Esophageal Pouch Research Articles

Studies on the Functional Morphology of the Digestive System of the Fresh Water Thiarid Snail, Mieniplotia scabra (MÜLLER, 1774), Family Thiaridae New to Egypt

Detailed functional morphology of the digestive system of the thiarid snail Mieniplotia scabra is given in this study. The basic anatomical structure is consisting mainly of the mouth opening, the buccal mass, the salivary gland, the esophagus, the stomach, the style sac, the digestive gland, the intestine and the rectum. It confirms to that of any other style – bearing caenogastropods. The muscular structure of the buccal mass of the present snail has been macro and micro anatomically studied. Their structure has been correlated with their function and with the mechanism of feeding. It has been compared with the corresponding constituents of other caenogastropods mainly in family Thiaridae. The esophagus is an almost long tube and divided into three parts; pro - mid-, and post esophagus. The absence of the esophageal pouches and the crop of the alimentary canal of the present species reveal that the present snail is not adapted for cilliary feeding. The main structure of the stomach and the style sac resembles to those described in other thiarid snails. The detailed microanatomy and function of the epithelial lining of the digestive tubules of the digestive gland vary from one group to another thiarid snail according to the mode of feeding and digestion. Thus, in the present style - bearing microphagous herbivorous species the cells of the digestive tubule can be found in any one of the following three phases of activity; absorption, digestion and excretion. Therefore, they may be mainly adapted for intracellular digestion, absorption and excretion. The pro - intestine with its typhlosole, the post - intestine and the rectum have a simple histological structure; each being basically formed of a simple ciliated columnar epithelium with mucus-secreting cells and an outer muscular coat. The anal papilla characterized by the relatively thick muscular coat and long cilia of the epithelial lining.

Short-interval staged thoracoscopic surgery for long-gap esophageal atresia

Long-gap esophageal atresia is defined by the impossibility to perform a primary anastomosis after birth. We propose a progressive traction surgery by thoracoscopy performed at intervals of 5–7 days. We describe the traction technique of the esophageal pouches through the thoracoscopic approach and without performing a gastrostomy. We use sliding sutures and clips to prevent esophageal tearing and preservation of the azygos vein. In a series of three patients, we have being able to reconstruct the esophagus in a period of 1–3 weeks after birth without complications. Repetitive thoracoscopy at shorts intervals in the neonatal period allows a tension-free anastomosis of the esophagus in long-gap type esophageal atresia.

Primary repair of long gap esophageal atresia in a neonate employing circular myotomy on upper pouch and a novel hemicircular myotomy on the distal pouch

Abstract Introduction Pure esophageal atresia (EA) with long gap between the pouches remains a challenge for primary repair. Several techniques to facilitate primary repair in long gap EA have been described: complete mobilization of proximal and/or distal esophageal pouch, single or double circular myotomies or spiral myotomy of upper pouch, circular myotomy of both upper and lower pouch, flaps raised from the upper pouch to bridge the gap and external traction sutures. Some of these techniques are not routinely performed for anatomical reasons or unfamiliarity with the technique. Complete mobilization of upper pouch with circular myotomy is standard and often favored approach. Complete mobilization of lower pouch with or without circular myotomy is described. It has a risk of impairing the blood supply to the lower pouch due to segmental nature of its blood supply. We present a novel case of primary repair of this defect using a circular myotomy on upper pouch along with a hemicircular myotomy of the lower pouch without complete circumferential mobilization of the lower esophageal pouch. This allowed adequate lengthening of the lower pouch without compromising its blood supply facilitating a minimal tension primary repair. Case We report the case of a 38 4/7 term infant with intra-uterine growth retardation (IUGR) and Tetralogy of Fallot (TOF) with a long 4.5 cm gap pure esophageal atresia who was repaired aged 16 weeks. Per-operative gap assessment revealed the gap to more than 4 vertebral bodies. Even after complete mobilization of the upper esophageal pouch, a 2.5 cm (cm) gap persisted. The upper pouch was narrow and hence unsuitable to facilitate flap reconstruction. A single circular myotomy was performed on the upper esophageal pouch approximately 1 cm proximal to its blind end. The lower pouch was then mobilized, taking care that its blood supply was not compromised. This still left a one cm gap that was overcome by performing a hemicircular (180°) myotomy on the lower esophageal pouch approximately 1 cm away from the blind end. A tension free primary esophageal anastomosis was then performed. Post operatively patient developed a stricture which was dilated successfully to 12 Fr (4 mm). No other complications are reported. Conclusion Hemicircular myotomy of the distal esophageal pouch can be employed successfully to achieve primary repair in cases of long gap esophageal atresia. This technique does not require full circumferential mobilization of lower pouch as required with full circular myotomy and has less risk of compromising blood supply to the distal esophageal pouch decreasing risks of anastomotic leak, failure and esophageal motility of lower pouch.

Flap Reconstruction as Alternative Anastomosis Technique for the Surgery of Oesophageal Atresia with Distal Oesophagotracheal Fistula

The creation of a primary anastomosis in newborns with oesophageal atresia and distal oesophageotracheal fistula (EA-DF) is technically challenging, especially in small children. The goal is to approximate the fragile oesophageal ends without suture disruption and to minimize the mobilisation of the lower segment. We describe an alternative anastomosis technique aiming at reducing the tension on the first sutures at the posterior wall. EA-DF was corrected in 13 newborns either by open (n = 11) or thoracoscopic (n = 2) surgery using this technique. The anastomosis technique is based on creation of a dorsal flap of the upper oesophageal pouch and insertion in the spatulated lower oesophageal segment after the fistula has been separated. Subsequently, the first sutures of the posterior wall can be accomplished with reduced tension. Upon completion of the anastomosis, a diagonally shaped anastomotic plane results. The method is a helpful alternative to approximate the oesophageal stumps of newborns with EA and distal oesophagotracheal fistula. By this technique, the first stabilising sutures of the posterior wall can be accomplished with reduced tension. This results in reduced tensile stress on the individual sutures and simplifies the anastomisation in comparison to the conventional end-to-end anastomosis.

Prediction of Gap Length by Plain Radiograph of Chest with Nasogastric Tube in the Upper Esophagus in Patients with Esophageal Atresia and Distal Tracheoesophageal Fistula.

Aim:This study was aimed at prediction of the gap length between the two esophageal ends in cases of esophageal atresia and distal tracheoesophageal fistula (EA-TEF) by preoperative radiography with a nasogastric tube in the upper esophagus and its correlation with intraoperatively measured gap length.Materials and Methods:All consecutive cases of EA-TEF were prospectively included in this study. Plain radiographs were taken with an 8 Fr nasogastric tube inserted in the upper esophageal pouch till its arrest. The patients were grouped into T1-T2; T2-T3; T3-T4; and T4 groups depending on the thoracic vertebral level of arrest of the NG tube on the radiograph. Intraoperative gap between the two esophageal ends was measured with Vernier caliper, and the patients were grouped into A, B, and C groups based on gap length (gap length >2.1 cm; >1–≤2 cm; and ≤1 cm). The operative gap groups were compared with the radiography groups.Results:A total number of 118 cases were included over a period of 3 years. The arrest of nasogastric tube at T1-T2 and T2-T3 vertebral level corresponded to gap length Group A in 39/41 (95.12%) * patients. In gap length Group B, the arrest of tube at T2-T3 and T3-T4 vertebral level was seen in 44/44 (100%)* patients, in gap length Group C, the arrest of tube was noted at T3-T4 and T4 vertebral level in 31/33 (93.93%)* patients (*P < 0.001).Conclusion:Prediction of gap length by vertebral level of arrest of the nasogastric tube in the upper pouch in a preoperative chest X-ray correlated well with intra operatively measured gap length in cases of EA-TEF.

Anisotropic hydrostatic intraluminal esophageal stretch: Prototyping and initial testing in vivo

BackgroundWe sought to fabricate and perform initial safety testing of a hydrostatic device for intraluminal axial distension of the esophagus, as a minimally invasive means of inducing esophageal stretch/lengthening. MethodsThe device consists of a modified infant endotracheal tube fitted with a unique anisotropically expandable balloon at its distal end. Structural integrity and functional parameters of the prototypes were measured in an expansion test rig. Subsequently, the impact of balloon inflation pressures on esophageal perfusion was examined in lambs (n = 6) with surgically created esophageal atresia. The device was placed in the proximal esophageal pouch and its intraluminal pressures were correlated with esophageal perfusion as assessed with a microvascular oximeter based on resonance Raman spectroscopy of hemoglobin. Statistical analyses included repeated measures with generalized estimating equations and inverse regression. ResultsThe helicoidal architecture of the balloon led to consistent anisotropic expansion, with a stable relationship between balloon length, body width, and tip radius during liquid-based expansion within the test rig. There was a significant decrease in oxygen saturation in the esophageal wall at intraluminal pressures ≥30 mmHg (Pearson r = −0.58, Wald test = 17.5, p = 0.027). Regression analysis identified that an intraluminal pressure of 32 mmHg correlated with oxygen saturations below 60% (p < 0.001). ConclusionsControlled axial distension of an esophageal pouch can be achieved via an intraluminal anisotropically expandable hydrostatic device under a predictable, safe relationship between device pressure and esophageal perfusion. Intraluminal esophageal stretch may become a practical option for esophageal lengthening in the management of long gap esophageal atresia. Level of EvidenceN/A (animal and laboratory study).

Thoracoscopic posterior tracheopexy during primary esophageal atresia repair: a new approach to prevent tracheomalacia complications

BackgroundEsophageal atresia (EA) is usually accompanied by some form of tracheomalacia (TM). During the early phases in life, excessive dynamic collapse of the trachea can cause a wide spectrum of symptoms ranging from mild complaints to apparent life-threatening events (ALTE's) or brief resolved unexplained events (BRUE's). Therapeutic strategies for severe TM include aortopexy to lift the anterior weakened cartilaginous rings or posterior tracheopexy of the floppy membranous tracheal intrusion. In this study, we describe the development of a new approach in which the posterior tracheopexy is performed directly during the primary thoracoscopic correction of EA. MethodsIn 2017, all nine consecutive EA patients with trachea-esophageal fistula underwent a rigid tracheo-bronchoscopy (RTB) evaluation during induction of anesthesia prior to the thoracoscopic EA repair. A floppy posterior membrane was diagnosed in four patients. During the subsequent thoracoscopic procedure, the posterior membranous trachea was fixed to the anterior longitudinal spinal ligament with non-absorbable sutures. Then, the anastomosis was made between the two esophageal pouches. ResultsOn preoperative RTB, two patients had a severe (70–90%) mid-tracheal collapse of the pars membranacea and two patients had a moderate (33–40%) mid-tracheal collapse. Thoracoscopic posterior tracheopexy with two or three sutures was possible in all four patients, prior to the formation of the esophageal anastomosis. Median time per suture was 6 min (range 4–12 min). All operative procedures were uneventful. A median follow-up of 6 months (range 4–9 months) revealed that all patients showed further recovery without any TM symptoms or ALTE/BRUE. ConclusionsThis is the first report that introduces a new approach to thoracoscopic posterior tracheopexy during primary EA repair. We believe that this technique can prevent the potentially deleterious sequelae of mild to severe TM that may complicate the lives of EA patients. Also, a second, sometimes complex surgical procedure can be prevented as the posterior tracheopexy is performed during the primary thoracoscopic EA correction. Level of EvidenceIV.

Surgical Surprise in a Case of Pure esophageal atresia: How High Can the Lower Pouch Be?

The gap between the upper and lower pouches in case of pure esophageal atresia (EA) is usually long and requires multistaged repair. However, in rare cases, the gap may be short and can be repaired primarily commonly through thoracotomy approach. We report an unusual case of a 2-day-old baby girl who presented with short gap EA where the lower esophageal pouch was found adjacent to the blind upper pouch in the neck and primary repair could be performed through the cervical route itself.

The Distended Fetal Hypopharynx: A Sensitive and Novel Sign for the Prenatal Diagnosis of Esophageal Atresia

Background/PurposeAlthough advances have been made in the prenatal diagnosis of esophageal atresia (EA), most neonates are not identified until after birth. The distended hypopharynx (DHP) has been suggested as a novel prenatal sign for EA. We assess its diagnostic accuracy and predictive value on ultrasound (US) and magnetic resonance imaging (MRI), both alone and in combination with the esophageal pouch (EP) and secondary signs of EA (polyhydramnios and a small or absent fetal stomach). MethodsWe retrospectively reviewed fetal US and MRI reports and medical records of 88 pregnant women evaluated for possible EA from 2000 to 2016. Seventy-five had postnatal follow-up that confirmed or disproved the diagnosis of EA and were included in our analysis. ResultsSeventy-five women had 107 study visits (range 1–4). DHP and/or EP were seen on US and/or MRI in 36% of patients, and 78% of those patients had EA. DHP was 24% more sensitive for EA than EP, while EP was 30% more specific. After 28weeks of gestation, DHP had a predictive accuracy for EA of 0.929 (P=0.001). ConclusionsDHP is a sensitive additional prenatal sign of EA. More accurate diagnosis of EA allows for improved counseling regarding delivery, postnatal evaluation, and surgical correction. Type of StudyDiagnostic. Level of EvidenceLevel II.

Magnet-Assisted Hydraulic Bougienage for Correction of Long-Gap Esophageal Atresia.

An infant born with long-gap esophageal atresia has its esophagus separated into two pouches, and typically undergoes multiple open-chest surgeries for esophageal reconstruction. In this paper, we study a possible approach for less invasive correction of long-gap esophageal atresia. Our technique utilizes a magnet-tipped catheter with a piston on the end to push the esophageal pouch from the inside. The attractive magnetic force helps the catheter stretch the esophageal pouches, while the hydraulic piston prevents the magnet from applying too large force. The piston also enables estimation of the esophageal tension based on the hydraulic pressure measurement. We have built a prototype system and performed bench-level tests on an esophageal mock-up. A hydraulic dither is applied to the piston to average out seal friction, thereby improving the tension estimation performance. The bench-level tests demonstrate that the prototype bougienage system gives a reliable low-frequency estimate of the esophageal tension in real-time, and also enables longitudinal bougienage by a desired amount of load, e.g., 2N, for various gap sizes. This study provides a foundation for the next step of designing a system for use on actual patients.

Case report on Tracheoesophageal Fistula with review of current literature

Major structural anomalies occur in 2-3% of live births all around the World. The reported global incidence of tracheoesophageal fistula (TEF) is roughly 1 in 2,500 live births varying by region. In Pakistan, incidence is reported only by those tertiary care centers that have pediatric surgery facilities available, making it an underreported and often mismanaged condition. We report a case of esophageal atresia (EA), rectovaginal fistula and tracheoesophageal fistula associated with Meconium Aspiration Syndrome (MAS) in an infant. The baby was 2 days old when she arrived at our center, born at 34 weeks, and weighed 2.3 kilograms. There was no significant antenatal history except that the mother was on antihypertensive drugs. The baby had an Apgar score of 3 and 4 at 1 and 5 minutes respectively, severe respiratory distress and cyanosis. Her chest examination revealed subcostal and intercostal recessions, bilateral crepitation and tachycardia at 180/minute. She was immediately put on ventilator and required frequent suctioning due to excessive secretion, developed abdominal distension, and had multiple episodes of desaturation and cyanosis. Complete blood picture showed leukocytosis and arterial blood gases signifying metabolic acidosis. Upon trying to pass to a catheter, baby passed stool through vagina. Contrast esophagogram showed evidence of distended stomach and proximal small bowel loops. No evidence of air was seen in the rectum. On passing the nasogastric tube into the esophagus, it curled on itself at D4 level with evidence of blind-ending proximal esophageal pouch that dilated with contrast medium. On 10th day of life baby’s condition deteriorated despite all efforts. Eventually she stopped breathing, her pupils dilated and all efforts to resuscitate her failed. This report highlights the importance of thorough clinical examination and availability of support facilities in a pediatric unit. TEF/EA should be suspected in any newborn who presents with respiratory distress, drooling, history of polyhydramnios with an inability to pass nasogastric tube. The parents should also be counselled as TEF/EA carries a 1% risk of recurrence.

Esophagoesophagopexy technique for assisted fistulization of esophageal atresia.

We describe our experience using a modified suture fistula technique for addressing tension in longer gap esophageal atresia (EA). Esophagoesophagopexy (EEP) is the tacking of the proximal and distal ends of esophageal pouches without formal anastomosis. In this retrospective cohort, we review the outcomes of patients with EA after EEP. We reviewed the operative reports of EA cases treated at our institution from 1997 to 2016 and identified all patients described as having EEP. Of 129 EA cases, five patients underwent EEP. Formal anastomosis was not done due to patient's instability, prematurity, or long gap. Median birth weight was 1.4kg (0.6-2.2kg), and median gestational age at birth was 29weeks (25-34 weeks). Age at time of EEP ranged 0-5 months. Esophagoesophageal fistula was confirmed in three patients. All three had strictures requiring weekly dilations. One of these patients died. The two surviving patients underwent fundoplication. We describe an alternative technique for esophageal anastomosis in patients for whom a standard anastomosis is not possible. EEP can lead to a functional anastomosis through fistulization and avoid the morbidity of multiple thoracotomies and lengthening procedures. Families should be educated on the potential need for dilations and antireflux procedures.

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

Tracheoesophageal Fistula: A Different Surgical Approach

SESSION TITLE: Cardiothoracic Surgery SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: Acquired tracheoesophageal fistula (TEF) is a relatively uncommon—but often life-threatening—complication of mediastinal malignancy, occurring in 5%-15% of patients with mediastinal/esophageal malignancies.1 TEFs are mainly treated with esophageal stenting2 or single-stage primary repair of both the airway and an esophageal defect with tissue flap interposition.3 We present a patient whose TEF was repaired by surgical creation of a “pseudodiverticulum” with a remnant esophageal pouch after definitive chemoradiation. CASE PRESENTATION: This 66-year-old man with esophageal squamous cell cancer was found to have a mass in the mid-esophagus. Bronchoscopy showed no airway involvement of the tumor. The patient opted for definitive chemoradiation. After treatment, he noted coughing while eating. Workup showed a TEF (Fig. 1). Because he had not tolerated previous stenting, he decided to proceed with esophagectomy. The patient underwent a planned right thoracotomy with intercostal muscle flap, but intraoperatively, the TEF was larger than expected, and its surrounding tissue was fibrotic. Due to concern that the esophagus was fused to the airway (and attempts at dissection would result in a larger fistula or more severe tracheal defect), the esophagus was transected 1 cm above the TEF. The distal esophagus was dissected and staple transected just above the hiatus. A spit fistula was created. After recovery and improvement of nutrition, the patient was brought back to the OR for reconstruction with a substernal gastric interposition. Now 3 years out from his original diagnosis, the patient is able to tolerate oral intake and shows no evidence of recurrent disease. Recent upper endoscopy showed widely patent gastric anastomosis and a stable-appearing pseudodiverticulum, with a small esophageal remnant on the posterior side of the proximal left mainstem bronchus (Fig. 2). DISCUSSION: The benefits vs. risks of surgical intervention for treatment of acquired TEFs must be carefully considered. This patient refused stenting due to prior negative outcomes, but given his presentation and esophageal fusion to the airway, the risk of additional complications by dissecting the fistula was too great. Instead of traditional stenting or standard TEF takedown and repair, we resolved his TEF by leaving the esophagus attached to the airway, transecting the esophagus above and below the fistula, and leaving a small pseudodiverticulum at the level of the fistula. This ultimately allowed him to eat without recurrent aspiration. CONCLUSIONS: Acquired TEFs may be successfully managed using this technique when traditional methods are unavailable or in patients for whom the risk of complications is higher (e.g., those with dense fibrosis and adhesions after radiation). Reference #1: Marulli et al. Eur J Cardiothorac Surg 2013;43(6):e155-161 Reference #2: Silon B et al. Dig Dis Sci. 2017;62(2):424-431 Reference #3: Puma F et al. J Thorac Dis. 2017;9(2):278-286 DISCLOSURE: The following authors have nothing to disclose: Taylor Ipsen, Paul Banks, Ross Bremner, Jasmine Huang No Product/Research Disclosure Information

Creation of an Esophageal Atresia Animal Model Using a Bifurcated Esophagus to Maintain Digestive Tract Continuity.

We previously developed a porcine model of long gap pure esophageal atresia (EA) to aid in the creation of novel devices and techniques for treatment of EA. Shortcomings of the model included difficulty decompressing the proximal esophageal pouch (leading to recurrent aspiration) and a requirement for gastrostomy tube (G-tube) feeds. Therefore, we sought to create a porcine model with a bifurcated esophagus wherein one portion of the esophageal lumen retained patency and the other part mimicked EA. After G-tube placement, thoracotomy was performed with subsequent partial stapled transection of the esophagus in a transverse manner, followed by longitudinal, partial stapled transection of the esophagus proximally and distally. Magnets were placed in the esophageal pouches. Proximal and distal esophageal pouches were created while preserving a parallel, narrower segment of continuous esophagus. G-tube feeds were used initially, but the animal ultimately tolerated full nutrition by mouth. The magnets successfully restored esophageal continuity. The animal regained much of the initial weight lost and survived to planned euthanasia. Necropsy revealed anastomosis formation without evidence of leak. A bifurcated porcine esophagus model was successfully devised, simulating EA while allowing the animal to receive oral feeds and clear oral secretions. This model is anticipated to promote animal well-being and ease of care during future investigations, as well as a platform for the safe development of new therapies for EA.

Esophageal Atresia with Tracheo-Esophageal Fistula Presenting Beyond 7 Days.

Aim: To describe our experience of neonates with esophageal atresia with tracheo-esophageal fistula (EA with TEF) who presented after a week. Design: Retrospective study of the patients of EA with TEF who presented after a week. Study Setting: Department of Pediatric Surgery, Government Medical College Nagpur. Study Duration: Eight years. Materials and Methods: Demographic information, hematological, biochemical and radiological data were obtained from the patients' medical records. The gap between two ends of the esophagus, nature of upper pouch and lower esophagus were noted intra-operatively. Outcome in terms of mortality and surgical complications were noted. In operated group, babies who survived were compared with non-survivors with respect to various preoperative variables. Results: Of 52 patients, 27 babies expired during initial stabilisation period before surgery. The causes of mortality were severe pneumonitis and septicemia. One baby had associated cyanotic heart disease. Twenty-five patients with mean age of 8.28±1.21 days underwent surgery. Nearly two-third of them were male. All of them were born at full-term with mean birth weight of 2.47±0. 12 kg. More than 80% were previously hospitalised and nearly 70% babies were given feeds before present hospitalization. Mean Downe’s score for respiratory distress was 5.8±1.49. All patients were positive for septic profile. Associated congenital anomalies were present in ten patients. Intra-operatively, two ends of esophagus were either approximating or have short gap in 24 patients. All patients had well developed, thick and muscular upper oesophageal pouch. Lower esophagus at fistula was thin but dilated in 18 patients while thin and narrowed in 7 patients. However, esophageal anastomosis was possible with ease without any tension in all except one patient. There were 15 deaths in our study (13 due to pneumonitis and 2 during follow up due to aspiration). Three survivors required anti-reflux surgery. Comparison of preoperative variables of survivors and non-survivors showed a significant difference with respect to the variables like feedings, abdominal girth, immature band cells to neutrophil ratio and nature of pharyngeal or endotracheal aspirate. Conclusions: Late presentations in EA with TEF are associated with high mortality but less anastomotic complications after surgery. Preoperative factors like feedings, abdominal distension, immature band cells to neutrophil ratio and bilious pharyngeal or endotracheal aspirate are associated with high mortality.

Esophageal atresia with tracheoesophageal fistula: A rare variant and cautionary tale

Abstract Esophageal atresia (EA) with or without tracheoesophageal fistula (TEF) are relatively common congenital anomalies. Additional variants of these anomalies have been reported, including EA-TEF associated with congenital esophageal stenosis (CES) and a few reports of EA-TEF associated with an esophageal web or membranous diaphragm. We report an extremely rare case of EA with distal TEF associated with both a CES and a separate esophageal web distal to the TEF. EA-TEF with an associated CES and/or mucosal web distal to the TEF presents both a diagnostic and management challenge, as the standard diagnostic/pre-operative work-up may not identify the distal areas of esophageal occlusion. Surgeons should be aware and should maintain a high index of suspicion for these anatomic variants as they can lead to operative complications. Use of a tube to confirm patency of the distal esophageal pouch as a standard technique during EA-TEF repair may help avoid the potential pitfalls associated with failure to recognize these conditions.

Long-term outcomes of oesophageal atresia without or with proximal tracheooesophageal fistula – Gross types A and B

PurposeBecause of an extended gap between esophageal pouches a variety of methods are employed to treat oesophageal atresia (OA) without (type A) or with (type B) proximal tracheooesophageal fistula. This retrospective observational study describes their single centre long-term outcomes from 1947 to 2014. MethodsOf 693 patients treated for OA 68 (9.7%) had type A (n=58, 8.3%) or B (n=10, 1.4%). Hospital records were reviewed. Main outcome measures were survival and oral intake. ResultsNine (13%) patients had early and 10 (15%) delayed primary anastomosis, 30 (44%) underwent reconstruction including colonic interposition (n=13), reversed gastric tube (n=11) and jejunum interposition (n=6), whereas19 (28%) had died without a definite repair. Median follow up was 35 (interquartile range, 7.4–40) years. Thirty-one (63%) of 49 patients with definitive repair survived long term. Survival was 22% for early and 80% for delayed primary anastomosis, 57% for colon interposition, 82% for gastric tube and 84% for jejunum interposition. Gastrooesophageal reflux was most common after gastric tube (80%), dysphagia after colon interposition (50%), and 3 (60%) of 5 survivors with jejunum interposition had permanent feeding ostomy because of neurological disorder. Endoscopic follow-up disclosed no oesophageal cancer or dysplasia. Repair in the most recent patients from 1985 to 2014 (n=14) included delayed primary anastomosis (n=7), jejunum interposition (n=6) and gastric tube (n=1) with 93% long-term survival. ConclusionMorbidity among long-term survivors of type A or B OA is high. With modern management survival is, however, excellent and patients without neurological disorder achieve full oral intake either after primary anastomosis or reconstruction. Levels of evidenceIV.

Can patients determine the level of their dysphagia?

AIMTo determine if patients can localise dysphagia level determined endoscopically or radiologically and association of gender, age, level and pathology.METHODSRetrospective review of consecutive patients presenting to dysphagia hotline between March 2004 and March 2015 was carried out. Demographics, clinical history and investigation findings were recorded including patient perception of obstruction level (pharyngeal, mid sternal or low sternal) was documented and the actual level of obstruction found on endoscopic or radiological examination (if any) was noted. All patients with evidence of obstruction including oesophageal carcinoma, peptic stricture, Schatzki ring, oesophageal pouch and cricopharyngeal hypertrophy were included in the study who had given a perceived level of dysphagia. The upper GI endoscopy reports (barium study where upper GI endoscopy was not performed) were reviewed to confirm the distance of obstructing lesion from central incisors. A previously described anatomical classification of oesophagus was used to define the level of obstruction to be upper, middle or lower oesophagus and this was compared with patient perceived level.RESULTSThree thousand six hundred and sixty-eight patients were included, 42.0% of who were female, mean age 70.7 ± 12.8 years old. Of those with obstructing lesions, 726 gave a perceived level of dysphagia: 37.2% had oesophageal cancer, 36.0% peptic stricture, 13.1% pharyngeal pouches, 10.3% Schatzki rings and 3.3% achalasia. Twenty-seven point five percent of patients reported pharyngeal level (upper) dysphagia, 36.9% mid sternal dysphagia and 25.9% lower sternal dysphagia (9.5% reported multiple levels). The level of obstructing lesion seen on diagnostic testing was upper (17.2%), mid (19.4%) or lower (62.9%) or combined (0.3%). When patients localised their level of dysphagia to a single level, the kappa statistic was 0.245 (P < 0.001), indicating fair agreement. 48% of patients reporting a single level of dysphagia were accurate in localising the obstructing pathology. With respect to pathology, patients with pharyngeal pouches were most accurate localising their level of dysphagia (P < 0.001). With respect to level of dysphagia, those with pharyngeal level lesions were best able to identify the level of dysphagia accurately (P < 0.001). No association (P > 0.05) was found between gender, patient age or clinical symptoms with their ability to detect the level of dysphagia.CONCLUSIONPatient perceived level of dysphagia is unreliable in determining actual level of obstructing pathology and should not be used to tailor investigations.

持続性食道盲端エロンゲータの研究 : I.基礎的研究及び空気圧エロンゲータの開発

持続性食道盲端エロンゲータの研究 : I.基礎的研究及び空気圧エロンゲータの開発