Repair Of Long-gap Esophageal Atresia Research Articles

Management Strategies and Outcomes of Distal Congenital Esophageal Strictures in the Setting of Long-gap Esophageal Atresia

BackgroundThe management of neonates with long-gap esophageal atresia (LGEA) combined with distal congenital esophageal strictures (CES) is challenging. We sought to review our approach for this rare set of anomalies. MethodsWe reviewed children with LGEA + CES surgically treated at two institutions (2018–2024). LGEA repair was performed using the Foker technique (traction-induced esophageal lengthening). A CES strategy was chosen based on preoperative evaluations and intraoperative findings. The configuration and length of the CES were assessed using retrograde flexible esophagoscopy via gastrostomy with contrast fluoroscopy. ResultsEight patients (75% male) with LGEA + CES were treated: Four had type A and four had type B EA. Median gap length was 3.5 cm. Three underwent thoracoscopic esophageal lengthening. After a median follow-up of 18 months (IQR: 9–25), all retained their native esophagus. However, those who had CES resection concurrent with the lengthening process or at the time of EA anastomosis had more challenging perioperative courses: one required additional time on traction and another required esophageal anastomotic stricture resection. ConclusionsOur experience with LGEA and distal CES emphasizes tailoring surgical approaches to each patient's unique condition, avoiding a one-size-fits-all strategy. However, if the esophageal tissue above the distal CES is in good condition, our preference has shifted towards retaining the CES during traction, performing gentle dilation at anastomosis time, and conducting definitive endoscopic management subsequently. We would caution against making the assumption that salvage of the native esophagus is not possible or that resection of the CES is always needed. Level of EvidenceLevel III.

Infant Perioperative Risk Factors and Adverse Brain Findings Following Long-Gap Esophageal Atresia Repair

Recent findings implicate brain vulnerability following long-gap esophageal atresia (LGEA) repair. We explored the relationship between easily quantifiable clinical measures and previously reported brain findings in a pilot cohort of infants following LGEA repair. MRI measures (number of qualitative brain findings; normalized brain and corpus callosum volumes) were previously reported in term-born and early-to-late premature infants (n = 13/group) <1 year following LGEA repair with the Foker process. The severity of underlying disease was classified by an (1) American Society of Anesthesiologist (ASA) physical status and (2) Pediatric Risk Assessment (PRAm) scores. Additional clinical end-point measures included: anesthesia exposure (number of events; cumulative minimal alveolar concentration (MAC) exposure in hours), length (in days) of postoperative intubated sedation, paralysis, antibiotic, steroid, and total parenteral nutrition (TPN) treatment. Associations between clinical end-point measures and brain MRI data were tested using Spearman rho and multivariable linear regression. Premature infants were more critically ill per ASA scores, which showed a positive association with the number of cranial MRI findings. Clinical end-point measures together significantly predicted the number of cranial MRI findings for both term-born and premature infant groups, but none of the individual clinical measures did on their own. Listed easily quantifiable clinical end-point measures could be used together as indirect markers in assessing the risk of brain abnormalities following LGEA repair.

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.

Long-Gap Esophageal Atresia Repair Using Staged Thoracoscopic Internal Traction: The First Kazakhstan Experience.

Introduction: The treatment of long-gap esophageal atresia (LGEA) remains an important issue for pediatric surgeons. There are several methods of treating LGEA with various advantages and disadvantages. Thoracoscopic esophageal elongation using internal traction sutures has been developed more recently. Therefore, we wanted to report on our first experience in treating such pathology using staged thoracoscopic internal traction. Objective: To share our first experience in the treatment of LGEA using staged thoracoscopic internal traction. Methods: Three children with LGEA were treated at the University Medical Center "National Scientific Center for Maternal and Child Health" in the Pediatric Surgery Department, Nur-Sultan, Kazakhstan, using the method of staged thoracoscopic internal traction. Results: At the age of 3-4 months, 3 patients were operated on successfully using staged thoracoscopic internal traction. In any case, converting to an open thoracotomy was not needed and no anastomotic leakage was observed. In 2 cases, stenosis occurred that was treated by dilatation at least twice, 1 child had no stenosis. Conclusions: Thoracoscopic internal traction technique for LGEA was performed for the first time in Kazakhstan that showed its safety and possible future use in the surgical treatment of this congenital malformation.

Impact of Infant Thoracic Non-cardiac Perioperative Critical Care on Homotopic-Like Corpus Callosum and Forebrain Sub-regional Volumes.

Previously, we reported quantitatively smaller total corpus callosum (CC) and total forebrain size in critically ill term-born and premature patients following complex perioperative critical care for long-gap esophageal atresia (LGEA) that included Foker process repair. We extended our cross-sectional pilot study to determine sub-regional volumes of CC and forebrain using structural brain MRI. Our objective was to evaluate region-specific CC as an in-vivo marker for decreased myelination and/or cortical neural loss of homotopic-like sub-regions of the forebrain. Term-born (n = 13) and premature (n = 13) patients, and healthy naïve controls (n = 21) <1-year corrected age underwent non-sedated MRI using a 3T Siemens scanner, as per IRB approval at Boston Children's Hospital following completion of clinical treatment for Foker process. We used ITK-SNAP (v.3.6) to manually segment six sub-regions of CC and eight sub-regions of forebrain as per previously reported methodology. Group differences were assessed using a general linear model univariate analysis with corrected age at scan as a covariate. Our analysis implicates globally smaller CC and forebrain with sub-region II (viz. rostral body of CC known to connect to pre-motor cortex) to be least affected in comparison to other CC sub-regions in LGEA patients. Our report of smaller subgenual forebrain implicates (mal)adaptation in limbic circuits development in selected group of infant patients following LGEA repair. Future studies should include diffusion tractography studies of CC in further evaluation of what appears to represent global decrease in homotopic-like CC/forebrain size following complex perioperative critical care of infants born with LGEA.

Gastric Transposition for Repair of Long-Gap Esophageal Atresia: Indications, Complications, and Outcome of Minimally Invasive and Open Surgery

Background: Gastric transposition (GT) is a possible option for esophageal replacement in long-gap esophageal atresia (LGEA). The present study aims to report and compare indications and outcome of laparoscopic-assisted GT (LAGT) versus open (OGT) GT for LGEA repair. Methods: Retrospective single-center analysis of all LGEA patients undergoing GT between 2002 and 2021. Results: Thirty-one children with LGEA underwent GT. Of these, 19 underwent LAGT (mean weight at surgery 5.6 kg; mean age 167 days) and 12 underwent OGT (6.1 kg; 233 days). Indications for OGT were previous surgery (n = 7), associated severe cardiac malformations (n = 4), and a simultaneous resection of a choledochal cyst (n = 1). The conversion rate was 1. The two procedures (LAGT/OGT) differed in anesthetic time (308/350 min), duration of ventilation (5.1/5.3 days), hospital stay (34/32 days), and complications (22/15). None of the differences reached statistical significance. Outcome was also comparable: completely oral nutrition uptake in 66%/73%, slow weight gain in the low centiles in both groups, no patient developed dumping syndrome, symptomatic reflux was seen in 1 patient after OGT. Conclusion: In our cohort, LAGT for repair of LGEA provided similar outcomes as open surgery. The minimally invasive approach preserves thoracal structures, prevents additional thoracotomy or laparotomy, and is faster. To realize LAGT, a postpartal treatment concept including gastrostomy placement via a microincision to minimize adhesions is essential. The open surgical approach should be considered in cases of previous extensive surgical attempts of EA correction causing severe adhesions as well as associated anomalies or genetic syndromes causing hemodynamic instability.

Infant study of hemispheric asymmetry after long-gap esophageal atresia repair.

ObjectivesPrevious studies have demonstrated that infants are typically born with a left‐greater‐than‐right forebrain asymmetry that reverses throughout the first year of life. We hypothesized that critically ill term‐born and premature patients following surgical and critical care for long‐gap esophageal atresia (LGEA) would exhibit alteration in expected forebrain asymmetry.MethodsTerm‐born (n = 13) and premature (n = 13) patients, and term‐born controls (n = 23) <1 year corrected age underwent non‐sedated research MRI following completion of LGEA treatment via Foker process. Structural T1‐ and T2‐weighted images were collected, and ITK‐SNAP was used for forebrain tissue segmentation and volume acquisition. Data were presented as absolute (cm3) and normalized (% total forebrain) volumes of the hemispheres. All measures were checked for normality, and group status was assessed using a general linear model with age at scan as a covariate.ResultsAbsolute volumes of both forebrain hemispheres were smaller in term‐born and premature patients in comparison to controls (p < 0.001). Normalized hemispheric volume group differences were detected by T1‐weighted analysis, with premature patients demonstrating right‐greater‐than‐left hemisphere volumes in comparison to term‐born patients and controls (p < 0.01). While normalized group differences were very subtle (a right hemispheric predominance of roughly 2% of forebrain volume), they represent a deviation from the expected pattern of hemispheric brain asymmetry.InterpretationOur pilot quantitative MRI study of hemispheric volumes suggests that premature patients might be at risk of altered expected left‐greater‐than‐right forebrain asymmetry following repair of LGEA. Future neurobehavioral studies in infants born with LGEA are needed to elucidate the functional significance of presented anatomical findings.

Head circumference in infants undergoing Foker process for long-gap esophageal atresia repair: Call for attention

IntroductionWe extended our pilot study in infants following long-gap esophageal atresia (LGEA) repair to report head circumference, an easily obtainable indirect measure of brain size. Data are presented in the context of previously reported body weight and T2-weighted MRI measures of intracranial and brain volumes. MethodsClinical information and head circumference were obtained for term-born (n = 13) and premature (n = 13) infants following LGEA repair with Foker process, as well as healthy term-born controls (n = 20) <1-year corrected age who underwent non-sedated research MRI. General Linear Model univariate analysis with corrected age at scan as a covariate and Bonferroni adjusted p values assessed group differences. ResultsWe report no difference in head circumference between the three groups. Such findings paralleled trends in body weight and total intracranial volume but not in brain volume as previously reported for the same pilot cohort. DiscussionResults suggest uncompromised somatic and head growth after repair of LGEA. In contrast, a novel finding of discrepancy between head circumference (novel data) and brain size (previously published data) in the same cohort suggests that head circumference might not be the best indirect measure of brain size in selected group of patients.

Usefulness of Gastrojejunostomy Prior to Fundoplication in Severe Gastro-Esophageal Reflux Complicating Long-Gap Esophageal Atresia Repair: A Preliminary Study

Background: Gastro-esophageal reflux disease (GERD), requiring surgical correction, and nutritional problems are reported after long-gap esophageal atresia (LGEA) repair and might jeopardize the postoperative course in some babies. We report an exploratory evaluation of the role of transgastric jejunostomy (TGJ) as a temporary nutritional tool before surgery for GERD in LGEA. Methods: Seven infant patients operated on for LGEA with intra-thoracic gastro-esophageal junction (GEJ) and growth failure, requiring improvement in their nutritional profile in anticipation of surgery, were retrospectively evaluated. Post-surgical follow-up, including growth evolution, complications, and parental quality of life (QoL), were considered. Results: The TGJ was placed at a mean age of 8.6 ± 5.6 months. The procedure was uneventful and well-tolerated in all seven cases. At 6.6 ± 2.0 months after TGJ placement, significant weight gain (weight z-score −2.68 ± 0.8 vs −0.9 ± 0.2, p < 0.001) was recorded, allowing the GERD surgery to proceed. A significant difference in hospital admissions between 3 months before and post-TGJ insertion was noted (4.8 ± 0.75 vs. 1.6 ± 0.52, p < 0.01). A significant amelioration of QoL after TGJ placement was also recorded; in particular, the biggest improvements were related to parents’ perceptions of the general health and emotional state of their babies (p < 0.001). Conclusions: The placement of TGJ as a temporary nutritional tool in selected cases of LGEA could improve nutritional conditions and parental QoL before fundoplication, allowing successful surgical treatment of GERD to be carried out.

DOZ047.93: Thoracoscopic multistage repair of long-gap esophageal atresia using internal traction suture technique—evolution of the method

Abstract Treatment of long-gap esophageal atresia poses a great challenge for a surgeon. A new multistage thoracoscopic repair of long-gap esophageal atresia using internal traction technique was developed that evolved with time and growing experience. The goal of this study is to present the changes in the strategy and important technical aspects of the operative method based on a retrospective analysis of performed surgeries. Methods and Materials Thirty-five cases of newborns with long-gap esophageal atresia (type A-26 cases and B-9 cases exclusively) were operated thoracoscopically between 2008 and 2019 using internal traction technique in different pediatric surgery centers (Poland–28, Czech–1, Ukraine–1, Switzerland–2, Egypt–2, Russia–1). The idea of the internal traction technique was to place the suture between thoracoscopically mobilized esophageal pouches and keep a static tension between them for a period of time. Patients were operated on as early as it was possible after birth. Results Of the 35 newborns operated on using internal traction 2 patients died before the final stage from not surgically-related causes. Two patients had complications that required neck fistula and had later Collis–Nissen and colon interposition, respectively. One case is awaiting the final procedure. For 31 cases the final esophageal anastomosis was completed in two stages–16 cases, three stages–9, four stages–2, five stages–2, and six stages–1. At the beginning the time between stages was planned for 4 weeks (for some cases it was even longer) and it was shortened for the last three cases to 5 days. It allowed avoiding gastrostomy in two cases. The internal traction was modified from using two traction loops to one traction loop with two slipping knots on each branch of the loop. The clips were applied transversely through the tip of each pouch and part of the traction loop to prevent disruption and pouch perforation. It also allowed increasing of the created static traction force. Conclusion Results of the study may indicate that in a majority of long-gap esophageal atresia it is possible to preserve the native esophagus by a thoracoscopic approach using an internal traction suture technique. Shortened time between stages allowed completion of the final esophageal anastomosis with gastrostomy avoidance.

DOZ047.13: Prophylactic endoscopic esophageal vacuum (EVAC) therapy of high-risk esophageal anastomoses in pediatric surgical patients

Abstract Summary Esophageal anastomotic leak (EAL) is a potentially severe complication of surgical procedures of the esophagus. Vacuum-assisted closure (VAC) therapy is increasingly used in the treatment of EAL, with observational studies suggesting it is a highly effective method for esophageal defect closure.1–3 It was hypothesized that prophylactic esophageal VAC (EVAC) placement at the time of new anastomosis creation may improve blood flow and healing, potentially leading to fewer EALs. Methods Between July 2015 and November 2018, patients who underwent surgery that resulted in a new esophageal anastomosis and were deemed to be high risk for anastomotic complications had a prophylactic EVAC placed at the time of surgery. Retrospective review of similar surgical procedures without prophylactic EVAC placement from January 2014 to November 2018 was performed for comparison. Results Thirteen pediatric patients had prophylactic EVAC placement at the time of esophageal repair. Procedures prompting EVAC placement included primary repair of long-gap esophageal atresia (LGEA) by the Foker technique (N = 7), stricture resection after repaired LGEA (N = 3) or type C esophageal atresia (N = 1), and stricture resection after delayed identification of a retained esophageal foreign body (N = 2). Three of 13 patients who had prophylactic EVAC placement (23.1%) experienced EAL in the post-operative period. Two patients were found to have technical failure of their EVAC leading to absence of suction, and one patient experienced delayed EAL 12 days after removal of the EVAC. In comparison, post-surgical EAL occurred in 13 of 58 patients who had the Foker procedure for LGEA and in 8 of 31 patients who had esophageal stricture resection without prophylactic EVAC placement. The rates of EAL in the prophylactic EVAC group were not significantly different from rates of EAL in either the post-surgical Foker (23.1% vs 22.4%, P = 0.999), post-stricture resection (23.1% vs 25.8%, P = 0.999), or combined post-Foker and stricture resection (23.1% vs 23.6%, P = 0.999) groups by Fisher's exact test. Conclusions Prophylactic EVAC placement does not carry increased risk of EAL compared to standard post-surgical care; however, further device refinement is needed to reduce technical failure.

DOZ047.124: Thoracoscopic anatomy of long-gap esophageal atresia. What can we predict?

Abstract Since the very beginning in 1999, thoracoscopic repair of esophageal atresia has become a gold standard in many pediatric surgery centers worldwide. Despite the advances in surgical technique, treatment of long-gap esophageal atresia still remains a challenge. The aim of this study is to assess whether the localization of esophageal stumps can predict number of stages needed to perform anastomosis. We analyzed video records of 21 patients who underwent staged thoracoscopic repair of long-gap esophageal atresia using internal traction technique. All procedures were performed by the same surgeon. We divided patients into two groups: first requiring single internal traction procedure, second who underwent multiple procedures. We assessed esophageal stump position in relation to thoracic vertebrae. The distance between stumps was measured in vertebral bodies. Mean distance between esophageal ends was 5.8 in single traction group. The distance between the stumps was significantly greater in multiple procedures group: 7.33 (P = 0.003). Patients who required multiple procedures had significantly lower localization of distal stump. Localization of proximal stump did not affect the possibility for anastomosis after single traction. Distance between both ends after internal traction was also significantly longer in multiple procedures group. Patients with lower localization of distal esophageal stump assessed during primary thoracoscopy are at higher risk for requiring multiple surgical procedures.

DOZ047.15: Esophageal anastomosis diameter at initial endoscopy after surgery predicts treatment outcomes in patients with esophageal atresia or stricture

Abstract Background Children with esophageal atresia (EA) are at risk for anastomotic stricture that may ultimately need surgical resection. No studies have examined the relationship between anastomotic diameter at the time of initial postop endoscopy and treatment outcomes. Methods A retrospective chart review was performed of patients with EA who underwent a Foker procedure for repair of long-gap esophageal atresia (LGEA), primary repair of EA, or stricture resection for refractory stricture who were seen between January 2016 and May 2018. A refractory stricture was defined as one requiring ≥5 dilations ≤5 months after surgery. The anastomosis diameter was estimated by the endoscopist. We divided diameter sizes into the following groups: 1–2.9 mm, 3–4.9 mm, 5–6.9 mm, 7–8.9 mm, 9–10.9 mm, and 11–14 mm. The Wilcoxon rank sum test and Fisher's exact test were used. Results Forty-five patients who had a Foker procedure, 37 who had primary repair, and 58 who had stricture resection were identified. The first EGD occurred a median of 22 days (IQR 21–28) after surgery. Among all EA patients with initial diameter of &lt;3 mm, 82% developed refractory stricture and 41% required stricture resection. Of all patients with initial diameter &lt;5 mm, 74% developed refractory stricture and 33% required stricture resection. Of patients who underwent a Foker procedure with initial diameter &lt;3 mm, 56% required stricture resection; of these patients with initial diameter &lt;5 mm, 53% required stricture resection. Among all EA patients, refractory strictures were significantly more likely in patients with smaller initial diameters (P &lt; 0.001), from 18 patients (82%) with stricture 1–2 mm to 0 patients (0%) with stricture 11–14 mm. Patients with smaller anastomoses were more likely to need stricture resection (P = 0.020); 9 patients (41%) with size 1–2 mm underwent stricture resection, while none (0%) with size 11–14 mm needed stricture resection. These differences remained statistically significant for patients who underwent a Foker procedure (P ≤ 0.001 for stricture resection and refractory stricture). Conclusion Endoscopy performed shortly after EA repair or stricture resection can help predict which patients are more likely to develop a refractory stricture or require a stricture resection.

DOZ047.34: Oral feeding attainment

Abstract Aim A primary goal of esophageal atresia repair is to establish esophageal continuity to allow for swallowing of secretions, liquid, and food boluses. The transition to oral feeding and acquisition of oral sensorimotor skills following repair of long-gap esophageal atresia (LGEA) can be challenging. The timing of attaining full PO status (F-PO), without need for enteral tube feeding support, can vary greatly. A retrospective study was performed to identify predictors of oral feeding success in children with LGEA. Methods A retrospective case series was conducted with chart review of patients with a diagnosis of LGEA who underwent Foker process for staged repair from 2012 to 2017. Children with previous failed attempts at esophageal repair or other significant surgeries were excluded. Comparison was made between patients who achieved full PO status (F-PO) within the study follow-up period (minimum of one year postrepair) and those who did not. Results Twenty-three patients were included: twelve male and eleven female. Eight patients (35%) had an accompanying genetic diagnosis. Thirteen patients (57%) were born prematurely. Six patients (26%) were F-PO at 6 month post-repair; four of which were on an age appropriate diet without restrictions/modifications. Thirteen patients (57%) achieved F-PO by end of the study follow-up period while 43% required supplemental nutrition. Gestational age ≥ 37 weeks (P = 0.03), younger age at first PO trial (P = 0.013), shorter time between Foker 2 and first PO trial (P = 0.011), consistent PO intake at 6 months post-repair (P = 0.02), and fewer total number of airway/esophageal procedures within 1 year post-repair (P = 0.018) were found to be significantly associated with achieving F-PO. Total number of esophageal dilations within 2 years of esophageal repair and presence of a genetic syndrome were not significantly different between groups. Conclusion A majority of patients (57%) who undergo repair of LGEA via Foker process will progress to oral feeding; however, the timing of this progression is variable. Predictors of oral feeding success can be used to guide prognosis and identify patients at greatest need of therapeutic services.

DOZ047.99: A unique case of ‘esophageal trachea’ requiring a multistep sequential surgical reconstruction

Abstract Introduction Communicating bronchopulmonary foregut malformations (CBPFMs) have been defined by Srikanth et al. in 1992 as a fistula between a portion of respiratory tissue and esophagus/stomach. Four types of CBPFMs have been described, none of those contemplating a complete communication between the distal trachea and esophagus. Case Report This study reports a case of a full-term neonate presenting with a VACTERL association and a tracheoesophageal malformation characterized by the presence of a long common duct including both the middle esophagus and distal trachea, which consists in esophageal tissue, without any cartilaginous rings 3–4 cm above the carina. A few days after birth, the esophagus and trachea have been surgically separated, keeping the common duct on the tracheal side and creating a residual long-gap esophageal atresia (LGEA). The resulting severe tracheomalacia has been simultaneously treated by posterior splinting using an autologous pericardium patch, as well as by anterior aortopexy. A terminal esophagostomy and a gastrostomy have been created to postpone esophageal reconstruction. Since the age of 18 months, delayed repair of LGEA has been performed by using a multistep strategy consisting of a combination of Kimura extrathoracic esophageal elongations and distal stump Foker external traction. Since no cartilaginous rings were present, refractory tracheomalacia has been further treated by a tracheoplasty through a combined median sternotomy and tracheoscopy approach at the age of 3 years by using a semitubular rigid Gore-Tex® prosthesis for an anterior external stenting. Today, 9 months after last surgery, complete weaning from respiratory support has been stably achieved, as well as full oral feeding. Conclusions This is the first description of an ‘esophageal trachea’, which may be considered as a new anatomic variant of CBPFMs. Multidisciplinary medical and surgical expertise was needed to manage this particular case, in order to properly plan multiple sequential surgical approaches. Native esophageal reconstruction should always be considered, even because colonic or gastric transposition might further affect severe tracheomalacia, resulting in more challenging treatment.

Esophageal Biomechanics Revisited: A Tale of Tenacity, Anastomoses, and Suture Bite Lengths in Swine

Anastomotic tension has repeatedly been associated with anastomotic leakages after esophagectomy for cancer or esophageal atresia repair. We therefore aimed to determine which anastomotic technique would come as close as possible to the native esophagus in sustaining traction forces. Constant traction for several minutes at esophageal remnants and large suture bites are also considered relevant in long-gap esophageal atresia repair. Porcine esophagi were subjected to linear traction using a motorized horizontal test stand. We compared breaking strengths of native esophagi to simple continuous, simple interrupted, stapled, and barbed suture anastomoses. We also investigated the effects of suture bite length and phases of constant traction on breaking strengths and powered all experiments to at least 80% using exploratory investigations (n= 5 per group). Continuous suture anastomoses had a breaking strength comparable to native esophagi (Δ=-5.25 Newton, 95% confidence interval:-10.69 to 0.19 Newton, p= 0.058) and outperformed all other investigated anastomoses (Δ ≥14.01 Newton, p ≤ 0.02). Breaking strength correlated with suture bite length (R= 0.905) and predicted breaking strength for the simple stitch (adjusted R2= 0.812, p < 0.0001), but not for anastomoses. Phases of incrementally increasing constant traction resulted in higher breaking strengths (Δ= 13.36 Newton, 95% confidence interval: 9.93 to 16.79 Newton, p< 0.0001) and higher length gain (Δ= 1.06 cm, 95% confidence interval: 0.65 to 1.48 cm, p < 0.0001) compared with controls. Only simple continuous anastomoses achieved the linear breaking strength of native tissue. Our study provides important insights in tolerance to traction forces, but its results have to be corroborated in living animals as anastomotic leakages are multifactorial processes.

Surgical repair of long-gap esophageal atresia: A retrospective study comparing the management of long-gap esophageal atresia in the Nordic countries

BackgroundSeveral surgical procedures have been described in the reconstruction of long-gap esophageal atresia (LGEA). We reviewed the surgical methods used in children with LGEA in the Nordic countries over a 15-year period and the postoperative complications within the first postoperative year. MethodsRetrospective multicenter medical record review of all children born with Gross type A or B esophageal atresia between 01/01/2000 and 12/31/2014 reconstructed within their first year of life. ResultsWe included 71 children; 56 had Gross type A and 15 type B LGEA. Delayed primary anastomosis (DPA) was performed in 52.1% and an esophageal replacement procedure in 47.9%. Gastric pull-up (GPU) was the most frequent procedure (25.4%). The frequency of chromosomal abnormalities, congenital heart defects and other anomalies was significantly higher in patients who had a replacement procedure. The frequency of gastroesophageal reflux (GER) was significantly higher after DPA compared to esophageal replacement (p = 0.013). At 1-year follow-up the mean body weight was higher after DPA than after organ interposition (p = 0.043). ConclusionDPA and esophageal replacement procedures were equally applied. Postoperative complications and follow-up were similar except for the development of GER and the body weight at 1-year follow-up. Long-term results should be investigated. Type of studyTreatment study. Level of evidenceLevel III.

Staged Thoracoscopic Repair of Long-Gap Esophageal Atresia Without Temporary Gastrostomy.

Introduction: Primary repair of long-gap esophageal atresia (LGEA) continues to present a surgical challenge. The number of treatment options, including the use of native esophagus or esophageal replacement, shows the difficulty in the treatment and lack of one superior option. Until recently all children with LGEA required temporary gastrostomy before esophageal reconstruction. Objective: The aim of the study is to present new therapeutic management in patients with LGEA, involving staged thoracoscopic procedure with internal traction without gastrostomy. Materials and Methods: Four neonates with LGEA were treated in two academic Departments of Pediatric Surgery in Poland from 2015 to 2018. The intervention was staged thoracoscopic approach, consisting in internal traction, followed by delayed esophageal anastomosis in neonatal period. The outcome measures were successful anastomosis, short time anastomosis complications, and timing of gastric/oral feeding. Results: Internal traction was placed between 2 and 6 days of life. A successful repair of native esophagus by the second approach in neonatal period without gastrostomy was achieved in 3 out of 4 neonates, 5-8 days after internal traction placement. No anastomotic leakage was observed, two anastomoses developed stricture managed with three and four sessions of repeated dilatation. Nasogastric tube feeding started between 5 and 7 days with full oral feeding achieved between 10 and 35 days after anastomosis. Follow-up was after 1-34 months. Conclusions: Our technique should be considered an alternative first-line strategy for the repair of LGEA without the use of a gastrostomy.

Mother's Lived Experience During Repair of Long-Gap Esophageal Atresia: A Phenomenological Inquiry.

Infants born with long-gap esophageal atresia (LGEA) pose unique physiologic risks in the newborn period. Anatomic and physiologic anomalies require an extended hospitalization with procedural analgesia and sedation that impact the mother's experience of birth, maternal response, and nurturing of her infant. The aim of this study was to understand the meaning of experiences that mothers of infants born with LGEA encounter in the neonatal intensive care unit while their infant undergoes esophageal repair. A hermeneutical phenomenological design was used to guide this inquiry. Three mothers were interviewed on 3 separate occasions. The conversations were audio-recorded and transcribed verbatim. The findings were analyzed using fundamental existential lifeworld themes. The essence that conceptualized the study was "making connections: day-by-day." Themes that emerged are (a) the many phases; (b) the long and winding road; (c) a new me, my purpose; and (d) our new community. Nurses' knowledge and understanding of maternal experiences of having an infant with LGEA will enable for increased physical closeness, optimizing time spent together to learn their infant's unique personality. Creating partnerships with mothers can enhance our understanding of their perspectives, concerns, needs, and guide interventions. Further exploration of family dynamics including fathers, siblings, and contextual factors may illuminate interventions to enhance relationships and communication that may influence developmental outcomes for families of infants with LGEA.

Brain Oxygenation During Thoracoscopic Repair of Long Gap Esophageal Atresia

BackgroundElongation and repair of long gap esophageal atresia (LGEA) can be performed thoracoscopically, even directly after birth. The effect of thoracoscopic CO2-insufflation on cerebral oxygenation (rScO2) during the consecutive thoracoscopic procedures in repair of LGEA was evaluated.MethodsProspective case series of five infants, with in total 16 repetitive thoracoscopic procedures. A CO2-pneumothorax was installed with a pressure of maximum 5 mmHg and flow of 1 L/min. Parameters influencing rScO2 were monitored. For analysis 10 time periods of 10’ during surgery and in the perioperative period were selected.ResultsMedian gestational age was 35+3 [range 33+4 to 39+6] weeks; postnatal age at time of first procedure 4 [2–53] days and time of insufflation 127[22–425] min. Median rScO2 varied between 55 and 90%. Transient outliers in cerebral oxygenation were observed in three patients. In Patient 2 oxygenation values below 55% occurred during a low MABP and Hb < 6 mmol/L. The rScO2 increased after erythrocytes transfusion. Patient 5 also showed a rScO2 of 50% with a Hb <6 mmol/L during all procedures, except for a substantial increase during a high paCO2 of 60 mmHg. Patient 4 had a rScO2 > 85% during the first procedure with a concomitant high FiO2 > 45%. All parameters recovered during the surgical course.ConclusionsThis prospective case series of NIRS during consecutive thoracoscopic repair of LGEA showed that cerebral oxygenation remained stable. Transient outliers in rScO2 occurred during changes in hemodynamic or respiratory parameters and normalized after interventions of the anesthesiologist. This study underlines the importance of perioperative neuromonitoring and the close collaboration between pediatric surgeon, anesthesiologist and neonatologist.