Major anastomotic dehiscence after repair of esophageal atresia: conservative management or reoperation?

Anastomotic leaks and the relationship with anastomotic strictures after esophageal atresia surgery; effects of patient characteristics

BACKGROUND

This study aimed to evaluate the link between anastomotic leaks (AL) and anastomotic strictures (AS) after esophageal atresia surgery and the influence of patient demographics.

MATERIALS AND METHODS

The clinical data of neonates who underwent surgical repair for esophageal atresia were retrospectively reviewed. The results of AL treatment and the relationship with AS, also the effects of patient characteristics were examined with logistic regression analysis.

RESULTS

Primary repair was performed on 122 of 125 patients who underwent surgery for esophageal atresia. AL occurred in 25 patients and 21 were treated non-operatively. While 4 patients were re-operated, AL recurred in 3 and led to the death of one. There was no correlation between the development of AL and sex or the presence of additional anomalies. The gestational age and birth weight of patients with AL were significantly higher than those of patients without. AS developed in 45 patients. The mean gestational age was significantly higher in patients who developed AS (p < .001). While the development of AS was significantly higher in patients with AL (p = .001), the number of dilatation sessions needed was also significantly higher in these patients (p = .026). Complications related to anastomosis were less common in patients whose gestational age was ≤33 weeks.

CONCLUSION

Non-operative treatment remains effective for AL after esophageal atresia surgery. AL increases the risk of developing AS and significantly increases the number of dilatation sessions needed. Anastomotic complications are less common in patients with lower gestational age.NOVEL ASPECTSGestational age and birth weight were found to be significantly higher in patients with anastomotic leaks than in those without and fewer anastomotic complications were encountered in patients whose gestational age was ≤ 33 weeks.Anastomotic stricture development was significantly higher in patients with anastomotic leaks and the number of dilatation sessions needed for treatment was also significantly higher in these patients.

Pediatric esophageal stenoses: Challenges and new surgical device promoting tension-free esophageal anastomosis

Esophageal stenoses of childhood have a broad spectrum of underlying causes. Their treatment is usually minimally invasive by endoscopic means, but sometimes surgery is necessary in refractory cases. Techniques employed in the surgical treatment of esophageal strictures include resection of the stenotic esophageal segment or esophageal substitution procedures. Esophageal anastomosis has always been a challenge in pediatric surgery. Anastomosis complications are linked to anatomical, biological and technical aspects. Mechanical tension between esophageal ends is an important cause of complications including anastomotic leaks or dehiscence. Eleven cases of esophageal stenoses, surgically treated in the Pediatric Surgery Department of Emergency Clinical Hospital for Children 'Marie S. Curie' by a single team in 5 years, were included in the present study. The results showed that, the main causes of esophageal stenosis were represented by corrosive esophageal injury in five cases, complications of esophageal atresia repair in three cases, congenital esophageal stenosis in two cases and chemotherapy-induced esophageal necrosis in acute lymphoblastic leukemia treatment in one case. The authors also designed and presented a device facilitating esophageal anastomosis under tension. Its principle involved temporary absorption of tension at secure points of the two esophageal pouches and reallocating it in equal amounts following anastomosis while decreasing any stretch-related tissue trauma. In conclusion, this auxiliary tool is beneficial for esophageal anastomosis; however, the standard steps of the esophageal anastomosis procedure should still be considered when necessary.

Risk factors for anastomotic complications after one-stage anastomosis for oesophageal atresia

BACKGROUND

Oesophageal atresia is a congenital malformation of the oesophagus and a serious malformation of the digestive system, postoperative complications include acute respiratory failure, pneumonia, anastomotic fistula, anastomotic stenosis, tracheal stenosis, gastroesophageal reflux and eosinophilic oesophagitis, anastomotic fistula is one of the important causes of postoperative death. The objective of this study is to identify the risk factors for anastomotic complications after one-stage anastomosis for oesophageal atresia.

METHODS

A retrospective analysis was performed on the clinical data of 107 children with congenital oesophageal atresia who underwent one-stage anastomosis in our hospital from January 2013 to December 2018. Single-factor and multivariate logistic regression analyses were performed to determine the risk factors for anastomotic fistula and anastomotic stenosis.

RESULTS

A total of 107 children with oesophageal atresia underwent one-stage anastomosis, and the incidence of anastomotic fistula was 26.2%. The probability of anastomotic stenosis in the long term was 52.3%, and the incidence of refractory stenosis (dilation ≥5 times) was 13.1%. Analysis of the clinical count data in the anastomotic fistula group and non-anastomotic fistula group showed that preoperative albumin (F = 4.199, P = 0.043), low birth weight (F = 7.668, P = 0.007) and long gap defects (F = 6.107, P = 0.015) were risk factors for postoperative anastomotic fistula. Further multivariate logistic regression analysis showed that low birth weight (Wald2 = 4.499, P = 0.034, OR = 2.775) and long gap defects (Wald2 = 6.769, P = 0.009, OR = 4.939) were independent risk factors for postoperative anastomotic fistula. Premature delivery (F = 5.338, P = 0.023), anastomotic fistula (F = 11.381, P = 0.001), endoscopic surgery (F = 6.343, P = 0.013), preoperative neutrophil count (F = 8.602, P = 0.004), preoperative low albumin (F = 8.410, P = 0.005), and a preoperative prognostic nutritional index < 54 (F = 5.54, P = 0.02) were risk factors for refractory anastomotic stenosis in children. Further multivariate logistic regression analysis showed that postoperative anastomotic fistula (Wald2 = 11.417, P = 0.001, OR = 8.798), endoscopic surgery (Wald2 = 9.633, P = 0.002, OR = 4.808), and a prognostic nutritional index < 54 (Wald2 = 4.540, P = 0.002, OR = 2.3798) were independent risk factors for refractory anastomotic stenosis.

CONCLUSION

Low birth weight and long gap defects are important predictors of postoperative anastomotic fistula, and the possibility of refractory anastomotic stenosis should be considered. The long-term risk of anastomotic stenosis was increased in children undergoing endoscopic surgery and in those with a preoperative prognostic nutritional index < 54.

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.

A chest tube may not be needed after surgical repair of esophageal atresia and tracheoesophageal fistula

BACKGROUND

After definitive repair of esophageal atresia (EA) and tracheoesophageal fistula (TEF), a chest tube (CT) may be left in place to diagnose and conservatively treat a postoperative anastomotic leak, although its necessity is controversial. The purpose of this study was to determine if the use of a CT decreases rates of early postoperative complications after EA and TEF repair.

METHODS

A retrospective chart review was performed to identify all patients with EA and TEF who underwent repair between 1985 and 2012. Univariate analysis was performed to compare patients who did or did not have a CT in terms of preoperative characteristics and postoperative outcomes.

RESULTS

One hundred twenty neonates were included; 69 had a CT inserted intraoperatively, while 51 did not. The two groups were similar in terms of patient characteristics. There was no statistically significant difference between the groups in terms of length of hospital stay (31 ± 12 vs. 36 ± 16 days, p = 0.5), or complication rates (13% vs. 12%, p = 0.9) for those with or without CT, respectively.

CONCLUSIONS

The use of a CT does not alter early postoperative complications after EA/TEF repair.

Use of pericardium to repair anastomotic leak after esophageal atresia surgery; experience with one case

Diverse therapies for the management of anastomotic leakage after esophageal atresia repair have been reported with various outcomes. The surgical management of anastomotic leakage after esophageal atresia repair can be challenging. We present a child with long-gap esophageal atresia and anastomotic leakage repair with pericardium. This article aimed to illustrate that pericardium may be a substitute for esophageal leakage repair.

Role of feeding jejunostomy in major anastomotic disruptions in esophageal atresia: A pilot study

Aims:

To investigate the role of feeding jejunostomy (FJ) in patients of esophageal atresia with anastomotic leak (AL) to decrease the degree of gastroesophageal reflux (GER) and its effect on anastomotic healing.

Materials and Methods:

Twenty neonates, with major AL and severe GER after primary repair were managed with decompressing gastrostomy and transgastric FJ and analyzed prospectively.

Results:

Male to female ratio was 1.7:1. Mean birth weight was 2.2 kg. Anastomotic gap ranged from 0 to 4 cm. The amount of leak was more than 20% of nasogastric feeds. Gastrostomy and FJ was done on an average of the 12^th postoperative day, after observing the general condition, chest tube output, lung expansion, and ventilatory requirement. There was a drastic reduction in chest tube output and lung expanded in all patients. Average hospital stay was 36 days (8-80 days). Sixty percentage patients were discharged successfully on FJ. Esophagogram demonstrated healing and leak free patency after an average of 1.5 months. GER was noted in seven patients, four developed stricture, and one had pseudodiverticulum in follow-up.

Conclusion:

Decompressing gastrostomy and FJ can be an alternative to managing major ALs. It helps in healing of anastomotic dehiscence and in preserving the native esophagus.

The outcome of conservative treatment for anastomotic leakage after surgical repair of esophageal atresia

OBJECTIVE

The aim of this study was to evaluate the clinical outcome of conservative management of anastomotic leakage (AL) after surgical repair for esophageal atresia.

METHODS

Data from 85 neonates with esophageal atresia who underwent surgical correction were retrospectively analyzed. Conservative treatment had been adopted for AL. The incidence and severity of postoperative AL as well as its effects were analyzed.

RESULTS

Among the 85 neonates, postoperative AL occurred in 21 (25%) cases, with major leaks in 15 cases and minor leaks in 6. The stricture index of the 21 neonates with AL (0.615 ± 0.032) was significantly different (P = .008) from that of the 64 neonates without leakage (0.509 ± 0.018). The overall incidence of gastroesophageal reflux (GER) was 36%. Esophageal dysmotility and clinically significant tracheomalacia were observed in 69 and 7 infants, respectively, of the 80 surviving patients. The incidence of GER, dysmotility, and tracheomalacia in patients with or without AL was similar. The severity of GER in patients with different numbers of sessions of dilation was significantly different (P = .0015).

CONCLUSIONS

Postoperative esophageal AL is effectively treatable by conservative methods in most neonates. The occurrence of AL may aggravate the severity of esophageal stricture but does not affect the incidence of GER, esophageal dysmotility, and tracheomalacia.

Novel use of glycopyrrolate (Robinul) in the treatment of anastomotic leak after repair of esophageal atresia and tracheoesophageal fistula

Anastomotic leak after tracheoesophageal fistula repair is a well-known complication and can represent a challenging clinical scenario. We present the case of an infant girl with VACTERL syndrome who underwent repair of a type C esophageal atresia and tracheoesophageal fistula repair, which was complicated by an anastomotic leak. Glycopyrrolate (Robinul), an anticholinergic agent, was successfully used to decrease copious salivary secretion and promote spontaneous closure of the leak. This report represents the first description in the medical literature of the use of glycopyrrolate in the treatment of an esophageal anastomotic leak. Glycopyrrolate may be a useful adjunct in the management of anastomotic leak after tracheoesophageal repair.

Experience in treating congenital esophageal atresia in China

PURPOSE

The aim of the study was to evaluate our recent experience in treating esophageal atresia (EA) and the outcomes observed at a single center for pediatric surgery.

MATERIALS AND METHODS

The records of infants with EA from 2006 to 2009 were reviewed. Birth weight, associated anomalies, details of management, complications, and outcomes were examined.

RESULTS

Forty-eight consecutive infants with EA were identified from 2006 to 2009, of which 33 (69%) were boys. Mean birth weight was 2668 g (range, 1700-3800 g). Common associated malformations (35%) were cardiac anomalies, imperforate anus, limb anomalies, and chromosomal anomalies. Forty-seven were Gross type C, and one was Gross type A. Forty-five infants underwent ligation of the tracheoesophageal fistula and end-to-side primary anastomosis, and one received a colonic interposition. Six patients died (12.5% mortality). Three died before or during operation because of severe pneumonia and complex cardiac anomalies, and 3 died during recovery (within 1 month after repair) because of aspiration and severe pneumonia (early postoperative mortality was 6.67%). Complications included pneumonia, anastomotic leakage (16%, all recovered after conservative treatment), wound sepsis (11%), recurrent tracheoesophageal fistula (9%) (3/4 recovered after conservative treatment), anastomotic stricture (10%), and gastroesophageal reflux in about 2 of 3 patients. Preoperative computed tomographic imaging and 3-dimensional graphic reconstruction used in 15 patients were useful.

CONCLUSIONS

Most patients with EA have excellent short- to midterm surgical outcomes. The main factors for mortality are complex cardiac anomalies, aspiration, and pneumonia. Computed tomographic imaging and 3-dimensional graphic reconstruction can provide surgeons with excellent preoperative reference about the anatomy of the defect. Most anastomotic related complications resolve with conservative treatment. Patients of low-risk prognosis group with type A and long gap EA can be managed with a primary colonic interposition with good results. The main midterm complications are gastroesophageal reflux and stricture.

The role of prophylactic chest drainage in the operative management of esophageal atresia with tracheoesophageal fistula

INTRODUCTION

Anastomotic leakage and respiratory complications are among the most common and potentially life-threatening complications following the surgical repair of esophageal atresia. Controversies exist regarding the efficacy of prophylactic extrapleural chest tube (EPCT) drainage in patients who have undergone repair of esophageal atresia.

MATERIALS AND METHODS

In this prospective study, 50 newborns with esophageal atresia and distal tracheoesophageal fistula (EA-DTEF) were randomized into two groups, with no significant differences regarding gender ratio, birth body weight and delivery status. Group 1 (n = 29) underwent a right thoracotomy and a single-stage extrapleural esophageal anastomosis. Group 2 (n = 21) received additionally an intraoperative EPCT next to the anastomosis. These groups were then compared with regard to postoperative respiratory complications (such as respiratory distress, pneumonia, pneumothorax, lung collapse, and apnea), anastomotic leakage, need for mechanical ventilation, time on mechanical ventilation, and outcome. Statistical analyses were performed with Mann-Whitney U test, Fisher's exact test, and binary logistic regression analysis.

RESULTS

The rates of respiratory complications and anastomotic leakage, need for mechanical ventilation, time on mechanical ventilation, and mortality rate were comparable between the two groups (P > 0.05). Mortality was associated with respiratory complications (P = 0.003) and anastomotic leakage (P = 0.007).

CONCLUSION

It seems that prophylactic EPCT drainage does not decrease the early postoperative respiratory complications and mortality rates in newborns with EA-DTEF.