia treated with delayed primary repair. Preoperative imaging showed a distal pouch with a unusually long tapering end, and a 5-vertebral body gap. Delayed exploration with mobilization of the distal pouch allowed for successful primary repair without the need of myotomy. The characteristic radiological appearance of this rare variant enables its preoperative recognition and warrants attempting primary repair with a good expectation of success.
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Affiliation(s)
- P Davison
- Department of Surgery, Queen's University, Kingston, Ontario, Canada
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Lipshutz GS, Albanese CT, Jennings RW, Bratton BJ, Harrison MR. A strategy for primary reconstruction of long gap esophageal atresia using neonatal colon esophagoplasty: a case report. J Pediatr Surg 1999; 34:75-7; discussion 77-8. [PMID: 10022147 DOI: 10.1016/s0022-3468(99)90232-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Treatment options for long gap esophageal atresia without tracheoesophageal fistula generally require several stages over many months. An early neonatal vascularized conduit would allow a tension-free anastomosis, but the precarious blood supply of the neonatal bowel makes mobilization and immediate interposition hazardous. This report describes the successful application of a strategy for primary reconstruction in the neonate using a short piece of colon mobilized into the mediastinum for subsequent delayed anastomosis.
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Affiliation(s)
- G S Lipshutz
- Fetal Treatment Center, Department of Surgery, University of California, San Francisco 94143, USA
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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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