End Of Esophagus Research Articles

Esophageal atresia type III? Intraoperative surprise and different approaches.

A newborn was referred due to clinical and radiological suspicion of esophageal atresia (EA) type III. Surgery revealed an esophagus without evident interruptions; however, intraoperative advancement of the nasogastric tube was unsuccessful, and the distal esophagus inflated with each ventilation, indicating the presence of a distal fistula. An intraoperative esophago-tracheobronchoscopy showed a proximal esophageal pouch with a tiny tracheoesophageal fistula and a large distal tracheoesophageal fistula. The esophageal ends were blind but overlapping, with no external discontinuity observed. With the diagnosis of Krediet type IIIc2 esophageal atresia, we performed a meticulous esophago-tracheal dissection, distal fistula closure, and end-to-end anastomosis. Due to hemodynamic instability, the proximal fistula was closed two weeks later via cervicotomy without incidents.

Long-gap esophageal atresia: is native esophagus preservation always possible?

Esophageal atresia (EA) is a congenital defect that causes esophageal discontinuity, often with an associated tracheo-esophageal fistula (TEF) in 70%-90% of cases. When the distance between esophageal ends precludes primary anastomosis, it results in long gap esophageal atresia (LGEA), complicating the surgical management. This study retrospectively reviewed LGEA cases from the past decade, treated with the goal of preserving the native esophagus, comparing surgical techniques and outcomes with current literature. The data of patients treated for LGEA between 2013 and 2024 were collected from medical charts, focusing on patients treated with the preservation of their native esophagus. Ten patients were enrolled for this study. All of them had a gap between the esophageal ends equal to or greater than three vertebral bodies. Four patients (40%) underwent a delayed primary anastomosis (DPA) procedure, while the remaining six (60%) underwent a traction staged repair. All patients were treated with open surgery. The follow-up period extended from 3 months to 10 years. Preserving the native esophagus in patients with LGEA is a challenging but feasible goal, with delayed primary anastomosis and traction techniques playing key roles. We advocate for the preservation of the native esophagus as the preferred approach for ensuring a high quality of life for patients, as it helps to avoid severe long-term complications associated with esophageal substitution.

Application value of high-frequency ultrasound combined with ultrasonography in the diagnosis of neonatal esophageal atresia.

To explore the application value of high-frequency ultrasound combined with ultrasonography in the diagnosis of neonatal esophageal atresia (EA). Seventy neonates with suspected EA who received healing in our hospital from August 2019 to April 2022 were retrospectively selected as the study subjects and their preoperative esophageal high-frequency ultrasound and ultrasound hydrography data were analysed. The diagnostic value of high-frequency ultrasound, ultrasound hydrography and combined detection in neonatal EA was analysed using intraoperative findings as the gold standard. (1) Among the 70 children with suspected EA, 62 were confirmed to be positive and 8 were negative; 59 were positive and 11 were negative by ultrasound hydrography alone; 61 were positive and 9 were negative by high-frequency ultrasound alone; 62 were positive and 8 were negative by combined detection.(2) The accuracy of combined detection was 97.14%, which was notably different from 92.86% by high-frequency ultrasound and 84.29% by ultrasound hydrography (P < 0.05).(3) The diagnostic AUC of ultrasound hydrography, high-frequency ultrasound, and combined detection for EA was 0.6125, 0.6500, and 0.6563, respectively (P < 0.05).(4) There was no significant variation in the distance between preoperative high-frequency ultrasound, ultrasound hydrography, and intraoperative measurements of distal and proximal blind ends of type IIIA and IIIB EA esophagus (P > 0.05). High frequency ultrasound and super fresh water injection angiography have good application value in the diagnosis of neonatal EA. There is no significant difference between the distance between the distal and proximal blind ends of the esophagus before and during the operation of type III EA and that during the operation of super fresh water injection angiography. However, in consideration of the risk of radiation and poisoning caused by esophagography, it is recommended that high-frequency ultrasound be selected first for diagnosis and if necessary, esophagography be supplemented for joint diagnosis.

Two new species of Dichelyne Jägerskiöld, 1902 (Nematoda: Cucullanidae) parasitising marine fishes in Iraq.

Recent examinations of some marine fishes from off the southern coast of Iraq revealed the presence of two new species of Dichelyne (Dichelyne) Jägerskiöld, 1902 (Nematoda: Cucullanidae), both intestinal parasites, namely: D. (D.) lethrini n. sp. from the smalltooth emperor Lethrinus microdon Valenciennes (Lethrinidae, Acanthuriformes) and D. (D.) iraqiensis n. sp. from the humphead snapper Lutjanus sanguineus (Cuvier) (Lutjanidae, Acanthuriformes). Specimens are described and illustrated based on light and scanning electron microscopical examinations. Dichelyne (D.) lethrini n. sp. is mainly characterised by the length of spicules (522 µm), presence of a dorsal caecum, location of deirids at the level of the posterior end of oesophagus and the post-oesophageal position of the excretory pore, number (10 pairs) and distribution of caudal papillae in the male, and the presence of two minute terminal spines on the female tail tip. Dichelyne (D.) iraqiensis n. sp. differs from the species of the subgenus Dichelyne mainly based on the absence of caudal spines, the presence of a dorsal caecum, the length of spicules (789-884 µm), the location of deirids and the excretory pore approximately at the same level, and the size of eggs (72-78 × 42-51 µm). These new species infecting marine fishes in Iraq represent new geographic records of cucullanids of the subgenus Dichelyne from fishes in marine waters off Iraq.

Thoracoscopic Repair of Esophageal Atresia

The surgical repair of esophageal atresia is one of the most difficult and challenging procedures in pediatric surgery. The operation can either be performed in a classic extrapleural open manner via a posterolateral thoracotomy or in a minimally invasive thoracoscopic manner. While good comparative studies are lacking due to the small and heterogeneous patient cohort, there is currently no good evidence for or against the thoracoscopic method. Arguments for open surgery may consist of shorter operation time, and avoidance of the intrapleural space. On the other hand, there could be fewer patients with later scoliosis, thoracic wall defects and winged scapula following thoracoscopic repair. We hereby offer a detailed and step-by-step guide to performing thoracoscopic surgery for esophageal atresia. Using two or more thoracoscopic sliding knots which are tightened one by one in small increments step by step, the two esophagus ends may be brought together, whereby the pull is distributed to different points of the esophagus. Explaining several tricks and pitfalls, this video is intended to serve as a guide for experienced pediatric surgeons to optimally and timely carry out this difficult operation.

Longitudinal Force Measurement and its Relationship to Technical Competence for Esophageal Anastomosis in a Thoracoscopic Esophageal Atresia/Tracheo-Esophageal Fistula Simulator

PurposeThoracoscopic esophageal atresia with tracheo-esophageal fistula (EA/TEF) repair requires the gentle manipulation of delicate tissue. Force sensors were attached to the upper and lower esophagus of a 3D-printed EA/TEF simulator to explore force parameters as markers of performance. MethodsParticipants completed one intracorporeal suture between the anterior walls of upper and lower esophageal ends. Longitudinal force data were recorded at each end. A blinded pediatric surgeon marked attempt videos. Excessive force events, maximum tension, and force interquartile range (IQR) were measured. Data were reported as median (range) significance of p < 0.05. Results17 participants of varying levels of experience performed the task. OSATS scores showed significant differences between experts and novices. Experts completed the task in a median time of 4 min. They used lower maximum tension, higher force IQR, and had fewer excess force events compared to the intermediate and novice groups. DiscussionThe application of force was dependent on expertise with more skilled participants having fewer excess force events. The higher expert force IQR likely reflects the consistent tension needed for task completion. Analysis of force data may be an indicator of competence, and trainees may benefit from a thoracoscopic simulator which provides force data feedback. Level of evidenceNot applicable.

Early tissue growth and cell fate determination following segmental esophageal repair using a tissue engineered esophageal implant composed of a polyurethane scaffold seeded with autologous adipose-derived mesenchymal stromal cells

IntroductionEnd-stage or chronic esophageal disease may eventually lead to surgical intervention and could potentially result in an esophagectomy, followed by a gastric pull-up or colon interposition procedure. Biostage's Cellspan™ Esophageal Implant (CEI) is designed to repair and replace full-circumferential esophageal surgical resections (≤6 cm) using autologous adipose derived mesenchymal stromal cells (Ad-MSCs) seeded on a retrievable polyurethane scaffold. The use of a segmental implant has the advantage of preserving the native non-diseased esophageal tissue as well as the stomach or intestinal tissue following esophagectomy. The mechanism of action, the fate of the Ad-MSC component (biodistribution) and the process of early tissue regrowth/wound repair following implantation remains to be elucidated. MethodsCEIs seeded with Ad-MSCs transduced with green fluorescent protein (GFP) were implanted into a pig model of esophageal segmental resection. A 5 cm full-circumferential esophageal resection was performed followed by CEI implantation using an end-to-end anastomoses to bridge the gap between the 2 native esophageal ends. Cell fate and tissue development were assessed at 14 (N = 3), 21 (N = 3), and 28 days (N = 3), post-CEI implantation. ResultsAll animals in all groups exhibited a contiguous biologic esophageal conduit with a denuded patent lumen at necropsy. Epithelial cell proliferation/regrowth was evident from both anastomotic margins toward the implant center. Morphometric analysis indicated an increase in epithelial regrowth and a concomitant reduction in denuded tissue from day 14 to day 28. Histological evaluation revealed fibrovascular tissue and neovascularization on the adventitial side, with no discernible differences in tissue organization between 14 and 28 day implants. The majority of GFP + cells were on the abluminal esophageal surface and localized around vascular structures. No GFP + cells were detected in lymph nodes or on retrieved scaffolds. ConclusionThese findings support luminal continuity by day 14 post-implantation with Ad-MSC derived pericytes contributing to the neo-fibrovascular tissue. Morphometric analysis of the lumenal surface indicates that the process of lumenal re-epithelialization results from epithelial cell proliferation from the implant margins towards the center of the implant.

Delayed primary anastomosis for repair of long-gap esophageal atresia: technique revisited

The operative management of patients born with long-gap esophageal atresia (LGEA) remains a major challenge for most pediatric surgeons, due to the rarity and complex nature of this malformation. In LGEA, the distance between the proximal and distal esophageal end is too wide, making a primary anastomosis often impossible. Still, every effort should be made to preserve the native esophagus as no other conduit can replace its function in transporting food from the oral cavity to the stomach satisfactorily. In 1981, Puri et al. observed that in newborns with LGEA spontaneous growth and hypertrophy of the two segments occur at a rate faster than overall somatic growth in the absence of any form of mechanical stretching, traction or bouginage. They further noted that maximal natural growth arises in the first 8–12 weeks of life, stimulated by the swallowing reflex and reflux of gastric contents into the lower esophageal pouch. Since then, creation of an initial gastrostomy and continuous suction of the upper esophageal pouch followed by delayed primary anastomosis at approximately 3 months of age has been widely accepted as the preferred treatment option in most LGEA cases, generally providing good functional results. The current article offers a comprehensive update on the various aspects and challenges of this technique including initial preoperative management and subsequent gap assessment, while also discussing potential postoperative complications and long-term outcome.

Suture approximation of esophageal atresia leads to esophageal recanalization

Esophageal atresia is a congenital pathology in 1:4000 live newborns, which can occur isolated, associated with tracheoesophageal fistula or long gap (>2 vertebral bodies); the surgical objective is the ligation of the fistula and the esophageal anastomosis in the same surgery. However, this may not be possible in all cases [1]. The staged approach initially begins with the ligation of the tracheoesophageal fistula and gastrostomy, and definitive surgery focuses on the esophageal anastomosis. It is performed when the patient presents adequate clinical and anatomical conditions. Spontaneous recanalization of esophageal atresia is rare. The exact mechanism by which it occurs is unknown. Gastric reflux, being in contact with the esophageal distal end, generates inflammation and erosion of the wall, producing communication between the esophageal segments. We propose approximating the proximal and distal esophageal segments utilizing sutures produces an inflammatory process due to a foreign body generating a fistulous tract between the two esophageal components and esophageal recanalization [2]. We present two cases of esophageal recanalization to describe the clinical presentation, diagnostic and therapeutic approaches through imaging tests and endoscopy, contributing to the management of this unusual condition. • Esophageal atresia is a challenge; it presents variations in the location of the tracheoesophageal fistula and the length of the esophageal ends. It occurs isolated or associated with malformations. The pediatric surgeon must individualize treatment for each patient. • In all cases, extreme premature patients have hemodynamic alterations and fragile esophageal tissue, which do not allow performing a primary esophageal anastomosis. • Upper gastrointestinal endoscopy is a diagnostic and therapeutic resource in patients with spontaneous esophageal recanalization or the presence of a recurrent tracheoesophageal fistula.

Progressive dysphagia caused by IgG4-related sclerosing disease involving the esophagogastric junction

A 46-year-old man presented at our clinic because of intermittent dysphagia sensations for 1 year, and this symptom had progressed in the recent 2 months. EGD showed a protruding mass with a lobulated surface and firm density, causing a stenotic lumen at the esophagogastric junction (A). The initial pathologic examination of the biopsy specimen showed ulcerated mucosa with granulation tissue and leukocytic infiltration. Repeated EGD was performed to obtain multiple biopsy specimens, and no evidence of malignancy or specific pathogens such as viral and fungal infection was identified by serial stains. Because of the suspicion of esophageal cancer, 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET)/CT was arranged and showed increased FDG uptake at the cardiac portion of the stomach and distal end of the lower esophagus (B). Because of progressive dysphagia and a concern regarding malignancy, esophagectomy was performed, and multiple nodular lesions with fibrotic changes at the esophagogastric junction were found (C). Immunostaining showed increased IgG4-positive plasma cells, finding ≤225 per high-power field, with a 50.2% IgG4+/IgG+ plasma cell ratio (IgG4 stain, orig. mag. ×200) (D). These findings were consistent with IgG4-related sclerosing disease involving the esophagogastric junction.

Biomechanics of regenerated esophageal tissue following the implantation of a tissue engineered CellspanTM Esophageal Implant

The esophagus is a tubular organ with a multi-laminated tissue structure that functions to transport nutrition from the oral cavity to the stomach. Several diseases of the esophagus including congenital disorders require complete surgical esophagectomy. Ideally, segmental removal of the diseased/damaged tissue would spare the unaffected tissue and preserve organ function. To this end, a novel tissue engineered implant, the CellspanTM Esophageal Implant (CEI) was used to repair the esophagus following segmental resection of the thoracic esophagus in a porcine model. The current study investigated the mechanical strength and the associated tissue architecture of the CEI-stimulated tissue. The CEI bridged the proximal and distal native esophageal ends to restore the conduit by stimulating a regeneration process that progressed from a fibrovascular scar at 30-days to a fully epithelialized lumen at 90-days, followed by submucosal regeneration and regeneration of a ‘laminated’ adventitia with smooth muscle development in the 365-day cohort. The mechanical strength of the newly developed tissue as well as the flanking native tissue were assessed using a probe-burst pressure test (ASTM D6797-15). The burst pressures at all three time points were comparable to the native tissue flanking the implant. In addition, the overall pressure required to burst through both the native and regenerated tissues increased with increasing time post-implantation.

Protective Effect of Targeted Fluid Therapy on Patients with One-Lung Ventilation.

Objective To evaluate the protective effect of target-directed fluid therapy on the lungs and postoperative rehabilitation in elderly patients with single-lung ventilation undergoing total endoscopic radical resection of esophageal cancer. Methods Seventy elderly patients who underwent total endoscopic radical resection of esophageal cancer from January 2017 to December 2019 in our hospital were selected and divided into two groups by the random number table method: the goal-directed fluid treatment group (group G, n = 35) and the control group (group C, n = 35). Venous blood was extracted before surgery (T1), at the end of free esophagus (T2) by thoracoscopy, at the end of abdominal surgery (T3), and at the end of surgery (T4). IL-6 and IL-10 levels were detected by ELISA. The clinical pulmonary infection score (CIPS) was used to evaluate the pulmonary inflammation on the second day after surgery and the occurrence of complications. Duration of antibiotic use and length of hospital stay were recorded. Results At T1, there were no significant differences in IL-6 and IL-10 levels between the two groups (P > 0.05). At T2, the IL-6 level in group G increased to 26.65 ± 1.80 pg/ml but was significantly lower than that in group C (32.28 ± 3.22 pg/ml) (P < 0.01). At T3 and T4, IL-6 and IL-10 levels in group G were significantly lower than those in group C (P < 0.01). The CIPS score of group G was lower than that of group C (1.5 ± 1.0 vs 2.7 ± 1.4), and the duration of antibiotic use in group G was shorter than that in group C (211.2 ± 15.4 vs 232.6 ± 18.7 h), with statistical significance (P < 0.01). The incidence of complications in group G was lower than that in group C (28.6% vs 40.0%), and the length of hospital stay in group G was shorter than that in group C (10.5 ± 1.7 vs 11.2 ± 1.9 days), but there was no significant difference between the two groups (P > 0.05). Conclusion Target-directed fluid therapy inhibited inflammatory cytokine levels and had better lung protection, but no significant benefit in the complications or the length of hospital stay was observed.

The role of motion tracking in assessing technical skill acquisition using a neonatal 3D-printed thoracoscopic esophageal atresia/tracheo-esophageal fistula simulator

IntroductionAcquiring the technical skills required for thoracoscopic repair of esophageal atresia with tracheo-esophageal fistula (EA/TEF) is challenging. A high-fidelity 3D-printed pediatric thoracoscopic EA/TEF simulator has been developed to address this issue. This study explored motion-tracking as an assessment tool to distinguish between surgeons of different expertise using the simulator. MethodsParticipants performed a single intracorporeal suture between the esophageal ends in EA with TEF. Total relative path lengths of the right and left surgical instruments were recorded during the task. Each video-recorded attempt was assessed by a blinded pediatric surgeon using a modified Objective Structured Assessment of Technical Skills (OSATS) score. Data recorded as median (range) and statistical significance as p<0.05. ResultsThe task was performed by 17 participants. The median OSATS scores identified a significant difference between experts and novices. A difference between left- and right-hands was only found in the mid-skill level group. Right-hand path length was greatest in novices and lowest in experts. Left-hand path length was greatest in novices and the mid-skill level group compared to experts. ConclusionExperts had the lowest total path length for either hand, suggesting they had the greatest efficiency of movement. The similar high path lengths in both hands for novices indicate their relatively low level of skill with either hand. The difference between right- and left-hand path lengths in the mid-skill level group likely reflects the improved right-handed technical skills in contrast to the still developing left hand. Further focus on the left hand during simulation training may improve left-handed economy of movement.

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.

Endoscopic management of esophageal leak post-heller myotomy for achalasia cardia in children

A 9-year-old male child diagnosed to have achalasia cardia when he presented with a history of vomiting of undigested food particles with poor weight gain. He underwent lap Heller myotomy and Dor fundoplication. The immediate postoperative period was uneventful. After discharge, he presented with peritonitis and septic shock. On contrast-enhanced computed tomography abdomen, leak at the lower end of esophagus with intra-abdominal pus collection was identified. After intra-abdominal pus drainage and stabilizing the child, endoscopic covered stent was placed. He recovered well. Endoscopic esophageal covered stent placement is a viable and best option for a sick child with esophageal leak post-Heller myotomy.

Factors affecting outcome in neonates with esophageal atresia with or without tracheesophageal fistula

BACKGROUND: Esophageal atresia (EA) with or without tracheesophageal fistula (TEF) is a common congenital anomaly requiring urgent surgical intervention after birth. Due to improvement in antenatal diagnosis and postnatal management in neonates with EA, there are better overall survival rates in the developed countries. However, the outcome is still poor in developing countries where multiple factors contribute to higher morbidity and mortality. AIM: To evaluate various factors affecting the perioperative management and their outcome in neonates with EA with or without TEF. MATERIALS AND METHODS: This descriptive observational study was conducted for 4 years. Neonates who underwent surgery for EA with or without TEF at our institute were included. Age of the neonate at presentation, gender, birth weight, period of gestation, antenatal diagnosis records, clinical presentation, associated congenital anomalies, surgical interventions, gap between upper and lower esophageal ends, postoperative complications, and outcome was recorded. RESULTS: Total, 44 neonates underwent surgery for esophageal atresia with or without TEF in our institute. Male-to-female ratio was 2.4:1. The mean birth weight of neonates was 2500 ± 900 g. The mean gestation age was 35 ± 5 weeks. Sepsis was the leading cause of postoperative morbidity seen in 45.5%, followed by anastomotic leak in 22.7%. Postoperative mortality was 59% with the survival rate of 41%. CONCLUSION: Sepsis, hypothermia, delayed diagnosis, delayed referral, aspiration pneumonitis, anastomotic leaks were the preventable factors affecting the outcome.

Detail correction for Gross classification of esophageal atresia based on 434 cases in China.

Detail correction for Gross classification of esophageal atresia based on 434 cases in China.

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.

Per-oral Endoscopic Myotomy with Division of Septum (D-POEM) in Epiphrenic Esophageal Diverticula: Outcomes at a Median Follow-Up of Two Years.

Esophageal epiphrenic diverticula (EED) are rare pulsion-type outpouchings at the lower end of esophagus. Traditionally, surgery has been performed in EED. More recently, per-oral endoscopic myotomy with septotomy (D-POEM) has emerged as an option in these cases. In this study, we aim to determine the efficacy and safety of D-POEM in cases with EED. The data of cases who underwent D-POEM in cases with EED from March 2013 to Nov 2020 were analyzed, retrospectively. The primary outcome of the study was clinical success. Secondary outcomes included technical success, procedure duration, reflux esophagitis, and adverse events. 13 patients (males 9, 48.07 ± 17.55years) with EED underwent D-POEM during the study period. Median size of the EED was 45mm (range 25-70). Associated esophageal motility disorder was found in 10 (76.9%) cases including type II achalasia (3), type I (3), hypercontractile esophagus (2), and unspecified (2). Technical success was achieved in 12 (92.3%) cases. Median length of total and gastric myotomies were 10cm (range 6-20) and 3cm (1-3), respectively. At a median follow-up of 25months, clinical success was achieved in 84.6% cases. Mean integrated relaxation pressures reduced significantly after POEM procedure (25.80 ± 13.24 vs 9.40 ± 3.10, p = 0.001). There was one major adverse event requiring surgical intervention. D-POEM is an effective procedure in cases with EED. Long-term follow-up studies are required to ascertain the durability of response in these cases.

Congenital and acquired tracheoesophageal fistulas in children

Tracheoesophageal fistulas (TEF) are an anomalous communication between airway and esophagus. There are several types of TEF. Congenital are mainly associated to an esophageal atresia. The type III or C, in which the upper segment of the esophagus ends in a blind pouch and there is distal tracheoesophageal fistula above the carina, accounts for 85% of esophageal atresias. The other are extremely infrequent. H-type or N-type TEF, classified as type 5 or E, is an uncommon variant and accounts for less than 4%.Recurrent TEF is a serious complication after first surgery of esophageal atresia and TEF. The rate of recurrence of TEF is estimated between 3-15%. The treatment is a challenge with a high rate of recurrence after surgery.Classical symptoms of RTEF include coughing especially after drinking, abdominal distension, repeated cyanosis, and respiratory infections. In the case of H-type fistula the symptoms are similar but appear during the first month of life.In this chapter we presented the management and alternative treatments of the congenital and acquired TEF.