Native Esophagus Research Articles

Caustic and Toxic Ingestions

Ingestion of caustic substances remains a potentially fatal public health concern with extensive morbidity and the possibility of long-term sequelae. The management strategies of these complex injuries continue to be extensively studied in the literature. Areas of interest include the most efficacious treatment of caustic esophageal stricture to preserve the native esophagus, use of steroids, and use of esophageal stents. Prevention of accidental ingestion through strategies to limit the availability of caustic substances is a key factor in reducing the incidence of injury, but there continues to be a high rate of accidental ingestion in developing countries with less rigorous manufacturing standards. Initial evaluation includes endoscopic evaluation of the esophagus and tracheobronchial tree. Optimal treatment strategies, including the use of proton pump inhibitors to reduce gastroesophageal reflux, steroid use to prevent stricture formation, and use of stents for management of strictures, continue to be debated. Initial surgical management includes esophagectomy for full-thickness injury with abdominal exploration. Multiple surgical options exist for both restoration of gastrointestinal continuity after esophagectomy and the management of strictures refractory to medical management, including reverse gastric tube, colonic interposition, and gastric advancement. Numerous small studies have evaluated the efficacy of these interventions, but there continues to be a need for larger prospective studies to develop a worldwide consensus opinion on best practices. We provide a review of the recent literature and practice recommendations for the management of injuries due to caustic ingestion. This review contains 7 figures, 10 tables, and 51 references. Key words: caustic ingestion, endoscopic management, stricture, surgical management

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

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

Childhood outcome after correction of long-gap esophageal atresia by thoracoscopic external traction technique

BackgroundThoracoscopic external traction technique (TTT) is a relatively new surgical intervention for patients with long-gap esophageal atresia (LGEA) that preserves the native esophagus. The major accomplishment with TTT is that esophageal repair can be achieved within days after birth.This study evaluates the childhood outcome in LGEA patients treated with TTT, including gastrointestinal outcome, nutritional status and Health-Related Quality of Life (HRQoL). MethodsA cohort study including all LGEA patients that underwent TTT between 2006-2017 was conducted. Patients and/or their parents were invited to fill out questionnaires regarding reflux symptoms and HRQoL. ResultsTTT was successful in 11/13 patients (85%). Esophageal anastomosis was accomplished at a median age of 12 days (range 7-138), first oral feeding was started at a median of 16 days postoperatively (range 5-37). All patients required multiple dilatations and 10 patients required anti-reflux surgery.At median follow-up of seven years, five patients reported mild and one moderate reflux complaints. All patients but one reached age-appropriate oral diet. Most patients (80%) were within normal growth range. Overall HRQoL was comparable to healthy controls. ConclusionTTT provides acceptable results in childhood. Oral feeding can be started as soon as two weeks postoperatively. Almost all patients are able to eat an age-appropriate oral diet. Overall HRQoL was comparable to healthy controls.

Evolution, lessons learned, and contemporary outcomes of esophageal replacement with jejunum for children

BackgroundThe jejunal interposition is our preferred esophageal replacement route when the native esophagus cannot be reconstructed. We report the evolution of our approach and outcomes. MethodsThe study was a single-center retrospective review of children undergoing jejunal interposition for esophageal replacement. Outcomes were compared between historical (2010–2015) and contemporary cohorts (2016–2019). ResultsFifty-five patients, 58% male, median age 4 years (interquartile range 2.4–8.3), with history of esophageal atresia (87%), caustic (9%) or peptic (4%) injury, underwent a jejunal interposition (historical cohort n = 14; contemporary cohort n = 41). Duration of intubation (11 vs 6 days; P = .01), intensive care unit (22 vs 13 days; P = .03), and hospital stay (50 vs 27 days; P = .004) were shorter in the contemporary cohort. Anastomotic leaks (7% vs 5%; P = .78), anastomotic stricture resection (7% vs 10%; P = .74), and need for reoperation (57% vs 46%; P = .48) were similar between cohorts. Most reoperations were elective conduit revisions. Microvascular augmentation, used in 70% of cases, was associated with 0% anastomotic leaks vs 18% without augmentation; P = .007. With median follow-up of 1.9 years (interquartile range 1.1, 3.8), 78% of patients are predominantly orally fed. Those with preoperative oral intake were more likely to achieve consistent postoperative oral intake (87.5% vs 64%; P = .04). ConclusionWe have made continuous improvements in our management of patients undergoing a jejunal interposition. Of these, microvascular augmentation was associated with no anastomotic leaks. Despite its complexity and potential need for conduit revision, the jejunal interposition remains our preferred esophageal replacement, given its excellent long-term functional outcomes in these complex children who have often undergone multiple procedures before the jejunal interposition.

A new method of primary engineering of esophagus using orthotopic in-body tissue architecture

PurposeTissue engineering of esophagus is required for management of long-gap esophageal atresia (LGEA). Collagenous connective tissue membranes fabricated by in-body tissue architecture (iBTA), called biosheets, can repair esophageal defects and generate tissues similar to native esophagus. However, iBTA requires second-stage surgery because of heterotopic preparation of biosheets. Our aim was to develop orthotopic iBTA for primary engineering of the esophagus by interposing a tubular mold to the esophageal defect. MethodThe cervical esophagus of six rats was transected. An acrylic tube (internal diameter 2.6 mm, length 7.0 mm) was inserted and fixed between the ends of the upper and lower esophagus, and a 3 mm-long esophageal defect was created. Four weeks later, the rats were sacrificed for histological analysis. ResultsPostoperatively the rats could intake liquid food. After four weeks, the esophageal defects were filled with regenerated tissues. Histologically the new esophageal walls stained positive for collagen type I. The inner surfaces were covered with stratified squamous epithelium that expressed pan-cytokeratin. In only one of six rats, regeneration of muscular-like tissue was suggested by positive immunohistochemical staining for desmin. ConclusionOrthotopic iBTA can regenerate a substitute esophagus with esophageal epithelium and collagenous wall. This technique may be a novel treatment for esophageal atresia with gaps of various lengths including LGEA.

The Effectiveness of Combined Balloon and Bougie Dilatation Technique in Children with Impassable Esophageal Stricture.

Background: Impassable caustic esophageal strictures (CES) can be rendered passable through sophisticated dilatation techniques, hence avoiding the esophageal replacement surgery and its complications. Patients and Method: Patients with impassable CES who were presented to our hospital between January 2015 and April 2020 underwent a combined balloon and bougie dilatation. This technique aims at doing an initial partial dilatation of the proximal segment of the stricture, using a balloon catheter to pave the way for the endoscope to be advanced more distally. Therefore, a guide wire could be passed down to the stomach to complete the dilatation session using bougie dilators. Results: Seven patients out of 138 patients who underwent endoscopic dilatation for CES at the pediatric surgery department were enrolled in this study. Their ages ranged from 2.5 to 6 years. This technique was successful in 6 patients indicating technique reproducibility of 85.7%. These 6 patients continued their next dilatation sessions using bougie dilator only, whereas 4 patients were completely cured from dysphagia indicating technique efficiency of 57%, 1 is still on dilatation, and 1 patient had a resistant stricture. The dilatation through the proposed technique failed in 1 patient, who was referred for a replacement surgery. Conclusion: Combined dilatation is safe and effective to preserve the native esophagus in some difficult CES.

Serum cytokine profile indicators after subcutaneous implantation of the decellularized esophagus matrix in rats

Study of postimplantation immune response to decellularized matrices has great importance for assessing biocompatibility of tissue-engineered structures based on them, since inflammatory process and excessive production of inflammatory mediators lead to complications and implant rejection. The aim of this research: serum cytokine profile studying after subcutaneous implantation of decellularized esophagus matrix in rats. Experimental data were obtained on male Wistar rats aged 5-6 months (n=55). Rats were divided into 4 groups: two control groups, experimental and comparison group. Control group 1 consisted of conditionally healthy rats (n=10), control group 2 - shame-operated animals (incision in scapula without implantation, n=15). In experimental group (n=15), rats underwent subcutaneous implantation of decellularized esophagus fragments; in group 2 (n=15) - native esophagus fragments. Peripheral blood sampling and fragment explantation were performed on 7th, 14th and 21st experimental days. Serum samples were tested for IL1a, IL2, IL4, IL17A, TNFa, IFNy, GM-CSF content by ELISA. Explanted native esophagus and decellularized esophagus fragments were subjected to histological analysis. On 7th experimental day, significant increase in IL1 a content was observed in rats with implantation of decellularized esophagus fragments. IL17A, IFNy, GM-CSF content significantly decreased. On 14th day, IL17A concentration sharply decreased in comparison with value on 7th experimental day and control 1. IL1 a and IFNy concentration decreased in comparison with control group 1 values and 7th day respectively. On 21st day, dynamics of decrease in IL17A, IFNy, IL1 a content in this rat group was revealed. Thus, it was found change in concentrations of studied cytokines corresponds to regeneration histomorphological picture in group that underwent implantation of acellular matrices against of active inflammatory reaction in comparison group. Concentrations of IL1 a, IL4, IL17A, IFNy reflect positive dynamics of wound healing process and absence of decellularized matrix rejection.

Pedicled jejunal interposition as esophageal substitute in pediatric patients. Technical considerations and long-term results

The current study reports the surgical technique and the clinical long term results of pediatric esophageal substitution with a pedicled jejunal loop in two patients with long gap esophageal atresia and one patient with severe esophageal stenosis due to a caustic lesions. Postoperative course was uneventful in all patients. At a long term follow-up of 29 and 43 years for the patients with esophageal atresia and 21 for the one with caustic stenosis, no feeding troubles were reported due to malfunction of the esophageal replacement nor to loss of its original functions and the patients referred a highly satisfying quality of life. Pedicled jejunal interposition confirms as a good substitute of the esophagus in pediatric age with the advantage to maintain good performances for very long time. Although these patients do not share the same risks of illness as other patients still harboring their native pathologic esophagus, a far sighted surveillance is recommended due to long term potential morbility risk.

Foker technique for esophageal reconstruction after cervical esophagostomy

The approach to patients with complicated esophageal atresia continues to be a challenge for the pediatric surgeon. Patients with long-gap esophageal atresia (LGEA) or who had complications during their first surgery may require cervical esophagostomy and gastrostomy for posterior definitive correction. Usually reconstruction is performed through esophageal replacement with gastric, ileal, or colonic interposition. This paper reports on two cases in which the intraoperative stretching technique - Foker - maintaining the native esophagus was used, for reconstruction of the digestive tract in patients submitted to cervical esophagostomy and gastrostomy at birth, one due to diagnosis of LGEA and the other due to complications in the primary correction.

SURGICAL TACTICS OF SAVING THE NATIVE ESOPHAGUS IN CASE OF LONG GAP ESOPHAGEAL ATRESIA

Introduction. The absence of a single surgical tactic for a long gap esophageal atresia (LGEA) treatment as well as frequent unsatisfactory results of applying existing treatment methods urge searching and implementing of a new surgical approach to remediation of malformation. Objective. To optimize surgical treatment of LGEA and provide preservation of native esophagus by elongating and pouches growth inducting. Materials and methods. 6 clinical cases of patients with LGEA who had been treated in National children specialized hospital “Okhmatdyt” during 2018-2019 were analyzed. All patients received staged malformation remediation by elongating of esophagus pouches with traction sutures with further formation of anastomosis. Results. 6 patients with LGEA were surgically treated by esophageal lengthening using the Foker process. The duration of traction varied from 6 to 19 days, the average daily distance of traction of each segment was from 2,4 to 4,8 mm. Segment growth efficiency was observed by diagnostics of metal clips positioning at the ends of esophagus segments on X-ray, or esophagography. In all 6 cases the application of dozed staged traction resulted in esophagus lengthening with elimination of gap from 0-1,0 sm, so that anastomosis of native esophagus was accomplished with the further oral feeding. Conclusions. The method of growth induction allows to overcome a long gap between segments of the atretic esophagus, create conditions for the formation of anastomosis and preserve own esophagus with the restoration of age-related oral nutrition. The concept of induction of esophageal growth eliminates or reduces the use of intestinal plastic of esophagus. The Foker process is an organ-preserving method and is an alternative to operations with loss of an esophagus.

Esophageal elongation using Foley catheter in long-gap esophageal atresia

Esophageal atresia/tracheoesophageal fistula (EA/TEF) is a rare congenital anomaly that poses major surgical challenges, particularly when the distance between the two esophageal ends exceeds 3 cm. Many surgical techniques are advocated for bridging the gap between the two esophageal ends. In this paper, we propose a simple and effective technique to elongate the esophagus in the long gap EA. This technique has successfully been applied in two infants with type C EA/TEF, where a primary end to end esophageal anastomosis was not feasible. The technique uses two Foley catheters for traction of upper and lower esophageal ends in long-gap EA/TEF. This method helps preserve the native esophagus, providing comfortable suction of the upper esophageal pouch, and assuring postoperative continuous feeding through the lower esophageal segment.

Esophagus stretch tests: Biomechanics for tissue engineering and possible implications on the outcome of esophageal atresia repairs performed under excessive tension.

Esophageal biomechanical studies are important to understand structural changes resulting from stretches during repair of esophageal atresias as well as to obtain values to compare with the biomechanics of tissue-engineered esophagus in the future. This study aimed to investigate light microscopic changes after uniaxial stretching of the ovine esophagus. In vitro uniaxial stretching was performed on esophagi (n = 20) of 1-month-old lambs within 4-6h post-mortem. Esophagi were divided into 5 groups: control and stretched (1.1, 1.2, 1.3 and 1.4). Force and lengthening were measured with 5 cycles performed on every specimen using a PBS organ bath at 37°C. Histological studies were performed on the 5 groups. Low forces of ~ 2N (N) were sufficient for a 1.2-1.25 stretch in the 1st cycle, whereas a three times higher force (~ 6N) was needed for a stretch of 1.3. In the 2nd to 5th cycle, the tissue weakened and a force of ~ 3N was sufficient for a stretch of 1.3. Histologically, in the 1.3-1.4 stretch groups, rupture of muscle fibers and capillaries were observed, respectively. Changes in mucosa and collagen fibers could not be observed. These results offer norm values from the native esophagus to compare with the biomechanics of future tissue-engineered esophagus. Esophageal stretching > 1.3 leads to tears in muscle fibers and to rupture of capillaries. These findings can explain the decrease in microcirculation and scarring in mobilized tissue and possibly offer clues to impaired motility in esophagus atresias repaired under excessive tension.

Distal esophagostomy tube feedings in the treatment of long gap esophageal atresia: Experience with 10 cases

Abstract There are different strategies for the treatment of long gap esophageal atresia (LEA), but many aspects of its management is still controversial. The best treatment is conserving the native esophagus through the connection of two esophageal pouches. In this study, we shared our experiences in management of LEA treatment and introduced a new approch for the conservative management of this condition. In our experience, ten patients with long gap esophageal atresia were treated, followed up and managed by our own designed method. In our technique, we lengthened the both upper and lower pouches instead of one pouches. On the one hand, with the effect of saliva pressure, the upper pouch became longer without proximal esophagostomy. On the other hand, the lower pouch was mechanically lengthened by the feeding effect of gavage. These reduced the distance between the two ends of the esophagus and provided the conditions for the primary anastomosis and saving the native esophagus. There were no complication in these ten patients but this procedure needs more investigation.

Serum cytokine profile during subcutaneous implantation of the decellularized esophagus matrix in rats.

to study non-specific immune response characteristics (serum cytokine profile) in rats after subcutaneous implantation of the decellularized esophagus matrix. Data were obtained in Wistar rats. The rats underwent subcutaneous implantation of decellularized esophagus (DE) and native allogeneic esophagus (NE). Explantation of sampling were carried out on the 7th, 14th and 21st day of the experiment. Explanted NEs and DEs were processed for histologic examination. The content of IL1α, IL2, IL4, IL17А, TNFα, IFNγ and GM-CSF in serum samples were tested by ELISA. In rat serum with DEs on the 7th day of the experiment it was significant increase in IL1α level in comparison with control group, IL2, TNFα, IL4 levels did not differ from the control group levels that indicates the stabilization of inflammation. The content of IL17A, IFNγ and GM-CSF significantly decreased compared to control. On the 14th day, IL17A concentration analysis showed a sharp decrease in comparison with the the 7th experimental day. We found decrease in IL1α level vs control group and decrease in IFNγ level vs 7th day. On the 21st experimental day was shown a significant decrease in the IL17A, IFNγ and IL1α content in DE rats. It was found dynamic change in studied rat cytokine concentrations that correspond to favourable clinical picture in DE group in comparison with an active inflammatory reaction in NE group. IL1α, IL4, IL17A and IFNγ concentrations reflect positive dynamics of the wound healing process and the absence of local inflammation and rejection of decellularized matrices.

Early Management of Esophageal Leak in Esophageal Atresia: Changing Paradigms.

Introduction: A leak at the esophageal anastomosis can occur in 10%-20% of cases of esophageal atresia (EA). Thoracoscopic repair is trans-pleural, with the potential development of an empyema. Standard treatment of an anastomotic leak in a stable patient is often nonoperative, which can lead to prolonged parenteral nutrition and hospitalization. Our objective is to show that early thoracoscopic redo anastomosis management is safe and feasible. Materials and Methods: Retrospective study of a case series of four infants, diagnosed with EA and treated with early thoracoscopic esophageal leak repair between 2013 and 2018. Variables analyzed included age, weight, type of EA, day of leak, surgical approach, time to start feeding, surgical complications, and follow-up. Results: Three patients were type III, and one was type I originally repaired with a thoracoscopic approach. Leaking of the anastomosis was found the second postoperative day in one patient, third day in two patients, and the fifth day in the last one. All were confirmed with an esophagogram. All patients were operated in the first 24 hours after diagnosis by the thoracoscopic approach. The site of leak was found and re-sutured. Patients started feeding between the third and fourth day through a transanastomotic tube, starting oral feeding at the seventh day after an esophagogram did not show a leak. No complications were found. Mean time to complete oral feeding was 10 days. Two patients needed esophageal dilations. Mean time of follow-up has been 33 months. Conclusion: Early thoracoscopic repair of an anastomotic leak can be considered an alternative to the standard nonsurgical management. The early re-suture of the area of leak is a change in paradigm, but it offers the benefits of preservation of the native esophagus, early resumption of enteral feedings, and a shorter length of parental nutrition and hospitalization. Level of Evidence: IV.

Iatrogenic esophageal perforation caused by endoscopic dilatation of caustic stricture: Current management and possibility of esophageal salvage

BackgroundIatrogenic esophageal perforation (EP) is an undesirable complication of endoscopic dilatation of caustic esophageal stricture. We reported our current management protocol with possibility of continuing the dilatation program. Patients and methodsFrom January 2009 to January 2020 medical records were reviewed for patients presented with iatrogenic EP. Management according to each case condition was reported. Results24 patients were enrolled, aged from 1.5 to 6 years old. Perforation was cervical in one case, abdominal in two cases, and thoracic in 21 cases. Immediate surgical repair was performed in the abdominal cases. Conservative management was chosen in 22 cases; two cases didn't respond and underwent esophageal diversion, and one of them died owing to severe sepsis. Three patients refused another trial of dilatation. Two cases failed to be redilated. 17 patients continued a dilatation program. Time passed between perforation and redilatation ranged from 35 days to 7 months. 15 patients were cured completely from dysphagia, one patient had marked improvement of his dysphagia, and one case with a resistant stricture was referred for esophageal replacement. ConclusionPreserving the native esophagus is possible after iatrogenic EP of caustic esophageal stricture. A conservative approach should be attempted with caution not to endanger patient's life.Level IV of evidence

Staged thoracoscopic treatment of longgap esophageal atresia without the need for a gastrostomy

Introduction . Primary reconstruction of long gap esophageal atresia still represents a serious surgical issue. A variety of treatment options including preservation of native esophagus or its replacement for other segments of the digestive tract shows that the condition is difficult to treat and that a single approach is lacking. Until recently, all children with long gap esophageal atresia required a temporary gastrostomy to provide nutrition during lengthening of the existing esophagus. This study presents a new therapeutic approach when thoracoscopic elongation of the esophagus by traction can be performed without a gastrostomy. Materials and methods . Two cases of long gap esophageal atresia were reported in children who underwent treatment at the Center of Neonatal Surgery of Ivan and Matryona City Children’s Hospital in Irkutsk from 2017 to 2018. Internal sutures were applied using thoracoscopy with subsequent remote esophageal anastomosis that was also performed with the help of thoracoscopy. The treatment was estimated through the possibility of anastomosis application, anastomosis complications and interval of a patient’s transition to oral feeding. Results . The esophageal traction lasted 5 and 6 days, respectively. Both patients had native esophagus preserved without the need for a gastrostomy. Neither patient had anastomosis leakage. Feeding via the nasogastric tube started at days 6 and 7 after the surgery. Oral feeding was possible at days 30 and 35 after anastomosis construction. Anastomotic stenosis was developed in two patients and required 3 and 4 sessions of balloon dilatation. At 12-month follow-up, the patients’ food regimen was similar to that of their peers. Conclusions . The presented method of esophageal traction without the need for a gastrostomy must be considered as an alternative treatment strategy of long gap esophageal atresia.

Laparoscopic-assisted gastric pull-up: initial experience and technical details

To describe our initial experience in laparoscopic-assisted gastric pull-up via posterior mediastinal route in comparison with our historic experience performed by open laparotomy gastric pull-up via retrosternal route. The results of the two approaches were evaluated in this study. Between 2000 and 2017, we conducted a retrospective review of all patients that had undergone gastric transposition for esophageal atresia (EA) and long caustic strictures when preservation of the native esophagus was not possible. A total of 17 pediatric patients underwent gastric pull-up transposition as esophageal replacement technique. The patients were divided into two groups. Group A (2000–2015) consisted of 11 patients that underwent open laparotomy gastric pull-up via the retrosternal route. Three Group A patients had EA Type I, two had EA Type II, five had EA Type III, and one long caustic stricture. Associated anomalies included VACTERL association in two cases, Down syndrome in one case and intestinal malrotation in one case. The mean age at surgery was 2.2 years and the mean follow-up was 9.3 years. All patients were able to achieve oral feeds. Group B (2016–2018) consisted of six patients that underwent laparoscopic-assisted gastric transposition via posterior mediastinal pathway. Three had EA Type I, two had EA Type III, and one had a long caustic esophageal stricture. Associated anomalies included a single case of VACTERL association. Previous surgeries included two thoracotomies and two esophagostomies in patients with EA/TEF and one gastro-jejunal anastomosis in a patient with pyloric total disconnection after pyloric balloon dilatation for caustic esophageal and pyloric stricture. All patients underwent gastrostomy. Laparoscopic procedure was successfully completed in all patients without conversion. The mean follow-up in Group B was 27 months. All patients were able to establish oral feeds. Laparoscopic-assisted gastric pull-up as esophageal replacement technique is safe and has few complications. Slight modifications of the technique such as pyloric dilation reduce laparoscopic surgical time.

Outcome of thoracoscopic repair of type-C esophageal atresia: a single-center experience from North Africa.

Thoracoscopic repair of esophageal atresia is gaining popularity worldwide attributable to availability and advances in minimally invasive instruments. In this report, we presented our experience with thoracoscopic esophageal atresia/tracheoesophageal fistula (EA/TEF) repair in our tertiary care institute. A prospective study on short-gap type-C EA/TEF was conducted at Cairo University Specialized Pediatric Hospital between April 2016 and 2018. Excluded were cases with birth weight < 1500gm, inability to stabilize physiologic parameters, or major cardiac anomalies. The technique was standardized in all cases and was carried out by operating team concerned with minimally invasive surgery at our facility. Primary outcome evaluated was successful primary anastomosis. Secondary outcomes included operative time, conversion rate, anastomotic leakage, recurrent fistula, postoperative stricture, and time till discharge. Over the inclusion period of this study, 136 cases of EA/TEF were admitted at our surgical NICU. Thoracoscopic repair was attempted in 76 cases. In total, 30 cases were pure atresia/long gap type-C atresia and were excluded from the study. Remaining 46 cases met the inclusion criteria and were enrolled in the study. Mean age at operation was 8.7days (range 2-32), and mean weight was 2.6 Kg (range 1.8-3.6). Apart from five cases (10.8%) converted to thoracotomy, the mean operative time was 108.3minutes (range 80-122minute). A tension-free primary anastomosis was possible in all thoracoscopically managed cases (n= 41) cases. Survival rate was 85.4% (n= 35). Anastomotic leakage occurred in seven patients (17%). Conservative management was successful in two cases, while esophagostomy and gastrostomy were judged necessary in the other for five. Anastomotic stricture developed in five cases (16.6%) of the 30 surviving patients who kept their native esophagus. Despite the fact that good mid-term presented results may be due to patient selection bias, thoracoscopic approach proved to be feasible for management of short-gap EA/TEF. Authors of this report believe that thoracoscopy should gain wider acceptance and pediatric surgeons should strive to adopt this procedure.

Transhiatal isoperistaltic colon interposition without cervical oesophagostomy in long-gap oesophageal atresia.

Background:Oesophageal colonic interposition in oesophageal atresia (OA) patients is almost exclusively done as a staged operation with an initial oesophagostomy and gastrostomy followed by the definitive surgery months later. This study presents a series of patients in whom a cervical oesophagostomy was not performed before the substitution surgery.Patients and Methods:Records of EA patients were evaluated for those who underwent colon interposition without cervical oesophagostomy.Results:There were five patients: three with pure EA and two with proximal tracheo-oesophageal fistula. A delayed primary repair could not be performed because of intra-abdominally located distal pouch. The mean age at the time of definitive operation was 5.54 (±2.7) months and the mean weight was 6.24 (±1.3) kg. A right or a left colonic segment was used for interposition keeping the proximal anastomosis within the thorax. The post-operative results were quite satisfactory within a median follow-up period of 33.2 months.Conclusion:Avoiding cervical oesophagostomy and its inherent complications and drawbacks is possible in a subset of patients with long-gap EA who underwent colonic substitution surgery. This approach may be seen as an extension of the consensus that the native oesophagus should be preserved whenever possible, because it uses the native oesophagus in its entirety.