Surgery For Esophageal Atresia Research Articles

Study of 24 cases with congenital esophageal atresia: What are the risk factors?

Recovery from esophageal atresia (EA) and tracheoesophageal fistula (TEF) has improved markedly over the years. But postoperative complications, however, have remained. This study evaluates recovery, preoperative, and postoperative status of patients with EA/TEF. A retrospective study review was undertaken in 24 patients with EA/TEF after primary anastomosis (January 1975 through September 2003). There were no patients who had major cardiac anomalies or trisomy 18. In total, 17 of 24 (70.8%, group A) patients have survived and seven (29.2%, group B) have died. Birthweight and Apgar Scores in group A were significantly higher than in group B. The ratio of GAP (the distance of the location of the blind pouch from the ends of the upper and lower esophagus) to body length in group B was significantly higher than in group A. The birthweight and Apgar Scores in group A were significantly higher than in group B. When the authors compared their sample of cases by means of the Waterston classification, the Montreal classification and the Spitz classification, there were statistically significant differences between the results using the Waterston classification and the results using to the Spitz classification. For the cases of EA surgery that were examined, the authors concluded that bodyweight at birth and the existence of pre-surgery respiratory system complications have a significant effect on post-surgery recovery, and that results appear to indicate the importance of classification using the Waterston classification and Spitz classification as a means of assessing the degree of risk. Results also appeared to indicate that the control of Respiratory Distress Syndrome throughout both the pre-surgery and post-surgery periods is critical.

Clinically Relevant Tracheomalacia after Repair of Esophageal Atresia: the Role of Minimal Intra-Operative Dissection and Timing for Aortopexy

Tracheomalacia is associated with esophageal atresia (EA), but may go unnoticed from external splinting forces. Intra-operative dissection with fistula division releases external splinting, revealing tracheomalacia only post-operatively. Analysis of surgical technique may disclose an iatrogenic etiology. From 1995 - 2004, 44 neonates underwent surgery for EA. All patients underwent pre-, intra- and postoperative bronchoscopy. Operative and bronchoscopic notes were studied for malacia, and extensive dissection of the esophagus and fistula from the trachea. Surgical mortality was 6.8 %. Pre-operative tracheomalacia was diagnosed in 3 patients, who eventually fared well. In 17 other patients, the pre-operative bronchoscopy was negative, but airway obstruction developed post-operatively. Tracheomalacia was documented at the site of the former fistula and surgical release maneuvers. Aortopexy was required in 5 instances, whereas 12 others with malacia were managed conservatively. Mediastinal connective tissue and the fistula may splint open the marginally diseased airway in patients with EA, the lack of which may disclose previously unknown tracheomalacia after repair. When aggressive release maneuvers have been required, early aortopexy may be preferred to ventilator dependency.

Endoscopic treatment of congenital H-Type and recurrent tracheoesophageal fistula with electrocautery and histoacryl glue

Congenital H-Type tracheoesophageal fistulae (H-Type TEF) and recurrent fistulae after primary repair of esophageal atresia represent a difficult problem in diagnosis and management. The treatment traditionally involved an open technique via a cervical or thoracic route, approaches with high morbidity and mortality rates of up to 50%. Endoscopic closure of fistulae has been reported with various techniques such as tissue adhesives, electrocautery, sclerosants and laser. However, the published case series contain a small number of patients with usually short-term follow-up. The aim of this paper is to present the experience of a decade at Toronto's Hospital for Sick Children, using diathermy and histoacryl tissue adhesive and discuss the indications and limitations of this technique. Since 1995, 192 patients have been managed in this institution with tracheoesophageal fistulae of which 10 patients have been treated endoscopically. The fistulae were both of H-Type and recurrent tracheoesophageal fistulae following surgery for esophageal atresia and fistula division. One fistula occurred following trauma. The procedure was undertaken under general anesthesia in the image guided therapy suite under fluoroscopic control. Flexible ball electrocautery and injection of histoacryl glue were used either on their own or in combination. Fistula closure was achieved in 9 out of 10 fistulae. Four patients had a second endoscopic procedure. No major respiratory or other complications were encountered in association with the procedure. Follow-up has been between 3 months and 9 years. We conclude, endoscopic treatment of tracheoesophageal fistulae with electrocautery and histoacryl glue has been a safe and successful technique of managing H-Type and recurrent tracheoesophageal fistulae. In this paper, we discuss the indications and the surgical steps of the procedure. We highlight that diathermy should be carefully controlled and applied preferably in the small non-patulous fistulae. A fistula that has not closed after two endoscopic attempts is not suitable for further endoscopic treatment and therefore an external approach should be recommended.

Appendiceal Mass in a Neonate After Surgery for Esophageal Atresia and Tracheoesophageal Fistula: Report of a Case

A 23-day-old girl presented with abdominal distension and vomiting. She had been previously operated on for esophageal atresia and tracheoesophageal fistula (EA/TEF) when she was 2 days old. An immediate laparotomy revealed an appendiceal mass caused by perforated appendicitis. The occurrence of appendicitis and an appendiceal mass is extremely rare in neonates and this may be the first such report in the world literature.

P1027 ESOPHAGEAL STRICTURES IN CHILDREN. REPORT OF DIGESTIVE ENDOSCOPIC UNIT ACTIVITY

Introduction: Esophageal strictures are associated with a substantial morbidity in children. It remains a serious clinical problem despite the improvement of its management. The aims of this study were to assess the prevalence of esophageal strictures in a pediatric endoscopic unit and to specify its etiologies. Methods: 6226 upper gastrointestinal endoscopies were performed between 1994 and 2003. All cases of esophageal strictures were reviewed with a special regard to epidemiologic data and etiology of esophageal stricture in each case. Results: One hundred and nineteen cases (71 males and 48 females) of esophageal strictures were collected which represented 1,9% of all gastrointestinal endoscopies. Fifty five patients (46%) had peptic strictures, 36 cases (30%) had caustic strictures and 18 cases (15%) had an anastomotic stricture following esophageal atresia surgery. Other causes of esophageal strictures causes were observed: epidermolysis bullosa (n = 5) and congenital esophageal strictures (n =5). Median ages of the occurrence of peptic stricture was 2.9 years (range: 2 months and 14 years) while 4.2 years (range: 1 and 12 years) for caustic stricture. The difference of age between the two groups was statistically significant. Conclusion: Despite the improvement of the management of gastroesophageal reflux disease, peptic stricture remains the most common cause of esophageal stricure in our country.

Oesophageal atresia: a simplified approach to early management.

Management following the repair of oesophageal atresia (OA) with tracheooesophageal fistula (TOF) in the past included the routine use of an intercostal chest drain, a gastrostomy, or a transanastomotic tube (TAT) for enteral nutrition and a routine contrast swallow (CS) before oral feeds. There has been a trend towards simplification of the management, but this is not universal. The aim of this study was to evaluate the safety of a simplified management regime in infants undergoing primary repair of OA in a retrospective case note review of infants undergoing surgery for OA with TOF under the care of one consultant over a 12-year period. Intercostal chest drains, TATs, and CSs were not routinely used. Early enteral feeding was initiated and oral feeding was allowed in babies of adequate birth weight (BW) and gestation. A CS was only performed when there were specific anastomotic concerns. Parameters recorded included demographic details, time to first enteral feed by tube or mouth, time to full oral feeds, and complications. Forty patients were studied; 17 were managed without (group 1) and 23 with (group 2) a TAT. Sex distribution, gestational age, and BW were comparable in the two groups. In group 1, the time to the establishment of full oral feeds was 2-8 days (average 3.9). Four infants developed strictures; 2 were managed with dilatation alone and 2 required surgery. In group 2, the time to the establishment of full enteral feeds was 2-12 days (average 5.9). Four patients developed strictures; 2 underwent an anti-reflux procedure and a 3rd resection of a cartilaginous remnant. There was 1 death in a patient with intractable cardiac failure. The majority of infants with OA and TOF can thus be safely managed without routine chest drainage or CS. A sizeable minority do not require a TAT. Early introduction of oral feeds in the non-TAT group is not associated with an increased complication rate.

Aortopexy in severe tracheal instability: short-term and long-term outcome in 29 infants and children

Background. Tracheal instability is a hazardous situation after operation for esophageal atresia. In cases with life-threatening apneas, aortopexy is a therapeutic option. To assess efficacy, short-term and long-term outcome was analyzed retrospectively. Methods. Between 1985 and 2000, 29 patients (age, 1.5 months to 5.2 years) were operated on. A flaccid trachea after operation for esophageal atresia was the cause for life-threatening apneas in 27, and there was external vascular compression in 2 patients. The operative procedure consisted of ventropexy of the aortic arch to the sternum and ventral thoracic wall. Results. There was neither early nor late mortality. A reversible lesion of the phrenic nerve was observed in 2 patients, a pneumothorax in 3, and secondary wound healing in 1. In all but 1 patient symptoms improved markedly or disappeared within days or within the first 3 months postoperatively. An increased susceptibility to respiratory infections was observed in long-term follow-up. Conclusions. Aortopexy can be performed with no mortality and low morbidity. Aortopexy is effective to prevent further life-threatening apneas, but does not prevent an increased susceptibility to respiratory infections.

Long-term outcomes of balloon dilation of esophageal strictures in children

The purpose of this study was to determine the long-term success of the use of angioplasty balloons for dilation of esophageal strictures in children. The authors studied 24 children who had undergone fluoroscopically guided angioplasty balloon dilation of esophageal strictures. Ten children had stricture of the anastomosis after surgical repair of esophageal atresia; five had achalasia; three had strictures due to gastroesophageal reflux; three had corrosive strictures; two had congenital stenosis; and one had stricture after radiation therapy. Success was defined as resolution of the dysphagia a year after dilation. A year after the last dilation, 15 of the 24 children had no dysphagia. Patients in whom treatment was successful included eight children with strictures after surgery for esophageal atresia, one with achalasia, three with strictures caused by gastroesophageal reflux, one with a corrosive stricture, one with congenital stenosis, and one with a stricture resulting from radiation therapy. The long-term results of balloon catheter dilation are highly successful in patients with stricture after surgical repair of esophageal atresia and stricture due to gastroesophageal reflux. Dilation is not as valuable in the treatment of esophageal strictures resulting from other causes.

Prophylactic oesophageal calibration in oesophageal atresia surgery

Anastomotic structure is the most common complication following surgery for oesophageal atresia. The management of this problem provides a continuing challenge to paediatric surgeons. In an effort to reduce the rate as well as the morbidity and mortality associated with oesophageal stricture formation, a regime of routine postoperative prophylactic oesophageal calibration has been undertaken in Princess Margaret Hospital for Children over the last 12 years. Retrospective review of the results of this treatment modality shows low stricture (1.8%) and morbidity rates associated with the procedure.

Lung function abnormalities in repaired oesophageal atresia and tracheo-oesophageal fistula.

Respiratory complications are common after neonatal repair of oesophageal atresia and tracheo-oesophageal fistula. The prevalence of lung function abnormalities and the relation between gastrointestinal complications and lung function has not been studied in a large number of patients. Lung volumes and flow-volume loops were measured in 155 patients without spinal curvature aged 6-37 years who had undergone surgery for oesophageal atresia and tracheo-oesophageal fistula. Sixty four of the 155 patients had evidence of mild lower airways disease, with values for FEV1 more than two standardised scores below the predicted value in 39 (25%) and above 2 standardised scores for the residual volume (RV)/total lung capacity (TLC) ratio in 64 (41%). Restrictive lung disease (TLC more than 2 standardised scores below predicted) was present in 28 (18%). Severe lung function abnormalities were present in under 10% of the 155. Half the subjects had some evidence of extra-thoracic tracheal obstruction, with a high ratio of expiratory to inspiratory flow for peak flow in 76 (50%) and at 50% of vital capacity in 59 (38%). Patients with radiological gastro-oesophageal reflux in early childhood had more airways obstruction and smaller lung volumes. Patients with current gastrointestinal symptoms were similar in their lung function to symptom free patients. Minor lung function abnormalities are common in patients after repair of oesophageal atresia. Early diagnosis and management of gastro-oesophageal reflux may help to minimise these lung function abnormalities.

Oesophageal atresia: the first survival in the Southern hemisphere.

The first known survival in the Southern hemisphere following a corrective operation for oesophageal atresia, is reported. Contrary to previous reports, this survival was in 1948 not in 1949 and the survival occurred in New Zealand not in Australia.

Insertion of a soft silastic nasogastric tube at operation for esophageal atresia: A new technical method

A new and simple technical method for insertion of a soft silastic nasogastric tube into the stomach in neonates born with esophageal atresia is described. The technique is simple, easy to perform, and enables feeding the baby through this tube a day after the operation. Our method is based on the principle used in insertion of Broviac-Hickman catheters, namely the use of a “peel-away sheath” through which the silastic feeding tube is threaded. We have used this technique in five patients with esophageal atresia without any complication.

Anastomotic leakage following surgery for esophageal atresia

Of 199 neonates undergoing primary or delayed primary repair of esophageal atresia, 34 (17%) developed anastomotic leakage, 7 of which (3.5%) were major anastomotic disruptions. Infants with major leaks developed signs within 5 days and all required early reoperation, necessitating abandonment of the esophagus in 6. The remaining 27 were minor leaks demonstrated by water-soluble contrast studies and were successfully treated nonoperatively. Gastroesophageal reflux was unassociated with this complication but the use of braided silk sutures was associated with a significantly increased risk of anastomotic leakage when compared with polyglycolic acid (relative risk, 3.2) or polypropylene (relative risk, 2.6) sutures. Following anastomotic leakage there was a significantly increased risk (relative risk, 2.04) of subsequent esophageal stricture formation.

The use of fibrin sealant in pediatric surgery

After giving a brief historic survey of sealing procedures with biological sealants the authors report on the application of Tisseel/Tissucol in pediatric surgery on the basis of literature and own experiences. Socalled absolute and relative indications are listed in a table. The use of fibrin sealant in neonatal surgery for esophageal atresia as well as splenic and hepatic birth injuries is presented on the basis of casuistics. The completely decapsulated spleen of a newborn baby could be preserved by enveloping the entire organ with fibrin sealant. Postoperative bleeding did not occur. 4 months post surgery normal arterial and venous blood flow was established. In the same infant the hemorrhage from the decapsulated facies diaphragmatica on the left side of the liver could also be managed by the application of fibrin sealant.

Ultrafast CT of laryngeal and tracheobronchial obstruction in symptomatic postoperative infants with esophageal atresia and tracheoesophageal fistula.

We evaluated the role of ultrafast CT in the diagnosis and follow-up of nine consecutive, symptomatic infants with suspected laryngeal and tracheobronchial obstruction after surgery for esophageal atresia. With 80% or more area collapse as a criterion for the diagnosis of laryngomalacia and 50% or more for tracheomalacia, six patients had tracheomalacia, one had laryngomalacia, and two had both. Tracheomalacia was focal in four patients and diffuse, involving the thoracic trachea, in the other four. Associated bronchomalacia was present in two patients. The site and degree of abnormality were verified by endoscopy in five of nine patients. The degree of tracheal collapse did not always correlate with the size of the esophageal pouch or with the site of the tracheo-esophageal fistula. These findings support the concept that the larynx and/or tracheal walls are often abnormal in symptomatic infants with esophageal atresia, tracheoesophageal fistula, and airway obstruction. Ultrafast CT was a reliable technique for detecting and assessing the site, extent, severity, and dynamics of airway collapse in five of seven symptomatic infants with congenital tracheoesophageal anomalies when the imaging findings were compared with endoscopic findings and previously published normal standards.

A CASE OF ESOPHAGEAL ATRESIA TYPE A WITH USEFUL PREOPERATIVE INFORMATION OF DIRECT SAGITTAL CT SCAN

We have observed interesting findings in twice performed direct sagittal CT scan in the course of the elongation method treating of esophageal atresia without tracheoesophageal fistula. A patient with esophageal atresia type A was placed in the plane of the gantry so that sagittal scanning could be performed for the mediastinum and peritoneal cavity. So far, plain esophagogram with stretched pouches by the bougies has been routinely carried out for the planning of surgery of esophageal atresia. As compared to the plain esophagogram, however, direct sagittal CT scan is less invasive and able to provide more accurate information of the pouches in natural state.

Pathohistological studies of the upper oesophageal blind pouch—A contribution to the discussion of the cause of anastomotic insufficiency after operation for oesophageal atresia: P.F. Mahnke and J. Bennek. Z Kinderchir 42:14–18, (February), 1987

Pathohistological studies of the upper oesophageal blind pouch—A contribution to the discussion of the cause of anastomotic insufficiency after operation for oesophageal atresia: P.F. Mahnke and J. Bennek. Z Kinderchir 42:14–18, (February), 1987

The left recurrent laryngeal nerve at birth: anatomy and surgical applications.

The aim of this study was to define the origin, course, caliber and relations of the left recurrent laryngeal nerve (N Laryngeus recurrens) in order to localize the nerve during surgery for esophageal atresia. Eighteen anatomic specimens were dissected and 12 surgical cases were analysed. Left recurrent laryngeal nerve palsy after this particular form of neonatal surgery is a very real risk. It seemed useful to describe an anatomic technique of identifying the nerve in the mediastinum during such surgery, in order to prevent this complication.

Balloon-dilatation of esophageal strictures in children.

Dilatation of benign esophageal strictures by means of a balloon-catheter is a well-established procedure in adults. This method is also useful in children. The technique is described and the results of treatment in 10 children are reported. In all our patients the stricture developed after an operation for esophageal atresia with an end-to-end anastomosis. Dilatation with a balloon-catheter seems to have the same or an even better effect than the traditional dilatation with bougies. Complications following balloon-dilatations have been few and negligible in this series and dilatations can be performed using sedation instead of general anaesthesia. Therefore, this method is recommended.

A comparison between gap-length and waterston classification as guides to mortality and morbidity after surgery for esophageal atresia

In a retrospective study of tracheoesophageal fistula repairs in the Oxford Region, 1968 to 1982, 64 consecutive cases were classified according to Waterston group and gap length (less than 2 cm or greater than 2 cm); where possible their current status was assessed by interview or questionnaire. Waterston group and gap length varied independently. Both affected the course of the first admission but thereafter, Waterston classification was a poor prognostic guide. However, those with a long gap were significantly more likely to have respiratory and swallowing difficulties and stunted growth.