Fifty years' experience with esophageal atresia and tracheoesophageal fistula. Beginning with Cameron Haight's first operation in 1935

Management of long-gap esophageal atresia

A uniquely challenging subset of infants diagnosed with esophageal atresia (EA) are those born with long-gap EA (LGEA). The common unifying feature in infants with LGEA is that the proximal and distal segments of the esophagus are too far apart to enable primary anastomosis via a single operation in the newborn period. Although any type of EA can technically result in a long gap, the Gross type A variant occurs in 8% of all EA cases and is most commonly associated with LGEA. In this review, we provide an evidence-based approach to the current challenges and management strategies employed in LGEA. There are fortunately a range of available surgical techniques for LGEA repair, including delayed primary repair, staged repair based on longitudinal traction strategies to lengthen both ends (e.g., Foker procedure, internal traction), and esophageal replacement using other portions of the gastrointestinal tract. The literature on the management of LGEA has long been dominated by single-center retrospective reviews, but the field has recently witnessed increased multi-center collaboration that has helped to increase our understanding on how to best manage this challenging patient population. Delayed primary repair is strongly preferred as the initial approach in management of LGEA in the United States as well as several European countries and is supported by the American Pediatric Surgery Association recommendations. Should esophageal replacement be required in cases where salvaging the native thoracic esophagus is not possible, gastric conduits are the preferred approach, based on the relative simplicity of the operation, low postoperative morbidity, and long-term durability. Long-term followup for monitoring of swallowing function, nutritional status, aspiration/respiratory illnesses, gastroesophageal reflux, and associated comorbidities is essential in the comprehensive care of these complex patients.

Azygos vein preservation revisited: impact on early outcomes after repair of esophageal atresia/tracheoesophageal fistula in newborns

Since the first successful repair of esophageal atresia/tracheoesophageal fistula (EA-TEF) was performed approximately 8 decades ago, surgeons have made considerable technical advances in solving intraoperative surgical challenges and reducing postoperative complications. According to some surgeons, preserving the Azygos vein makes this modification attractive. This study aimed to evaluate the benefits of preserving the Azygos vein during surgery for esophageal atresia with tracheoesophageal fistula and to highlight its advantages in reducing anastomotic leak, stricture, and other postoperative outcomes. This prospective comparative series was conducted between April 2020 and April 2023. The study included all newborns with EA-TEF eligible for primary repair. Patients were randomized to either Group A or B. Group A underwent Azygos vein preservation, whereas the remaining patients (Group B) underwent Azygos vein disconnection. Sixty-four patients were included in this study. Thirty-two patients (Group A) underwent Azygos vein preservation during EA-TEF repair, and the remaining thirty-two patients (Group B) underwent Azygos vein ligation and disconnection. Both groups were comparable in terms of demographics, clinical data, and operative findings (P > 0.05). Pneumonitis occurred in 4 patients in Group A and 16 patients in Group B. Anastomotic leaks occurred in two (6.2%) patients in Group A and six (18.7%) patients in Group B. There were two deaths in Group A and six deaths in Group B, with a significant difference between the two groups (P = 0.0485). Preserving the Azygos vein during esophageal atresia repair reduces the occurrence of postoperative pneumonia, leakage, and stenosis, and decreases postoperative mortality. Therefore, we declare that this modification is a significant and valuable addition to the current surgical procedures.

Whether prophylactic intraoperative chest drain insertion in esophageal atresia-tracheoesophageal fistula is an evidence-based practice or just a prejudice: A systematic review and meta-analysis

BACKGROUND

Various controversial practices in the management of Esophageal atresia-tracheoesophageal fistula (EA-TEF) can be noticed among pediatric surgeons. Routine intraoperative chest drain (IOCD) insertion is often debated and lacks any concrete evidence. This meta-analysis aims to compare the postoperative outcomes among newborns with and without IOCD insertion.

METHODS

The authors searched EMBASE, PubMed, Scopus, and Web of Science on 30^th April 2021. The requirement for chest drain in the postoperative period (POCD), anastomotic leak (and/or pneumothorax), mortality rate, and revisit(s) to the operation room (RVOR) were compared among two groups of newborns, i.e. groups A and B with and without IOCD insertion respectively. The statistical analysis was performed using a fixed-effects model. The pooled risk ratio (RR) and heterogeneity (I²) were calculated. The methodological quality of the studies was assessed utilizing the Downs and Black scale.

RESULTS

A total of 498 newborns were included in the present analysis. As compared to group B, newborns within group A showed no significant difference in the requirement for POCD (RR 2.47; 95% CI 0.88-6.98, p = 0.09), the occurrence of anastomotic leak and/or pneumothorax (RR 1.35; 95% CI 0.89-2.06, p = 0.16), and mortality rate (RR 2.24; 95% CI 0.81-6.26, p = 0.12). However, RVOR was significantly higher in group A (RR 1.75; 95% CI 1.07-2.87, p = 0.03). All included studies had a moderate risk of bias.

CONCLUSIONS

The present meta-analysis revealed no additional benefit of prophylactic IOCD insertion. However, due to moderate risk of bias, further studies need to be conducted for an optimal comparison between the two groups.

Can 18-years of data from a tertiary referral center help to identify risk factors in esophageal atresia?

BACKGROUND

Esophageal atresia is a complex esophageal malformation with an incidence of 1 in 3,500-4,000 live births, and it usually occurs together with anomalies in other systems or chromosomes. This study aimed to investigate the short-term and long-term results of cases of esophageal atresia retrospectively in our institution and to analyze the factors affecting the outcome.

METHODS

Charts of the patients managed for esophageal atresia in our tertiary pediatric surgery department were investigated retrospectively. Statistical analysis was performed to determine the risk factors for morbidity and mortality.

RESULTS

One hundred and thirteen (95.8%) of 118 cases underwent a single-stage or staged esophagoesophagostomy procedure. In only five of the 40 patients with a long gap between the two atretic ends was an esophageal replacement procedure required. The most common early and late complications were anastomotic stenosis (41.6%) and gastroesophageal reflux (44.9%). In logistic regression analysis, the birthweight (OR [95% CI] = 0.998 [0.997, 0.999], P = 0.001) and preoperative inotrope requirement (OR [95% CI] = 13.8 [3.6-53.3], P < 0.001) were the two risk factors in the mortality prediction model obtained by multivariate analysis. The gap length between the two atretic ends (OR [95% CI] = 1.436 [1.010, 2.041], P = 0.044) and the number of sutures for anastomosis (OR [95% CI] = 1.313 [1.042, 1.656], P = 0.021) were the two risk factors in the gastroesophageal reflux prediction model obtained by multivariate analysis.

CONCLUSIONS

Our study's early and late complication rates were like those found in other studies. Identifying risk factors would be beneficial and might help reduce the severity of potential complications in esophageal atresia patients. Prospective studies on large patient series would help develop registry-based, standardized management protocols.

Clinical comparison between thoracoscopic and thoracotomy repair of Gross type C esophageal atresia

Background

To compare the clinical outcomes between thoracoscopic approach and thoracotomy surgery in patients with Gross type C Esophageal atresia (EA) and tracheoesophageal fistula (TEF).

Methods

Patients with Gross type C EA/TEF who underwent surgery from January 2007 to January 2020 at Beijing Children’s Hospital were retrospectively analyzed. The patients were divided into two groups according to surgical approaches. The perioperative factors and postoperative complications were compared among the two groups.

Results

One hundred and ninety patients (132 boys and 58 girls) with a median birth weight of 2975 (2600, 3200) g were included. The primary operations were performed via thoracoscopic (n = 62) and thoracotomy (n = 128) approach. After comparison of clinical characteristics between the two groups, we found that there were statistically significant differences in associated anomalies, method of fistula closure, duration of mechanical ventilation after surgery, feeding option before discharge, management of pneumothorax, and prognosis (all P < 0.05). To a certain extent, thoracoscopic surgery reduced the incidence of anastomotic leakage and increased the incidence of anastomotic stricture in this study. However, there were no statistically significant differences between the two groups in terms of operative time, postoperative pneumothorax, anastomotic leakage, anastomotic stricture, and recurrent tracheoesophageal fistula (all P > 0.05).

Conclusions

Thoracoscopy surgery for Gross type C EA/TEF is a safe and effective, minimally invasive technique with comparable operative time and incidence of postoperative complications.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12893-021-01360-7.

The history of surgery for esophageal atresia

Until the successful repair of esophageal atresia (EA) and distal tracheoesophageal fistula (TEF) in 1941 by Cameron Haight of Ann Arbor, MI, every infant operated upon for this anomaly died within days and often hours of surgery. A key step was the posterior extrapleural approach to the mediastinum pioneered by Charles Mixter of Boston in 1929 that gave direct exposure of the anomaly without entering the pleural cavity and collapsing the lung. From 1936 to 1939 Thomas Lanman, also of Boston, made five unsuccessful attempts at primary repair of EA. His experience established the basic principles of early radiological diagnosis and prompt surgical intervention to minimize the risks of aspiration pneumonia, dehydration, and inanition. In 1939 N. Logan Leven of Minneapolis and William Ladd of Boston independently had the first long-term survivors of EA with a series of operations to construct skin-lined tubes on the anterior chest wall that connected an esophagostomy to a gastrostomy. Haight first tried primary repair in 1939, finally succeeding in his fourth case in March 1941. In their publications Lanman (1940), Haight (1943 and 1944), and Ladd (1944 and 1947) presented case-by-case chronologies. The evolution of surgical management thus can be traced from a fatal condition to one where survival became the expected outcome. History recognizes Haight for his work with EA, not only for its first successful primary repair, but also his lifelong dedication to its surgical management.

Conservative Management of Major Anastomotic Leaks Occurring after Primary Repair in Esophageal Atresia with Fistula: Role of Extrapleural Approach

Aims:

We are reporting single-institution's experience regarding the role of conservative management in 38 cases of minor and major anastomotic leaks [AL] occurring after primary surgery of esophageal atresia [EA] with tracheo-esophageal fistula [TEF] during last 17 years between 2000 and 2017. In this retrospective review, we are sharing our experience and protocol of management of AL with more emphasis to evaluate: (a) role of conservative treatment in major AL (b) role of extra-pleural approach in enhancing the success rate in conservative treatment in major AL (c) to define the criteria for major & minor leaks and (d) to evaluate the role of ventilation in primary EA surgery to control AL.

Methods:

All these cases were operated through extra-pleural approach and out of total 203 cases, 38[18.7%] developed anastomotic leaks. In 29 of the 38 cases [14.3%], leak was minor and in 9 cases [4.4%] the leak was a major one. All these cases of leaks were managed conservatively.

Results:

All cases of major and minor leaks showed spontaneous healing except one case of minor leak that died before healing due to major cardiac anomaly. For minor leaks, average healing time was 9.5 days while for major leaks it was 17.4 days. Overall mortality was 14.8% and there was no mortality directly attributable to major or minor leak. During follow up, the incidence of stricture was 40% in cases having anastomotic leaks, while in cases without a leak, the incidence of stricture was 23.3%. These all cases of stricture responded to regular dilatations.

Conclusion:

We believe in cases of major AL, where primary repair is done by EP approach, a conservative treatment should be the treatment of choice. With this conservative approach of management of major AL, we not only save the native esophagus, the best conduit, but there is also less morbidity and mortality.

Thoracoscopic repair of esophageal atresia with distal tracheoesophageal fistula: is it a safe procedure in infants weighing less than 2000 g?

Background

Since Rothenberg first performed thoracoscopic repair for esophageal atresia with distal tracheoesophageal fistula (EA/TEF) successfully in 2000, thoracoscopic repair has achieved status as a routine procedure worldwide. Previously, an international multicenter study reported that this procedure was not inferior to conventional open surgery. However, thoracoscopic surgery is a highly difficult operation for surgeons and anesthesiologists; as a result, the safety and efficacy of the surgery is still under debate. Considering these circumstances, the purpose of this study was to analyze the results of single-center thoracoscopic surgery and to compare the outcomes relative to the patient’s weight at the time of surgery.

Methods

We retrospectively analyzed patients with EA/TEF who underwent thoracoscopic surgery in a single center between October 2008 and February 2017.

Results

In total, 41 cases of thoracoscopic repair of EA/TEF were performed. Upon subgrouping by over and under 2000 g of body weight at the time of operation, 34 were found to be over 2000 g and seven were under 2000 g. Intraoperative factors and events were not significantly different between the two groups. Additionally, most of the postoperative outcomes, including the rate of postoperative leakage and strictures, showed no difference. On the other hand, the under 2000 g group had more gastroesophageal reflux requiring fundoplication than did the heavier group (P = 0.04).

Conclusions

The results of this center’s thoracoscopic repair of EA/TEF were not inferior to other centers’ outcomes. Additionally, the intraoperative and postoperative outcomes were similar despite differences in weight at operation. Therefore, thoracoscopic repair might be a feasible surgical option for infants weighing less than 2000 g when performed by a surgeon and anesthesiologist team who are experienced in pediatric thoracoscopic surgery.

The Impact of Congenital Esophageal Atresia on the Family Functioning

PURPOSE

Most of the research in the field of esophageal atresia (EA) is focused on diagnostic problems and surgery. There is scarce literature addressing the impact of EA on the lives of families of patients. The aim of this paper is to investigate whether the presence of underlying associated malformations, disease-specific feeding problems and prematurity would have a significant influence on the family of a child after surgical repair of EA.

DESIGN AND METHODS

The study sample consisted of 73 participants who were parents of children after surgery of EA. The impact of EA on families was assessed using an Authors-Designed Questionnaire (ADQ) to collect medical and sociodemographic background data as well as standardized questionnaire: the PedsQL™ Family Impact Module (PedsQL-FIM).

RESULTS

The presence of cardiac impairment significantly (p = 0.037) affects the functioning of the family in the emotional domain. The coexistence of skeletal impairment seems to have the greatest impact on the functioning of the family, three statistically significant correlations have been demonstrated: (p = 0.021) - in the social domain, (p = 0.009) - in the cognitive domain and (p = 0.023) - in the domain of communication. The families of patients with tracheoesophageal fistula (TEF) had the statistically lower (p < 0.05) score of functioning in the emotional domain than those with children without TEF.

CONCLUSION

Feeding problems and the presence of associated anomalies significantly affect the functioning of the family of the child with EA.

Preoperative laryngotracheobronchoscopy in infants with esophageal atresia: why is it not routine?

The value of laryngotracheobronchoscopy (LTB) immediately prior to repair of esophageal atresia with or without tracheo-esophageal fistula is contentious. Currently, there is a wide range of opinion on the utility of this investigation which is reflected by huge variation in clinical practice. This review is a critical analysis of the arguments for and against performing routine LTB prior to esophageal atresia repair. Reserving LTB for selected cases only is potentially disadvantageous since it limits the surgeon's and anesthetist's familiarity with the procedure, equipment, and range of potential findings. There is sufficient evidence to suggest that routine preoperative LTB becomes the standard of care.

Musculoskeletal deformities following neonatal thoracotomy: long-term follow-up of an esophageal atresia cohort

BACKGROUND

Musculoskeletal deformities (MD), including scoliosis and chest wall anomalies, are potential long-term complications of neonatal thoracotomies.

METHODS

We studied the incidence of MD in patients who underwent open repair of esophageal atresia between 1997 and 2012, had no other predisposition to MD, and subsequently received longitudinal follow-up in a multidisciplinary esophageal atresia clinic. Detailed chest wall and musculoskeletal exams were performed at each visit. Incident rate and incident rate ratios were used to determine the incidence of deformities. Logistic regression methods were used to test the effect of independent variables including sex, gestational age, muscle division, number of thoracotomies, and operative complications on the occurrence of MD.

RESULTS

The study cohort consisted of 52 patients followed for a median of 8 (range 1-19) years. MD developed in 13 (25%), with an incident rate of 2.92 per 100 child-years. Division of the serratus anterior was associated with a significantly higher probability of developing MD (log-rank p=.0237) and was also a strong predictor of the same [OR 8.6 (95% CI 1.8-42.1)] after adjusting for possible confounders.

CONCLUSIONS

Musculoskeletal deformities develop in a significant proportion of neonates following thoracotomy. A muscle-sparing technique decreases the incidence of these deformities.

TYPE OF STUDY

Prospective Cohort Study.

LEVEL OF EVIDENCE

II.

Recurrent and acquired tracheoesophageal fistulae (TEF)-Minimally invasive management

OBJECTIVE

Recurrent and acquired fistulae are a serious complication of congenital esophageal atresia and tracheoesophageal fistula (TEF) repair and foreign body ingestion (FBI) (e.g., button battery). We report our experience with a minimally invasive approach to recurrent and acquired TEF.

METHODS

Medical records of patients referred for management of recurrent and acquired TEF between 2003 and 2015 were reviewed retrospectively. Patients underwent endoscopic procedures (de-epithelization of fistulous tract and fibrin tissue adhesive-Tisseel^R) under general anesthesia.

RESULTS

Nine children (7 male, 2 female) with age range 3months to 3years (mean 1.5year) were managed. TEF closed spontaneously in four patients, whereas in 5 patients the TEF closed after combined endoscopic procedure. Three patients required repeat endoscopic procedures. Follow-up ranged between 7months to 10years (mean 4.2years).

CONCLUSIONS

Active observation and repeat combined endoscopic procedures are safe alternatives to open surgical repair of acquired and recurrent TEF.

LEVEL OF EVIDENCE

Level IV study.

Thoracoscopic surgery for esophageal atresia

This review centers on the thoracoscopic management of esophageal atresia (EA) and distal tracheoesophageal fistula (TEF). The first thoracoscopic repair of EA was performed by Rothenberg and Lobe in Berlin in 1999 just prior to an IPEG meeting. Since that time, the largest report describing the use of thoracoscopy for EA/TEF repair came in 2005 with a multi-national, multi-institutional retrospective review from six institutions around the world. The outcomes reported were quite good and very comparable to large series of open operations that had been previously reported. This review will describe a single surgeon's technique for thoracoscopic repair of EA/TEF. In addition, further controversies regarding the usefulness of preoperative bronchoscopy, ligation of the distal TEF, and type of suture used for the esophageal anastomosis will also be discussed. Finally, there is a discussion on the advantages and disadvantages of the thoracoscopic approach.

Neonatal and pediatric esophageal perforation

Esophageal perforation (EP) is a rare complication that is often iatrogenic in origin. In contrast with adult patients in whom surgical closure of the defect is preferred, nonoperative treatment has become a common therapeutic approach for EP in neonates and children. Principles of management pediatric EP includes rapid diagnosis, appropriate hemodynamic monitoring and support, antibiotic therapy, total parenteral nutrition, control of extraluminal contamination, and restoration of luminal integrity either through time or operative approaches.

Thoracoscopic versus open repair of tracheoesophageal fistulas and rates of vocal cord paresis

BACKGROUND/PURPOSE

The purpose of this study was to investigate the rates of vocal cord paresis/paralysis (VCP) in patients treated for esophageal atresia (EA) with and without fistula performed thoracoscopically versus open.

METHODS

A retrospective review of EA cases performed from 2008 to 2014 in an integrated health care system was performed.

RESULTS

A total of 31 cases of EA were performed by 6 surgeons at 4 different institutions. Seventeen cases were performed thoracoscopically, whereas 14 cases were performed open. In the thoracoscopic group, the average gestational age (weeks) of the patient was significantly higher 38.3 vs. 35.2 (p=0.016) as well as the average birth weight (grams) 2843 vs. 2079 (p=0.005). There was no difference in the postoperative length of stay, rates of anastomotic stricture, leak, or tracheomalacia. There were 10 cases of vocal cord paresis, 9 from the thoracoscopic group and one from the open group (p=0.007). Of the 10 cases of VCP, 6 were unilateral (left sided) and 4 were bilateral. Of the 10 cases, 6 resolved, 2 resulted in permanent paralysis, and 2 are currently still being evaluated.

CONCLUSIONS

Thoracoscopic repair of EA appears to have higher rates of VCP. The results are thought to be from thoracoscopic dissection of the esophagus high into the thoracic inlet.

Slide tracheoplasty for the treatment of tracheoesophogeal fistulas

PURPOSE

The purpose of this study is to determine the surgical outcome of slide tracheoplasty for the treatment of tracheoesophageal (TE) fistula in pediatric patients.

METHODS

After internal review board approval, the charts of pediatric patients (0-18years old) who had undergone slide tracheoplasty for tracheoesophageal fistula were retrospectively reviewed. Patient information and surgical outcomes were reviewed.

RESULTS

Nine patients underwent slide tracheoplasty for correction of TE fistula. In five patients the original TE fistula was congenital. Other causes included battery ingestion, tracheostomy tube complications, foreign body erosion, and an iatrogenic injury. The average age at repair was 48±64 months (range: 1-190). Seven patients had undergone previous TEF repair either open or endoscopically. There were no recurrences after repair. Two patients had sternal periosteum interposed between the esophagus and trachea. There were no TEF recurrences. A single patient had dehiscence of the tracheal anastomosis and underwent a second procedure.

CONCLUSION

Slide tracheoplasty is an effective method to treat complex TE fistulas. The procedure was not associated with any recurrences. This is the first description of a novel, effective, and safe method to treat TE fistulas.

Post-operative management of esophageal atresia-tracheoesophageal fistula and gastroesophageal reflux: a Canadian Association of Pediatric Surgeons annual meeting survey

BACKGROUND

Esophageal atresia (EA), with or without tracheoesophageal fistula (TEF), is commonly associated with gastroesophageal reflux (GER) after surgical repair. One risk factor for anastomotic stricture is post-operative GER. This survey assessed practice patterns among attendees at the Canadian Association of Pediatric Surgeons (CAPS) annual meeting with respect to management of GER post EA-TEF repair.

METHODS

A pre-piloted survey was handed out and collected at the 2012 CAPS annual meeting. Data were entered and coded, and descriptive statistics were calculated.

RESULTS

We distributed 70 surveys, and 57 (81.4%) surveys were returned. On average, the incidence of EA-TEF is 8-10 cases per institution, per year. Anti-reflux medication is started immediately post-operatively in 74% of patients at institution of feeds (11%), or if symptoms of reflux develop (14%). Proton pump inhibitors and H2-receptor antagonists are used in approximately equal proportion. Patients are typically kept on anti-reflux medication for 3-6 months (37%) or 6-12 months (35%).

CONCLUSIONS

Most CAPS attendees treat postoperative GER prophylactically. However, there is no consistency in management strategy regarding which anti-reflux agent to use or for how long. A multi-centered study is required to establish a standardized protocol for the post-operative management of EA-TEF to prevent reflux and its effect on anastomotic strictures.

Treatment of persistent esophageal leaks in children with removable, covered stents

Removable, fully covered, expandable metal esophageal stents are routinely used in adults for both malignant and benign esophageal disease. Several case reports have demonstrated the use of these stents in the management of caustic esophageal strictures in children. Most iatrogenic esophageal perforations and esophageal anastomotic leaks in children may be expected to heal with nonoperative treatment, although, in a small percentage, the leak may persist. We report 3 patients with complicated esophageal perforations refractory to nonoperative therapy who were successfully managed using covered esophageal stents.

Surgical advances in the fetus and neonate: esophageal atresia

This article focuses on selected topics in the diagnosis and management of patients with esophageal atresia (EA) with or without tracheoesophageal fistula. The current status of prenatal diagnosis and recent advances in surgical techniques, including thoracoscopic repair for short-gap EA and tension-induced esophageal growth for long-gap EA, are reviewed. Although no consensus exists among pediatric surgeons regarding the role of these procedures in the treatment of EA, one can reasonably expect that, as they evolve, their application will become more widespread in this challenging patient population.

Recurrent tracheoesophageal fistula after thoracoscopic repair: vanishing clips as a potential sign

We present a case of a neonate who underwent surgery for esophageal atresia (EA) with tracheoesophageal fistula (TEF) with an unusual finding on postoperative chest radiographs. In retrospect, this was a clue to a recurrent TEF: disappearance of the surgical clips from the site of surgical repair. Knowledge of this radiographic finding could aid in the diagnosis of a recurrent fistula in patients with previous repair of EA.

Esophageal atresia/tracheoesophageal fistula in very low-birth-weight neonates: improved outcomes with staged repair

INTRODUCTION

The surgical management of esophageal atresia with distal tracheoesophageal fistula (EA/TEF) involves early division of the TEF and primary esophageal anastomosis. However, in premature infants, the morbidity associated with primary repair remains high, and the optimal surgical approach has not been well defined.

METHODS

Medical records of very low-birth-weight infants (<1500 g) with EA/TEF from June 1987 to 2008 were retrospectively reviewed. Patients were separated into 2 groups: (1) primary repair and (2) ligation and division of TEF followed by delayed repair of EA. Demographics, anastomotic, and postoperative complications were compared.

RESULTS

Twenty-five premature infants with EA/TEF were identified. Sixteen patients (64%) underwent primary repair, and 9 (36%) were repaired in a staged manner. The leak rate confirmed by esophagram was significantly higher after primary repair (50%) compared to staged repair (0%) (P = .034). Strictures occurred significantly more often in the primary repair (81%) vs the staged repair (33%) group (P = .036). Postoperative pneumonia and sepsis were significantly higher in patients treated with primary repair (P = .028).

CONCLUSION

Staged repair of EA/TEF in very low-birth-weight premature infants results in a significantly lower rate of anastomotic complications and overall morbidity and should be considered the preferred surgical approach in this group of patients.

Usefulness of large pleural flap for the treatment of children with recurrent tracheoesophageal fistula

PURPOSE

Recurrent tracheoesophageal fistula (RTF) complicates 5-11% of cases of children treated at birth for esophageal atresia with inferior tracheoesophageal fistula (ITF), and it represents an important problem of respiratory morbility and mortality. Surgical correction of RTF is complex with high incidence of recurrence. The aim of this work is to demonstrate the usefulness of large vascularized pleural flap in the treatment of RTF and the prevention of recurrences.

METHODS

From 2000 to 2007, four children (3 males and 1 female) referred to our hospital for respiratory symptoms secondary to RTF. Diagnosis of RTF was made by bronchoscopy and esophagogram with contrast medium. Operative repair involved resection of the fistula, suture of trachea and esophagus followed by interposition of large vascularized pleural flap (PF).

RESULTS

There were no complications during surgical procedure and after 48 h, with easy respiratory weaning after 24 h. Hospital discharge ranged from 5 to 10 days. Long-term follow-up (range 18 months-5 years) demonstrated no evidence of recurrences.

CONCLUSION

Large vascularized PF to closure RTF is a highly effective and physiologic method for preventing second recurrences.

The best 10 clinical articles for the last 50 years from the Division of General Surgery, Hospital for Sick Children, Toronto, Ontario, Canada

PURPOSE

The aim of the review was to present the best 10 clinical articles for the last 50 years (1956-2006) from the Division of General Surgery, Hospital for Sick Children (HSC), Toronto, Canada. These articles were judged by the major change (impact) in clinical practice of pediatric general surgery after their publication.

METHODS

All clinical articles from 1956 to 2006 inclusively written by members of the division (while working at HSC) were evaluated. The 2 authors of this article (retired honorary staff surgeon and recently trained chief surgical resident/fellow) separately rated the articles. Each lead author (if possible) was asked to comment on "the significance of their paper, then and now." If the lead author was unavailable, 1 of the 2 authors of this article commented on the articles.

RESULTS

The best 10 clinical articles selected involved spleen trauma, necrotizing enterocolitis, esophageal replacement, Hirschsprung's disease, tracheal compression, fecal incontinence, gastroesophageal reflux, diaphragmatic hernia, and ruptured appendix. There were 8 staff members and 5 surgical residents/fellows who were lead authors, along with 10 staff from other divisions, departments, and/or hospitals.

CONCLUSION

The conservative management of splenic trauma was judged the best article from this Division that made the largest clinical impact for the last 50 years.

The use of biosynthetic mesh to separate the anastomoses during the thoracoscopic repair of esophageal atresia and tracheoesophageal fistula

Recurrent tracheoesophageal fistula following the repair of esophageal atresia and tracheoesophageal fistula (EA/TEF) is a difficult complication to manage, which makes prevention the dominant concern of surgeons performing the primary repair. To this end, the surrounding pleural tissues are usually brought over the tracheal closure to prevent the development of a recurrence during the open repair. This maneuver is not usually feasible when using the thoracoscopic approach. Therefore, in this paper, we describe a case in which we interposed a biosynthetic mesh between the esophageal and tracheal suture lines during the thoracoscopic repair of EA/TEF on a 2.9-kg newborn girl.

Prognosis of congenital tracheoesophageal fistula with esophageal atresia on the basis of gap length

Congenital tracheoesophageal fistula (TEF) with esophageal atresia (EA) is not an uncommon disease of newborns. Several classifications have been advocated for predicting the outcomes of these patients but all are physiological and concentrated on associated medical condition that influences survival. We emphasize a new classification on the basis of gap between two esophageal pouches to define the magnitude of surgical problems in the primary repair and correlate them with the outcomes in terms of anastomotic leak, esophageal stricture and mortality, keeping other prognostic factors constant. A total of 50 cases of congenital TEF with EA were included and all underwent primary esophageal anastomosis after the ligation of TEF. The gap between the two pouches was meticulously measured intraoperatively using a vernier caliper before the ligation of TEF, and patients were divided into four groups on the basis of gap length. Group A, where gap length was >3.5 cm (ultralong), group B where gap length was 2.1-3.5 cm (long gap), group C where gap length was >1 cm but not more than 2 cm (intermediate group) and group D, where the gap between two esophageal pouches was 1 cm or less (short gap). The incidence of anastomotic leak was 80, 50, 28, 10.5% and the incidence of esophageal stricture was 100, 75, 22.5, 19% after successful primary repair, respectively, in groups A, B, C and D. The mortality was highest in group A (80%) followed by group B (50%) and 22% in group C and least 15.6% in group D. The incidences of esophageal leak and mortality were found to be statistically significant. This classification which is based on easily measurable criteria provides a useful method to predict morbidity, long-term outcome and mortality of EA with TEF surgery.

Congenital anomalies of the esophagus

Normal anatomy, embryology, and congenital anomalies of the esophagus are discussed in this article. The classification, epidemiology, embryology, diagnosis, and management, including outcome following repair of esophageal atresia with or without an associated tracheoesophageal fistula, are described. The diagnosis and management of less common anomalies, such as congenital esophageal stenosis and congenital esophageal duplication, are outlined.

Efficacy of postoperative elective ventilatory support for leakage protection in primary anastomosis of congenital esophageal atresia

Anastomotic complications after primary repair of congenital esophageal atresia (EA) are recognized and feared complications. A close association exists between anastomotic leakage and the tension of the anastomosis on the suture line. This study aimed to evaluate the efficacy of postoperative elective ventilation support (PEVS) under paralysis with neck flexion after primary repair of EA. Forty-two EA patients; 4 cases with type A and 38 with type C by Gross classification received primary or delayed primary anastomosis between 1979 and 2003. PEVS has been introduced in the postoperative management of all EA cases since 1998. Vecuronium bromide was administered together with fentanyl citrate for five postoperative days. Patients were retrospectively divided into two groups: with or without PEVS management. There was no difference in operation data such as gastrostomy construction, gap between esophageal upper and lower pouch, primary or delayed primary anastomosis. PEVS under paralysis with neck flexion reduced postoperative anastomotic leakages in primary anastomosis with or without a Livaditis procedure. PEVS did not adversely increase anastomotic stricture, atelectasis, severe gastro-esophageal reflux, prolong days on ventilatory support or decrease survival rate. PEVS is an effective management method to decrease anastomotic complications for EA neonates.

Development of an adenocarcinoma of the esophagus 22 years after primary repair of a congenital atresia

Esophageal cancer development after previous atresia repair is extremely rare in young patients. We present the clinical course of a patient who developed an adenocarcinoma of the esophagus at the age of 22 years, after repair of a tracheoesophageal fistula with esophageal atresia in the neonatal period. She developed a stricture of the esophageal anastomosis requiring frequent dilatations. Six years after an antireflux procedure because of a difficult treatable severe gastroesophageal reflux, an advanced adenocarcinoma was detected at the site of the end-to-end anastomosis of the previous atresia.

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.

Gastroesophageal reflux: prevalence in adults older than 28 years after correction of esophageal atresia

OBJECTIVE

To study the incidence of gastroesophageal reflux (GER)related complications after correction of esophageal atresia (EA).

SUMMARY BACKGROUND DATA

The association of EA and GER in children is well known. However, little is known about the prevalence of GER and its potential complications in adults who have undergone correction of EA as a child.

METHODS

Prospective analysis of the prevalence of GER and its complications over 28 years after correction of EA by means of a questionnaire, esophagogastroscopy, and histologic evaluation of esophageal biopsies.

RESULTS

The questionnaire was returned by 38 (95%) of 40 patients. A quarter of the patients had no complaints. Swallowing solid food was a problem for 13 patients (34%), and mashed foods for 2 (5%). Heartburn was experienced by 7 patients (18%), retrosternal pain by 8 (21%). However, none of the patients were using antireflux medication. Twenty-three patients (61%) agreed to undergo esophagogastroscopy, which showed macroscopic Barrett esophagus in 1 patient, which was confirmed by histology. One patient developed complaints of dysphagia at the end of the study. A squamous cell esophageal carcinoma was diagnosed and treated by transthoracic subtotal esophagectomy.

CONCLUSIONS

This study shows a high incidence of GER-related complications after correction of EA, but it is still very disputable if all EA patients should be screened at an adult age.

Outcomes in esophageal atresia and tracheoesophageal fistula

BACKGROUND/PURPOSE

The purpose of this analysis was to investigate outcomes in newborns with esophageal atresia (EA) or tracheoesophageal fistula (TEF) with respect to prognostic classifications and complications.

METHODS

Charts of all 144 infants with EA/TEF treated at British Columbia Children's Hospital (BCCH) from 1984 to 2000 were reviewed. Patient demographics, frequency of associated anomalies, and details of management and outcomes were examined.

RESULTS

Applying the Waterston prognostic classification to our patient population, survival rate was 100% for class A, 100% for class B, and 80% for class C. The Montreal classification survival rate was 92% for class I and 71% for class II (P =.08). Using the Spitz classification, survival rate was 99% for type I, 84% for type II, and 43% for type III (P <.05). The Bremen classification survival rate was 95% "without complications" and 71% "with complications." Complications included stricture (52%), gastroesophageal reflux (31%), anastomotic leakage (8%), recurrent fistula (8%), and pneumonia (6%). Seventeen patients underwent fundoplication for gastroesophageal reflux, 16 pre-1992 and one post-1992.

CONCLUSIONS

Comparing the major prognostic classifications, the Spitz classification scheme was found to be most applicable. In our institution, the trend in management of gastroesophageal reflux after repair of EA/TEF has moved away from fundoplication toward medical management.

Tracheoesophageal fistula

Acquired TEF is a rare complication that can occur from a variety of causes. The most common etiology of nonmalignant TEF is as a complication of intubation with cuff-related tracheal injury. Most patients present with increased secretions, pneumonia, and evidence of aspiration of gastric contents while the patient is on mechanical ventilation. When diagnosed after extubation, the most frequent sign of TEF is coughing after swallowing. A high index of suspicion is required in patients at risk for developing a TEF. The diagnostic evaluation is by bronchoscopy and esophagoscopy. When the diagnosis has been made, the immediate goal should be to minimize tracheobronchial soilage by placing the cuff of a tracheostomy tube distal to the fistula. Reflux of gastric contents is diminished by placement of a gastrostomy tube, and adequate nutrition is facilitated by inserting a jejunostomy tube. Surgical correction is required because spontaneous closure is rare, but surgery should be postponed until the patient is weaned from mechanical ventilation because positive pressure ventilation after tracheal repair carries an increased risk of anastomotic dehiscence and restenosis. An anterior cervical collar incision can be used for most cases of post-intubation TEFs. The esophagus should be closed in two layers over a nasogastric tube and buttressed with a pedicled strap muscle flap. If the tracheal defect is small, primary repair can be employed. In most cases, however, the best results can be achieved with tracheal resection and reconstruction. The patient should be extubated at the completion of the case, if possible. With this strategy, as first described by Grillo and colleagues [27], single-stage repair can be performed safely and with a high success rate. Malignant TEFs cannot be cured because of the underlying incurable disease process. As with nonmalignant TEFs, the principal complications are tracheo-bronchial contamination and poor nutrition. Without prompt palliation, death occurs rapidly, with a mean survival time of between 1 and 6 weeks in patients who are treated with supportive care alone. The most common primary tumor causing malignant TEF is esophageal carcinoma. The other frequent cause is lung cancer. Patients present with signs and symptoms typical of TEF, including coughing after swallowing. Diagnosis is made by barium esophagography, and the location and size of the fistula is determined by bronchoscopy and esophagoscopy. Treatment must correct the two problems of airway contamination and poor nutrition. The most effective treatments are esophageal bypass and esophageal stenting. Bypass is demonstrated to resolve respiratory soilage and allow fairly normal swallowing, but it should be reserved for patients who can tolerate a major operation. Stenting can be offered to nearly all patients regardless of their physiologic condition. Stenting also limits aspiration and allows swallowing. Esophageal exclusion is rarely indicated in the current era of familiarity with stenting techniques. Direct fistula closure and fistula resection do not yield satisfactory results. Radiation therapy and chemotherapy combined might offer a survival benefit compared with supportive care alone. The complication of TEF secondary to malignancy is a devastating problem that carries a bleak prognosis, but when it is performed promptly after the diagnosis of a malignant TEF, esophageal bypass or stenting improves survival and quality of life for these unfortunate patients.

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.

Gastric transposition for esophageal replacement in children: experience with 41 consecutive cases with special emphasis on esophageal atresia

OBJECTIVE

To evaluate the authors' experience with gastric transposition as a method of esophageal replacement in children with congenital or acquired abnormalities of the esophagus.

SUMMARY BACKGROUND DATA

Esophageal replacement in children is almost always done for benign disease and thus requires a conduit that will last more than 70 years. The organ most commonly used in the past has been colon; however, most series have been fraught with major complications and conduit loss. For these reasons, in 1985 the authors switched from using colon interpositions to gastric transpositions for esophageal replacement in infants and children.

METHODS

The authors retrospectively reviewed the records of 41 patients with the diagnoses of esophageal atresia (n = 26), corrosive injury (n = 8), leiomyomatosis (n = 5), and refractory gastroesophageal reflux (n = 2) who underwent gastric transposition for esophageal replacement.

RESULTS

Mean +/- SE age at the time of gastric transposition was 3.3 +/- 0.6 years. All but two transpositions were performed through the posterior mediastinum without mortality or loss of the gastric conduit despite previous surgery on the gastric fundus in 8 (20%), previous esophageal operations in 15 (37%), and previous esophageal perforations in 6 (15%) patients. Complications included esophagogastric anastomotic leak (n = 15, 36%), which uniformly resolved without intervention; stricture formation (n = 20, 49%), all of which no longer require dilation; and feeding intolerance necessitating jejunal feeding (n = 8, 20%) due to delayed gastric emptying (n = 3), feeding aversion related to the underlying anomaly (n = 1), or severe neurological impairment (n = 4). No redo anastomoses were required.

CONCLUSIONS

Gastric transposition reestablishes effective gastrointestinal continuity with few complications. Oral feeding and appropriate weight gain are achieved in most children. Therefore, gastric transposition is an appropriate alternative for esophageal replacement in infants and children.

Gastric transposition for esophageal replacement in children: experience with 41 consecutive cases with special emphasis on esophageal atresia

OBJECTIVE

To evaluate the authors' experience with gastric transposition as a method of esophageal replacement in children with congenital or acquired abnormalities of the esophagus.

SUMMARY BACKGROUND DATA

Esophageal replacement in children is almost always done for benign disease and thus requires a conduit that will last more than 70 years. The organ most commonly used in the past has been colon; however, most series have been fraught with major complications and conduit loss. For these reasons, in 1985 the authors switched from using colon interpositions to gastric transpositions for esophageal replacement in infants and children.

METHODS

The authors retrospectively reviewed the records of 41 patients with the diagnoses of esophageal atresia (n = 26), corrosive injury (n = 8), leiomyomatosis (n = 5), and refractory gastroesophageal reflux (n = 2) who underwent gastric transposition for esophageal replacement.

RESULTS

Mean +/- SE age at the time of gastric transposition was 3.3 +/- 0.6 years. All but two transpositions were performed through the posterior mediastinum without mortality or loss of the gastric conduit despite previous surgery on the gastric fundus in 8 (20%), previous esophageal operations in 15 (37%), and previous esophageal perforations in 6 (15%) patients. Complications included esophagogastric anastomotic leak (n = 15, 36%), which uniformly resolved without intervention; stricture formation (n = 20, 49%), all of which no longer require dilation; and feeding intolerance necessitating jejunal feeding (n = 8, 20%) due to delayed gastric emptying (n = 3), feeding aversion related to the underlying anomaly (n = 1), or severe neurological impairment (n = 4). No redo anastomoses were required.

CONCLUSIONS

Gastric transposition reestablishes effective gastrointestinal continuity with few complications. Oral feeding and appropriate weight gain are achieved in most children. Therefore, gastric transposition is an appropriate alternative for esophageal replacement in infants and children.

Lateral esophagostomy: an alternative in the initial management of long gap esophageal atresia without fistula

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.

The last fifty years of neonatal surgical management

Neonatal surgical mortality has steadily fallen over the last five decades. Improved survival does not appear to be related to the introduction of new operative procedures. Most of the basic procedures were developed by 1960. Eight developments appear to be responsible: (1) The growth of pediatric surgery resulted in widespread availability of neonatal surgeons and dissemination of knowledge about newborn surgical emergencies. (2) The parallel growth of pediatric anesthesia, beginning in 1946, provided specialized intraoperative management of the neonate. (3) Understanding neonatal physiology is the key to successful management; major advances occurred between 1950 and 1970. (4) New inventions revolutionized patient care; the transistor (1947) made it possible for medical devices to sense, amplify and control physiologic responses and opened the communication and computer age. (5) Neonatal mechanical ventilation had a prohibitive mortality and was seldom utilized; the development of CPAP and a continuous flow ventilator in the 1970s allowed safe ventilatory support. (6) Total parenteral nutrition (1968) prevented starvation that frequently affected infants with major anomalies. (7) The effective treatment of infection began with the clinical use of penicillin (1941); antibiotics have reduced mortality but infants suffering from the septic syndrome have a prohibitive mortality; cytokine, proinflammatory agent research, and the development of anti-inflammatory and blocking agents in the 1980s have not affected mortality. (8) The establishment of newborn intensive care units (1960) provided an environment, equipment, and staff for effective physiologic management.

Nissen fundoplication in the management of gastroesophageal reflux occurring after repair of esophageal atresia

BACKGROUND/PURPOSE

Gastroesophageal reflux is a major cause of complications after esophageal atresia repair. The suitability of the Nissen fundoplication in these patients is still disputed. Therefore, the authors evaluated the results of their prospective treatment protocol in those patients who underwent a Nissen fundoplication.

METHODS

From 1984 to 1996, 125 patients underwent anastomosis for esophageal atresia. A Nissen fundoplication was later performed in 29 patients. The prospective protocol included x-ray after 10 days, 6 weeks, 12 weeks, 6 months, and 12 months. Forty-eight-hour pH measurements were performed between 6 and 12 weeks. Mean postfundoplication follow-up was at least 5 years (range, 2 to 13 years).

RESULTS

Two of the 29 patients died after the Nissen fundoplication from unrelated causes. A third patient was excluded from the study group. Nineteen of the remaining 26 patients showed severe stricture. pH-metry succeeded in 18 patients, showing pathological reflux in 17. In 24 patients the fundoplication was performed between 1 and 24 months (median, 4 months), in the other 2 patients much later. In 4 of the 26 patients(15%) the Nissen proved to be insufficient and had to be redone. The remaining 22 patients had no short-term or long-term complications.

CONCLUSION

The authors' findings in this group of patients, comparing them with the results reported in the literature, indicate that there is no reason to change their prospective treatment protocol nor their policy to perform Nissen fundoplications at an early stage.

TWENTY FIVE YEARS OF INTERACTION WITH ESOPHAGEAL ATRESIA AND TRACHEO-ESOPHAGEAL FISTULA

Clinical presentation and management modalities for 585 patients of esophageal atresia and/or tracheo-esophageal fistula reporting to Department of Paediatric Surgery, SMS Medical College, Jaipur over twenty five years (1972-1996) were analyzed in five phases of five years each retrospectively. Over the period of observation, the incidence of new cases as well the number of associated anomalies have shown a steady increase due to availability of modern diagnostic facilities. The operative mortality has shown a progressive decline from 95% early in the series to 40% in last few years. Post-operative anastomotic leaks occurred in 21% of cases, strictures in 8% and recurrent fistula in 1% of cases. The presence of severe associated anomalies, prematurity, pulmonary complications and sepsis still remain the major killers in our setup. Early detection and referral has lead to more infants reaching the specialized centres with less pulmonary complications. In the last decade, the survival rate for infants in Waterston's risk group A has improved to 86% but there is still a substantial difference in the survival rate reported from developed countries. The various factors resulting in poorer results in our set up have been highlighted.

Development of a true primary repair for the full spectrum of esophageal atresia

OBJECTIVE

To determine whether or not a true primary repair, without myotomies and with the gastroesophageal junction below the diaphragm, can be accomplished across the esophageal atresia (EA) spectrum. Our hypothesis is that the esophageal anastomosis can withstand significant tension. The consequences, particularly for those patients with a very long gap atresia, were assessed.

SUMMARY OF BACKGROUND DATA

Difficulties arise roughly in proportion to the size of the gap between esophageal segments. Reported surgical complications remain frequent, and particularly at the far end of the EA spectrum, not all children are left with a satisfactorily functioning esophagus or esophageal substitute.

METHODS

The outcomes of all infants who had a true primary repair of EA from 1976-1997 were determined. Surgically, the methods used to achieve a reliable true primary repair were expanded to accomplish this, even for a very long gap EA.

RESULTS

From 1976-97, 70 infants with or without associated tracheoesophageal fistula (TEF) had primary repairs performed with no surgery-related deaths and 11% later deaths. No interpositions were performed since 1983. There were no discernible anastomotic leaks and one late recurrent TEF related to the early use of balloon dilation. Ten infants had gaps of 5.0-6.8 cm and, among these, four had gaps of 5.5-6.8 cm that could not be pulled together initially. Traction sutures in the esophageal ends, however, produced sufficient lengthening within 6-10 days for a true primary repair. Very long gap repairs produced more reflux (10 of 10 required a fundoplication versus 24 of 70 overall) and more dilations to relieve strictures. Two infants underwent stricture resection with no recurrence. On follow-up, all patients over 2 years of age were eating well or satisfactorily, and none had a gastrostomy tube.

CONCLUSIONS

(1) The esophageal anastomosis can withstand considerable tension and allows a reliable true primary repair for the full EA spectrum. (2) Growth is rapid and traction sutures will produce significant esophageal lengthening within days. (3) With increasing tension, gastroesophageal reflux (GER) and strictures are more common; however, both are treatable. Follow-up reveals the benefits of true primary repair over other solutions.

Esophageal atresia and tracheoesophageal fistula: surgical experience over two decades

BACKGROUND

Despite improvements in survival, for infants born with esophageal atresia tracheoesophageal fistula, or both, the morbidity associated with repair of these anomalies remains high.

METHODS

This report retrospectively analyzes 81 patients with esophageal atresia, tracheoesophageal fistula, or both presenting to our institution between 1975 and 1995, with a focus on anastomotic complications.

RESULTS

There were 46 male and 35 female patients with a mean gestational age of 37 weeks and mean birth weight of 2443 g. Forty-four patients underwent primary esophageal anastomoses, 7 underwent delayed primary anastomoses, 12 patients underwent staged repairs, and 5 underwent repair of H-type fistulas. Among 62 patients with anastomoses, complications included stricture in 25/62 patients (40%), leakage in 12/62 patients (19%), and recurrent tracheoesophageal fistulas in 6/62 patients (10%). Stricture rates for esophagoclonic anastomoses versus esophagoesophageal anastomoses were 4/8 cases (50%) versus 21/54 cases (39%). This difference was not statistically significant. All esophagoesophageal strictures were managed successfully with dilations; three of four esophagocolonic strictures required anastomotic revision. The leakage rate for esophagocolonic anastomoses versus esophagoesophageal anastomoses was 6/8 cases (75%) versus 6/54 cases (11%). This difference was statistically significant (p = 0.0003). Two patients required revision of their colon grafts secondary to necrosis. Eighteen of 81 patients (22%) died. Operative mortality was 9/74 (12%). Causes of death included associated anomalies (n = 15), recurrent aspiration and sepsis secondary to missed fistula (n = 1), and unknown (n = 2).

CONCLUSIONS

Although the morbidity associated with surgical repair of these anomalies is high, this does not affect the overall survival. The high complication rate associated with colonic interposition suggests that one should preserve the native esophagus as a primary conduit whenever feasible.

Efficacy of partial wrap fundoplication for gastroesophageal reflux after repair of esophageal atresia

Gastroesophageal reflux (GER) often develops in children who have undergone prior repair of esophageal atresia/tracheoesophageal fistula (EA/TEF). Fundoplication is necessary in many of these children. The complete wrap (Nissen) fundoplication is often used in this setting. However, poor results have been noted, with a mean failure rate of 30% reported in four recent studies. A partial wrap fundoplication for GER associated with EA/TEF is theoretically attractive, because the poor esophageal motility and diminished acid clearance (already physiologically present) is exacerbated by a complete wrap fundoplication. The authors reviewed their extensive experience with partial wrap (Thal) fundoplication in EA/TEF to determine if the failure rate was better than that reported for the Nissen fundoplication. In the past 18 years, the authors performed 1,467 fundoplication procedures. During the same period, 143 children underwent repair of EA/TEF. Fifty-nine children underwent fundoplication after a previous EA/TEF repair. Most of the fundoplications (58 of 59, 98%) were Thal procedures. Defining failure strictly as a need for reoperation, the failure rate in our series was 15% (9 of 59 children). Compared with the failure rate in the 1,408 non-EA/TEF patients (61 of 1408, 4.3%), results were significantly worse for the EA/TEF group (P > .001). The failure rate of Thal fundoplication performed for GER in the EA/TEF population is substantially higher than the non-EA/TEF patients. The same factors responsible for the development of reflux in these children (poor acid clearance, altered motility, esophageal shortening) may contribute to the higher failure rate. Although partial wrap fundoplication frequently failed (15%), the results were still substantially better than those reported for Nissen fundoplication in these children (30% failure rate).

Elective, postoperative ventilation in the management of esophageal atresia and tracheoesophageal fistula

The management of esophageal atresia (EA) with or without tracheoesophageal fistula (TEF) has undergone many changes. As a result of recent advances in neonatal intensive care and pediatric anesthesia, the survival of infants with EA and TEF has improved markedly, but the occurrence of anastomotic complications has remained constant. To overcome this problem, various techniques and suture materials have been used. This review of 20 consecutive cases of EA/TEF stresses the importance and influence of non-reversal of anesthesia, paralysis, and elective ventilation for protection of the esophageal anastomosis following repair of EA and TEF.