Early primary repair of long gap esophageal atresia: the VATER operation

Quality of life after type-A esophageal atresia surgery: changes over time and effect of pre-anastomotic elongation

AIM

To assess mid-/long-term postoperative quality of life (QOL) of esophageal atresia (EA) patients.

METHODS

Modified gastrointestinal quality-of-life index surveys were administered to postoperative EA patients who were at least 7 years old at evaluation to assess three topics about general lifestyle (GL), five topics about EA, and four topics about mental health (MH). For MH, caregivers were also interviewed, but separately. Subjects were divided according to age: children (7-12 years old), teenagers (13-19), and adults (20 and over) and compared according to Foker or Kimura elongation (FK) or bougienage stretching (BS).

RESULTS

There were 22 patients evaluated. Responses for GL, EA, and MH did not differ significantly between age groups, but MH responses by caregivers for subjects who were children or teenagers scored significantly lower than responses they made themselves. For primary esophageal elongation technique (PET), age at esophagoesophagostomy was significantly higher in FK. Despite FK scoring 15.1 versus 12.4 for BS during EA evaluation, this difference was not statistically significant.

CONCLUSION

Changes in QOL responses according to age were unremarkable. However, discrepancies in MH indicate that subjects felt better than their caregivers thought. PET did not appear to influence QOL.

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

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).

Management of long gap esophageal atresia: A systematic review and evidence-based guidelines from the APSA Outcomes and Evidence Based Practice Committee

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.

Elongation of esophageal segments by bougienage stretching technique for long gap esophageal atresia to achieve delayed primary anastomosis by thoracotomy or thoracoscopic repair: A first experience from China

OBJECTIVES

The treatment of long gap esophageal atresia (LGEA) is one of the most challenging congenital malformations in neonatal surgery. A preoperative bougienage stretching technique for elongation of the two segments of esophagus is applied to achieve utilizing the native esophagus to establish esophageal continuity by open or thoracoscopic approach.

METHODS

From January 2015 to May 2017, 12 neonates who suffered from LGEA were admitted to our department. They were divided into 2 groups (A and B) according to their admission time. They all accepted bougienage stretching technique before esophageal anastomosis.

RESULTS

Initially the lengths of esophageal gap in 12 infants ranged from 4 to 7.5 vertebral bodies (M=5.8±1.1). The gap lengths became -1 to 2.5 vertebral bodies after bougienage stretching technique and tension-free anastomosis were performed successfully for all 12 cases: Group A (n=5) by thoracotomy and group B (n=7) by thoracoscopic approach. 12 cases have been followed up for 1-25 months (M=12.4±8.5) after definitive surgery.

CONCLUSIONS

Bougienage stretching technique for LGEA is feasible with satisfactory clinical results. Thoracoscopic approach is a good choice for primary anastomosis in LGEA.

LEVELS OF EVIDENCE

Treatment Study Level IV.

Type A esophageal atresia: a critical review of management strategies at a single center

PURPOSE

The purpose of was to study the short- and long-term outcomes in the management of isolated esophageal atresia with different operative strategies.

METHODS

All patients undergoing type A atresia repair over a 15-year period were included. Demographic data, birth weight, gestational age, incidence of associated anomalies, management, and long-term outcomes were studied.

RESULTS

Fifteen patients with type A atresia (9 male) were treated in the study period. The mean gestational age was 35.5 weeks (range, 27-39 weeks), and the mean birth weight was 2179 g (range, 670-3520 g). Eight babies had associated anomalies. Thirteen patients underwent gastrostomy as the initial procedure, and 2 underwent the Foker procedure. In the delayed management group, 9 patients underwent primary anastomosis, with 2 patients needing proximal pouch myotomy. Two patients underwent a Collis gastroplasty. Two patients underwent a cervical esophagostomy and a gastric tube replacement at 4 months and 1 year, respectively. Eight patients (60%) in this group had anastomotic leaks. All patients are currently on prokinetics and proton pump inhibitors. Seven required antireflux surgery. The median length of hospital admission was 4 months (range, 3-19 months). The native esophagus was preserved in 13 (85%) of 15 babies. All patients are alive, and 14 of 15 are capable of feeding orally.

CONCLUSIONS

Type A esophageal atresia continues to be associated with significant morbidity despite advances in surgical technique and intensive care.

Repair of long-gap esophageal atresia: gastric conduits may improve outcome—a 20-year single center experience

INTRODUCTION

Treatment of long-gap esophageal atresia (LEA) is a major challenge. Options for reconstruction include native esophagus, or replacement with stomach, colon, or small intestine. However, debate continues regarding the optimal conduit for esophageal replacement.

METHODS

Medical records of patients with a diagnosis of esophageal atresia during a 20-year period were reviewed.

RESULTS

Twenty-eight cases of LEA were identified. Ten patients underwent primary anastomosis either after serial pouch dilations (9/10) and/or after a lengthening procedure (2/10). Nine received colonic interpositions, and the remainder were reconstructed with a gastric tube (n = 3), or gastric interposition (n = 2). One patient died prior to repair, and two await definitive treatment. Repeat esophageal reconstruction was required in four patients because of conduit ischemia. Two ischemic events occurred in the colonic interposition group, and two in the native esophageal repairs. All patients, except one who relocated, received long-term follow-up (mean 4.2 years: range 0.5-11.5 years).

CONCLUSIONS

Surgeon's expertise and patient's anatomy should be considered when selecting an appropriate operation for LEA. Although native esophagus is generally preferred, it is associated with a high rate of stricture. Although our study has a limited by numbers, we found that patients with gastric conduits had lower complication rates and no conduit ischemia. We suggest that gastric transposition may be favored as an initial reconstructive option.

Long gap esophageal atresia: lengthening technique and primary anastomosis

OBJECTIVE

The treatment of long gap esophageal atresia remains a major surgical challenge. The authors describe a modification of a lengthening technique based on tissue expansion to avoid sutures cutting through the esophagus.

METHODS

Between January 2004 and August 2006, 4 patients did not respond to stretching, and underwent this modified esophageal lengthening technique using silastic tubes. RESULTS AND FOLLOW-UP: All infants recovered and have an intact esophagus. All infants developed gastroesophageal reflux. Thal antireflux procedure was performed in the first infant. The other 3 patients were managed conservatively. Follow-up ranged between 6 and 34 months.

CONCLUSIONS

The tissue expansion principle can be successfully applied in the esophagus through external traction. Silastic tube fixation at esophageal ends may help to apply even traction and avoid sutures cutting through the esophageal tissue.

Long-term results of delayed primary anastomosis for pure oesophageal atresia: a 27-year follow up

The management of a newborn with pure oesophageal atresia continues to be challenging. We started treating babies with pure oesophageal atresia by delayed primary anastomosis in 1977. The purpose of this study was to review the long-term outcome in infants with pure oesophageal atresia (EA) treated by delayed primary anastomosis with special emphasis on gastroesophageal reflux (GOR) related morbidity. The medical charts of all patients treated by delayed primary anastomosis between 1977 and 2004 were retrospectively reviewed. All survivors were followed up with completion of a questionnaire and personal/phone interviews. There were 26 patients in total admitted during the 27-year study period with the diagnosis of pure oesophageal atresia. Three died prior to surgery due to associated anomalies; two had almost no distal oesophageal segment and underwent oesophageal replacement surgery. The remaining 21 children were treated with delayed primary anastomosis and made up our study group. There were four deaths (19%) in this group, and all were prior to 1980. The median gestational age was 35.5 weeks and the median birth weight was 2.6 kg; median initial gap was 3.7 cm and median preoperative gap was 1.5 cm; median age at operation was 80 days and the median hospital stay was 5.5 months. The median follow-up period was 13.5 years. Fourteen children (66%) developed symptomatic gastroesophageal reflux and nine of these needed fundoplication (43%). Sixteen children developed strictures at the anastomotic site; ten responded to repeated dilatations while six needed resection and reanastomosis. At the time of this study, 15 out of the 17 survivors (88%) were on normal diet with no respiratory problems and 2 (12%) were dependent on gastrostomy feeds. Our long-term follow-up data shows that the delayed primary anastomosis provides excellent functional results in patients born with pure oesophageal atresia. The high incidence of gastroesophageal reflux and associated morbidity requires early intervention to prevent ongoing feeding problems due to oesophagitis and stricture formation.

Multistaged esophageal elongation technique for long gap esophageal atresia: experience with 7 cases at a single institution

BACKGROUND/PURPOSE

Esophageal reconstruction for long gap esophageal atresia (LGEA) is still controversial. We successfully managed 7 cases of patients with LGEA by doing staged elongation of the native esophagus and subsequent end-to-end anastomosis. The technique and efficacy of this procedure are evaluated.

METHODS

During the last 10 years, 7 patients with LGEA (Gross type A, 5; B, 1; C, 1) underwent multiple extrathoracic esophageal elongations (ETEEs) of the upper esophagus and subsequent esophagoesophagostomy. Medical records were reviewed in regard to the number of ETEE before definitive esophageal reconstruction, interval between each ETEE, operation time, time before initiation of sham feeding, duration of hospital stay, and complications.

RESULTS

The definitive esophageal reconstruction was successfully achieved without major complications in all patients after 2 to 4 stages of ETEE. The interval between each ETEE was 72 days on average. The average operation time was 98 minutes. The elongation was 1 to 3.5 cm during each session. Oral sham feeding was recommenced 4.1 days after each ETEE, and the hospital stay was 9.6 days on average. Gastroesophageal reflux occurred in all patients, requiring antireflux surgery.

CONCLUSIONS

We conclude from our experience (a) that effective esophageal lengthening with preservation of the native esophagus was achieved with multiple ETEE in LGEA and (b) that this procedure allows oral sham feeding at home until esophageal reconstruction.

Can 'long-gap' esophageal atresia be safely managed at home while awaiting anastomosis?

BACKGROUND

Neonates with "long gap" esophageal atresia (EA) are often managed with gastrostomy and tube drainage of the proximal pouch for a number of months while awaiting definitive repair. Because of the risk of aspiration and need for complex nursing care, most remain hospitalized during this time. However, prolonged hospitalization utilizes scarce resources and may be difficult for many families.

METHODS

The authors report on 5 patients who were treated successfully at home while awaiting esophageal anastomosis.

RESULTS

Four patients had pure EA (one had a duodenal atresia), and one had a distal fistula. Gestational ages ranged from 31 to 41 weeks. All had a gastrostomy within days of birth. Age at definitive repair ranged from 6 to 12 months. Time at home while awaiting anastomosis ranged from 42 to 113 days. Care at home included nursing care, suction equipment and training, gastrostomy feeding, and ability to perform cardiopulmonary resuscitation. The only complications noted while at home consisted of ear infection in one patient and recurrent upper respiratory tract infections in another patient.

CONCLUSIONS

Selected patients with long gap esophageal atresia can be treated safely at home while awaiting esophageal anastomosis. Success of this approach depends on a motivated, reliable family, and adequate support from community health care providers.

An exclusively intraabdominal distal esophageal segment prevents primary delayed anastomosis in children with pure esophageal atresia

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.