Repair Of Tracheoesophageal Fistula Research Articles

Veno- venous extracorporeal membrane oxygenation during surgical repair of a large tracheoesophageal fistula

Veno- venous extracorporeal membrane oxygenation during surgical repair of a large tracheoesophageal fistula

Efficacy and safety of endoscopic dilatation in the management of esophageal strictures in children.

Objectives:To determine the outcomes of endoscopic dilatation of esophageal strictures in children.Methods:Children younger than 18 years of age diagnosed with esophageal strictures over a period of 7 years (June 2010 to June 2017) were reviewed and analyzed retrospectively. The study took place at King Khalid University Hospital, Riyadh, Saudi Arabia. The patients’ clinical characteristics, endoscopic findings, and details of the strictures, treatment, and outcomes were documented.Results:Forty-three children with esophageal strictures were identified (median age, 8.1 years; range, 2-17 years; 23 [53.5%] boys). The median age at presentation was 2 years (range, 1-16 years), and the median follow-up period was 3 years (range, one month-17 years). Tracheoesophageal fistula (n=14, 32.6%), gastroesophageal reflux disease (n=10, 23.3%) and eosinophilic esophagitis (n=8, 18.6%) were the leading causes of esophageal strictures. Forty-three patients underwent 180 dilatation sessions; the median number of dilatation sessions per patient was 3 (range, 1-48), and the median interval between sessions was 8 weeks (range, 1-24 weeks). Among 180 dilatation sessions, 3 events (1.7%) of esophageal perforation were observed. The outcomes varied depending on the primary cause of the stricture; complete response was achieved the best in eosinophilic esophagitis-related strictures (87.5%), followed by anastomotic strictures post tracheoesophageal fistula repair (71.4%) and gastroesophageal reflux disease-related strictures (70%).Conclusion:Endoscopic dilatation is a safe and effective intervention in the management of esophageal strictures in children, with minimal complications when conducted by experts.

A chest tube may not be needed after surgical repair of esophageal atresia and tracheoesophageal fistula.

After definitive repair of esophageal atresia (EA) and tracheoesophageal fistula (TEF), a chest tube (CT) may be left in place to diagnose and conservatively treat a postoperative anastomotic leak, although its necessity is controversial. The purpose of this study was to determine if the use of a CT decreases rates of early postoperative complications after EA and TEF repair. A retrospective chart review was performed to identify all patients with EA and TEF who underwent repair between 1985 and 2012. Univariate analysis was performed to compare patients who did or did not have a CT in terms of preoperative characteristics and postoperative outcomes. One hundred twenty neonates were included; 69 had a CT inserted intraoperatively, while 51 did not. The two groups were similar in terms of patient characteristics. There was no statistically significant difference between the groups in terms of length of hospital stay (31 ± 12 vs. 36 ± 16 days, p = 0.5), or complication rates (13% vs. 12%, p = 0.9) for those with or without CT, respectively. The use of a CT does not alter early postoperative complications after EA/TEF repair.

Gastric Duplication Cyst Associated with Esophageal Atresia and Anorectal Malformations: A Rare Association

Esophageal atresia (EA) and tracheoesophageal fistula (TEF) and anorectal malformations (ARM) in a newborn usually present with frothing of saliva and massive abdominal distension rendering it difficult to diagnose associated intrabdominal pathologies. We report a large gastric duplication (GD) cyst in a 2-day-old neonate with EA and TEF. GD cyst was detected in the early post-operative period as the abdominal distension persisted after repair of EA and TEF. The baby underwent excision of GD cyst with good outcome thereafter.

Barrett's esophagus in children: what is the evidence?

This study systematically reviewed etiology, prevalence, treatment and outcome of Barrett's esophagus (BE) in the pediatric population. PubMed® was searched for terms "Barrett's esophagus" and "children". End points were age of patients, etiology, association with other syndromes, treatment, incidence of carcinoma and outcome. This review was conducted according to the PRISMA guidelines. Data were collected, entered and analyzed into a Microsoft Excel® spreadsheet database. Search revealed 278 articles published between 1984 and 2017, of which 18 met the inclusion criteria. There were 130 patients for analysis witha mean age 10.6years (0.8-17.2years). BE was diagnosed in 80 patients with confirmed gastroesophageal reflux (GER) only; further20 patientswere neurologically impaired and had GER, 13after esophageal atresia (EA) with or without tracheoesophageal fistula (TEF) repair with associated GER, 6 post-chemotherapy, 1 afterpost caustic burns, 1 after esophageal replacement with stomach, 1 afterpeptic esophageal stricture, 1 withsecretory diarrhea, 1 withFanconi anemia, 1tetralogy of Fallot, and 5 healthy children. Regarding treatment, 26 were on medical treatment only, 16 had surgeries combined with medical treatment, 80 patients underwent surgery only, 1 was on dietmanagement, 4 were on surveillance only and 2 were never treated for BE as death occurred because of associated conditions. Fundoplication was the most commonly performed surgery (82.2%). Adenocarcinoma was found in one 23-year-old patient. Mean follow-up was 3.45years (10months-13years) and long-term outcome showed recurrences in 8 and esophago-mediastinal fistula and proximal esophagus ulcer in 1. There were 7 lethal outcomes which were not directly associated with BE. Although BE is considered a premalignant condition; incidence of carcinoma in pediatric population is low. Long-term follow-up with endoscopies and biopsies seems to be advisable for BE evidence and malignant alterations.

IPEG 2018The 27th Annual Congress for Endosurgery in ChildrenApril 11–14, 2018, Seattle, Washington

IPEG 2018The 27^th Annual Congress for Endosurgery in ChildrenApril 11–14, 2018, Seattle, Washington

Surgery for intrathoracic tracheoesophageal and bronchoesophageal fistula

Benign tracheoesophageal fistula (TEF) results from an abnormal communication between the posterior wall of the trachea or bronchi and the adjacent anterior wall of the esophagus. It can be acquired or congenital. The onset of the TEF has a negative impact on the patient's health status and quality of life because of swallowing difficulties, recurrent aspiration pneumonia, and severe weight loss. Several acquired conditions may cause TEF. The most frequent is prolonged orotracheal intubation (75% of the cases). Usually, there is an erosion of the tracheal and esophageal wall by the continuous pressure between the endotracheal tube and the esophageal wall; particularly in the presence of a nasogastric or feeding tube within the esophageal lumen. Furthermore, tracheal stenosis is often associated, and adds complexity to the disease. Preparation for the surgical procedure may take weeks or even months. It includes definitive weaning from mechanical ventilation, treatment of respiratory infection, physiotherapy, and correction of malnutrition through enteral feeding. Surgical repair of a TEF is an elective procedure. It consists of division of the fistula, suture of the esophagus and trachea and protection of the suture lines with a buttressed muscle flap. TEF repair is a complex and challenging procedure, thus, high morbidity and mortality are expected. Nonetheless, surgical management yields excellent long-term results, and it should be considered the first-line treatment for this condition. Definitive fistula closure occurs in about 90-95% of the cases.

The Case for Simulation-Based Mastery Learning Education Courses for Practicing Surgeons.

Pediatric surgeons rely on simulation courses to develop skills for safe minimally invasive repair of complex congenital anomalies. The majority of minimally invasive surgery (MIS) training courses occur during short "exposure courses" at annual conferences. Little data are available to support the benefit of these courses relative to the safe implementation of new skills. The purpose of this article is to determine the impact of an exposure course for advanced neonatal MIS on self-perceived comfort levels with independent performance of advanced MISs. Participants of a 4-hour hands-on course for neonatal MIS were surveyed regarding clinical practices and pre- and post-training perceived "comfort levels" of MIS skills for thoracoscopic esophageal atresia with tracheoesophageal fistula (tTEF) repair, thoracoscopic left upper lobe pulmonary lobectomy (tLobe), and laparoscopic duodenal atresia (lapDA) repair. Descriptive analyses were performed. Seventeen participants completed pre- and postcourse surveys. The majority of participants had no prior experience with tLobe (59%) or lapDA (53%), and 35% had no experience with tTEF repair. Similarly, the majority were "not comfortable" with these procedures. After the short course, the majority of surgeons reported that they were "likely to perform" these operations within 6 months, despite low levels of baseline experience and comfort levels. An exposure training course led to immediate perception of increased skills and confidence. However, these courses typically do not provide basic tenets of expert performance that demands deliberate practice. Future course design should transition to a mastery learning framework wherein regular skill assessments, milestones, and unlimited education time are prioritized before implementation of the new skills.

Abstract No. 598 Neonatal thoracic duct embolization: technical and clinical outcomes

To report technical success and clinical outcomes of thoracic duct embolization (TDE) in neonates. 3 patients, 2 (66.6%) males and 1 (33.3%) female, underwent TDE between April 2017 and September 2017. Mean age was 3 weeks (range, 2-4 weeks) and mean weight was 2.9 kg (range, 2.0-4.4 kg). Indications for embolization, leak type, preoperative imaging, drainage appearance and output, site of cannulation, needles and wires used for cannulation, microcatheter type, embolic agent used, technical success, clinical success, complications, outcomes, and follow-up were recorded. Indications included: iatrogenic injury (n = 2; 66.6%) from congenital diaphragmatic hernia (n = 1; 33.3%) and tracheoesophageal fistula repair (n = 1; 33.3%), and idiopathic congenital chylous ascites (n = 1, 33.3%). Types of chyle leak included: chylothorax (n = 2; 66.6%) and chylous ascites (n = 1; 33.3%). Pre-operative imaging included chest radiography in 2 patients and magnetic resonance lymphangiography in 1 patient. Drainage appearance was milky yellow in all patients with mean output of 272 mL/day (range, 48-653 mL/day). Cannulation site was at L3 in 2 patients and L4 in 1 patient. 21-gauge, 7 cm micropuncture needles, 0.018-inch Transend wires, and 2.4-French microcatheters were used for catheterization in all patients. Embolic agents used included glue and coils (n = 1), glue and sotradecol (n = 1), and glue only (n = 1). Technical success of cannulation of the thoracic duct was 100%. Clinical success was 66.6% with 2 patients having complete resolution of chylothorax after the procedure. The patient with congenital chylous ascites had successful embolization, but developed additional proximal leaks requiring surgical mesh placement with clinical resolution. 1 complication was encountered with non-target embolization of glue to the coronary sinus, right atrium, and pulmonary arteries which was salvaged with a snare and surgical pulmonary embolectomy. All patients were alive with clinical resolution of chyle leak at mean of 72 days (range, 5-168 days). Neonatal thoracic duct embolization is feasible with high technical and clinical success. Lymphatics may be accessed at lower levels than that in adults.

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

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

Recent advances in anesthetic management in repair of tracheoesophageal fistula repair

Thoracosopic repair of tracheoesophageal fistula and esophageal atresia (TREAT) is an advanced endoscopic procedure which requires a skilled approach in minimally invasive surgeries. TREAT is considered as a superior technique in achieving cosmesis and avoiding complications when compared to open thoracotomy. It requires a team of surgeons, anesthesiologists, and assistants and neonatal intensivists to look after the neonate in the perioperative period. Recent meta-analysis has shown no significant difference in outcome and functional evaluation in open thoracotomy and thoracoscopic approach to TEF repair. Anesthesiologists should be well versed with knowledge and ability to anticipate challenges in managing neonates under thoracoscopic TEF repair which plays an important role in the management and survival of these kids. We searched PubMed and Google Scholar databases with the following keywords anesthetic management, tracheoesophageal repair, surgical repair, non-intubated video-assisted thoracoscopic surgery, video-assisted thoracoscopic surgery, video-assisted thoracoscopic surgery, pediatric one-lung ventilation, and pediatric regional anesthesia. The last search was made on July 31, 2018.

Pneumothorax in a preterm during tracheoesophageal fistula repair: Challenges in diagnosis and management.

Pneumothorax in a preterm during tracheoesophageal fistula repair: Challenges in diagnosis and management.

Tracheoesophageal Fistula Repair by Sternocleidomastoid Muscle Rotation

Tracheoesophageal Fistula Repair by Sternocleidomastoid Muscle Rotation

Pneumomediastinum following iatrogenic pharyngeal perforation during tracheoesophageal fistula repair.

Pneumomediastinum following iatrogenic pharyngeal perforation during tracheoesophageal fistula repair.

Airway anomalies in paediatric congenital heart diseases: Utility of bedside fibreoptic flexible bronchoscopy

Background : Acute respiratory diseases are common neonatal conditions leading to neonatal intensive care unit admissions (NICU). Noisy respiration with increased work of breathing, persistent need for respiratory assistance and persistent radiological opacities prompts evaluation by fibreoptic flexible bronchoscopy (FFB). FFB has several benefits in neonates, however, this modality is not widely used due to lack of expertise or non-availability of equipment. We present our 7 years of experience with neonatal FFB. Methods : A retrospective, medical chart search study was conducted at a tertiary care multispecialty hospital, in neonates who underwent FFB over a period of 7 years (2011-2017). Results : Total 88 bronchoscopies were performed in 83 neonates admitted in the NICU. Median birth weight and gestational age were 2600 grams (range 820- 3660) and 37 weeks (range 26-41). Median age at the time of FFB was 27.5 days (range 1-152). While 51 procedures were done transnasally, 37 bronchoscopies were done through endotracheal tube. Most common co-morbid condition noted was congenital heart diseases (20.4%). Indications included persistent oxygen requirement (32/88) lung collapse (21/88), stridor (27/88), extubation failure (4/88), recurrent apnea (2/88) and suspected airway anomaly (2/88). Tracheobronchitis (8/32) and tracheobronchomalacia (8/32) were the common findings in neonates with prolonged oxygen requirement. Most common cause of stridor in neonates was laryngomalacia (16/27) followed by subglottic stenosis (4/27). Myriad of congenital airway anomalies could be diagnosed by FFB including laryngomalacia (18/88) choanal atresia (4/88), laryngeal cleft (4/88), tracheoesophageal fistula (TEF) (4/88), and one each of pyriform stenosis, laryngeal web, vocal cord paresis, absent tracheal ring and complete tracheal rings. Radiological improvement was seen in 17/21 (80.9%) cases of lung collapse after FFB. Bronchoalveolar lavage was done in 52 procedures, and microbiological yield was obtained in 16 (30.7%). Change in medical management by either, adding systemic steroids or changing antibiotics, after FFB was done in 35/88 occasions. Surgical intervention were undertaken in 15 cases (17%), including tracheostomies (9/15), TEF repair (4/15), lateralization of vocal cord (1/15), excision of laryngeal web (1/15). Transient hypoxemia was seen in (4/88) occasions while 83/88 cases did not suffer any complications. Conclusion : Airway anomalies are common in newborns and their early detection by FFB can be beneficial for optimum management. FFB can be used as an important diagnostic tool that can guide medical and surgical interventions in NICU.

Airway anomalies detected in neonates by fibreoptic flexible bronchoscopy: Experience of 7 years

Background : Acute respiratory diseases are common neonatal conditions leading to neonatal intensive care unit admissions (NICU). Noisy respiration with increased work of breathing, persistent need for respiratory assistance and persistent radiological opacities prompts evaluation by fibreoptic flexible bronchoscopy (FFB). FFB has several benefits in neonates, however, this modality is not widely used due to lack of expertise or non-availability of equipment. We present our 7 years of experience with neonatal FFB. Methods : A retrospective, medical chart search study was conducted at a tertiary care multispecialty hospital, in neonates who underwent FFB over a period of 7 years (2011-2017). Results : Total 88 bronchoscopies were performed in 83 neonates admitted in the NICU. Median birth weight and gestational age were 2600 grams (range 820- 3660) and 37 weeks (range 26-41). Median age at the time of FFB was 27.5 days (range 1-152). While 51 procedures were done transnasally, 37 bronchoscopies were done through endotracheal tube. Most common co-morbid condition noted was congenital heart diseases (20.4%). Indications included persistent oxygen requirement (32/88) lung collapse (21/88), stridor (27/88), extubation failure (4/88), recurrent apnea (2/88) and suspected airway anomaly (2/88). Tracheobronchitis (8/32) and tracheobronchomalacia (8/32) were the common findings in neonates with prolonged oxygen requirement. Most common cause of stridor in neonates was laryngomalacia (16/27) followed by subglottic stenosis (4/27). Myriad of congenital airway anomalies could be diagnosed by FFB including laryngomalacia (18/88) choanal atresia (4/88), laryngeal cleft (4/88), tracheoesophageal fistula (TEF) (4/88), and one each of pyriform stenosis, laryngeal web, vocal cord paresis, absent tracheal ring and complete tracheal rings. Radiological improvement was seen in 17/21 (80.9%) cases of lung collapse after FFB. Bronchoalveolar lavage was done in 52 procedures, and microbiological yield was obtained in 16 (30.7%). Change in medical management by either, adding systemic steroids or changing antibiotics, after FFB was done in 35/88 occasions. Surgical intervention were undertaken in 15 cases (17%), including tracheostomies (9/15), TEF repair (4/15), lateralization of vocal cord (1/15), excision of laryngeal web (1/15). Transient hypoxemia was seen in (4/88) occasions while 83/88 cases did not suffer any complications. Conclusion : Airway anomalies are common in newborns and their early detection by FFB can be beneficial for optimum management. FFB can be used as an important diagnostic tool that can guide medical and surgical interventions in NICU.

Retrotracheal Aberrant Right Subclavian Artery: Congenital Anomaly or Postsurgical Complication?

The aberrant right subclavian artery (ARSA) was first described by Hunauld in 1735, with the clinical symptom of the so-called “dysphagia lusoria” or “difficulty in swallowing due to a quirk of nature,” as described by David Bayford in 1787.1 In Bayford’s words, the symptoms “may be called lusoria, from Lusus Naturae that gives rise to it.”2 It is also known as arteria lusoria as suggested by Arkin.3 ARSA is one of the most common intrathoracic vascular anomalies. The majority of ARSA involves the subclavian artery passing posterior to the esophagus and rarely, if ever, passing in front of the esophagus.4 To our knowledge, this is the first case of ARSA with imaging correlation of a course anterior to the esophagus, interposing between the trachea and esophagus in a living patient. We discuss the available literature on epidemiology, embryology, diagnosis, and possible management of this rare vascular anomaly, in addition to the vascular anomalies associated with repair of esophageal atresia (EA) and tracheoesophageal fistula (TEF).

Ultrasound-guided selective intubation in a preterm neonate undergoing type-C esophageal athresia correction. Case report

Introduction: Neonatal patients presenting with tracheoesophageal fistula represent a challenge to the anesthesiologist due to the multiple difficulties this pathology involves for airway management. Case discussion: Following is a description of a case of a neonate undergoing tracheoesophageal fistula repair using ultrasound-guided orotracheal intubation as an adjunct to selective intubation. Conclusion: Perioperative ultrasound is a promising tool for airway management of the pediatric patient. Further studies to assess the possibility to position the technique as a standard of care are needed.

Anesthesia concerns in neonate with large ventricular septal defect with bidirectional shunt undergoing tracheoesophageal fistula repair

Anesthesia concerns in neonate with large ventricular septal defect with bidirectional shunt undergoing tracheoesophageal fistula repair

Cautery ablation of a remote recurrent tracheoesophageal fistula

Abstract Complications subsequent to repair of a congenital tracheoesophageal fistula (TEF) with esophageal atresia (EA) include leak at the anastomosis, stricture formation, and recurrent fistula. Recurrence is uncommon, and the optimal management for a recurrent fistula is debatable. As many of the symptoms of TEF recurrence are similar to common postoperative sequelae, diagnosis of these recurrences can be quite challenging. We report the case of a 12 year old patient with a history of Type B EA/TEF (proximal pouch fistula, distal atresia) who was discovered to have a TEF recurrence over a decade after his initial repair which was successfully treated with cautery ablation of the fistula tract.