Esophageal Atresia With Tracheoesophageal Fistula Research Articles

A 3D printed esophageal atresia–tracheoesophageal fistula thorascopy simulator for young surgeons

We developed a 3D-printed thoracoscopic surgery simulator for esophageal atresia with tracheoesophageal fistula (EA-TEF) and assessed its effectiveness in educating young pediatric surgeons. Prototype production and modifications were repeated five times before producing the 3-D printed final product based on a patient’s preoperative chest computed tomography. A 24-item survey was used to rate the simulator, adapted from a previous report, with 16 young surgeons with an average of 6.2 years of experience in pediatric surgery for validation. Reusable parts of the thoracic cage were printed to combine with replaceable parts. Each structure was fabricated using diverse printing materials, and subsequently affixed to a frame. In evaluating the simulator, the scores for each factor were 4.33, 4.33, 4.27, 4.31, 4.63, and 4.75 out of 5, respectively, with the highest ratings in value and relevance. The global rating was 3.38 out of 4, with ten stating that it could be used with slight improvements. The most common comment from participants was that the esophageal anastomosis was close to the actual EA-TEF surgery. The 3D-printed thoracoscopic EA-TEF surgery simulator was developed and reflected the actual surgical environment. It could become an effective method of training young pediatric surgeons.

ARE LOW BIRTH WEIGHT AND MAJOR CONGENITAL HEART DISEASES CONTRAINDICATIONS FOR THORACOSCOPIC REPAIR OF ESOPHAGEAL ATRESIA WITH TRACHEOESOPHAGEAL FISTULA?

BACKGROUND Thoracoscopic repair of esophageal atresia (EA) with tracheoesophageal fistula (TEF) is becoming an increasingly widespread technique; there is still controversy about its indication in certain patients. Our objective is to analyze if potential risk factors such as major congenital heart disease (CHD) or low birth weight are a limitation to this approach. METHODS Retrospective study (2017-2021) of patients with EA and distal TEF who underwent thoracoscopic repair were included. Patients with low birth weight <2000g or major congenital heart disease were compared to the rest. RESULTS Twenty-five patients underwent thoracoscopic surgery. Nine patients (36%) had major CHD. Five of them (20%) were low birth weight <2000g and only 8% presented both risk factors (2/25). There were no differences in terms of operative time, conversion rate, tolerance evaluated with gasometric parameters (pO2, pCO2, pH) or complications (anastomotic leak and stricture, both early or during follow-up) in patients with major CHD and LBW (1473 ± 319g vs 2664 ± 402g). One conversion to thoracotomy was performed in a baby weighing 1050 g due to anesthetic intolerance. There was no recurrence of TEF. One patient died at the age of 9 months, due to major uncorrectable heart disease. CONCLUSIONS Thoracoscopic repair of EA/TEF is feasible technique in patients with CHD or LBW, with similar results to other patients. The complexity of this technique warrants individualizing the indication in each case.

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.

Thoracoscopy versus thoracotomy for esophageal atresia and tracheoesophageal fistula: Outcomes from the Midwest Pediatric Surgery Consortium

Background/purposeControversy persists regarding the ideal surgical approach for repair of esophageal atresia with tracheoesophageal fistula (EA/TEF). We examined complications and outcomes of infants undergoing thoracoscopy and thoracotomy for repair of Type C EA/TEF using propensity score-based overlap weights to minimize the effects of selection bias. MethodsSecondary analysis of two databases from multicenter retrospective and prospective studies examining outcomes of infants with proximal EA and distal TEF who underwent repair at 11 institutions was performed based on surgical approach. Regression analysis using propensity score-based overlap weights was utilized to evaluate outcomes of patients undergoing thoracotomy or thoracoscopy for Type C EA/TEF repair. ResultsOf 504 patients included, 448 (89%) underwent thoracotomy and 56 (11%) thoracoscopy. Patients undergoing thoracoscopy were more likely to be full term (37.9 vs. 36.3 weeks estimated gestational age, p < 0.001), have a higher weight at operative repair (2.9 vs. 2.6 kg, p < 0.001), and less likely to have congenital heart disease (16% vs. 39%, p < 0.001). Postoperative stricture rate did not differ by approach, 29 (52%) thoracoscopy and 198 (44%) thoracotomy (p = 0.42). Similarly, there was no significant difference in time from surgery to stricture formation (p > 0.26). Regression analysis using propensity score-based overlap weighting found no significant difference in the odds of vocal cord paresis or paralysis (OR 1.087 p = 0.885), odds of anastomotic leak (OR 1.683 p = 0.123), the hazard of time to anastomotic stricture (HR 1.204 p = 0.378), or the number of dilations (IRR 1.182 p = 0.519) between thoracoscopy and thoracotomy. ConclusionInfants undergoing thoracoscopic repair of Type C EA/TEF are more commonly full term, with higher weight at repair, and without congenital heart disease as compared to infants repaired via thoracotomy. Utilizing propensity score-based overlap weighting to minimize the effects of selection bias, we found no significant difference in complications based on surgical approach. However, our study may be underpowered to detect such outcome differences owing to the small number of infants undergoing thoracoscopic repair. Level of evidenceLevel III.

A case of esophageal atresia complicated by a right-sided aortic arch with right ductus arteriosus and inferior vena cava interruption with hemiazygos continuation

During the repair of esophageal atresia with tracheoesophageal fistula (EA/TEF), cardiovascular malformations occasionally create a technical challenge. We report a novel case of a 4-day-old girl with EA/TEF and multiple cardiovascular malformations, including right-sided aortic arch (RAA), right ductus arteriosus (RDA), single ventricle with single atrium, common atrioventricular valve, pulmonary atresia, bilateral superior vena cava, and interruption of the inferior vena cava (IVC) with hemiazygos continuation. In this case, a right-sided approach would require the mobilization of the RAA and RDA, which were supplying the pulmonary blood flow due to pulmonary atresia. Alternatively, the left-sided approach would require the mobilization of the hemiazygos vein, which was essential for venous return from the lower body due to IVC interruption. We performed the less intrusive left-sided approach, and the postoperative course was uneventful. Right-sided EA/TEF repair should be avoided because RDA spasm or injury caused by RAA mobilization would be fatal. In cases of interrupted IVC with azygos or hemiazygos vein continuation, care must be taken not to ligate these vessels or block the venous return. Preoperative evaluation is important to prevent complications in such complicated cases. If sufficient information is not available, the left-sided approach may be preferred. • In case of RAA with RDA, the EA/TEF repair should be approached from the left side. •Detection of cardiovascular malformations is necessary in case of EA/TEF with RAA. •This is the first case report of EA/TEF with RAA that clearly records RDA.

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.

КОМБИНАЦИЯ АТРЕЗИИ ПИЩЕВОДА С ТРАХЕОПИЩЕВОДНЫМ СВИЩОМ И ДУОДЕНАЛЬНОЙ АТРЕЗИЕЙ: АНАЛИЗ ЛЕЧЕНИЯ ПЯТНАДЦАТИ ПАЦИЕНТОВ

КОМБИНАЦИЯ АТРЕЗИИ ПИЩЕВОДА С ТРАХЕОПИЩЕВОДНЫМ СВИЩОМ И ДУОДЕНАЛЬНОЙ АТРЕЗИЕЙ: АНАЛИЗ ЛЕЧЕНИЯ ПЯТНАДЦАТИ ПАЦИЕНТОВ

Newborn with annular pancreas and H-Type tracheoesophageal fistula

Esophageal atresia with tracheoesophageal fistula (EA/TEF) and annular pancreas are both rare congenital anomalies, with very few reports of neonates presenting with both. More specifically, there are no reported cases of neonates with both annular pancreas and the rarest form of TEF, the H-type fistula. Here, we present the case of a neonate with annular pancreas diagnosed at birth requiring duodenoduodenostomy with delayed diagnosis of concomitant H-type TEF requiring subsequent fistula ligation with favorable outcomes. When patients with known congenital anomalies have persistent symptoms of unidentified etiology, heightened suspicion for other concomitant congenital anomalies can lead to prompt diagnosis, timely surgical management and good outcomes.

A unique case of distal tracheoesophageal fistula with proximal esophageal atresia duplication

Esophageal atresia with tracheoesophageal fistula (EA-TEF) is a congenital malformation typically identified during the neonate period. TEFs are classified according to their anatomic configuration. We present a case that demonstrates a unique anomaly that involves a distal TEF with proximal esophageal atresia duplication. Our case reveals the importance of preoperative planning and intraoperative exploration during this surgical procedure.

Effect of transanastomotic feeding tubes on anastomotic strictures in patients with esophageal atresia and tracheoesophageal fistula: The Quebec experience

PurposeRecent studies have identified transanastomotic tubes (TATs) as a risk factor for the development of anastomotic strictures after repair of esophageal atresia with tracheoesophageal fistula (EATEF). We further investigated these findings in a multicenter study. MethodsWe conducted a retrospective cohort study at three university-affiliated hospitals in the province of Quebec. All patients with types C and D EATEF who underwent primary repair between January 1993 and August 2018 were included. Anastomotic stricture was defined as clinical symptoms of stricture with confirmation on esophagram or endoscopy. Multivariate logistic regression and the Wilcoxon Rank-Sum test were used to evaluate the primary outcome of stricture within one year of surgery and secondary outcome of duration of postoperative total parenteral nutrition (TPN). Results244 patients were included, of which 234 (96%) were type C and 10 (4%) were type D. The anastomotic stricture rate at 1 year was 30%. TATs were utilized in 61% of patients. Thirty-six percent of patients with TATs developed a stricture within one year, as compared to 19% of patients without TATs (p = 0.005). TATs were associated with stricture on univariate analysis (OR 2.49, p = 0.004, 95% CI: 1.37–4.69). On multivariate analysis, after adjusting for gestational age, birth weight, leak, long gap, anastomotic tension, and daily acid suppression, patients with TATs had 2.72 times higher odds of developing a stricture as compared to patients without TATs (p = 0.006, 95% CI: 1.35–5.74). The median duration of TPN was 9 days in both groups (p = 0.139, IQR 6–14 in patients with TATs versus IQR 7–16 in patients without). ConclusionTransanastomotic tubes are associated with a significantly higher risk of postoperative stricture following repair of esophageal atresia with tracheoesophageal fistula and do not shorten the duration of total parenteral nutrition. Level of evidenceIII.

Vascular and pulmonary comorbidities in children with congenital EA/TEF.

Esophageal atresia with tracheoesophageal fistula (EA/TEF) is associated with many congenital and vascular malformations; however, reports utilizing computed tomography (CT) and computed tomography angiography (CTA) are limited. The objective of this study is to review CT scans of the chest from patients with EA/TEF and report their pulmonary and vascular findings. We completed a retrospective chart review of children with congenital EA/TEF evaluated in the aerodigestive clinic at Children's Hospital Colorado. Results of the most recent CTA or CT of the chest were investigated. Demographics, medical conditions, and bronchoscopy findings were also recorded. The ratio of tracheal lumen area between inspiratory and expiratory CTA images was measured. Of the patients with congenital EA/TEF seen in the program, 47 patients had a chest CT available for review. Eight patients (17%) had bronchiectasis. Of the contrast CT scans, 15 (58%) had a vascular abnormality and 16 (62%) demonstrated tracheal compression (38% at the level of the innominate artery, 35% from other structures). Nineteen of the CTAs had volumetric expiratory images of the trachea to evaluate tracheomalacia. The mean expiratory:inspiratory area was 0.57 (SD ± 0.23) at the level of the innominate. Patients with EA/TEF frequently have vascular abnormalities that may alter airway mechanics as well as pulmonary comorbidities that may affect long-term management. For patients experiencing persistent respiratory symptoms, CTA of the chest should be considered adjunct to bronchoscopy to help with medical and surgical management of these children.

The learning curve for thoracoscopic repair of esophageal atresia with distal tracheoesophageal fistula: A cumulative sum analysis

BackgroundThoracoscopic repair of esophageal atresia with tracheoesophageal fistula (EA/TEF) remains technically challenging due to the rarity of these procedures. The aim of this study is to report our experience with thoracoscopic repair of type C EA/TEF and to evaluate the learning curve based upon the surgeon's skill level. MethodsWe retrospectively reviewed data of thoracoscopic EA/TEF repair performed in our center between October 2008 and May 2019. The learning curve was evaluated using the cumulative sum (CUSUM) method based on operative time. ResultsOf the 50 consecutive cases evaluated, the mean birth weight was 2634 ± 608 g and the median age at operation was 3 days (range, 1–29 days). The mean operation time was 144 ± 65 min. Anastomosis leakage occurred in 3 cases (6%) and strictures requiring balloon dilatations occurred in 16 cases (32%). The CUSUM analysis evaluated a learning curve of approximately 10 cases of thoracoscopic type C EA/TEF repair. A lower gestational age was associated with longer operation time. ConclusionsThoracoscopic repair of type C EA/TEF is a feasible and safe procedure. The number of procedures required to achieve a stable learning curve was 10. The learning phase may be shortened by adequate set-up under the supervision of an expert endoscopic surgeon. Type of studyRetrospective Comparative Treatment Study. Level of evidenceIII

Insufflation in minimally invasive surgery: Is there any advantage in staying low?

AimMinimally invasive repair of esophageal atresia with tracheoesophageal fistula (EA/TEF) and congenital diaphragmatic hernia (CDH) is feasible and confers benefits compared to thoracotomy or laparotomy. However, carbon dioxide (CO2) insufflation can lead to hypercapnia and acidosis. We sought to determine the effect of lower insufflation pressures on patients' surrogate markers for CO2 absorption — arterial partial pressure of CO2 (PaCO2), end tidal CO2 (EtCO2) and pH. MethodsSingle center retrospective review, including neonates without major cardiac anomaly. Selected patients formed 2 groups: Historical pressure (HP) group and low pressure (LP) group. We reported on the patients' preoperative characteristics that potentially confound the degree of CO2 absorption or elimination. Outcome measures were perioperative PaCO2, EtCO2, arterial pH and anesthetic time. Results30 patients underwent minimally invasive surgery for CDH and 24 patients for EA/TEF with similar distribution within the HP and LP group. For CDH patients as well as for EA/TEF patients, there were no significant differences in their preoperative characteristics or surgery duration comparing HP and LP groups. With a decrease in insufflation pressure in CDH patients, there were a significant decrease (p = 0.002) in peak PaCO2 and an improvement in nadir pH (p = 0.01). For the EA/TEF patients, the decrease in insufflation pressure was associated with a significant decrease (p = 0.03) in peak EtCO2. Considering all 54 patients, we found EtCO2 to be highly significantly inversely correlated with pH and positively correlated with intraoperative PaCO2 (p < 0.001). Baseline Hb was inversely correlated with mean EtCO2 (p < 0.001). ConclusionWith lower insufflation pressures, CDH patients had significantly improved hypercapnia and acidosis, while EA/TEF patients had significantly reduced EtCO2. EtCO2 was correlated with acidosis and hypercapnia. Type of studyRetrospective case control study. Level of evidenceLevel III.

Novel approach for the dissection of upper pouch during primary repair of esophageal atresia with tracheoesophageal fistula: Technique and results

BackgroundWe describe a technical modification to approach for dissection of proximal pouch in patients undergoing the primary repair of congenital Esophageal atresia with tracheoesophageal fistula (EA-TEF). MethodsA prospective comparative study was performed from January 2016 to December, 2019 including the patients who were undergoing primary repair of EA-TEF (Type C). The patients were divided into Group A (upper pouch dissection by classical approach) and Group B (technical modification). The two groups were compared for operative outcome and complications. Modified OSATS score was used to rate the performance of operators in two groups and were compared. ResultsTotal of 70 patients were included. In Group B, the mean operating time was less compared to Group A. The incidence of tracheal injury was also less when compared to previous data (p = 0.042). Mean OSATS score for flow of operation and overall performance was better in Group B (p = 0.002, p = 0.005). The OSATS score was also better for fifth and seventh case in Group B, proving its faster learning by trainee fellows. ConclusionThe technical modification decreases chances of tracheal injury and shortens the learning curve for upper pouch dissection. Level of evidenceLevel III.

Crossover Upper Pouch in Type C Esophageal Atresia: An Uncommon Variant Causing Diagnostic Dilemma

Esophageal atresia with tracheoesophageal fistula (EA-TEF) is a well-known congenital anomaly and Type C variety of gross classification is the most common. Even for Type C variety, anatomy of upper pouch and lower pouch is not always the same. We are presenting three cases of Type C EA-TEF with unusual anatomy. In this type, upper pouch crosses over the lower pouch for a significant length. The cases are described here to highlight this variant of Type C EA-TEF which produces diagnostic dilemma. An early diagnosis of this variant, prevents morbidity and mortality.

Repair of congenital esophageal atresia with tracheoesophageal fistula repair in Ontario over the last 20years: Volume and outcomes.

This study was designed to determine the volume, postoperative surgical outcomes and, if possible, the relationship between outcome and institutional / surgeon volume in neonates undergoing repair of esophageal atresia with tracheoesophageal fistula (EA-TEF) over the last 20years in Ontario. Using administrative databases, a population based cohort study of patients undergoing EA-TEF repair in Ontario between 1993 and 2012 was conducted. 465 patients with the diagnosis of EA-TEF met inclusion criteria. The mean number of EA-TEF repairs per year per was 5.8. There was a significant difference in hospital annual volume between institutions (range 12.3-3.35: p<0.05). The average number of cases/surgeon for the last 10 study years ranged between 0.5 and 2 cases/year. Primary outcome revealed that repair of recurrent fistula or intestinal interposition was 5.3%, with no reportable difference between institutions. Secondary outcomes revealed that 45.6% underwent dilatation for esophageal strictures, and 19.8% underwent some type of drainage procedure of the chest. These rates were not significantly different between institutions. This study provides insight into the outcomes following EA-TEF repair in Ontario and the difficulty in determining surgeon or institution volume outcome relationships, as both primary and secondary outcome event rates are very low. 2.

Minimally Invasive Surgery for Esophageal Atresia with Tracheoesophageal Fistula After Low Esophageal Banding in a Low-Birth Weight Infant

Background: Birth body weight has been recognized as a remarkable prognostic factor in esophageal atresia with tracheoesophageal fistula (EA/TEF). Surgical repair, either open or thoracoscopic, leads to inevitable lung manipulation and adversely affects lung functions. Low esophageal banding (LEB) has been recommended in high-risk patients as the initial operation, which temporarily occludes the esophagocardiac junction (ECJ) and prevents the communication between airway and stomach.1,2 The definitive surgical repair can be conducted in stable conditions of adequate body weight and better lung functions. We present a low-birth weight infant with EA/TEF who received minimally invasive surgery after LEB. Materials and Methods: A premature infant was born with birth weight of 1389 g. Nasal respirator support was required for respiratory distress soon after birth. Contrast study showed EA/TEF. The abdomen was progressively distended because of constant air pumping into the stomach. A decision was made to perform LEB on day 2 of life. Through an upper midline incision, a 12F G-tube was initially placed to decompress the pumping air from TEF and have a better surgical exposure. The ECJ was identified. A retroesophageal window was made. The low esophagus was wrapped doubly circumferentially with a vessel loop. Two clips were put on the vessel loop to tighten up the banding. Enteral feeding through the G-tube was initiated on postoperative day 3 after the contrast study confirmed no gastroesophageal reflux. At 45 days of age with the body weight of 2569 g, thoracoscopic repair was arranged. The patient was placed in the left semiprone position. Three ports of 5, 5, and 3 mm were made at 1 cm below the scapular tip, fourth, and sixth intercostal spaces along midaxillary line, respectively. Lung was collapsed with CO2 insufflation at pressure of 3 mm Hg. The azygos vein was cauterized and divided. TEF was clipped with a hemolock and left undivided at this time point. The proximal esophageal pouch was mobilized. After confirmation that the proximal esophagus has appropriate length, TEF was divided. An 8F feeding tube was inserted into the distal esophagus until resistance was encountered. Esophagoesophagostomy was accomplished with 5-0 polydioxanone interruptedly. A chest tube was placed. The patient was changed to supine position for laparoscopic banding removal. Severe adhesions were noted particularly between the anterior stomach wall and the liver. A loose space was found between pylorus and liver. Continuing dissection upward along the lesser curvature of the stomach, the vessel loop was discovered and removed. Under the direct vision of transgastrostomy endoscope, the nasogastric tube was placed into the stomach smoothly. Results and Conclusions: There was no leakage shown in the esophagogram on postoperative day 10. Oral feeding was restored. Minimally invasive EA/TEF repair is technically feasible after LEB. A long vessel loop should be left along the lesser curvature of the stomach to facilitate banding removal. No competing financial interests exist. Runtime of video: 6 mins 9 secs

Evaluation of developmental prognosis for esophageal atresia with tracheoesophageal fistula.

This study investigated risk factors for developmental disorders after the repair of esophageal atresia with tracheoesophageal fistula (EA/TEF). The clinical charts of all infants with EA/TEF (gross type C) treated at our institution between 1993 and 2013 were analyzed. Patients with chromosomal aberrations were excluded. Forty-seven patients were divided into groups according to the presence (D) or absence (N) of developmental disorders. Patients were assessed with appropriate developmental examinations at age >3years. Group D comprised 13 patients. The 34 patients in the group N had received a standard education. In groups D and N, gestational age was 36.5 versus 38.5weeks, birth weight was 1808 versus 2662g, and congenital cardiac anomalies occurred in 76.9 versus 23.5%. These differences reached significance. Operative data did not differ significantly. Overall complications occurred in 69.2 versus 29.4%, gastroesophageal reflux (GER) requiring fundoplication in 46.1 versus 8.8%, and oral ingestion difficulty in 61.5 versus 14.7%, which were significantly different. The frequencies of anastomotic leakage, anastomotic stricture, and recurrent fistula did not differ significantly. Gestation, birth weight, and cardiac anomalies could be risk factors for developmental disorders. Moreover, overall complications, GER, and oral ingestion may affect development.

Evaluation of the intraoperative risk factors for esophageal anastomotic complications after primary repair of esophageal atresia with tracheoesophageal fistula.

The aim of this study is to identify the risk factors for esophageal anastomotic stricture (EAS) and/or anastomotic leakage (EAL) after primary repair of esophageal atresia with tracheoesophageal fistula (EA/TEF) in infants. A retrospective chart review of 52 patients with congenital EA/TEF between January 2000 and December 2015 was conducted. Univariate and multivariate analyses were performed to identify the risk factors for anastomotic complications. Twenty-four patients were excluded from the analysis because they had insufficient data, trisomy 18 syndrome, delayed anastomosis, or multi-staged operations; the remaining 28 were included. Twelve patients (42.9%) had anastomotic complications. EAS occurred in 12 patients (42.9%), and one of them had EAL (3.57%). There was no correlation between anastomotic complications and birth weight, gestational weeks, sex, the presence of an associated anomaly, age at the time of repair, gap between the upper pouch and lower pouch of the esophagus, number of sutures, blood loss, and gastroesophageal reflux. Anastomosis under tension and tracheomalacia were identified as risk factors for anastomotic complications (odds ratio 15, 95% confidence interval (CI) 1.53-390.0 and odds ratio 8, 95% CI 1.33-71.2, respectively). Surgeons should carefully perform anastomosis under less tension to prevent anastomotic complications in the primary repair of EA/TEF.

Determinants of gap length in esophageal atresia with tracheoesophageal fistula and the impact of gap length on outcome.

Aim:This study was aimed at identifying factors which may affect the gap length in cases of esophageal atresia with tracheoesophageal fistula (EA-TEF) and whether gap length plays any role in determining the outcome.Materials and Methods:All consecutive cases of EA-TEF were included and different patient parameters were recorded. Plain radiographs with a nasogastric tube in the upper esophagus were taken. Patients were grouped into T1-T2; T2-T3; T3-T4; and T4 depending on the thoracic vertebral level of the arrest of the tube. During surgery, the gap length between the pouches was measured using a Vernier caliper and the patients were grouped into A, B, and C (gap length >2.1 cm; >1-≤2 cm and ≤1 cm). The operative gap groups were compared with the radiography groups and the other recorded parameters.Results:Total numbers of cases were 69. Birth weight was found to be significantly lower in Group A (mean = 2.14 kg) as compared to Group B (mean = 2.38 kg) and Group C patients (mean = 2.49 kg) (P = 0.016). The radiographic groups compared favorably with the intraoperative gap length groups (P < 0.001). The need for postoperative ventilation (70.83% in Group A vs. 36.84% in Group C, P = 0.032) and mortality (62.5%, 26.9% and 15.8% in Group A, B, and C, respectively, P = 0.003) co-related significantly with the gap length.Conclusion:Birth weight had a direct reciprocal relationship with the gap length. Radiographic assessment correlated with intraoperative gap length. Higher gap length was associated with increased need for postoperative ventilation and poor outcome.