Transanastomotic Tube Research Articles

Thoracoscopic repair of esophageal atresia and tracheoesophageal fistula in neonates, first decade's experience

The first thoracoscopic esophageal atresia with tracheoesophageal fistula (EATEF) repair was performed in March of 2000. This report evaluates the results and evolution of the technique in a single surgeons' experience after the first decade of thoracoscopic EATEF repair. From March 2000 to September 2012, 52 consecutive patients with type 3 EATEF, and an additional nine patients with pure esophageal atresia (EA) were repaired by or under the direct supervision of a single surgeon. Patient weight ranged from 1.2 to 3.8 kg (mean 2.6 kg). Twenty-two patients had significant associated congenital anomalies. The repairs were performed using three ports. The fistula was ligated using a single endoscopic clip, and the anastomosis was performed using a single layer of interrupted sutures. A transanastomotic tube and chest drain were left in all cases. Fifty-one of the 52 procedures were completed successfully thoracoscopically. Operative times ranged from 50 to 120 minutes (average 85 minutes). There were three clinical leaks, one in an EATEF and two in patients with long-gap pure EA, all resolved with conservative therapy. Oral feedings were started on day 5 in all other patients. Twelve of 61 patients required dilations (1-9), and 18 required a Nissen fundoplication for severe reflux. One patient required a thoracoscopic aortopexy for severe tracheomalacia. All patients are currently on full oral feedings. No patient has any evidence of chest wall asymmetry, winged scapula, or clinically significant scoliosis. There have been no recurrent fistulas. Thoracoscopic EA repair has proven to be an effective and safe technique. Initial experience resulted in a higher stricture rate, but this improved with experience and changes in technique. The results are superior to that of documented open series and avoid the morbidity of an open thoracotomy.

Techniques of biliary reconstruction following bile duct resection (with video)

In several clinical situations, including resection of malignant or benign biliary lesions, reconstruction of the biliary system using the Roux-en-Y jejunum limb has been adopted as the standard procedure. The basic technique and the procedural knowledge essential for most gastroenterological surgeons are described in this article, along with a video supplement. Low complication rates involving anastomotic insufficiency or stricture can be achieved by using proper surgical techniques, even following small bile duct reconstruction. Using the ropeway method to stabilize the bile duct and jejunal limb allows precise mucosa-to-mucosa anastomosis with interrupted sutures of the posterior row of the anastomosis. Placement of a transanastomotic stent tube is the second step. The final step involves suturing the anterior row of the anastomosis. In contrast to the lower extrahepatic bile duct, the wall of the hilar or intrahepatic bile duct can be recognized within the fibrous connective tissue in the Glissonean pedicle. The portal side of the duct should be selected for the posterior wall during anastomosis owing to its thickness. Meticulous inspection to avoid overlooking small bile ducts could decrease the chance of postoperative intractable bile leakage. In reconstruction of small or fragile branches, a transanastomotic stent tube could work as an anchor for the anastomosis.Electronic supplementary materialThe online version of this article (doi:10.1007/s00534-011-0475-5) contains supplementary material, which is available to authorized users.

Trans-anastomotic tubes reduce the need for central venous access and parenteral nutrition in infants with congenital duodenal obstruction

To determine the effect of trans-anastomotic tube (TAT) feeding on outcome following repair of congenital duodenal obstruction (CDO). Retrospective comparative study of all infants with CDO over 10 years. Data are median (range). Mann-Whitney U test and Fisher's exact test were used. Of 55 infants with CDO (48 atresia, 7 stenosis), 17 were managed with a TAT, 38 without. Enteral feeds were commenced earlier in infants with a TAT compared to those without (TAT 2 days post-repair [1-4] vs. no-TAT 3 days post-repair [1-7]; p = 0.006). Infants with a TAT achieved full enteral feeds significantly sooner than those without (TAT 6 days post-repair [2-12] vs. no-TAT 9 days post-repair [3-36]; p = 0.005). Significantly fewer infants in the TAT group required central venous catheter (CVC) placement and parenteral nutrition (PN) than in the no-TAT group (TAT 2/17 vs. no-TAT 28/38, p < 0.0001). There were six CVC-related complications (5 infections, 1 PN extravasation) and four TATs became displaced and were removed before achieving full enteral feeds. One infant with a TAT with trisomy 21 and undiagnosed Hirschsprung disease developed an anastomotic leak and jejunal perforation requiring re-operation. A TAT significantly shortens time to full enteral feeds in infants with CDO significantly reducing the need for central venous access and PN.

Successful enteral nutrition in the treatment of esophagojejunal fistula after total gastrectomy in gastric cancer patients

BackgroundEsophagojejunal fistula is a serious complication after total gastrectomy in gastric cancer patients. This study describes the successful conservative management in 3 gastric cancer patients with esophagojejunal fistula after total gastrectomy using total enteral nutrition.MethodsBetween January 2004 to December 2008, 588 consecutive patients with a proven diagnosis of gastric cancer were taken to the operation room to try a curative treatment. Of these, 173 underwent total gastrectomy, 9 of them had esophagojejunal fistula (5.2%). In three selected patients a trans-anastomotic naso-enteral feeding tube was placed under fluoroscopic vision when the fistula was clinically detected and a complete polymeric enteral formula was used.ResultsThe complete closing of the esophagojejunal fistula was obtained in day 8, 14 and 25 respectively.ConclusionIn some selected cases it is possible to make a successful enteral nutrition using a feeding tube distal to the leak area inserted with the help of fluoroscopic vision. The specialized management of a gastric surgery unit and nutritional therapy unit are highlighted.

Biliary reconstruction with wide‐interval interrupted suture to prevent biliary complications in pediatric living‐donor liver transplantation

Liver transplantation is an established therapy for children with end-stage chronic liver disease or acute liver failure. However, despite refinements of surgical techniques for liver transplantation, the incidence of biliary tract complications has remained high in recent years. Therefore, we suggest our anastomotic technique with wide-interval interrupted suture to prevent biliary complications in pediatric living-donor liver transplantation (LDLT). Forty-nine LDLTs were performed on 49 pediatric recipients with end-stage liver disease. Biliary reconstruction was performed using a 2.5× magnifying surgical loupe, via end bile duct to side Roux-en-Y hepaticojejunostomy (n = 47) and duct-to-duct choledochocholedochostomy (n = 2) with an external stent. A stay suture with 6-0 absorbable materials was placed at each end of the anastomotic orifice. Two interrupted sutures of the posterior row were performed. After completion of the suture of the posterior row, an external transanastomotic stent tube was inserted into the intrahepatic bile duct and was fixed with posterior row material. Finally, two interrupted sutures of the anterior wall were performed, totaling six stitches. The transanastomotic stent tube emerging out of the blind end of the Roux-en-Y limb was covered with a round ligament and was usually left in place for 1 month after the operation. The median follow-up period was 58.0 months (range 8-135 months). In 33 recipients, the bile duct was used to perform the reconstruction with a single lumen. In 5 cases, there were 2 bile ducts that were formed to enable a single anastomosis. In 10 cases, there were 2 separated ducts and each duct was anastomosed with the recipient jejunum. In one case, there were 3 ducts that were formed to enable two anastomoses. Twenty-two percent of the living-donor grafts required 2 biliary anastomoses. Forty-four patients (89.8%) are alive (ranging from 8 months to 11 years), and 5 patients have died. Two patients had biliary complications, an anastomotic stricture in one (2.0%) and bile leakage in one. There were no complications due to anastomotic tubes. Biliary reconstruction with wide-interval interrupted suture prevents anastomotic strictures and bile leakage in pediatric LDLT.

Duct‐to‐duct biliary reconstruction in selected cases in pediatric living‐donor left‐lobe liver transplantation

The feasibility of D-D biliary reconstruction in pediatric LDLT using left-lobe graft has been discussed in few reports. The use of a trans-anastomotic biliary tube seemed to be the favorable method to avoid the complications according to these reports. We had performed left-lobe LDLT for seven pediatric cases and D-D was done originally. Three cases were converted to R-Y hepaticojejunostomy due to radical resection of hepatoduodenal ligament (n = 1) and severe kinking of D-D (n = 2). Four cases received D-D using 6-0 PDS interrupted sutures without external stent tube. One D-D case died of intra-cerebral hemorrhage 10 days after operation with a functioning graft. There was one biliary leakage in a D-D patient who required PTCD stent for 4 months without any sequale. From our limited experience, D-D biliary reconstruction without external stent tube in left-lobe LDLT is feasible in certain pediatric cases having normal extra-hepatic bile ducts. In smaller recipient with larger graft, the use of a trans-anastomotic biliary tube can prevent anastomotic kinking although we suggest R-Y biliary reconstruction is better for this condition.

Use of transanastomotic feeding tubes during esophageal atresia repair

Purpose Esophageal atresia (EA) with tracheoesophageal fistula (TEF) type C accounts for 85% of all EA. In our center, patients were previously started on total parenteral nutrition (TPN) postoperatively and oral feedings initiated only after a contrast esophagogram. Our aim is to assess the benefit of intraoperatively placed transanastomotic feeding tubes (TAFTs). Methods A 7-year retrospective review analyzed the outcomes of children with EATEF type C as they relate to the use of TAFT. Demographics, associated anomalies, operative findings, complications, duration of TPN, resumption of oral feeding, length of stay, and follow-up were examined. Results Twenty-one patients had EATEF type C. Eleven (55%) and 9 (45%) patients were identified as nonfeeding tube (NFT) and TAFT groups, respectively. There were no differences in gestational age, birth weight, associated anomalies, and interval to operative intervention or operative time. Excluding one patient with a severe cardiac malformation in the NFT group, there were no significant differences in anastomotic leak (8% vs 22%), stenosis (36% vs 22%), TPN duration (20 days vs 12 days), and cholestasis (36% vs 11%). Conclusion Transanastomotic feeding tube may lead to shorter TPN duration and decreased cholestasis, but a larger prospective study would be required to prove these benefits and ensure that it does not increase anastomotic leaks. This could be done through an expanded Canadian Pediatric Surgery Network study.

Laparoscopic Gastric Pull-Up for Long Gap Esophageal Atresia

Esophageal replacement (ER) is indicated for long gap esophageal atresia (LGEA) when anastomosisis not possible, especially in cases without fistula or when elongation techniques have failed. The authors show their techniques and analyze preliminary results of the laparoscopic gastric pull-up (LGPU) for ERin LGEA. Four children with LGEA admitted for ER (three type A, one type C) underwent LGPU. Using three ports, including the gastrostomy site, surgical steps included releasing the stomach while preserving the right gastric and gastroepiploic arteries, pyloromyoplasty, and retromediastinal blunt dissection through a laparoscopic view. The esophagostomy was freed and the superior mediastinum was dissected, the stomach was pulled up for cervical anastomosis to the distal esophagus in two cases and to the gastric fundus in another two, adding thoracoscopy in two. All operations were performed without major surgical complications, conversion, death, or reoperation.There were no abdominal complications. Two children presented atelectasis and one case evolved to pneumonia.A girl had a cervical fistula close spontaneously. Transanastomotic tube feeding began after 2-4 days,oral feeding after 8-12 days. Mild anastomotic stenosis (2) was resolved with endoscopic dilatations. After a follow-up of 9-26 months all children have functional grafts and satisfactory oral feeding. One child has duodeno-gastric reflux. Cosmetics have been excellent. The children have the same scars they had before (umbilicus,gastrostomy, and esophagostomy) plus a tiny 3 mm scar on the right flank. Video-assisted esophageal replacement with the stomach for LGEA can be safely performed in children and infants, even after a previous mediastinal operation; however, larger comparative series are required in the future.

Multiple jejunoileal atresia and colonic atresia managed by multiple primary anastomosis with a single gastroperineal transanastomotic tube without stomas

Multiple jejunoileal atresia is a challenge to the pediatric surgeon. The aim of the study is to preserve bowel length and prevent the long-term complications of short bowel syndrome. The authors present a rare case of combined multiple jejunoileal atresia and colonic atresia managed by 9 primary anastomoses over a gastroperineal transanastomotic tube. This technique avoided the use of stomas and their attendant complications.

The technical pitfalls of duct‐to‐duct biliary reconstruction in pediatric living‐donor left‐lobe liver transplantation: The impact of stent placement

The feasibility of D-D biliary reconstruction in pediatric LDLT using a left-lobe graft is still controversial. The medical records of 19 pediatric patients (age: four months to 16 yr) were reviewed. The biliary reconstruction was performed in an end-to-end fashion using absorbable sutures. An external biliary tube was placed into the bile duct through the anastomotic site (n = 10) and not through the anastomotic site (n = 4). An external tube was not used in five patients. The median follow-up was 4.7 yr. Nine patients had 11 biliary complications (leakage, n = 2; stricture, n = 7; stricture with leakage, n = 2). Due to biliary complications, conversion to an R-Y was required in five patients, and four patients required radiological or endoscopic management. The patients younger than one yr of age required conversion to R-Y within one wk after LDLT. The analysis of factors related to biliary complications revealed that the use of a trans-anastomotic biliary tube was the only significant factor to avoid biliary complications. In conclusion, D-D biliary reconstruction in LDLT using a left-lobe graft is feasible in selected cases, though it remains challenging. The use of a trans-anastomotic biliary tube is important to avoid biliary complications.

Retrograde tube drainage for esophageal anastomotic leaks and perforation

The mortality and morbidity of esophageal anastomotic leaks or perforations remain high. We performed retrograde transanastomotic esophageal sump tube drainages for esophageal anastomotic leak or perforation in three patients. Our method is a modified procedure of the T-tube drainage. The Levin gastric tube was simply inserted into the esophagus via anastomotic leak or perforation to develop a defined fistula. All three patients were treated with a satisfactory outcome. An advantage of this method is that it is technically easy, and available for patients whose diseases are difficult to treat with standard T-tube drainage. In addition, one of our patients was successfully managed non-operatively by fluoroscopical guidance. This retrograde esophageal sump tube drainage was technically very easy, safe and useful for esophageal anastomotic leaks or perforations.

Early enteral feeding through a trans-anastomotic tube can be beneficial following congenital esophageal atresia repair

Early enteral feeding through a trans-anastomotic tube can be beneficial following congenital esophageal atresia repair

Duct‐to‐duct biliary reconstruction in pediatric living donor liver transplantation

The results of duct-to-duct biliary reconstruction in six pediatric patients who received a living donor liver transplant aged from 2 months to 11 yr old are reported. The graft was either entire or a part of the left lateral segments. The orifice of the bile duct of the graft was anastomosed to the recipients' hepatic duct in an end-to-end fashion by interrupted suture using 6-0 absorbable material. A transanastomotic external stent tube (4 Fr) was passed through the stump of the recipients' cystic duct. Mean time for reconstruction was 24 min. All the recipients survived the operation and reinitiated oral intake on postoperative day 3. There were no early biliary complications. One 5-yr-old boy suffered from an anastomotic stenosis 9 months after transplantation. He underwent re-anastomosis by Roux-en Y (R-Y) procedure and recovered uneventfully. Duct-to-duct anastomosis in pediatric living donor liver transplantation has benefits while the complication rate is comparable to R-Y reconstruction.

Technique de sauvetage peropératoire d'une anastomose œsojéjunale après gastrectomie

Leakage of oesophagojejunostomy is a severe complication of total gastrectomy. We present a technique allowing preoperative preservation of a defective oesophagojejunostomy: this technique involves closure of the cervical esophagus with stapler, double-lumen transanastomotic tube, mediastinal drainage and feeding jejunostomy.

Feasibility of thoracoscopic U-clip esophageal anastomosis: an alternative for esophageal atresia reconstruction

Background The authors propose that U-Clips can significantly decrease the technical difficulty of performing thoracoscopic esophageal reconstruction, thus, reducing operating time, the incidence of postoperative leak, and stricture rate. Methods After obtaining Institutional Animal Care and Use Committee approval, 3 4-kg female piglets underwent complete thoracoscopic esophageal transections. The esophagus was reconstructed thoracoscopically using S50 and S60 U-Clips over an 8F transanastomotic tube. Esophagrams were performed on postoperative day (POD) 7, 21, 44, and 77. Results Mean operating time was 57 minutes (45 to 75 min). Two of 3 piglets had no evidence of leak on POD 7 esophagrams. One animal had a small leak that resolved spontaneously on antibiotics. All 3 piglets tolerated a formula diet orally by POD 8. Over a 77-day survival period all 3 piglets had steady weight gain on an oral diet. Conclusions U-Clips are a feasible alternative to sutures for esophageal reconstruction in thoracoscopic surgery. Further study is warranted to investigate the full potential of U-Clips in minimally invasive pediatric surgery.

Transanastomotic feeding tube after an operation for duodenal atresia.

The aim of this study was to answer the question whether or not, after an operation for duodenal atresia, a transanastomotic feeding tube reduces the time to full preanastomotic feeding. The method used was a retrospective study and a prospective observation. 18 consecutive newborns with duodenal atresia, nine from each of two different centres of paediatric surgery, were studied retrospectively. The patients in one centre received a nasogastric tube and a transanastomotic feeding tube during the operation, while in the other centre only a nasogastric tube was used. Seven control patients with duodenal atresia treated postoperatively with a nasogastric tube and a transanastomotic feeding tube were prospectively observed. The main outcome measure used to compare these two groups was the time required to achieve full preanastomotic feeding. The patients who were treated postoperatively with the transanastomotic feeding tube needed significantly less time to achieve full preanastomotic feeding than those with a nasogastric tube only (P < 0.001, Mann-Whitney U test). The use of a transanastomotic feeding tube, after an operation for duodenal atresia, leads to earlier full preanastomotic feeding.

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.

Neonatal intestinal obstruction: reducing short-term complications by surgical refinements.

Over the last ten years advances in neonatal intensive care, such as the advent of parenteral nutrition, have led to a significant decrease in the mortality rates of neonates with intestinal obstruction. Nevertheless, surgical short-term complications associated with the intestinal anastomosis performed, such as stenosis or leakage, and long-term nutritional complications due to extensive resections are still responsible for mortality and for a high morbidity rate. 39 newborns referred to our hospital in the past 3 years for intestinal obstruction were retrospectively evaluated with particular attention to the surgical management, surgical techniques and subsequent complications. Age on admission was from 1 hour to 24 days; weight from 1.4 to 3.8 kg; 41% of newborns had a prenatal diagnosis. 57 surgical procedures were performed: among them 44 intestinal anastomoses. Short-term surgical complications, namely perforation and stenosis, were observed in 18.1% of anastomoses. The complication rate after simple end-to-end anastomosis was as high as 30%. However, certain technical refinements such as tailoring the dilated upper pouch, positioning a transanastomotic feeding tube and an intubated lateral stoma resulted in a much lower complication rate (3.7%). Thus, in our experience these technical refinements are effective in reducing the incidence of short-term surgical complications.

The long-term outcome of hepaticojejunostomy in the treatment of benign bile duct strictures.

The authors review the treatment and outcome of patients with benign bile duct strictures who underwent biliary enteric repair. The authors conducted a retrospective review of all clinical records of patients referred for treatment of benign bile duct strictures caused by surgery, trauma, or common bile duct lithiasis or choledochal cyst. The authors performed univariate and multivariate analyses of clinical and pathologic factors in relation to patient outcome and survivals. Eighty-four patients with documented benign bile duct strictures underwent hepaticojejunostomy, choledochojejunostomy, and intrahepatic cholangiojejunostomy during a 15-year period (January 1975 to December 1989). Morbidity, mortality, and patient survival rates were measured. Early and late outcomes correlated neither with demographic and clinical features at presentation nor with etiologic or pathologic characteristics of the stricture. Best results correlated with high biliary enteric anastomoses and degree of common bile duct dilatation independently of bile duct stricture location. High biliary enteric anastomosis provides a safe, durable, and highly effective solution to the problem of benign strictures of the bile duct. Transanastomotic tube stenting is unnecessary. Endoscopic and percutaneous transhepatic dilatation seems more appropriate for the treatment of patients in poor condition and those with anastomotic strictures.

Transanastomotic feeding tubes in repair of esophageal atresia

To avoid the need for a gastrostomy and parenteral nutrition during the 7- to 10-day healing period after esophageal anastomosis, the authors modified their technique for esophageal atresia repair to include placement of a transanas-tomotic feeding tube. A SILASTIC ® transanastomotic feeding tube and early enteral nutrition was used for 19 of 23 consecutively treated patients after repair of esophageal atresia and tracheoesophageal fistula. One of the 19 patients had recurrent fistula and another had an anastomotic leak. Five patients had significant gastroesophageal reflux (noted on barium esophagram), and four had strictures that required dilatation. Parenteral nutrition was necessary for only two patients. The authors conclude that transanastomotic feeding tubes and early enteral nutrition are safe and effective, reduce costs, and do not appear to increase the incidence of anastomotic leaks, strictures, or gastroesophageal reflux.