Proximal Fistula Research Articles

The Canadian Experience With Magnetic Esophageal Anastomosis: A Report From the Canadian Consortium for Research in Pediatric Surgery Study (CanCORPS).

Magnetic anastomosis is an innovative technique for establishing esophageal continuity in infants born with esophageal atresia. Few case series featuring this technology have been published, with even fewer reports on complications. We present the entire Canadian experience with this approach. A nationwide retrospective review of all esophageal atresia patients treated with magnetic anastomoses in Canada was conducted through the Canadian Consortium for Research in Pediatric Surgery (CanCORPS). Magnetic anastomoses were attempted in nine patients including four Type A, two Type B, and three Type C. The median pre-operative esophageal gap was 2.9cm (range 0.0-5.5cm). In four patients, magnetic anastomosis was used as a salvage technique, after failed attempted primary repair. Seven patients (78%) achieved esophageal patency after magnet insertion. Strictures developed in all successful cases and required a median of 10 dilatations (range 3-16). In one patient with a failed anastomosis, the proximal magnet perforated the proximal esophageal pouch, while in the second case, the magnets failed to couple together. One patient had an anastomosis form but required operative intervention shortly afterwards to both revise the anastomosis and address a missed proximal fistula. In the Canadian experience, magnetic anastomosis was successful in establishing esophageal continuity in most patients. However, all patients developed strictures requiring multiple dilatations, and there was a substantial risk of complications requiring additional operative procedures. Further refinement of this technique may establish magnetic anastomosis as another tool for the pediatric surgeon treating long-gap and other challenging cases of esophageal atresia.

Esophageal atresia type III? Intraoperative surprise and different approaches.

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

Intermediate and long-term outcomes of transcatheter closure of congenital coronary cameral fistulas in 66 children

Objective: To evaluate the intermediate and long-term outcomes and technical aspects of transcatheter closure (TCC) of coronary cameral fistulas (CCF) in pediatric patients. Methods: This was a case-control study. All pediatric patients with CCF who underwent TCC between January 2005 and December 2019 were retrospectively reviewed. Data was collected from medical records, including demographic characteristics, procedural details, intraoperative and postoperative serious adverse events, follow-up results and prognosis. Patients with serious adverse events and without serious adverse events were compared regarding their clinical features and CCF characteristics. Comparisons between groups were performed with independent sample t test, chi-square test or Fisher exact test. Results: A total of 66 CCF patients (34 boys, 32 girls, 3.9 (1.9, 6.2) years old, 15 (11, 20) kg) underwent attempted TCC. All of the CCF were all medium or large fistulas including 55 proximal fistulas (83%) and 11 distal fistulas (17%). The CCF originated more frequently from the right coronary artery (38 cases (58%)), followed by the left coronary artery (28 cases (42%)). The incidence of coronary artery aneurysms (CAA) was 61% (40/66).Procedural treatment was achieved in 64 patients and procedural success was achieved in 59 patients (92%). Six (9%) serious adverse events occurred in 5 patients during the perioperative period. Acute complications included procedure-related death in one patient and acute myocardial infarction in one patient. Periprocedural complications occurred in 3 patients at one day postoperatively including acute myocardial infarction (2 cases), occluder detachment (1 case), and tricuspid chordae tendinae rupture (1 case). Clinical follow-up data were available in 58 of the 62 patients who underwent initial successful TCC with a follow-up period of 9.3 (6.5, 13.4) years. Ten adverse events occurred in 9 patients including 5 complications consisted of aortic valve perforation (1 case), coronary thrombosis (1 case), progressive aneurysmal dilation after reintervention (1 case), and new-onset tricuspid valve prolapse with significant regurgitation (2 cases) and large residual shunts due to fistula recanalization (5 cases). Therefore, the incidence of intermediate and long-term adverse events was 17% (10/58). During the periprocedural and follow-up period, 16 adverse events occurred in 13 patients, whereas no adverse events occurred in 51 patients. Patients with seriovs adverse events presented with larger proportion of large CCF (11/13 vs. 39% (20/51), P=0.005), giant CAA (10/13 vs.14% (7/51), P=0.030), and higher mean pulmonary artery pressure ((20±9) vs.(16±6) mmHg, 1 mmHg=0.133 kPa, t=2.02, P=0.048) compared to patients without serious adverse events. Conclusions: TCC in CCF children appears to be effective with favorable intermediate and long-term outcomes. Strict indication of TCC is mandatory.

Distal AVF creation with marginal calcified radial artery: Multicentric experience of intraoperative intravascular lithotripsy.

The first-choice vascular access to starting dialysis in patients with End Stage Renal Disease (ESRD) is autogenous distal arteriovenous-fistula (AVF) to spare vascular district avoiding proximal fistula complications. One of most significant exclusion criteria to create distal AVF is still now the presence of huge calcification of the feeding artery due to large numbers of early failure (EF) and failure in maturation (FTM). In recent years the possibility to use new devices able to deliver intravascular lithotripsy (IVL) to treat high calcified stenosis could be a possibility to recruit these marginal arteries to create distal AVF. ESRD patients with totally calcified radial artery wall were enrolled to participate to this prospective, single arm, multicentric study. The selected patients were treated with intraoperative IVL at surgical time, during anastomosis creation to soften calcified radial artery. Patients were followed 1 month after surgery with eco-doppler, for flow and vessels maturation assessment. At 3 month was investigated how many patients have started dialysis treatment with two needle cannulation and good efficiency. Nineteen distal forearm radio-cephalic fistula were built in 19 patients. One-month doppler assessment showed mean AVF flow of 743 ml/min and efferent vein caliper of 6.46 mm. At 3 months 14 patient have started stable 2 needles dialysis (other three patients were not yet dialysis dependent CKD). Were observed one immediate failure, one failure in maturation, and two late failures at 4 and 16 months respectively. Sixteen months primary and secondary patency was 78.9% and 89.5% respectively. These results showed how intraoperative IVL could help to recruit huge calcified marginal artery to create autogenous distal forearm AVF, avoiding proximal AVF, risking distal ischemia syndrome, and sparing vascular district to eventually rebuilt more proximal AVF in future.

Standardization of Pre-operative Evaluation to Improve the Outcome of Arteriovenous Fistula for Vascular Access of Hemodialysis: A Review of 700 Cases.

Background With the advent of COVID-19, mortality rates of end-stage kidney disease (ESKD) rose by 37% which makes its treatment an important part of healthcare. Arteriovenous fistula (AVF) is linked to higher patient survival rates. Cimino-Brescia fistula is the most effective vascular access technique, but it has a high rate of primary failure (PF) and a several-week maturation period before it can be used. The current study aims to verify the preoperative evaluation in improving survival among AVF patients. Methodology The current study is a retrospective analysis of the hospital database from Jan 2022 to July 2023, with patients of a mean age of 60.2 years. The sample size was around 700, including the patients indicated for long-term hemodialysis (HD) with an estimated GFR of less than 20 mm/min/1.73m². Following AVF surgery, post-operative outcomes, PF, and maturation time were considered. Results Among the 757 AVF procedures, 588 (82%) were new cases, and 112 (16%) had prior AVF history on the same side. PF was observed in 126 (18%) AVFs, while 574 (84%) achieved maturation. Age at surgery did not correlate with PF. Male sex and brachiocephalic AVF (BCAVF) had lower PF rates, while female gender, non-BCAVF, and vascular chronic kidney disease (CKD) were independent predictors. Proximal fistulas had a higher failure risk (32%). During surgery, the PF occurred six times more frequently in patients with veins and arteries under 2 mm and without a bruit. Conclusion AVF maturation aims to achieve a functional AVF for easy dialysis, requiring meticulous vein selection, doppler vascular mapping, and a standardized process to reduce PF rates. Factors determining PF include thrill and bruit, flow rates, and comorbidities. These findings can help clinicians make informed decisions and improve outcomes for patients undergoing fistula surgery.

Use of oral diet and nutrition support in management of stricturing and fistulizing Crohn's disease.

Crohn's disease (CD), a form of inflammatory bowel disease, involves chronic inflammation within the gastrointestinal tract. Intestinal strictures and fistulas are common complications of CD with varying severity in their presentations. Modifications in oral diet or use of exclusive enteral nutrition (EEN) are common approaches to manage both stricturing and fistulizing disease, although supporting research evidence is generally limited. In the preoperative period, there is strong evidence that EEN can reduce surgical complications. Parenteral nutrition (PN) is often utilized in the management of enterocutaneous fistulas, given that oral diet and EEN may potentially increase output in proximal fistulas. This narrative review highlights the current practices and evidence for the roles of oral diet, EEN, and PN in treatment and management of stricturing and fistulizing CD.

#3408 A META-ANALYSIS OF VASCULAR ACCESS OUTCOMES IN HEMODIALYSIS PATIENTS OVER 75 YEARS OF AGE

Abstract Background and Aims The age of patients with end-stage renal disease is constantly growing, but evidence for the best vascular access for hemodialysis is scarce and controversial for elderly. A meta-analysis was performed in hemodialysis patients over 75 years old to compare the outcomes of different vascular access procedures in the sub-group of elderly ESRD patients ≥ 75 years of age. Method A literature search was performed using the electronic databases MEDLINE and SCOPUS up to October 2021. Twelve eligible articles fulfilled the inclusion criteria and were finally selected in the meta-analysis (Table). Three of these studies including ESRD patients >70 years of age were exceptionally included as the mean age was well above 75 years. First step analysis was focused on studies that reported the primary patency rates of autologous vs. prosthetic vascular accesses (5 studies). Second step analysis was focused on articles comparing the results of primary and secondary patency rates of distal (forearm) vs. proximal (upper arm) fistulas in elderly patients (8 studies). All these studies were retrospective cohort studies, none was randomized controlled trial. Results Regarding the first step analysis, primary failure rate at 24 months was in favor of AVFs (OR: 0.56, 95% CI: 0.38-0.83, p = 0.003, Fig. 1). Although several studies have shown that AVG patency is not affected by age, this meta-analysis showed patency benefit of AVF in this subgroup of elderly patients ≥75 years of age. In a second step, the 12-month primary failure rate was by far in favor of proximal AVFs (OR: 2.14, 95% CI: 1.53-2.97; p<.00001, Fig. 2). The 12-month secondary patency rate of the forearm AVFs was also inferior compared to the proximal AVF (OR: 1.76, 95% CI: 1.12-2.78; p<.01, Fig. 3) These findings favor the use of proximal AVFs as first choice access in this subgroup of elderly patients, especially when they are late referrals or have low life expectancy. Conclusion The question of the right access in elderly ESRD patients does not have an easy answer. The present study shows that patients ≥75 years old should not be excluded from creation of an autologous access, with proximal AVFs having better patency rates.

#5446 A COHORT OF DIALYSIS PATIENTS WITH LOW PREVALENCE OF UPPER ARM FISTULAS

Abstract Background and Aims International guidelines encourage the use of distal native fistula (AVF) which is the best first-line vascular access (VA). But, despite these indications, all over the world, except for Japan, the prevalence of upper arm fistula (UAF) is dramatically increasing. Previous surveys in our department included about 50% of Haemodialysis patients (HP) and showed prevalence of UAFs less then 5%–very low, if compared with those of our country, reported by DOPPS 5 study. We decided to analyse 100% of HP in our department, in order to confirm or exclude the low prevalence of UAF. Method Puglia, southern east of Italy, has 1.4 millions inhabitants, of which 1365 need dialysis; 1295 on haemodialysis in 17 different centers and 70 on peritoneal dialysis. The department is organized on a Hub and Spoke model for VA management (Fig. 1). Hub performs simple and complex AVFs, Graft, PTA of non matured or stenotic fistulas, PTA of central stenosis, and surgical rescue of thrombosed or stenotic fistulas. Our four spokes perform mainly simple distal forearm fistula (DFF). In December 2021 we collected datas of VA prevalence of all 1295 HP. The AVFs were classified, according to their anatomical site, in DFF, mean-proximal forearm fistula (MPFF) and UAF. Results The average age of 1295 HP was 69 ± 14,65% yo (65% males and 21% diabetics) and 458 of them (35%) where more than 75 yo. The prevalence of DFF, MPFF, UAF, GRAFT and CVC was 63.5%, 10.1%, 3%, 0.7%, 22.5% respectively (fig. 2). Patients aged ≥75 years, women and diabetics showed a higher prevalence of CVC and a lower prevalence of DFF. Conclusion Data collected on all patients confirm the low prevalence of UAF detected in the previous surveys -which involved only a part of haemodialysis patients. Zero upper arm fistulas is an utopian goal, but it seems possible to reduce the prevalence of proximal fistulas to 5% or less as the Japanese experience has showed.

#6848 DIABETES AND HEMODIALYSIS ARTERIOVENOUS ACCESS CONSTRUCTION – A RETROSPECTIVE STUDY IN A SINGLE CENTER

Abstract Background and Aims The preferred vascular access for patients with end-stage renal disease is native arteriovenous fistula (AVF). However, in some patients, given their co-morbidities, vascular access (VA) construction is not feasible. Diabetes Mellitus (DM) is described as one of the main factors associated with vascular access failure. The aim of this study is to characterize in a non-diabetic versus diabetic population the pre-surgical vascular mapping by doppler ultrasound (DUS), as well as analyze which VA could theoretically be constructed, what VA was effectively were constructed and its patency between the two groups. Method We present a retrospective study of a cohort of patients that were evaluated by DUS for pre-surgical planning and VA construction from 2018 to 2021. We collected demographic, clinical and DUS parameters. The feasibility for VA construction was classified in pre-surgical evaluation as possible, non-advisable or as borderline. The patency after surgery was observed until day 45. Results We analyzed a total of 355 patients. Almost half of the population had diabetes (n = 161, 45.4%). The demographics and clinical parameters are summarized in Table 1. Concerning pre-surgical vascular mapping, we observed that patients with diabetes had more severe calcifications than the non-diabetic group. Table 2 summarizes the doppler characteristics of right and left radial and brachial arteries in both groups. Regarding the feasibility of VA construction, the non-diabetic group was more likely to receive a radiocephalic fistula than the diabetic group (33% vs 23.6%, pvalue 0.12). Surprisingly, in our study the non-diabetic group had also more patients that could only sustain a prosthetic fistulas (15.5% vs 12.4%, pvalue 0.41). Diabetic patients showed more likelihood to construct proximal fistulaes (67.4% vs 56.8%, p = 0.06). In terms of what type of VA was effectively created, more radiocephalic fistulas were performed in the non-diabetic group (13.95% vs 7.5%, pvalue 0.17). In the diabetic group more brachiocephalic fistulas (65.6% vs 62.4%, pvalue 0.17) and more prosthestic fistulaes (19.4% vs 14.4%, pvalue 0.17) were constructed. Concerning VA patency at 45 days the diabetic group demonstrated higher rates but with no statistical significance (88.4% vs 83.2%, pvalue < 0.18). Only arterial hypertension, showed to be predictive for VA patency, in the univariate and multivariate analysis that included age, sex, diabetes and ethnicity (OR 0.3, pvalue <0.09 and OR 0.32, pvalue <0.019 respectively). Conclusion We found that diabetic patients had significantly more comorbidities (older age, obesity and peripheral artery disease). Regarding the construction of a VA, in diabetic patients there was a lower probability of creating a radiocephalic fistula but a similar possibility of constructing a proximal fistula. Besides that, after VA construction, no differences were found between the two groups in terms of vascular patency. Although diabetes status reduced the probability for radiocephalic fistulas, once VA construction was successful no differences in VA survival at 45 days was verified.

Potential Utility of Hand Acceleration Time in Quantifying the Degree of Malperfusion in Patients With Suspected Hemodialysis Access–Induced Distal Ischemia

Steal phenomenon after upper extremity hemodialysis access is a clinical diagnosis and consists of signs and symptoms ranging from pain during dialysis to tissue loss. Duplex ultrasonography of the access site and limb arterial perfusion often serves as an adjunct to the diagnosis but can have limitations and there is no specific duplex measurement that indicates that an intervention will be a success. We have used hand acceleration time (HAT) to assess perfusion in a number of trauma and shock cases and hypothesized that this approach could also be beneficial in assessing patients with hemodialysis access–induced distal ischemia (HAIDI), both for identifying patients who are candidates for intervention and to measure whether the intervention will be successful. Specifically, we hypothesized that a HAT <100 ms is associated with normal hand perfusion. We performed a retrospective review of 4 patients with upper extremity arteriovenous fistulas who presented with pain and tissue loss involving the ipsilateral hand. In 2 cases, the tissue loss was not primarily due to steal (one due to skin slough from antibiotic reaction and the other due to focal calciphylaxis), and 2 patients had diffuse calcific disease of the forearm arteries. All 4 patients had antegrade flow in the forearm arteries and HAT >100 ms. One patient with soft tissue sloughing was managed with banding of the proximal fistula, and 3 had proximalization of the fistula. All 4 achieved HAT <100 ms and had resolution of symptoms. Hand acceleration time may be a valuable adjunct to determine whether intervention in the setting of hemodialysis access–induced distal ischemia HAIDI may assist with wound healing.

Comparison of adequacy of blood flow between proximal forearm AV fistula placed at elbow and distal forearm AV fistula placed at wrist in the early post-operative period

Background: In patients with a failed DRCF or unsuitable for DRCF, the current recommendation is to perform a brachiocephalic fistula. Proximal forearm radiocephalic fistulas are created less frequently. Aims and Objectives: The aim of the present study was to evaluate the outcomes of proximal forearm AV fistula placed at elbow and distal forearm AV fistula placed at wrist in terms of adequacy of blood flow in the early post-operative period. Materials and Methods: The present cross-section study was conducted on patients with end-stage renal disease with proximal or distal AV fistula at wrist for a period of 2 years at radiodiagnosis department. The patients were divided into two groups, those with proximal AVF and those with distal AVF. The Doppler ultrasound findings were analyzed and compared between the two groups to identify any differences that could be associated with the success or failure of the AVF. Results: The difference in mean arterial diameter between the proximal and distal groups may indicate that the proximal fistulas have a better chance of providing adequate blood flow for dialysis. The difference in TAV between proximal and distal group may indicate difference in the location and type of fistula and the blood vessels involved in them. Conclusion: Proximal forearm AV fistula is an appealing option to brachiocephalic fistulas in failed distal forearm AV fistula and patients who cannot obtain a distal radiocephalic fistula because to their much lower initial failure rate, higher patency rate, and reduced complication rate.

Ішемічні порушення кінцівки при АВФ для хронічного гемодіалізу

Ischemic steal syndrome (ISS) develops from 2 to 20% of cases in patients on chronic hemodialysis with arteriovenous fistula (AVF) or arteriovenous prosthesis (AVP). Moreover, there is a different frequency of ISS development in patients with distal (radiocephalic) AVF and proximal AVF. For radiocephalic fistulas, this index is about 2%. With proximal fistulas, ISO can reach up to 20-25%. The purpose of the study: To conduct an analysis of the clinical course of ischemic syndrome distal to permanent vascular access for people suffering from Stage 5 of Chronic kidney disease with efferent renal replacement therapy. Research materials and methods. The terms of the development of ischemic disorders after the formation of permanent vascular access (PVA) in patients with AVF are from an hour to a week ("acute"), but can appear after a month or more ("chronic") and even after several years. Despite the fact that the severity of "chronic" ischemia is usually moderate, long-term complaints of hypoperfusion can lead to trophic disorders, up to necrosis and gangrene (about 1% of patients). It is also noted that up to 25% of patients have temporary ischemic complications after the formation of AVF and AVP. There is currently no generally accepted ISS classification. In the foreign literature, there are several attempts by different researchers to develop a classification that would be of practical importance for the diagnosis and treatment of ISS. Research results and their discussion. Most of the authors base their practice primarily on the clinical diagnosis of ISS. Instrumental diagnostics has a clarifying character. Taking an anamnesis can reveal risk factors for the development of ISS. To identify complaints, some authors proposed a questionnaire based on the visual analog scale (VAS), in which points are obtained by multiplying the subjective severity of symptoms (from 0 to 10) by their frequency of occurrence (0 – never, 10 – always). A decrease in tactile and temperature sensitivity may be detected during a neurological examination. One of the most severe variants of acute ischemic syndrome is the development of so-called unilateral ischemic neuropathy. Trophic disorders occurring on the limbs containing arteriovenous access (AVA) can also be the result of venous hypertension, which is accompanied by edema. NKF/DOQI 2006 recommendations require the immediate elimination of access when an UIN is detected. However, even in cases where this complication is detected in the shortest possible time, and the fistula is ligated, full regression of symptoms does not occur in all patients. Delay in surgical tactics significantly worsens the prognosis. Conclusions. The most serious complaint that complicates full-fledged hemodialysis is pain due to ischemia of all three nerves of the forearm, which appears or worsens during the replacement therapy procedure. Weakening of the pulse distal to the AVF is characteristic of most patients, both with proximal and distal AVF.

Early and midterm patency of arteriovenous fistula for hemodialysis access using different techniques and their advantages and disadvantages.

This descriptive retrospective study was done to observe the different techniques of arteriovenous fistula creation for advantages and disadvantages, complications, and early and midterm patency. Fifty-three arteriovenous fistulas were created from September 2018 to August 2020 using four different techniques. Radio-cephalic arteriovenous fistula was usually the first option. Other techniques like brachio-cephalic arteriovenous fistula, radio-basilic arteriovenous fistula, and brachio-basilic arteriovenous fistula were used when the radio-cephalic fistula had thrombosed or could not be constructed due to small-sized cephalic vein in the forearm. The majority of patients (41 (77.35%)) underwent radio-cephalic fistula creation. Early patency was 38 (92.7%) in the radio-cephalic technique whereas it was 12 (100%) in the radio-basilic, brachio-cephalic, and brachio-basilic techniques combined. The midterm patency was 32 (78%) in the radio-cephalic technique, 5 (83%) in the brachio-cephalic technique, 3 (75%) in the radio-basilic technique, and 1 (50%) in the brachio-basilic technique. Radio-basilic and brachio-cephalic are alternative techniques for fistula creation after radio-cephalic depending upon the size of the basilic vein in the forearm or cephalic vein in the cubital fossa or arm. The radio-basilic technique may have advantages over the brachio-cephalic technique which need to be further evaluated. Proximal fistulas like brachio-basilic and brachio-cephalic are more commonly associated with limb edema.

Esophageal atresia with proximal and distal fistulae in a neonate with interrupted vena cava and azygos continuation

Esophageal atresia with proximal and distal fistulae in a neonate with interrupted vena cava and azygos continuation

Outpatient use of tPA to recanalize thrombosed native fistulas a case series and discussion of literature

Background: The present study aims to evaluate the effectiveness of ultrasound-guided percutaneous alteplase (t-PA) injection for the treatment of long segment ( ≥14cm) thrombi in the efferent veins of native arteriovenous fistulas in hemodialysis patients. Methods: A total of 9 patients who underwent t-PA application under ultrasound guidance in the interventional radiology clinic between 2019 and 2021 were included in the study. During the intervention, information such as thrombosed segment length, t-PA dose, number of sessions, presence of aneurysmal segment, bleeding after the intervention and the need for percutaneous transluminal angioplasty (PTA) were recorded. Restoring the flow in the fistula was considered the successful outcome. All statistical evaluations were performed with the IBM SPSS Statistics 21 software (version 21.0; SPSS Inc, Chicago, Illinois) for Windows. Results: Mean age of the patients was 48.7±14 years, the fistula age was 28.7±11 months, the thrombosis age was 3.5±2 days, and the thrombosed segment length was 17.7±2.9 cm. Post-intervention bleeding that did not require treatment was encountered in 2 patients, and stenosis in the proximal fistula was encountered in 6 patients. PTA was applied to 7 patients after t-PA. After the interventions, effective flow was provided in all patients. Conclusion: Ultrasound-guided percutaneous t-PA injection should be considered as an effective intervention which is less invasive, can be performed as an outpatient intervention and has fewer complications, even if the thrombi segments are long (>10 cm). This technique avoids the potential endothelial damage and saves the cost of the mechanical devices.

A single centre experience using internal traction sutures in managing long gap oesophageal atresia

AimThoracoscopically placed internal traction sutures (ITS) for the initial management of long gap oesophageal atresia (LGOA), not amenable to primary anastomosis, was first described in 2015. Here we describe our experience using ITS both thoracoscopically and at thoracotomy where the gap between upper and lower oesophagus is too wide for primary anastomosis. MethodThe case notes of all infants treated with ITS for oesophageal atresia (01/10/2015 to 01/12/2019) were reviewed. Gaps considered too wide for an anastomosis had ITS placed between the two pouches as described by Patkowski in 2015. All patients were gastrostomy fed. Patients returned to theatre with an expectation to complete the anastomosis or re-tighten the traction sutures. ResultsSeven patients (4 OA, 1 OA with proximal fistula, 2 OA/distal TOF) median birthweight 2.28 kg (1.2–3.6 kg) were managed using ITS. Median gap length 4.5 (3–9) vertebral bodies. ITS were placed thoracoscopically in 5 cases and at thoracotomy in 2 at median 46 days (1–120) old. In all cases, ITS was associated with significant intra-thoracic adhesions. Five patients leaked from the traction sutures. Four patients had a delayed primary anastomosis performed at thoracotomy and 3 required a cervical oesophagostomy. The median length of stay was 159 days (98–282). All patients started thoracoscopically eventually required thoracotomy. ConclusionThe use of ITS in our department was associated with significant complications, particularly intra-thoracic leaks and adhesions. In our hands ITS did not improve the feasibility of thoracoscopic repair for LGOA and has been abandoned by us. Level of EvidenceLevel IV Case Series.

MO765: Should We have to Create A Proximal Fistula in First Instance for Patients ≥75 Years Old?

Abstract BACKGROUND In France, the Network Epidemiology and Information in Nephrology evaluated the incidence of cases of chronic end-stage renal disease (ESRD), treated by dialysis, of patients aged ≥75 years at 39.8% (2015). Timely placement and development of functional fistulas for haemodialysis remain difficult logistical problems along with their high failure rate. Cardiovascular (CV) morbidity-mortality increases when patients initiate catheter-based treatment. The recommendations call for a glomerular filtration rate (GFR) between 15 and 30 mL/min/1.73m² (EBPG 2007 and Canadian 2006) to implement a fistula. The older the patients, the more the quality of the venous network deteriorates. In this population, clinicians face a simple problem: creating a too early fistula and preparing patients for an adequate supply. The surgery of vascular approaches tries to avoid two pitfalls: ‘too much to preserve’ the vascular capital, ‘too much to privilege’ the permeability of the first by creating proximal approaches (Barrou B.). The guidelines [Kidney Disease Outcomes Quality Initiative (K/DOQI) 2006] recommend the most distal vascular approach possible. Since 2016, CKD patients aged ≥75 years, have been implanted with arteriovenous fistula (native or prosthetic), localized in the first line of the humero-cephalic vein, huméro-basilique, or humero-axillary. Our primary objective is to assess primary permeability in a population of patients aged ≥75 years with stage IV/V chronic kidney disease (CKD) after the first-line proximal fistula. METHOD All patients aged ≥75 years for which a first-line proximal VA was created between 1 January 2016 and 31 December 2019 have been retrospectively reviewed in an observational study. They were followed for 12 months. A quarterly compilation of data has been produced. RESULTS A total of 31 patients (74% of men) benefit from the creation of a native fistula (90.3%) or prosthetic. During follow-up, 8 patients were excluded. 29% of patients had started catheter haemodialysis treatment prior to the creation of their first fistula. A total of 7 changed fistula from initial surgery during the study, of which 2 after the first use. At the creation of the vascular access, the median age of patients is 81 years, of which 35.5% have vascular nephropathy and 19.4% have diabetic nephropathy. The location of the anastomosis is as follows: 84% FAV brachiocephalic, 10% FAV brachiobasilic and 6% FAV axillary. At 12 months, 16 patients were still under observation. A total of 5 patients had thrombosis of their VA (80% of native fistulas). The average interval between the creation of the first, and the thrombosis is 2.18 months. Patients dialyzed with VA were 68%. On a scale from 0 (no difficulty) to 10 (puncture not performed), the average difficulty score of the first puncture is 2.2. The average time in the day between the first puncture and first ‘effective’ dialysis on the first 13.9 days and the average weekly duration of dialysis at the first effective puncture is 11.29 hours. There are 28 hospitalizations, 21% of which are related to VA, 37 ultrasound, 9 angiography and 4 surgical repairs were performed on VA. Only one ischaemia of the hand is observed, treated medically. Estimates of the risk of thrombosis associated with diabetes are confirmed [P = 0.02; 95% confidence interval (95%CI); hazard ratio (HR): 0.054–0.332]. At 12 months, 94% of the surroundings are permeable without any thrombosis. CONCLUSION This study confirms the interest in a proximal vascular approach in people aged ≥75. We have voluntarily included patients from the creation of their VA and for the majority before the time of starting haemodialysis. The average age is high in a high-risk epidemiological context (HTA, diabetes) and the number of early deaths (16%). The quality of the surroundings is confirmed by the percentage of native fistula at nearly 90% in accordance with the guidelines. The surgical team is motivated and sensitized in this collaborative project. A total of 52% of patients remained in observation at M12 and 94% had a permeable first with satisfactory dialysis quality. These results are encouraging and require a broader multicentre prospective and comparative study like other problems in managing vascular access for haemodialysis.

Esophageal atresia with proximal and distal tracheo-esophageal fistulae

The esophageal atresia (EA) with distal fistula is the most common type of EA and is easily diagnosed by frothy discharge from mouth and nose, respiratory distress and coiling of nasogastric tube in the upper esophagus. The EA with double fistula (proximal and distal) is the least common type of EA which can easily be ignored preoperatively and intraoperatively. So it offers diagnostic challenge. Herein, we present a case of EA with double fistula in which the proximal fistula was not preoperatively appreciated by us, but identified during dissection.

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

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

Nuances of Arteriovenous Fistula Creation for Vascular Access in Hemodialysis.

Background With rising incidence and increased life expectancy of patients with chronic kidney disease (CKD) and end-stage renal disease (ESRD), the number of patients requiring hemodialysis has increased substantially. Vascular access is the lifeline for a patient on hemodialysis (HD), and an arteriovenous fistula (AVF) is the undisputed gold standard for HD access. An effective and long-lasting fistula serves to increase the life expectancy of ESRD patients and improves their quality of life. Learning Objectives This paper aims to give a comprehensive overview of AVF creation, including the various techniques, patient selection, troubleshooting with decision-making, and common complications. Authors share their experience from previous publications and over 2000 AVF surgeries. They have not only described a new modification of the technique of proximal fistula but have also established a direct correlation between bruit and thrill on operation table and success of fistula surgery. Conclusion A standardized, protocol-driven multidisciplinary approach with careful patient and site selection, guided by outcome predictors, is vital in AVF surgery. Knowledge about the potential complications of AVFs contributes to their timely detection and allows measures to be taken that might prevent deleterious consequences that range from loss of vascular access to serious morbidity and mortality.