Atresia of the esophagus: increased survival with staged procedures in the poor-risk infant

Thoracoscopic repair of esophageal atresia and tracheo-esophageal fistula in neonates: the current state of the art

The first thoracoscopic esophageal atresia with tracheo-esophageal fistula (EATEF) repair was performed in March of 2000. This report evaluates the results and evolution of the technique over the last decade. Thoracoscopic esophageal atresia repair has proven to be an effective and safe technique. Initial experience resulted in a higher stricture rate but this improved with experience and changes in technique over the last decade. The outcomes are similar to or superior to that of an open thoracotomy and avoid the musculoskeletal morbidity associated with that technique.

Thoracoscopic repair of esophageal atresia and tracheoesophageal fistula in neonates, first decade's experience

The first thoracoscopic esophageal atresia with tracheoesophageal fistula (EATEF) repair was performed in March of 2000. This report evaluates the results and evolution of the technique in a single surgeons' experience after the first decade of thoracoscopic EATEF repair. From March 2000 to September 2012, 52 consecutive patients with type 3 EATEF, and an additional nine patients with pure esophageal atresia (EA) were repaired by or under the direct supervision of a single surgeon. Patient weight ranged from 1.2 to 3.8 kg (mean 2.6 kg). Twenty-two patients had significant associated congenital anomalies. The repairs were performed using three ports. The fistula was ligated using a single endoscopic clip, and the anastomosis was performed using a single layer of interrupted sutures. A transanastomotic tube and chest drain were left in all cases. Fifty-one of the 52 procedures were completed successfully thoracoscopically. Operative times ranged from 50 to 120 minutes (average 85 minutes). There were three clinical leaks, one in an EATEF and two in patients with long-gap pure EA, all resolved with conservative therapy. Oral feedings were started on day 5 in all other patients. Twelve of 61 patients required dilations (1-9), and 18 required a Nissen fundoplication for severe reflux. One patient required a thoracoscopic aortopexy for severe tracheomalacia. All patients are currently on full oral feedings. No patient has any evidence of chest wall asymmetry, winged scapula, or clinically significant scoliosis. There have been no recurrent fistulas. Thoracoscopic EA repair has proven to be an effective and safe technique. Initial experience resulted in a higher stricture rate, but this improved with experience and changes in technique. The results are superior to that of documented open series and avoid the morbidity of an open thoracotomy.

Image-guided esophageal anastomosis in esophageal atresia

Infants with tracheoesophageal fistulas may present with complex cardiac disease that may obviate or disrupt a safe operative repair. Here we present a case of an infant who developed cardiac instability during esophageal atresia repair, precluding formal anastomosis after approximation of the distal and proximal esophageal segments. Postoperatively, anastomosis of the esophagus was achieved using an image-guided technique with subsequent dilation. This approach may provide an alternative approach for establishment of esophageal continuity in patients who are high-risk operative candidates.

Thoracoscopic repair of esophageal atresia and tracheo-esophageal fistula in neonates: evolution of a technique

Advancements in minimally invasive surgical techniques and instruments for neonates have allowed even the most complex neonatal procedures to be endoscopically approached. In 1999, the first successful thoracoscopic repair of an esophageal atresia (EA) was performed in a 2-month-old infant. One year later, the first totally thoracoscopic repair of an atresia with distal fistula (tracheo-esophageal fistula [TEF]) was realized in a newborn. Over the ensuing 10 years, this technique was used and modified by a single surgeon in 49 consecutive patients. Overall, 43 patients with TEF and 6 with pure EA were repaired by using a thoracoscopic approach. An additional 3 patients with H-type TEF were also thoracoscopically treated. Weight ranged from 1.2 to 3.8 kg. Operative time ranged from 50 to 120 minutes. In fact, 48 out of 49 were successfully completed thoracoscopically. There were 2 patients with leaks that resolved with conservative management. Thirty percent of patients required at least one dilatation, but this number dropped to less than 10% in the second half of the series. There were no deaths and no recurrent fistula. Thoracoscopic TEF repair has proved to be an effective and safe technique. Evolution of the technique has resulted in fewer complications while avoiding the significant short- and long-term morbidity associated with thoracotomy in neonates.

Thoracoscopic repair of esophageal atresia and tracheoesophageal fistula: a multi-institutional analysis

OBJECTIVES

For the past 60 years, successful repair of esophageal atresia (EA) and distal tracheoesophageal fistula (TEF) has been performed via a thoracotomy. However, a number of reports have described adverse musculoskeletal sequelae following thoracotomy in infants and young children. Until now, only a few scattered case reports have detailed an individual surgeon's success with thoracoscopic repair of EA/TEF. This multi-institutional review represents the largest experience describing the results with this approach.

METHODS

A cohort of international pediatric surgeons from centers that perform advanced laparoscopic and thoracoscopic operations in infants and children retrospectively reviewed their data on primary thoracoscopic repair in 104 newborns with EA/TEF. Newborns with EA without a distal TEF or those with an isolated TEF without EA were excluded.

RESULTS

In these 104 patients, the mean age at operation was 1.2 days (+/-1.1), the mean weight was 2.6 kg (+/-0.5), the mean operative time was 129.9 minutes (+/-55.5), the mean days of mechanical ventilation were 3.6 (+/-5.8), and the mean days of total hospitalization were 18.1 (+/-18.6). Twelve (11.5%) infants developed an early leak or stricture at the anastomosis and 33 (31.7%) required esophageal dilatation at least once. Five operations (4.8%) were converted to an open thoracotomy and one was staged due to a long gap between the 2 esophageal segments. Twenty-five newborns (24.0%) later required a laparoscopic fundoplication. A recurrent fistula between the esophagus and trachea developed in 2 infants (1.9%). A number of other operations were required in these patients, including imperforate anus repair in 10 patients (7 high, 3 low), aortopexy (7), laparoscopic duodenal atresia repair (4), and various major cardiac operations (5). Three patients died, one related to the EA/TEF on the 20th postoperative day.

CONCLUSIONS

The thoracoscopic repair of EA/TEF represents a natural evolution in the operative correction of this complicated congenital anomaly and can be safely performed by experienced endoscopic surgeons. The results presented are comparable to previous reports of babies undergoing repair through a thoracotomy. Based on the associated musculoskeletal problems following thoracotomy, there will likely be long-term benefits for babies with this anomaly undergoing the thoracoscopic repair.

Significance of the clinical course and early upper gastrointestinal studies in predicting complications associated with repair of esophageal atresia

BACKGROUND/PURPOSE

In many centers, use of upper gastrointestinal (UGI) contrast studies in the early postoperative period after esophageal atresia (EA) repair is considered routine. Indications for this are many, including searching for existing problems and predicting future complications. However, most major complications, both early and late, usually are identified clinically before any radiologic studies. The purpose of this study was to investigate factors that may anticipate the development of postoperative complications after EA repair, looking particularly at the predictive value of routine early postoperative UGI studies.

METHODS

A total of 111 consecutive cases of EA were identified retrospectively over a 10-year period from 2 major Canadian pediatric health centers. One hundred one were associated with a distal tracheoesophageal fistula (TEF), of which, 90 had repairs. Ninety-seven percent of these had a UGI study at a median of 9.1 postoperative days (range, 2 to 23) before consideration of oral feeding. Charts were reviewed looking at patient variables, surgical factors, early UGI findings, and postoperative courses. Complications that required intervention were noted, including anastomotic leaks, gastroesophageal reflux (GER), strictures, and recurrent and missed fistulae. All initial UGI studies were reexamined by 1 of 2 pediatric radiologists. Logistic regression was used to examine relationships between these clinical and radiologic variables and outcomes.

RESULTS

Of the variables analyzed, univariate analysis showed clinically significant leaks to be associated with intraoperative factors (subjective degree of anastomotic tension, and the use of myotomies) and early postoperative clinical evidence suggesting a leak. In a multivariate model, all remained independently significant except for the use of myotomies. Later development of clinically significant GER also was associated with the degree of tension. It had no relationship, however, with findings of dysmotility, esophageal shortening, or reflux at the initial UGI study. Development of a stricture requiring dilatations or resection was associated with a history of clinically evident GER only; no relationships were seen with a history of an anastomotic leak or any other clinical, operative, or radiographic variables. Missed or recurrent fistulae were all suspected clinically before radiologic confirmation.

CONCLUSIONS

Early and late complications after repair of EA can be identified and potentially anticipated based on clinical findings at the time of repair and during the postoperative period. The use of early "routine" UGI studies, with no suspicion of a problem, has little value in terms of predicting complications or future clinical course.

Esophageal atresia in infants with very low birth weight

Infants with esophageal atresia (EA), with or without a tracheoesophageal fistula (TEF) frequently are of low birth weight. With advances in neonatal, respiratory, surgical, and anesthetic care, more infants with very low birth weight (VLBW; birth weight less than 1.5 kg) are surviving. The therapy of the VLBW neonate with EA is not longer automatically staged. Primary or delayed primary anastomosis can be performed safely if the patient is stable. This report will review the epidemiology, pathophysiology, treatment, and prognosis of EA in VLBW infants. The authors present their own experience in dealing with the VLBW with EA and review the world literature.

[Acute gastric distension necessitating gastrostomy after anesthetic induction for surgical correction of type III esophageal atresia]

IPPV during anaesthesia for management of oesophageal atresia with tracheo-oesophageal fistula (TOF) can cause gastric insufflation. We report such a complication in a one-day-old newborn, who developed, 15 min after induction, a distension of the abdomen, hypoxia and bracdycardia. An emergency gastrostomy was performed. His status improved rapidly and surgery could be completed. TOF was located at the carina and had a large calibre. To avoid gastric distension in such cases, the tip of the tube is located just proximal to the carina, but distal to the fistula to prevent intubation of the latter. Difficulties are due to position of the fistula (carina, main bronchi) or its large bore. Gastric distension carries a risk of regurgitation and inhalation of gastric contents, elevation of hemidiaphragm and lung compression, decreased tidal volume, decreased venous return, cardiovascular collapse and cardiac arrest. When insufflation peak pressures are low, gastrostomy is benefitful, as in our case, as the tidal volume loss through the stomach is acceptable. In case of high insufflation pressures because of co-existing lung disease, gastrostomy is better avoided, as most if not all the tidal volume may be lost through the stomach.

Factors contributing to poor results of treatment of esophageal atresia in developing countries

The results of treatment of 341 consecutive cases of esophageal atresia/tracheoesophageal fistula over an 11-year period have been analyzed to determine the factors resulting in a poorer prognosis of these cases in a developing country; 121 neonates in the first 6-year period are compared with 220 in the last 5 years. In the latter group only 8% were in Waterston's group A; 46% reached the hospital within 24 h of birth, 13% were normothermic on presentation, 70% had a chest infection, and 28% had major associated malformations. This was similar to the preceding 6-year period. In the last 5 years the overall mortality was 58%, compared to 67% in the preceding 6 years. Despite improvement in survival in the last 5 years, the overall survival is far inferior to that reported from the developed countries. The factors resulting in poorer results have been analyzed and remedial actions suggested.

Survival after gastrointestinal perforation from esophageal atresia and tracheoesophageal fistula

Management of premature infants with esophageal atresia (EA), tracheoesophageal fistula (TEF), and respiratory distress syndrome (RDS) can be one of the most challenging aspects in the surgical care of the newborn. Although not common, there have been reports of EA, TEF, and RDS with gastric perforation, but an associated duodenal perforation has not been reported. Two premature infants weighing less than 1,200 g with EA, TEF, and perforation are described. One baby developed a gastric perforation and the other a duodenal perforation. Emergency thoracotomy and fistula ligation were necessary after gastrostomy placement. These patients are the smallest infants reported to survive gastrointestinal perforation complicated by EA, TEF, and RDS.

"Waterseal" gastrostomy in the management of premature infants with tracheoesophageal fistula and pulmonary insufficiency

The perioperative management of premature infants with esophageal atresia and tracheoesophageal fistula (EA/TEF) complicated by pulmonary insufficiency continues to be a challenge. Definitive repair is usually delayed or staged and a gastrostomy is initially placed to prevent reflux aspiration. In patients with decreased pulmonary compliance, gastrostomy placement results in decreased intragastric pressure leading to a loss of ventilatory pressure via the tracheoesophageal fistula. A technique using the principle of underwater seal to maintain effective ventilatory pressure after gastrostomy placement is described, and two illustrative cases are presented. After acute respiratory decompensation in these patients, the gastrostomy tube was connected to underwater seal resulting in improved respiratory status. The underwater seal is allowed to intermittently "bubble," thereby permitting partial gastric decompression. This technique maintains effective ventilatory pressure after gastrostomy placement in premature infants with EA/TEF and pulmonary insufficiency until definitive therapy can be achieved.

Pressure-induced growth (PIG) of atretic esophagus: a contigent management for high-risk esophageal atresia

A method is described by which a balloon catheter is inserted into the lower pouch, avoiding aspiration pneumonia due to overflow of gastric contents via a lower tracheoesophageal fistula in high-risk cases of esophageal atresia. As a side-effect there is an enlargement of the lower pouch, termed by the authors "pressure-induced growth". The prevention of aspiration pneumonia, induction of growth of the atretic segment, and the application of this method as the first part of a staged management of esophageal atresia in high-risk cases are the advantages.

Management of esophageal atresia and tracheoesophageal fistula in the neonate with severe respiratory distress syndrome

In a 10-year period, 22 neonates with esophageal atresia (EA) and tracheoesophageal fistula (TEF) required high pressure ventilatory support soon after birth because of respiratory distress syndrome (RDS). Eleven of the 22 or 50% survived overall, but if the 5 patients who died before definitive surgical repair could be attempted are excluded, 11 of 17 or 65% survived. More importantly, 4 of 7 (57%) patients who had gastrostomy performed first survived while 7 of 10 (70%) who had fistula ligation performed first survived. The difficulties with intraoperative management of those who had gastrostomy performed first were even more impressive. Our experience leads us to conclude that patients with EA and TEF with severe RDS who require high pressure ventilation preoperatively represent a group of patients who require special consideration. The danger to such patients with increased pulmonary resistance is not gastric distention but sudden loss of intragastric pressure. In the presence of poor lung compliance, the upper gastrointestinal tract functions in continuity with the tracheobronchial tree. A sudden loss of intragastric pressure, as with placement of a gastrostomy tube, results in an acute loss of effective ventilating pressure. Resuscitation of such a patient is not possible until leakage from the esophagus is controlled by ligation of the fistula or transabdominal occlusion of the distal esophagus. Placement of a Fogarty catheter into the fistula via a bronchoscope is effective but may not be feasible in every case. Early thoracotomy and ligation of the fistula in patients with progressive RDS provides immediate improvement in ventilatory efficiency and relief of gastric distention.

Delayed primary anastomosis in poor-risk patients with esophageal atresia associated with tracheoesophageal fistula

Twelve patients with esophageal atresia with tracheoesophageal fistula (TEF) who were treated with delayed primary anastomosis were reviewed. All patients except two were classified as Waterston's group C, for whom multiple staged procedures usually can be considered. Gastrostomy for decompression was performed as the initial operation shortly after admission and adequate nutritional support was provided by a transpyloric or jejunostomy tube. Extrapleural division of the TEF and esophagoesophagostomy were delayed until these operations were considered safe to perform. Delayed primary anastomosis was done at varying ages from the 11th day of life to the 150th day. Eleven patients survived. It is concluded that the therapeutic program consisting of gastrostomy, enteral feeding and delayed division of TEF and esophagoesophagostomy is useful in treating poor-risk patients and should replace multiple staged procedures.

Esophageal atresia. Prognostic factors and contribution of preoperative telescopic endoscopy

In recent years, the surgical correction of esophageal atresia with distal tracheoesophageal fistula (TEF) has become increasingly successful. However, there remains a group of high-risk patients with specific anatomical abnormalities in whom the mortality remains appreciable. These associated disorders include cardiac, renal, and chromosomal anomalies as well as severe respiratory distress syndrome. These factors, rather than low birth weight or early gestational age, are primarily responsible for surgical mortality. Preoperative telescopic bronchoscopy has been a useful adjuvant confirming the diagnosis, identifying unusual variants, and permitting the proper anatomic placement of the endotracheal tube. A Fogarty balloon catheter can be passed bronchoscopically into the distal TEF in patients with severe respiratory distress syndrome to occlude the fistula and facilitate effective positive pressure ventilation. Thirty-two patients were treated for esophageal atresia among whom 28 had esophageal atresia with distal TEF, three had esophageal atresia alone, and one had esophageal atresia with proximal TEF. The higher-risk group comprised those with severe respiratory insufficiency as evidenced by a room air paO2 of less than 60 mmHg; this group accounted for nine of the ten deaths in the total series. There was one late death following surgical correction. In summary, in the absence of severe respiratory insufficiency or associated life-threatening congenital anomalies, the results of surgical correction for esophageal atresia are remarkably good and survival in this group approximates 100%.

The Fogarty balloon catheter as an aid to management of the infant with esophageal atresia and tracheoesophageal fistula complicated by severe RDS or pneumonia

Early ventilatory failure in an infant with EA/TEF may prove difficult to manage because of the low resistance "vent" provided by the TEF. In this Case Report Fogarty balloon occlusion of the vent was possible and aided management of the patient who was not a candidate for primary repair of the anomaly.

Esophageal atresia and tracheoesophageal fistula

Fifty-seven babies were surgically treated for esophageal atresia and tracheoesophageal fistula between 1968 and 1978. Forty-eight (84%) had proximal esophageal atresia and a distal tracheoesophageal fistula, 2 (4%) had proximal and distal esophageal atresia and no tracheosophageal fistula, and 7 (12%) had a tracheosophageal fistula without esophageal atresia. Primary repair was accomplished in 43 patients (75%), colon interposition was required in 5 (9%), while the remainder had staged or palliative reapirs. Forty-six (81%) survived surgical treatment. All 21 babies in Waterston Category A, 90% of 20 in Category B, and 44% of 16 in Category C survived surgical treatment. Serious complications occurred in 17 (30%), and dilatable strictures and other minor problems developed in 27 (47%). Late follow-up (mean, 48 months) revealed 3 (7%) late deaths, 2 of which were due to congenital heart disease. Three patients required late colon interposition, and several require frequent dilatations of the esophagus. The Category A and B survivors are all functionally well, while the 5 surviving Category C patients are all significantly impaired by associated anomalies.

A complication of continuous upper pouch suction in esophageal atresia

The use of a plastic sump catheter for continuous suction of the blind upper pouch in esophageal atresia has been widely accepted since the method was first described. The following case illustrates a complication which resulted from the use of such a catheter, namely, perforation of the upper pouch.

Preventable death in oesophageal atresia

We report on experience gained in the treatment of 158 cases of oesophageal atresia presenting during a period of 10 years. The factors influencing mortality were analysed. During the period studied there was a slight improvement in survival, and this was probably due mainly to improved preoperative preparation of those babies undergoing primary repair. At best, 'staging' was thought to have had little influence on the survival of poor risk cases. Midwives, obstetricians, paediatricians, surgeons, and general practitioners did not do all that they could have done to prevent morbidity and mortality in these babies. At least one-third of the 79 deaths could have been prevented, and several deaths were caused solely by lack of awareness of the possible complications and associated abnormalities.

Esophageal atresia and associated anomalies

One hundred and two patients with esophageal atresia possessed 237 additional anomalies. Risk grouping of these patients was useful and showed a direct relationship between the increased incidence of anomalies, low birth weight, and nonsurvival. Fifty-seven per cent of the patients with additional anomalies possessed multiple anomalies, most frequently occurring in the gastrointestinal, cardiovascular, and musculosketetal organ systems. Fifty-five per cent of the deaths appeared to result from the coexistent severe anomaly, while the remaining 45% of the deaths appeared to occur as a result of the presence of esophageal atresia. It is our suspicion that the insult producing esophageal atresia with a high incidence of associated anomalies occurs at a more critical time in organogenesis than that event that produces the esophageal atresis alone or with one moderate anomaly.

Primary repair of esophageal atresia without staging or preliminary gastrostomy

Twenty-two neonates with esophageal atresia and a distal tracheoesophageal fistula were treated by primary repair. Only if an anastomotic leak was demonstrated was a tube gastrostomy for decompression with trangastric placement of a duodenal tube for feeding performed. Twelve newborns were classified as high-risk by the presence of prematurity with low birth weight (less than 2,250 gm), significant pneumonia, or obvious significant associated anomalies. There was one operative death and 1 late death. Three babies required a tube gastrotomy and duodenal tube for anastomotic leaks. All 20 survivors are symptom free and thriving. Progress in perioperative management of neonates with esophageal atresia may obviate the need for routine gastrostomy and for staging of high-risk newborns.

Low birthweight babies with oesophageal atresia or tracheo-oesophageal fistula

Of 142 patients of known gestation with oesophageal atresia or tracheo-oesophageal fistula, 21% were preterm with a mean weight of 2 kg, 19% were small-for-dates with a mean weight of 2.23 kg, and the remaining 60% were born at term and weighed more than 2.5 kg. There were almost five times as many preterm and almost eight times as many small-for-date infants as in a normal population. Respiratory distress syndrome and additional severe congenital anomalies were commoner in babies of short gestational age, and pneumonia was more common in small-for-dates babies.

Esophageal atresia and tracheo-esophageal fistula. 25 years' experience and current management

A review of the experience with esophageal atresia and tracheoesophageal fistula over a 25-year period appears to lead to the advisability of the following procedures in surgical management:* Emergency gastrostomy under local anesthesia in all patients.* Extrapleural interruption of tracheo-esophageal fistula and end-to-end esophago-esophagostomy in patients who have the common type of upper esophageal atresia with distal tracheo-esophageal fistula.* Upper esophageal stretching and eventual esophago-esophagostomy in patients with proximal and distal esophageal atresia with or without proximal tracheo-esophageal fistula.