Developing a new predictive index for anastomotic leak following the anastomosis of esophageal atresia: preliminary results from a single centre

Esophageal Atresia and Tracheoesophageal Fistula: Diagnosis, Management, and Outcomes

Esophageal atresia is a congenital disease that results in discontinuity of the esophagus and can occur with or without fistulous connections to the trachea. It is often associated with other anomalies and has multiple long-term health implications. Because of the complexity of care involved in affected children, it is important to diagnose this lesion as early as possible. Surgical repair via either anastomosis of the native esophagus or reconstruction using either the stomach or intestine if this is not possible remain the mainstays of therapy, although variations in technique prevail. In this review, we summarize the approach to diagnosis, preoperative management considerations, surgical approach, medical considerations, and long-term outcomes of infants with esophageal atresia.

Does thoracoscopic repair of type C esophageal atresia require emergency treatment?

BACKGROUND

Thoracoscopic repair of esophageal atresia (EA) with tracheoesophageal fistula (TEF) has been performed with increasing frequency. Although many children have underwent surgery within three days after birth, the optimal timing for operation remains undetermined. This study aimed to investigate the appropriate timing for thoracoscopic repair of type C EA and its mid-term clinical outcomes.

METHOD

We retrospectively analyzed 142 patients with EA between April 2009 and April 2023. A total of 109 patients with type C EA who underwent thoracoscopic one-stage repair surgery were included. The patients were divided into two groups based on surgical timing: the early repair group (< 5 days) and the delayed repair group (≥ 5 days). Patients in the two groups were matched using propensity score matching (PSM) to eliminate the imbalance between groups caused by confounding factors such as severe cardiac complications, gestational age, and birth weight.

RESULT

The median age at surgery was 5 days (range: 1-16 days). After matching, 43 patients (out of 59) in the early repair group (group A) and 43 patients (out of 50) in the delayed repair group (group B) were included in the validation cohort. All cases (n = 86) successfully completed thoracoscopic one-stage repair surgery. Delayed surgery did not increase the incidence of preoperative and postoperative respiratory tract infections. Intraoperative and postoperative complications were comparable between the two groups. Intraoperative and postoperative complications were comparable between the two groups; however, patients in group B experienced a lower frequency of balloon dilation (1.8 ± 0.8 vs. 3.1 ± 1.1, P = 0.035) for anastomotic stricture during follow-up.

CONCLUSIONS

With improvements in neonatal surveillance, appropriately delayed surgery does not increase the incidence of respiratory infections, allowing surgeons to optimize treatment plans.

Repair of Type C Tracheo-esophageal Fistula/Esophageal Atresia With or Without Trans Anastomotic Tube: A Pilot Randomized Controlled Trial

BACKGROUND

The use of trans anastomotic feeding tube (TAFT) during the repair of Esophageal atresia/Tracheo-esophageal fistula (EA/TEF) aims to enhance outcomes by enabling early feeding, reducing the requirement for parenteral nutrition, and reducing complications such as anastomotic leak by stenting the anastomosis. However, TAFT's benefits and drawbacks are debated due to conflicting reports. Thus, we conducted a prospective pilot randomized control trial to elucidate the impact of TAFT on postoperative outcomes and the potential benefits of avoidance of TAFT.

METHODS

We performed a single-center randomized controlled trial in 53 neonates diagnosed with Type C EA/TEF who were operated on from January 2022 to June 2023. The patients were randomized into TAFT (n = 30) and non-TAFT (n = 23) groups. The patients were followed up for a minimum of 6 months following discharge. The primary objective of the study was to compare the rate of anastomotic leaks following primary repair of EA/TEF in both groups. Secondary objectives included early postoperative outcomes such as the occurrence of anastomotic stricture, time taken to initiate feeding, the time required to reach full feeding, the incidence of brief resolved unexplained events (BRUE) or acute life-threatening events (ALTE), the incidence of gastroesophageal reflux (GER), somatic growth, and all-cause mortality within 30 days post-surgery.

RESULT

The study demonstrated that TAFT placement was associated with a higher incidence of anastomotic leaks (20 % vs 0, p = 0.03). However, there was no difference in the 30-day mortality between both groups. Although the rate of anastomotic strictures and GER was higher in the TAFT group (54.5 % vs 27.8 %, p = 0.08 and 25 % vs 57.1 %, p = 0.076), it did not reach statistical significance. Avoiding TAFT resulted in earlier initiation of enteral feeding (18 vs 22 days, p = 0.002), shorter time to achieve full feeds (15 vs 21 days, p = 0.03), reduced duration of TPN (3 vs 10 days; p = 0.001), improved weight gain at the 2-week follow-up (27.5 vs. 24.4 g/kg/day, p-value = 0.037) and lesser incidence of ALTE/BRUE (11.1 % vs 48 %, p = 0.01) at 6 months.

CONCLUSION

While previous research has covered TAFT's impact on complications such as anastomotic leak, stricture, use of TPN and enteral feed, prospective randomized studies remain limited, and the impact on GER, somatic growth, and occurrence of ALTE/BRUE is still unexplored. This study evaluated the short-term outcomes of EA/TEF in a resource-challenged setting, shedding light on the potential benefits of repair without TAFT such as reduction in the rate of anastomotic leak, earlier feeding, reduced GER, better somatic growth and reduced incidence of ALTE/BRUE.

LEVEL OF EVIDENCE

Level II (Treatment study/Randomized controlled trial).

Glycopyrrolate as an Adjunct in the Management of Anastomotic Leak Following Repair of Esophageal Atresia: A Clinicoradiological Perspective

Context

Anastomotic leak after primary repair of esophageal atresia (EA) with tracheoesophageal fistula (TEF) is a well-known complication and can represent a challenging clinical scenario.

Aims

The present study aimed to evaluate the role of glycopyrrolate as an adjunct in the treatment of anastomotic leak after primary repair of EA Vogt type 3b.

Settings and Design

A retrospective study was carried out in our tertiary care teaching institute from January 2015 to December 2022.

Materials and Methods

Neonates with EA with distal TEF with primary repair who had developed anastomotic leak, managed by the author(s), were studied. The study included patients with major, minor, and radiological leaks. Glycopyrrolate was administered in the dose of 4 μg/kg 8 hourly. The outcomes of the study were either resolution or progression of the leak.

Results

There were 21 patients who were managed with glycopyrrolate in addition to the classical treatment of the anastomotic leak following repair of EA with distal TEF. The male: female ratio was 1:1.1. All the cases had anastomotic leaks with either clinically detectable in the chest tube (15) or radiological leak (6). The leaks were detected early in patients with major leak (mean = 3.2 ± 0.84 days) compared to minor leak (mean =4.9 ± 1.29 days). Radiological leaks were detected in all the neonates on postoperative day 7. In five patients with major leak, there was a negligible reduction in the amount of chest tube output, and were subjected to diversion procedures. There were a total of three deaths out of five in this group. In 10 patients with minor leak, there was complete resolution of anastomotic leak in eight patients (80%); there was one patient each with mortality and diversion procedure. The patients with a radiological leak (6) did not show any deterioration, and they were fed 1-5 days after the esophagogram.

Conclusions

Glycopyrrolate may be an advantageous postoperative adjunct in the management of minor and radiological leak after tracheoesophageal repair.