Anastomotic Dilatation Research Articles

Less is more: The use of a single biodegradable stenting to treat biliary anastomotic strictures in pediatric liver transplantation.

To report our experience of using biodegradable biliary stents for anastomotic biliary strictures in pediatric liver transplant patients. Analysis of a retrospective data collection from January 2014 to January 2023, including all pediatric liver transplant recipients in our center treated for anastomotic biliary strictures with biodegradable biliary stents (BBS). In phase 1 (2014-2019), there was an initial percutaneous transhepatic cholangiography (PTC) with anastomotic dilatation followed two weeks after by a second PTC with BBS insertion. In phase 2 (2019-2023), the BDS were placed shortly after anastomotic biliary strictures dilatation, requiring only one PTC. All patients were followed up with routine tests and ultrasound. Forty-six anastomotic biliary strictures were diagnosed in 43 pediatric liver transplant recipients with a median of 6.7 months post-liver transplantation (0.1-246.8 months). Eight out of 46 anastomotic biliary strictures (17.4%) treated with biodegradable biliary stents relapsed (median recurrence time: 6.5 months; 1.6-17.0 months). Four resolved with further BBS placement; only four needed surgical revision (8.7%) after a median follow-up time of 43.9 months (0.3-106.3). There were no differences in anastomotic biliary strictures recurrence rate, time between stent placement and recurrence, or the presence of cholangitis based on whether the BBS was deployed in one or two steps. Patients with end-to-end anastomosis had a higher anastomotic biliary strictures recurrence (or 10.8; 1.4-81.3, p=0.008) than those with bilioenteric anastomosis. The use of biodegradable stents stents could be good option for treating anastomotic biliary strictures in pediatric liver transplant patients, with our series showing a success rate of over 90% and an average follow-up of 43.9 months.

320. RISK FACTORS FOR BENIGN ANASTOMOTIC STENOSIS AFTER ESOPHAGEAL CANCER SURGERY

Abstract Background Benign strictures occur frequently following an esophagectomy, causing dysphagia, problems with eating, and a diminished overall quality of life. The aim of this study is to identify risk factors associated with anastomotic stenosis specified for anastomotic technique following esophagectomy for cancer. Methods This retrospective study included patients with esophageal and gastroesophageal junction cancer who underwent esophagectomy in a tertiary referral center between 2012 and 2022. Intrathoracic and cervical anastomoses were analyzed separately. Benign anastomotic stenosis was defined as the occurrence of postoperative dysphagia for which at least 1 endoscopic anastomotic dilation was needed. Possible predictive factors for anastomotic stenosis were analyzed with uni- and multivariate logistic regression. Results This study included 902 patients: 605 with an intrathoracic and 297 with a cervical anastomosis. Anastomotic stenosis was observed in 18.4% and 49.8% (p<0.001). Patients respectively requiring a median 4 and 7 dilations (p=0.001). Median of time to anastomotic stenosis was 99 and 78 days (p=0.001). In multivariate analysis of intrathoracic anastomosis, anastomotic leakage was a significant risk factor for stenosis (OR 2.034; 95% CI [1.116-3.708]). In patients without anastomotic leakage, stapler size 29mm was a negative predictor (OR 0.444; 95% CI [1.116-3.708]), immunosuppressants (OR 3.492; 95% CI [1.186-10.279]) and chronic pulmonary disease were significant risk factors (OR 2.717; 95% CI [1.293-5.707]). In multivariate analysis of cervical anastomosis, circular stapled anastomosis was a negative predictor (OR 0.350 95% [CI 0.188-0.652]) for stenosis. Conclusion This study identified the most important risk factors for anastomotic stricture after esophagectomy. Anastomotic leakage, the circular stapler diameter, and the circular stapled technique are factors that could be surgical modifiable, while patients taking immunosuppressants and with chronic pulmonary disease should be counseled for higher risk of stenosis.

315. LAPAROSCOPIC GASTRIC PULL-UP WITH GASTROJEJUNOSTOMY AS AN ALTERNATIVE TO COLON-TRANSPOSITION FOR CORROSIVE STRICTURE INVOLVING OESOPHAGUS AND ANTROPYLORIC REGION OF STOMACH

Abstract Background Various gastrointestinal segments are used for replacement of the scarred oesophagus following corrosive ingestion. Colon is preferred if scarring involves both the oesophagus and the stomach, however, in some patients only the antral part of the stomach maybe involved (in addition to the oesophagus), and a gastric pull-up with a roux en Y gastrojejunostomy may also be feasible. Methods Retrospective analysis of corrosive strictures managed surgically between 2020–2023. The short and long-term outcomes of laparoscopic gastric pull-up with roux en Y gastrojejunostomy (LGPU-GJ) were compared with colonic pull-up. Results During the study period, 45 patients underwent surgical management for corrosive injury to the oesophagus and stomach. Of these, 7 patients underwent a LGPU-GJ (group A) and 20 patients underwent a colonic pull-up (Group B) and formed the study group. The mean operative time and blood loss was (195.7 ± 55 and 322 ± 63 min, p = 0.001; 48.5 ± 24 and 108 ± 30.8 mL p < 0.001) in Group A and B respectively. One patient in Group A had a gastric staple line leak which was managed with intercostal drainage and antibiotics, 3 patients in Group B had cervical anastomotic leak which was managed conservatively. There was no mortality. Over a median followup of 18 months, 2 patients in Group A and 7 in Group B required at least one session at endoscopic anastomotic dilatation. There were no significant reflux symptoms reported and all patients were able to tolerate a standard Indian diet. Conclusion In a select group of patients with concomitant oesophageal and isolated gastric antral stricture a laparoscopic gastric pull-up with roux en Y gastrojejunostomy may be a feasible alternative to the more complex colonic pull-up with shorter operative times, less blood loss and equivalent outcomes.

Incidence and Mechanism of Refractory Postoperative Cholangitis After Hepatectomy with Hepaticojejunostomy

IntroductionMalignant tumors, such as hilar cholangiocarcinoma, have shown improved long-term outcomes, and measures to prevent late postoperative complications are important. Postoperative cholangitis after hepatectomy with hepaticojejunostomy (HHJ) may occur and can significantly decrease the quality of life. However, there are few reports on the incidence and pathogenesis of postoperative cholangitis after HHJ. MethodsWe retrospectively reviewed 71 cases post HHJ at Tokyo Medical and Dental University Hospital from January 2010 to December 2021. Cholangitis was diagnosed using the Tokyo Guideline 2018. Cases due to tumor recurrence around the hepaticojejunostomy (HJ) were excluded. Patients with three or more episodes of cholangitis were classified as the “refractory cholangitis group” (RC group). RC group patients were divided into a “stenosis group” and “non-stenosis group” according to intrahepatic bile duct dilatation at the onset of cholangitis. Their clinical characteristics and risk factors were analyzed. ResultsCholangitis occurred in 20 patients (28.1%), with 17 (23.9%) in the RC group. Most patients in the RC group developed their first episode within the first postoperative year. The stenosis group consisted of 6 patients, and their cholangitis was treated with repeated anastomotic dilatation and stent replacement. In the non-stenosis group, cholangitis was relatively mild and treated with antibiotics. Hepatobiliary scintigraphy for these cases showed bile congestion in the jejunum near the site of the hepaticojejunostomy. ConclusionThere are two types of postoperative cholangitis, each with different pathogenesis and treatment. It is essential to assess anastomotic stenosis early and provide the necessary treatment.

Anastomotic Stricture After Minimally Invasive Esophagectomy

BackgroundDespite improved outcomes, minimally invasive esophagectomy (MIE) continues to be associated with anastomotic strictures. Most resolve after a single dilation; however, some become refractory. Little is known about strictures after MIE in North America. MethodsWe performed a single-institution retrospective review of MIEs from 2015 to 2019. Primary outcomes were the proportion of patients requiring anastomotic dilation and the dilation rate per year. Univariate analyses of patients undergoing dilation by various risk factors were performed with nonparametric tests, and multivariate analyses of the dilation rate were conducted using generalized linear models. ResultsOf 391 included patients, 431 dilations were performed on 135 patients (34.5%, 3.2 dilations per patient who required at least 1 per patient). One complication occurred after dilation. Comorbidities, tumor histology, and tumor stage were not significantly associated with stricture. Three-field MIE was associated with a higher percentage of patients undergoing dilation (48.9% vs 27.1%, P < .001) and a higher rate of dilations (0.944 vs 0.441 dilations per year, P = .007) than 2-field MIE, and this association remained significant after controlling for covariates. When accounting for surgeon variability, this difference was no longer significant. Among patients with 1 or more dilations, those receiving dilation within 100 days of surgery needed more subsequent dilations (2.0 vs 0.6 dilations per year, P < .001). ConclusionsAfter controlling for multiple variables, a 3-field MIE approach was associated with a higher rate of repeat dilations in patients undergoing MIE. A shorter interval between esophagectomy and initial dilation is strongly associated with the need for repeated dilations.

Risk factors of anastomosis-related difficult endoscopic retrograde cholangiopancreatography following endoscopic ultrasound-guided gastro-gastrostomy using astandardized protocol (with video).

Little is known about how to perform the endoscopic ultrasound (EUS)-directed transgastric endoscopic retrograde cholangiopancreatography (ERCP; EDGE) in patients with gastric bypass using lumen-apposing metal stents (LAMS). The aim was to assess the risk factors of anastomosis-related difficult ERCP. Observational single-center study. All patients who underwent an EDGE procedure in 2020-2022 following a standardized protocol were included. Risk factors for difficult ERCP, defined as the need of >5 min LAMS dilation or failure to pass a duodenoscope in the second duodenum, were assessed. Forty-five ERCPs were performed in 31 patients (57.4± 8.2 years old, 38.7% male). The EUS procedure was done using a wire-guided technique (n= 28, 90.3%) for biliary stones (n= 22, 71%) in most cases. The location of the anastomosis was gastro-gastric (n= 24, 77.4%) and mainly in the middle-excluded stomach (n= 21, 67.7%) with an oblique axis (n= 22, 71%). The ERCP technical success was 96.8%. There were 10 difficult ERCPs (32.3%) due to timing (n= 8), anastomotic dilation (n= 8), or failure to pass (n= 3). By multivariable analysis adjusted by two-stage procedures, the risk factors for a difficult ERCP were the jejuno-gastric route (85.7% vs. 16.7%; odds ratio [ORa ] 31.875; 95% confidence interval [CI] 1.649-616.155; P= 0.022), and the anastomosis to the proximal/distal excluded stomach (70% vs. 14.3%; ORa 22.667; 95% CI 1.676-306.570; P= 0.019). There was only one complication (3.2%) and one persistent gastro-gastric fistula (3.2%) in a median follow-up of 4 months (2-18 months), with no weight regain (P= 0.465). The jejunogastric route and the anastomosis with the proximal/distal excluded stomach during the EDGE procedure increase the difficulty of ERCP.

Troubleshooting of embedded M-Intraductal lasso in fistula of endoscopic ultrasonography-guided hepaticogastrostomy.

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Endoscopic surveillance after bariatric surgery: Results from a large, single-institution cohort

Abstract Objective Sleeve gastrectomy (SG) and Roux-en-Y-gastric bypass (RYGB) are associated with long- term abnormalities, including erosive esophagitis (EE), hiatal hernia (HH), gastritis, Barrett`s esophagus and ulcers. The aim of this study is to assess the prevalence of abnormal endoscopic and histologic findings after SG and RYGB in a large cohort. Methods This is a retrospective analysis of 720 consecutive patients who underwent esophagogastroduodenoscopy (EGD) after primary SG or RYGB. Patients were invited for a control EGD after two years of follow-up. EGD was also performed in order to evaluate postoperative symptoms, such as nausea, vomiting or reflux. If revisional surgery was planned, an EGD was included in the prerevisional work up. Results 304 post-SG patients (64.1% female) and 416 post-RYGB patients (85% female) were included. The mean age at the time of operation was 43.9 years (95% confidence intervals (CI) 42.5–43.3 years) for the post-SG group and 40.5 years (95% CI 39.4–41.6 years) for the post-RYGB group (p&amp;lt;0.001). The mean preoperative body mass index (BMI) was 44.2 kg/m2 (95%CI 43.4–44.9) and 41.1 kg/m2 (95%CI 40.7–41.5) for the post-SG and the post-RYGB group respectively (p&amp;lt;0.001). EE, gastritis and HH were more prevalent after SG than RYGB (38.8% vs 8.9%, 62.5% vs 27.6% and 28% vs 2.6% respectively, p&amp;lt;0.001). RYGB was associated with more postoperative ulcers than SG (14.4% vs 0.7%, p&amp;lt;0.001). The incidence of anastomotic strictures requiring anastomotic dilatation after RYGB was 4.6%. No significant difference was found in the prevalence of Barrett`s esophagus (4.3% post SG vs. 4.1 post RYGB, p=1.000) and Helicobacter pylori (3.3% post SG vs. 1.2% post RYGB, p=0.065) between the two groups. Conclusion SG is associated with higher rates of EE, gastritis and HH, while the prevalence of ulcers is higher post RYGB. There is a low risk of anastomotic stricture post RYGB. The incidence of Barrett`s oesophagus is low after both procedures. Routine use of EGD after bariatric surgery should be evaluated.

Two-time perforation of the ileal J-pouch 6 and 18\xa0years after restorative proctocolectomy and ileal pouch\u2013anal anastomosis for familial adenomatous polyposis: a case report

BackgroundPerforation of the ileal J-pouch after restorative proctocolectomy and ileal pouch–anal anastomosis are extremely rare. There has been no report of perforation of the ileal J-pouch occurring twice over several years. We report the first case of perforation at 6 and 18 years following restorative proctocolectomy.Case presentationThe patient was a 52-year-old man who underwent a two-stage restorative proctocolectomy with a hand-sewn ileal J-pouch anal anastomosis due to familial adenomatous polyposis and sigmoid colon cancer at 34 years of age. At the age of 40, he underwent ileal pouch resection at its blind end, abdominal drainage, and anastomotic dilatation. The patient had a perforation of the blind end of the ileal J-pouch from increased intraluminal pressure, with anastomotic stricture and pervasive peritonitis. The patient had no symptoms for a few years; however, 18 years after the initial surgery and 12 years after the first perforation, the patient presented with severe abdominal pain. Computed tomography demonstrated pneumoperitoneum; accordingly, laparotomy was performed. Upon opening the abdominal cavity, contaminated ascites and inflammatory changes were documented involving the ileum. A 2-mm perforation involving the blind end of the ileal J-pouch was also observed and repaired, followed by temporary loop ileostomy creation. Postoperative endoscopy revealed an ulcer in the ileal J-pouch and a stricture located directly at the anastomosis.ConclusionsThe blind end of the J-pouch repeatedly perforated over the years due to recurrent anastomotic stricture. Regular surveillance is, therefore, considered necessary for the release of stricture, maintenance of anastomotic patency, and prevention of ileal J-pouch perforation.

Favorable Outcome of Electively Delayed Elongation Procedure in Long-Gap Esophageal Atresia.

The ideal approach to long gap esophageal atresia is still controversial. On one hand, preserving a patient's native esophagus may require several steps and can be fraught with complications. On the other hand, most replacement procedures are irreversible and disrupt gastrointestinal physiology. The purpose of this study was to evaluate the short- and medium-term outcome of electively delayed esophageal elongation procedures before esophageal reconstruction in patients with long-gap esophageal atresia. Since the neonatal esophagus grows over-proportionally and can increase its wall thickness in the first few months of life, we hypothesized that postponing the elongation steps until 3 months of age would lead to a lower complication rate. We thus retrospectively recorded complications such as mediastinitis, anastomotic leakage, stricture formation, or gastroesophageal reflux requiring surgery, and compared it to reported outcomes. In our treatment protocol, patients born with long-gap esophageal atresia underwent gastrostomy placement and were sham fed until 3 months of age. We then assessed the gap between the esophageal ends and started serial elongation procedures. We only proceeded to the reconstruction of the esophagus when its length allowed a tension-free anastomosis. From April 2013 to April 2019, we treated 13 Patients with long-gap esophageal atresia. Nine patients without prior surgical procedures underwent Foker procedures. Four patients arrived with a pre-existing cervical esophagostomy and thus underwent Kimura's procedure, two of them with a concomitant Foker elongation of the lower pouch. Esophageal reconstruction was feasible in all patients, while none of them developed mediastinitis at any point in their treatment. We managed the only anastomotic leak conservatively. Almost half of the patients did not require any further intervention following reconstruction, while three patients required multiple (≥5) anastomotic dilatations. All but one patient achieved full oral nutrition. Only one child required a fundoplication to manage gastroesophageal reflux symptoms. Electively delayed esophageal elongation procedures in patients with long-gap esophageal atresia allowed preservation of the native esophagus in all patients. The approach had low peri-procedural morbidity, and patients enjoy favorable functional outcomes. Therefore, we suggest considering this method in the management of patients with long-gap esophageal atresia.

Analysis of outcomes of a transoral circular stapled anastomosis following major upper gastrointestinal cancer resection.

Esophageal anastomoses performed following esophagectomy and total gastrectomy are technically challenging with a significant risk of anastomotic leak. A safe, reliable, and easy anastomotic technique is required to improve patient outcomes and reduce morbidity. This paper analyses 328 consecutive patients who underwent transoral circular stapled esophageal anastomosis (ORVIL™) from a prospectively collected single-center database between December 2011 and February 2019. Two hundred and twenty-seven esophagectomies and 101 gastrectomies were performed using OrVil™ anastomoses. The mean patient age was 63.7years. Of 328 consecutive OrVil™-based anastomoses, there were 10 clinically significant anastomotic leaks requiring radiological or operative intervention (3.05%). Twenty-eight (8.54%) patients developed anastomotic stricture, all of which were successfully treated with endoscopic balloon dilatation (a median of 1 dilatation was required per patient). The OrVil™ anastomotic technique is reliable and safe to perform. This is the largest reported series of the OrVil™ anastomotic technique to date. Leak rates and anastomotic dilations were similar to other reported series. Based on our experience, we consider the use of the OrVil™ device for reconstruction after major upper GI resection to be safe and reliable.

Comparison of end-to-side hand-sewn and side-to-side stapled cervical esophagogastric anastomosis in patients with lower thoracic esophageal cancer undergoing transhiatal esophagectomy: an Iranian retrospective cohort study

BackgroundControversies in terms of efficacy and postoperative advantages surround stapled esophagogastric anastomosis compared with the hand-sewn technique as a treatment for patients with esophageal cancer. The purpose of this study was to compare the clinical outcomes of hand-sewn end-to-side esophago-gastrostomy and side-to-side stapled cervical esophagogastric anastomosis after esophagectomy for the aforementioned patients.MethodsThis retrospective cohort study involved examining the medical records of 433 patients who underwent transhiatal esophagectomy for esophageal cancer from March 2010 to March 2016. All the patients were operated using end-to-side hand-sewn esophago-gastrostomy and side-to-side stapled cervical esophagogastric anastomosis. 409 of the patients received a year’s worth of follow-up evaluations. All the cases were revisited in 2 weeks as well as in four, eight, and 12 months after surgery. The patients were assessed in terms of postoperative outcomes, including reflux symptoms, anastomotic leakage and stricture, and the need for anastomotic dilatation.ResultsHand-sewn anastomosis was carried out in 271 (62.5%) patients, whereas stapled anastomosis was performed in 162 (37.4%) patients. The mean operative times were 214.46 ± 84.33 min and 250.55 ± 43.31 min for the stapled and hand-sewn anastomosis groups, respectively (P = 0.028). The two groups showed no significant differences with respect to stays in intensive care units and hospitals. Postoperatively, 38 (14.67%) cases of anastomotic leakage were detected in the hand-sewn anastomosis group, with incidence being significantly higher than that in the stapled anastomosis group (8 cases or 5.33%; P = 0.002). Anastomotic stricture occurred less frequently in the patients who underwent stapled anastomosis (P = 0.004). Within the one-year follow-up period, the patients treated via hand-sewn anastomosis more frequently required anastomotic dilatation (P = 0.02).ConclusionSide-to-side stapled cervical esophagogastric anastomosis may reduce operation times and decrease the rates of anastomotic leakage, anastomotic stricture, and anastomotic dilatation in patients with lower thoracic esophageal cancer undergoing transhiatal esophagectomy.

Management of refractory cervical anastomotic fistula after esophagectomy using the pectoralis major myocutaneous flap

IntroductionA refractory cervical anastomotic fistula which postoperatively remains unhealed for more than 2 months under conservative care severely impacts the quality of life of the patient and potentially leads to anastomotic stricture after the fistula heals. It is widely accepted that, to avoid this complication, refractory cervical anastomotic fistulas should undergo more aggressive treatments. However, when and which surgical intervention should be considered is unclear. ObjectiveThis study was designed to evaluate the role of the pectoralis major myocutaneous flap in the management of refractory cervical anastomotic fistulas based on our experience of 6 cases and a literature review. MethodsSix patients diagnosed with refractory cervical anastomotic fistula after esophagectomy treated using pectoralis major myocutaneous flap transfer were included in the study. The clinical data, surgical details, and treatment outcome were retrospectively analyzed. ResultsAll patients survived the operations. One patient who had a circumferential anastomotic defect resulting from surgical exploration developed a mild fistula in the neo-anastomotic site in the 5th postoperative day, which healed after 7 days of conservative care. This patient developed an anastomotic stricture which was partially alleviated by an endoscopic anastomotic dilatation. All the other 5 patients had uneventful recoveries after operations and restored oral intake on the 10th–15th days after operation, and they tolerated normal diets without subsequent sequelae on follow-up. One patient developed both local and lung recurrence and died in 15 months after operation, while the other 5 patients survived with good tumor control during the follow-up of 25–53 months. ConclusionThe satisfactory treatment outcome in our study demonstrates that pectoralis major myocutaneous flap reconstruction is a reliable management modality for refractory cervical anastomotic fistulas after esophagectomy, particularly for those patients who experienced persistent fistulas after conservative wound care and repeated wound closures.

Repair of oesophageal atresia by consultants and supervised trainees results in similar outcomes.

Consultants and trainees require exposure to complex cases for maintaining and gaining operative experience. Oesophageal atresia (OA) repair is a neonatal surgical procedure with indicative numbers for completion of training. A conflict of interest may exist between adequate training, maintaining consultant experience and achieving good outcomes. We aimed to review outcomes of procedures performed primarily by trainees and those performed by consultants. We carried out a retrospective case note review of all consecutive infants who underwent surgical repair of OA with distal tracheooesophageal fistula (TOF) between January 1994 and December 2014 at our institution. Only cases that underwent primary oesophageal anastomosis were included. Surgical outcomes were compared between cases that had a trainee and those that had a consultant listed as the primary operator. One hundred and twenty-two cases were included. A total of 52 procedures were performed by trainees, and 68 by consultants. Two cases were undeterminable and excluded. Infant demographics, clinical characteristics and duration of follow-up were similar between groups. All infants survived to discharge. Procedures performed by trainees and those performed by consultants as primary operators had a similar incidence of postoperative pneumothorax (trainees 4, consultants 3; p=0.46), anastomotic leak (trainees 5, consultants 3; p=0.29) and recurrent TOF (trainees 0, consultants 2; p=0.5). Overall 52% of cases had an anastomotic dilatation during follow-up, with no difference between the trainee and consultant groups (50% vs 53%; p=0.85). Surgical outcomes for repair of OA/TOF are not adversely affected by trainee operating. Trainees with appropriate skills should perform supervised OA/TOF repair. These data are important for understanding the interrelationship between provision of training and surgical outcomes.

Is Single-stage Primary Transanal Endorectal Pull through (TEP) feasible for Short Segment Hirschsprung's Disease in Neonates?- Our Experience in a Tertiary Hospital

Background: The surgical management of Hirschsprung's Disease (HD) includes so many procedures. TransanalEndorectal Pull through (TEP) represents the latest development in the concept of the minimally invasive surgery for HD. The purpose of this study was to evaluate the out come of the procedure in neonates.&#x0D; Methods: This retrospective study was carried out in a tertiary pediatric hospital during the period from January 2007 to December 2012 (5 years). The study included neonates of both sex, weight more than 2 kg, who were clinically suspected HD, radiologically transition zone at rectosigmoid and midsigmoid region and rectal biopsy proven HD and no evidence of sepsis or entrocolitis. Short segment HD with associated anomalies, and operated cases with less than 6 months' or irregular follow up were excluded.&#x0D; Results: During study period, single-stage transanalendorectal pull through (TEP) operation was done for short segment HD in 63 neonates, 9 patients were excluded from the study for irregular follow up. The mean operative time, mean blood loss, postoperative hospital stay, follow up period were 113 minutes, 20ml, 6.8 days and 19.6 months respectively. Transverse colostomy was needed in 6 patients for anastomotic leakage, thereafter developed anastomotic stricture, managed with regular anastomotic dilatation.&#x0D; Conclusion: Advancement in pediatric anesthesia, improvement of pediatric surgical expertise, perioperative management and nursing care has made single-stage primary transanalendorectal pull-through a feasible and safe surgical procedure for the treatment of short segment Hirschsprung's disease in neonate.&#x0D; Journal of Surgical Sciences (2014) Vol. 18 (2) : 45-50

Cryopreserved Venous Allografts in Supra-inguinal Reconstructions: A Single Centre Experience

This study introduces a novel technique for supra-inguinal arterial reconstructions with cryopreserved femoral vein and caval allografts with a low re-infection rate and an acceptable graft re-intervention rate on early mid term analysis. Patients treated from February 2012 to March 2018 with cryopreserved venous allograft reconstructions owing to infection in the supra-inguinal area were reviewed retrospectively. The primary end points were re-infection and the treatment related mortality rate. Secondary end points were 30 and 90 day and overall mortality and graft re-intervention rate. Of the 23 patients treated with cryopreserved venous allografts for infection in aorto-iliac area, 21 (91%) patients underwent reconstruction with cryopreserved femoral veins and two (9%) with vena cava. Indications for treatment were aortic graft infections (n=12 [52%]), mycotic aneurysms (n=5 [22%]), femorofemoral prosthetic infections (n=3 [13%]), anastomotic pseudo-aneurysms (n=2 [9%]), and aortic thrombosis with intestinal spillage (n=1 [4%]). In hospital and 90 day mortality were 9% (n=2); overall treatment related mortality during the median follow up of 15 months was 13% (n=3). During the follow up, two allografts were re-operated on owing to anastomotic dilatation and one because of re-infection, resulting in a re-intervention rate of 13% (n=3). None of the grafts was lost and there were no amputations. At the end of follow up 17 patients (74%) were alive. Kaplan-Meier estimation for survival was 76% (95% confidence interval [CI] 57%-95%) at one year and 70% (95% CI 49%-91%) at two years. Cryopreserved venous allografts appear to be an infection resistant and reasonably safe reconstruction material in the aorto-iliac axis based upon the early mid term analysis from a single centre experience. Further research is needed to compare their performance with other biological reconstruction material.

DOZ047.73: Endoscopic treatment of esophageal atresia

Abstract Aim of the Study The aim of this study was to provide an overview of endoscopic treatment in children after reconstruction of esophageal atresia. Methods This study, conducted at a single tertiary center, reviewed patients requiring endoscopic treatment during a 15-year period, from 2004 to 2018. Collected data include number, frequency, complications, and effectiveness of esophageal anastomotic dilations. Results A total of 55 children with esophageal atresia (EA) underwent upper gastrointestinal endoscopy. Of those, 37 required therapeutic endoscopy with dilation procedures for anastomotic strictures. Thirty-five patients underwent dilations using only through-the-scope (TTS) balloon (BD),1 patient using only a Savary bougie (SB), and 1 using both. A total of 126 dilations were performed using BD in 36 patients and 6 dilations using SB in 2 patients. Specifically, in children treated only with BD were performed 1 dilation in 6 children (17.1%), 2 in 6 children (17.1%), 3 in 7 children (20%), 4 in 6 children (17.1%), 5 in 6 children (17.1%), 7 in 2 children (5.7%), and 8 in 2 children (5.7%). Balloon catheter sizes ranged from 6 mm to 15 mm. In 2 patients (5.4%) stents were placed, 1 and 6 stents, respectively. Intralesional triamcinolone was injected in 8 patients (21.6%) as additional therapy. Major complications included perforation in 4 patients (10,8%), resolved with conservative treatment. All patients had clinical improvement in the follow-up. Conclusion Currently, endoscopic treatment for esophageal anastomotic stricture is the first procedure adopted in clinical practice after the surgical approach, since it is regarded safe and effective. Balloon dilations are preferred in our overview as a treatment option for esophageal anastomotic strictures. Symptom relief is reported in all cases, while the rate of complications is very low. Sometimes, refractory strictures influence the patient's quality of life and therapeutic alternatives such as stent placement should be considered.

Pneumonia after Repair of Esophageal Atresia-Incidence and Main Risk Factors.

Esophageal atresia (EA) is associated with significant respiratory mortality. We aimed to assess incidence and predictive factors of EA associated pneumonia during the first 5 years of life. Institutional ethical consent was obtained. Hospital records of patients with EA from 2002 to 2017 were reviewed. Episodes of pneumonia that were diagnosed in university or regional hospitals were included. For instance, respiratory infections other than pneumonia, anastomotic complications, aortopexy, fundoplication, major EA associated diseases, types of EA, and EA anastomosis dilatations were tested as potential risk factors for pneumonia. A total of 104 patients (56 males; type A 7, B 3, C 83, D 3, E 6, F 2) was included. Thirty-five (34%) patients had 94 episodes of pneumonia corresponding to median 2 (IQR [interquartile range]: 1-4) and 609 episodes per thousand patient years. Majority of pneumonias occurred before the age of 3 years. The cause of pneumonias could be identified as RS (respiratory syncytial) virus in 15(16%) and aspiration in seven (7.4%) episodes. In univariate analysis, pneumonia was predicted by occurrence and number of nonpneumonia respiratory infections, anastomotic reoperations, fundoplication, and number of EA anastomosis dilatations. In multivariate logistic regression analysis, significant risk factors for pneumonia were occurrence of nonpneumonia respiratory infections and number of anastomotic dilatations. Episodes of pneumonia occurred in one-third of patients with EA. After the final repair, the incidence of pneumonia was highest during the first 3 years of life. Patients with other acute respiratory infections and high number of dilatations were at the greatest risk.

PS01.195: UNCOMPLICATED GASTRIC CONDUIT FOR ESOPHAGEAL REPLACEMENT

Abstract Background Stomach is the most common conduit used for esophageal replacement. An properly constructed conduit is of paramount importance to success of the surgical procedure. We share our method (power point presentation) of creating gastric conduit with good results. Methods Standarized surgical technique (power point presentation) applied over last 50 consecutive esophagectomy for carcinoma esophagus during March 2016 and September 2017 in our institution by a single surgen and the surgical results were analysed. The primary end points were anastomotic leak, conduit necrosis and the secondary end points were need for anastomotic or pyloric dilatation. Results Radical esophagectomy for carcinoma esophagus with gastric pull up and neck anastomosis were performed in all (n = 50, male; 39, female;11, mean age of 51.3 + -11.2 years). There were 41 hybrid (thoracoscopy and laparotomy) and 9 total thoracolaparoscopic procedure. There were 0% anastomotic leak or conduit necrosis and at follow up of 3 months there were only 2 cases who needed anastomotic dilatation and none required pyloric dilatation. Conclusion Surgical complication related to the conduit can be minimised by standarising the surgical technique of its creation. Disclosure All authors have declared no conflicts of interest.

Tu2004 EOSINOPHILIC ESOPHAGITIS IN CHILDREN WITH ESOPHAGEAL ATRESIA: IS THERE AN ASSOCIATION?

Dysphagia is a common symptom after surgical repair of esophageal atresia (EA), usually related to stricture, dysmotility and peptic esophagitis. Recent studies suggest that esinophilic esophagitis (EoE) play a role in the reoccurrence of strictures in patients with EA. The aim of this study was to evaluate the association of EA and EoE in patients undergoing esofagogastroduodenoscopy (EGD) in a pediatric hospital in Rio de Janeiro, Brazil. A prospective longitudinal study was carried out in patients with EA who were submitted to EGD in a period of 6 months in a Pediatric Hospital in Brazil. The data collected were age, sex, type of EA, associated diseases, type of surgery performed, peripheral eosinophilia, clinical indication, endoscopy features and endoscopy biopsies. All patients presenting symptoms underwent EGD and biopsies of the proximal and distal esophagus. When stenosis was diagnosed, anastomotic dilatation was carried out. Seventeen patients were included in this study, and 10 were male (59%). Sixteen children (94%) had EA with distal fistula and one (6%) EA with proximal fistula. Thirteen patients (77%) were submitted to surgical repair with ligation of the fistula and 4 (23%) were submitted to gastric transposition. The most commonly associated disease was pneumopathy in 8 children (47%) and 3 (18%) had food allergies. 6 (35%) of patients were using proton pump inhibitor. The most common indication of endoscopy was dysphagia (65% patients) and 13 patients (76%) had symptoms in the first year after surgery. Eleven patients (65%) had stenosis of anastomotic and were submitted to esophageal dilatation. One patient (6%) had recanalization of the tracheoesophageal fistula. Only one patient (6%) had histological findings consistent with EoE. This patient was a 5 year-old girl with recurrent respiratory infection and gagging, without peripheral eosinophilia, and without esophageal anastomotic stricture. In our study, we found an association of EA and EoE in only one patient. It may be justified by the fact that most of our patients present dysphagia early in the postoperative period. In these cases, this symptom is more frequently related to an anastomotic stricture. Eosinophilic esophagitis is more often found in patients with EA repair and dysphagia later on in life. Although further studies are needed to follow up these patients, we recommend early routine endoscopy in all symptomatic infants after EA repair. We also recommend esophageal biopsies to exclude EOE in EA patients with symptoms that are refractory to IBP or recurrent stricture. Endoscopy with esophageal biopsies is reported to be associated with few complications, there has been an increasing prevalence of EoE in recent years, and patients who are treated for EoE early in the course of the disease, stricture formation may be prevented.