Treatment Of Esophageal Atresia Research Articles

What Proportion of Children With Complex Oesophageal Atresia Require Oesophageal Lengthening Procedures?

IntroductionBabies with oesophageal atresia (OA) who cannot achieve a primary anastomosis (complex OA) may be treated by attempted oesophageal lengthening. We contrast reported outcomes of lengthening with our experience of managing complex OA. Patients and methodsA consecutive series treated in an English regional centre was completed. Outcomes of interest were the rate of retention of the native oesophagus, complications requiring thoracotomy, rates of anastomotic leak, stricture, fundoplication, and mortality. Possible explanatory variables were the surgical techniques applied. Results29/215 (13%) OA were complex, and 25/207 survived to repair. 14/25 (56%) had no distal fistula, pure OA, while 11/25 (44%) had a long gap with distal fistula. 18/25 (72%) had delayed primary anastomosis, while 7/25 (28%) required oesophageal replacement. However, 2 of the replacements were salvage procedures following failed traction. Only 4/207 (2%) of OA were potentially treatable by traction. Salvage surgery was required in 2/23 (9%) complex OA not subjected to lengthening. The native oesophagus was retained without utilising lengthening in 200/207 (97%). Amongst complex OA where traction techniques had not been attempted, the native oesophagus was retained in 18/23 (78%) of cases, with median time to oesophageal continuity of 77 days. There was no in hospital mortality following treatment of complex OA, and overall survival was identical to non-complex OA among cases surviving to anastomosis. DiscussionManagement of complex OA without lengthening procedures leads a similar rate of retention of the native oesophagus as reports describing lengthening, but with significantly less morbidity. We see little need for oesophageal lengthening in the management of complex OA. Level of EvidenceIV.

СИСТЕМАТИЧЕСКИЙ ОБЗОР И МЕТААНАЛИЗ ТОРАКОСКОПИЧЕСКОГО И ОТКРЫТОГО ЛЕЧЕНИЯ АТРЕЗИИ ПИЩЕВОДА

Thoracoscopic reconstruction of esophageal atresia (EA) has become a standard procedure in many surgical centers Worldwide. The existing bibliographical reviews and meta-analyses have failed to demonstrate any significant difference in the immediate outcome of mini-aggressive treatment of EA. Authors had performed this truly systematic review and meta-analysis searching for the new evidence and confirmation of success of thoracoscopy in the treatment of EA. Materials and methods used: the systematic bibliographical review was prepared in accordance with the PRISMA 2020 statement guidelines. Thus, the scientific publications starting 1990 were searched in three major databases as follows: MEDLINE, PubMed and eLIBRARY.RU. Results: the included studies were published between 2008 and 2022 representing a total of 1958 cases that included 1369 (69.92%) open-surgery interventions and 589 (30.08%) thoracoscopic ones. Authors have found no significant difference between thoracoscopy and thoracotomy excluding an increased risk for esophageal anastomotic leak in the open-surgery treatment group (OR, 0.68; 95% CI, 0.46; 0.99; p = 0.04). A meta-analysis demonstrated that the thoracoscopy group had shorter time spent on lung ventilation (MD, -1.83; 95% CI, -3.02; -0.63; p = 0.003), shorter period to start oral feeding (MD, -1.34; 95% CI, -2.13; -0.56; p = 0.0008) and shorter hospital stay (MD, -4.26; 95% CI, -7.03; -1.49; p = 0.003). The data on the long-term outcomes of both thoracoscopic and open-surgery interventions were reported in a limited - insufficient number of observed cases and had demonstrated that gastroesophageal reflux was more common in the thoracoscopy group (OR, 2.82; 95% CI, 1.72; 4.61; p < 0.0001). Conclusion: the meta-analysis had proved that, compared to open-surgery, thoracoscopy is associated with an almost comparable rate of postoperative complications coupled with the exception of anastomotic leaks. However, it is impossible to ignore the significant advantages of the modern method for treatment of EA which is characterized - among other things - by the more rapid recovery of patients after the surgical interventions.

Treatment of isolated and recurrent tracheoesophageal fistula in children: a case series and literature review

BackgroundDespite improvements in the treatment of esophageal atresia with tracheoesophageal fistula (TEF) in recent decades, complications still exist. The rate of fistula recanalization after surgical repair is ~5% in large...

Surgical treatment of esophageal atresia with lower tracheoesophageal fistula in an extremely preterm infant (510 g, 25 + 5 weeks): a case report

BackgroundThe surgical management of esophageal atresia in extreme-low-birth-weight infants (< 1000 g) is challenging. We report on an extreme-low-birth-weight infant who was extremely preterm (510 g, 25 + 5 weeks) and of prenatally unknown Gross type C esophageal atresia.Case presentationAfter resuscitation and intubation, the tracheoesophageal fistula was closed on the first day of life in the neonatal intensive care unit via an extrapleural approach using a titanium clip. On the sixth day of life, the Caucasian child was extubated. To minimize the operative trauma in the initial neonatal period, we prolonged gastrostomy placement until the 22nd day of life (weight 725 g). At the age of 3 months (weight 2510 g), thoracoscopic esophageal anastomosis was performed. The postoperative course was unremarkable. During the further clinical course, eight esophageal dilations were necessary. Currently, the patient swallows without difficulties at the age of 4 years and thrives well [15 kg (Percentile 28); 100 cm (Percentile 24)].ConclusionsOur case shows that minimized postnatal surgical trauma with primary tracheoesophageal fistula closure at the bedside, delayed gastrostomy, and minimally invasive esophageal repair after substantial weight gain (> 2.5 kg) is a good strategy for esophageal atresia/tracheoesophageal fistula in extreme-low-birth-weight infants.

ТОРАКОСКОПИЧЕСКИЙ МЕТОД ЛЕЧЕНИЯ АТРЕЗИИ ПИЩЕВОДА: 18-ЛЕТНИЙ МЕЖДУНАРОДНЫЙ ОПЫТ ПРИМЕНЕНИЯ У 775 ПАЦИЕНТОВ В ПЯТИ ДЕТСКИХ ХИРУГИЧЕСКИХ ЦЕНТРАХ

The paper presents a synthesis of the multicenter retrospective comparative study of the treatment of patients with esophageal atresia (EA) from 5 children's hospitals located in different countries of the world. Materials and methods of research: The study examined the results of surgical treatment of 775 patients with EA who were treated in 5 children’s hospitals located in Russia, USA and Europe: Ivano-Matreninskaya Children's Clinical Hospital, Irkutsk (Russia) – 126 patients; Children's Hospital of the Rocky Mountains, Denver (Colorado, USA) – 143, Pirogov Russian National Research Medical University, Moscow (Russia) – 175, University Medical Center, Utrecht (Netherlands) – 173, University of Medicine, Wroclaw (Poland) – 158 patients. The study lasted 18 years, from the very beginning of technology adoption in these hospitals and endied in December 2018 (from 2000 to 2018). In relation to patients, uniform technological methods of performing thoracoscopic anastomosis of the esophagus and recommendations for the postoperative management of such patients were applied, issued and controlled by all participants in this process. Results: in the analysis of treatment outcomes, mortality associated with surgery and mortality that had no causal link with surgery were considered. Mortality associated with surgical intervention in the presented treatment series did not differ statistically significantly and amounted to 0,8% (minimum – 0,0%, maximum – 1,7%, p=0,320). Non-operation fatalities varied statistically significantly and ranged from 0,0% to 4,4% (weighted average – 3,0%, p=0,030), but a pairwise comparison with the Benjamini-Hochberg amendment shows no statistically significant differences between the cities of the study. Anastomotic leakage (failure) rate was comparable and was detected in 5,8% of cases (minimum 2,9%, maximum 9,7%, p=0,059). Statistically significant differences were found in the following parameters: anastomotic stenosis developed in 10,3–39,9% of cases (weighted average – 20,1%, p&lt;0,001); fistula recanalization was recorded in 2,7% of patients (minimum – 0,7%, maximum – 8,1%, p&lt;0,001); the need for fundoplication existed in 14,3% of patients (minimum – 2,5%, maximum – 26,0%, p&lt;0,001); the level of detection of tracheomalacia also differed in the presented treatment series and ranged from 0,0% to 9,2% (weighted average – 3,7%, p&lt;0,001). Thus, the use of thoracoscopy for the treatment of EA ensures a low level of postoperative mortality, a low incidence of early and late postoperative complications. Conclusion: thoracoscopic EA reconstruction can be safely performed by experienced endoscopic surgeons from different centers, united by one technology for performing endosurgical operations in newborns and infants.

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

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

Current Treatment of Esophageal Atresia with Tracheoesophageal Fistula - Updated Guidelines of the German Society of Pediatric Surgery

Esophageal atresia (EA) is a congenital anomaly that entails an interrupted esophagus with or without tracheoesophageal fistula (TEF). Depending on the distance of the two esophageal pouches a "short-gap" is distinguished from a "long-gap" variant. Up to 50% of newborns have additional anomalies. EA is prenatally diagnosed in 32-63% of cases. Recently, the interdisciplinary care in these children underwent substantial changes. Therefore, we summarize the current guideline of the German society of pediatric surgery for the treatment of patients with EA and distal TEF (Gross Type C). Controversies regarding the perioperative management include surgical-technical aspects, such as the thoracoscopic approach to EA, as well as general anesthesia (preoperative tracheobronchoscopy, intraoperative hypercapnia and acidosis). Moreover, postoperative complications and their management like anastomotic stricture are outlined. Despite significant improvements in the treatment of EA, there is still a relevant amount of long-term morbidity after surgical correction. This includes dysmotility of the esophagus, gastroesophageal reflux disease, recurrent respiratory infections, tracheomalacia, failure to thrive, and orthopedic complications following thoracotomy in the neonatal age. Therefore, close follow-up is mandatory to attain optimal quality of life.

Transpleural versus extrapleural approach in treatment of esophageal atresia

BackgroundSurgery is the only curative treatment of patients with esophageal atresia and tracheoesophageal fistula. A lot of surgeons recommend transpleural repair while others prefer extrapleural approach for repair. This study will evaluate the differences, advantages, outcome, and the disadvantages of the two techniques.ResultsDuration of surgery was significantly shorter in the group operated by transpleural approach. The incidence of pneumothorax was higher in patients operated by transpleural approach.ConclusionOperating esophageal atresia and tracheoesophageal fistula by transpleural approach has significantly shorter time of surgery, but there is no difference between the two groups as regards incidence of leakage or mortality.

Definition and application of magnetic compression anastomosis

As a new technical discipline, magnetic surgery (MS) has attracted attention of many researchers all over the world for its broad application prospects in the diagnosis and treatment of diseases. MS can be grouped as the following five categories according to different applications and principles: Magnetic compression technique (MCT), magnetic navigation technique (MNT), magnetic anchor technique (MCT), magnetic levitation technique (MLT) and magnetic tracer technique (MTT). Among these techniques, the magnetic compression anastomosis can be used to accomplish certain surgical procedures through the special properties between magnetic materials, such as lumen anastomosis and recanalization, closure of abnormal channels between tissues or organs and restriction anomalous flow of lumen contents. Since being first described in 1978 by Obora, magnetic anastomosis has been initially attempted in treatment of esophageal atresia and diverticula, diversion of gastrointestinal tract, and recanalization of the biliary stricture. Because of the encouraging and broad perspective of magnetic anastomosis in clinical medicine, a new word “magnamosis” has been recommended by Dr. Michael Harrison, one of the leading scientists in this field. Magnetic anastomosis, as an important branch of magnetic compression anastomosis, is essentially a technique that uses magnetic force to transform the lumen anastomosis from the conventional “penetrating” anastomosis to a novel “non-penetrating” anastomosis to greatly simplify the procedure and reduce the rate of postoperative complications. For patients with gastrointestinal lumen occlusion or stenosis, magnetic anastomosis provides a new treatment strategy. This new method can complete the recanalization of digestive tract lumen under intervention method, and avoid major operations, such as laparotomy or thoracotomy. As such, magnetic anastomosis can greatly reduce surgical trauma, as well as incidence of postoperative complications. In addition, magnetic anastomosis can provide treatment options for conditions that cannot be treated with conventional methods, allowing patients to avoid life-long external drainage or fistulas in their lives. More commonly, magnetic anastomosis technology can also be applied to end-to-end, end-to-side, and side-to-side vascular anastomosis. Upon this technique, the time duration of anastomosis can be significantly shortened. Thus, the ischemia and congestion time of target organ can also be shortened, and postoperative complication incidence is significantly reduced. At present, this technique has been successfully applied in coronary and portosystemic bypass surgery, as well as organ transplantation. Surface modification and shape design of magnetic device are two key issues to be considered in magnetic anastomosis technology. The surface modification scheme of the magnetic device mainly depends on the time it remains in the body, while the shape design of the magnetic device mainly depends on the anatomical factors of the lumen to be anastomized, the way of implanting the magnet, and the amount of magnetic force required for the anastomosis. For more than 10 years, we have developed different types of magnets, and performed substantial pre-clinical and clinical studies on utilization of magnetic compression method in vascular, intestines, and biliary lumens connection or anastomosis, demonstrating its safety, which indicates a promising and broad application prospect of magnetic anastomosis. In view of the huge application potential of magnetic anastomosis technology in lumen anastomosis and recanalization, in the future, magnetic anastomosis technology will provide new treatment strategies for other lumen reconstruction (ureteral stenosis, urethral obstruction, etc.).

Application of magnetic compression anastomosis technique in pediatric surgery

Malformation of digestive tract is common in neonates. Esophageal atresia (EA) comprises a group of congenital abnormalities defined by discontinuity of the esophagus. EA with communication with the trachea is known as tracheoesophageal fistula (TEF). For the repair of EA, it is needed to establish an anastomosis between two structures that may be significantly spaced apart, such as in long-gap EA (with a gap >3 cm). The repair across a long-gap can induce tension on the anastomosis, leading to dehiscence, anastomotic leak, or procedure failure. In neonatal patients with long-gap EA with TEF, the complications of significant gastroesophageal reflux, or anastomotic leaks and severe refractory esophageal stricture after surgery are common, which remains challenging for pediatric surgery. There are multiple options for lengthening and approximating the ends in long-gap EA such as myotomies, Gough flap, or the Foker technique. The treatment of long gap EA usually requires thoracotomy or thoracoscopy to place traction sutures on each esophageal in multiple stage operations, the treatment period of which is long. Esophageal stricture is the most common complication following EA repair. Refractory esophageal anastomotic stricture after repair of EA in infants is a challenging surgical problem. In general, these strictures can be successfully managed using endoscopic techniques including bougie and balloon dilation, stenting, and chemotherapeutic agents. If these techniques are unsuccessful, treatment options are limited to surgical resection of the strictured segment and reanastomosis, or esophageal replacement. Magnetic compression anastomosis (MCA) has been introduced for several decades. Recently, rare-earth magnets have been employed to create solid anastomosis for long-gap EA and refractory esophageal stricture in children. In MCA, a sutureless anastomosis of the gastrointestinal tract can be formed using two magnetic Harrison rings. Magnetic compress has been shown to be effective for the treatment of long-gap EA in children. MCA can be conducted during the same stage surgery of ligating the TEF with customized magnetic rings. Under the magnetic force, the two magnetic rings pull along the gastric tube to achieve anastomosis. Once the postoperative permanent suction of these two pouches is instituted, spontaneous growth can be awaited. MCA has been shown to be effective in anastomosis of stomach, small bowel and colon in both experimental and clinical cases. The magnets are most commonly made of neodymium-boron or samarium-cobalt, which can display strengths significantly greater than those of ferrite. Magnetic compression has been used to treat biliary strictures in adult patients who have undergone liver transplantation, as magnetic connectors for coronary surgery, and for the functional undiversion of ileostomy in pediatric patients. Reports also describe the use of magnetic compression in restoring patency of anastomotic strictures of the alimentary tract in patients who have undergone surgery for esophageal, gastric, and rectal cancer. Yamanouchi and colleagues have published many papers on their experience with Samarium cobalt magnets. They even used them to treat recurrent anastomotic strictures after initial MCA. It has been reported that in conditions such as congenital oesophageal atresia or rectal atresia in children, and also is a safe, minimally invasive way to gradually refunctionalize the excluded distal bowel after previous diverting ostomy. MCA using mated magnets with their interposed compressed tissue may result in serosa-to-serosa apposition. At present, MCA for the treatment of EA patients is restricted to gross type A (without TEF) and anastomotic stenosis without thoracotomy. Magnamosis offers a minimally invasive technique for repair of this congenital anomaly. This is particularly helpful in those patients who cannot undergo initial or repeat thoracotomy or thoracoscopy due to anatomic considerations or overall severity of illness. Translumenal digestive tract anastomosis using the constant magnetic field is reliable and feasible as a minimally invasive technique to treat congenital esophageal and anorectal abnormalities. Magnamosis is technically feasible for esophago-esophageal anastomoses. In anorectal malformations with favorable anatomy, this procedure may avoid an operative repair such as posterior sagittal reconstruction. We propose that magnamosis can be considered as an alternative for the treatment of rectal atresia in certain children.

Congenital esophageal atresia treated with thoracoscopic approach – results of surgical treatment

Introduction: The first thoracoscopic esophageal atresia (EA) surgery in Poland was performed by Professor Dariusz Patkowski in 2005 in Wrocław. In the Clinical Ward of Pediatric Surgery and Urology, Regional Specialistic Children’s Hospital in Olsztyn, thoracoscopic EA surgery was performed on 16 January 2009. Aim: Data presentation on thoracoscopic treatment of congenital EA. Material and methods: Between 2009 and 2018 in our Clinical Ward, 28 children (11 females and 17 males) diagnosed with EA underwent treatment. All patients presented with type III EA based on the Gross classification (lower tracheoesophageal fistula and atresia of the upper segment of the trachea) and 8 of them (29.6%) were diagnosed with coexisting diseases. Results and discussion: The duration of the surgery was 70–290 minutes with a mean time of 180 minutes. Conversion was performed in 6 (21.4%) cases. Leakage of the lymph occurred in 2 (7.1%) cases . In 3 (10.7%) cases, a radiographic image showed leakage of the anastomosis. Only 1 (3.6%) patient needed reoperation due to re-canalization of tracheoesophageal fistula. Pneumothorax occurred in 2 (7.1%) cases. In total, 4 (14.3%) patients died and 23 (82.1%) patients required additional esophageal dilatation due to its narrowing. Conclusions: The treatment results of thoracoscopic EA surgeries and undeniable advantages for the patient makes this technique a highly recommended method.

Comparative analysis of different surgical methods for treating esophageal atresia

Objective To investigate the difference in the clinical efficacy by thoracoscopy or thoracotomy for treating esophageal atresia. Methods Thirty-one cases of type-Ⅲ esophageal atresia undergoing surgical treatment from February 2015 to May 2018 at the Department of Pediatric Surgery of Fujian Provincial Maternity and Children′s Hospital were included, and according to the different surgical methods they were divided into thoracoscopic group (15 cases) and thoracotomy group (16 cases). The operation duration, blood loss, postoperative chest drainage time, posto-perative hospital stay and postoperative complications were analyzed between 2 groups. Results The mean time of operation was (181.33±13.86) min in the thoracoscopic surgery group and (139.06±10.98) min in the thoracotomy group, the thoracoscopic group had longer operation duration than thoracotomy group, and there was a significant difference in operation duration between two groups (t=9.44, P=0.000); mean blood loss was (3.07±0.96) mL in the thoracoscopic surgery group and (5.06±1.12) mL in the thoracotomy group, the thoracoscopic group had less amount of blood loss than thoracotomy group, and there was a significant difference in blood loss between two groups(t=-5.29, P=0.000); mean postoperative chest drainage time was(11.67±1.34) d in the thoracoscopic group and (12.25±1.06) d in the thoracotomy group, and there was no significant difference in postoperative chest drainage time between two groups(t=-1.34, P=0.19); mean time of postoperative hospitalization time was(15.20±0.94) d in the thoracoscopic group and (16.00±0.96) d in the thoracotomy group, and there was a significant difference in the postoperative hospitalization time between two groups (t=-2.33, P=0.027); the anastomotic leak rates were 33.33% (5 cases) versus 25.00% (4 cases) with closed or open approaches, respectively; anastomotic stricture rates were 40.00%(6 cases) versus 31.25% (5 cases) with closed or open approaches, respectively.There was no significant difference in postoperative incidence of anastomotic fistula and anastomotic stenosis between two groups. Conclusions Compared with thoracotomy in the treatment of esophageal atresia, thoracoscopic approach has smaller incision and less bleeding, less chest deformity, short hospital stay postoperatively, so it is safe and effective.However, the surgeon must have experience in doing thoracoscopic operation. Key words: Thoracoscopic surgery; Thoracotomy; Esophageal atresia

Use of Magnets as a Minimally Invasive Approach for Anastomosis in Esophageal Atresia: Long-Term Outcomes.

Introduction: The majority of esophageal atresia (EA) patients undergo surgical repair soon after birth. However, factors due to patient characteristics, esophageal length, or surgical complications can limit the ability to obtain esophageal continuity. A number of techniques have been described to treat these patients with "long-gap" EA. Magnets are a nonsurgical alternative for esophageal anastomosis. The purpose of this study was to report long-term outcomes for the use of magnets in EA. Materials and Methods: Between July 2001 and December 2017, 13 patients underwent placement of a magnetic catheter-based system under fluoroscopic guidance at six institutions. Daily chest radiographs were obtained until there was union of the magnets. Magnets were then removed and replaced with an oro- or nasogastric tube. Complications and outcomes were recorded. The average length of follow-up was 9.3 years (range 1.42-17.75). Results: A total of 85% of the patients had type A, pure EA, and 15% had type C with previous fistula ligation. The average length of time to achieve anastomosis was 6.3 days (range 3-13). No anastomotic leaks occurred, and all of the patients had an expected esophageal stenosis that required dilation given the 10F coupling surface of the magnets (average 9.8, range 3-22). Six patients (46%) had retrievable esophageal stents, and two underwent surgery; yet all maintained their native esophagus without interposition. A total of 92% were on full oral feeds at the time of follow-up. Conclusion: The use of magnets for treatment of long-gap EA is safe and feasible and accomplished good long-term outcomes. The main complication was esophageal stricture, although all patients maintained their native esophagus. A prospective observational study is currently enrolling patients to evaluate the safety and benefit of a catheter-based magnetic device for EA.

DOZ047.48: Postoperative anastomotic stricture after the operation for esophageal atresia

Abstract Introduction Anastomotic stricture is the most common complication after the treatment of esophageal atresia. It occurs in 20–80% of operated patients. Predisposing factors are the leakage of the anastomosis, undertension anastomosis, elongation, and gastroesophageal reflux. A few dilation techniques are being utilized. Material and Methods Between 2006 and 2018, 79 patients with esophageal atresia were treated in the clinic. Primary or delayed anastomosis was possible in 69 patients. Five patients died in the early postoperative period. Clinical data of the remaining 64 patient were analyzed retrospectively. Results All anastomoses were calibrated with either bougie or balloon dilators. The anticipated diameter of the anastomosis was acquired during calibration in 24 patients (seven of these with bougie and 17 with balloon dilations). The total number of bougie dilations was 29 and balloon dilations 35. The stricture was present in 40 patients. In this group under—tension anastomoses were present in 25 patients, anastomotic leakage in 13 (81% of all leaks), gastroesophageal reflux in 14 (66% of all refluxes). The stricture was dilated with the balloon in 22 cases, bougie in 18 cases, stent placement in 3 cases. The number of required dilations was most often 2 or 3. In 4 patients multiple dilations were necessary. Dilating procedures were finished with a satisfactory result before the age of 6 months in 26 patients, 12 months in 13 and 24 months in 5 patients. Rupture of the anastomotic site during dilation occurred in 4 patients. Conclusions Anastomotic stricture occurred in 63% of patients. The majority of the undertension and leaking anastomoses were complicated with stricture. A single calibration with balloon was successful in 49% of cases compared to 24% bougie calibrations. In 59% of dilated patients, the procedure was finished before the age of 6 months, which enabled physiological feeding pattern.

DOZ047.56: Esophageal stent placement for the treatment of severe stricture after the operation for esophageal atresia—preliminary report

Abstract Introduction Anastomotic stricture is the most common complication after the treatment of esophageal atresia. It occurs in 20%–80% of operated patients. The stricture can be usually effectively managed by repeated bougie or balloon dilations. Stent placement therapy is reserved for severe strictures. Material and Methods Between 2006 and 2018, 73 patients with esophageal atresia were admitted to the clinic. The esophagus was anastomosed in 63 of those patients. Clinical history of three patients with severe stricture treated with stent placement was analyzed retrospectively. Results Two patients were treated for esophageal atresia with lower tracheoesophageal fistula and one without the fistula (type ‘A’). In two patients, the undertension primary anastomosis was possible. The third patient underwent esophageal reconstruction with the large curvature of the stomach after upper esophagus elongation (Collis procedure). Anastomotic leakage and severe anastomotic stricture occurred in all three patients. Severe stricture was the indication for stent placement in two cases and a perforation during the dilation procedure in one. All stents were removed after the period of one week. The removal was accelerated by the aggravation of tracheomalacia symptoms in one case and by the onset of pulmonary tract infection due to gastroesophageal reflux in another. The third stent migrated to the stomach and had to be removed during endoscopy. One patient, qualified for stent therapy due to the perforation, did not require any other dilations after stent removal. In one patient with severe stricture, the stent therapy accelerated the healing—the narrowing never got tighter than the stent diameter and he required only three more dilations. In the third patient, no positive impact of the stent therapy was observed. Conclusions Stent placement for severe esophageal stricture after anastomosis was the definite therapy in one patient and substantially reduced the number of required dilations in one. Complications of the stent placement appeared in two out of three patients.

DOZ047.47: Flourish device for treatment of esophageal atresia

Abstract Esophageal atresia (EA) is usually repaired soon after birth. However, there are conditions in which early repair is not possible including prematurity, a large distance between the ends, failed attempt at primary anastomosis, and postoperative complications. Cases in which the ends of the esophagus are not able to be brought together without significant tension, or long-gap esophageal atresia (LGEA), remain a challenge to manage. A variety of techniques have been used to establish esophageal continuity consisting of extensive mobilization, myotomies, esophageal flaps, and traction of the segments. The use of magnets is a nonsurgical alternative for esophageal anastomosis. There have been a few series demonstrating initial success and accomplishment of magnamosis in EA patients. A prospective, single-arm, observational study is currently enrolling patients to evaluate the safety and benefit of the Flourish Device (Cook Medical), a catheter-based, magnetic device used to lengthen the atretic esophageal ends and create an anastomosis. The primary outcomes include stricture requiring dilation or surgery, anastomotic leaks or other adverse events with follow-up for two years. The distance of the esophageal gap is measured with metal probes. All patients require a mature gastrostomy and atretic segments &lt; 4 cm apart. The proximal catheter has a suction port and the distal portion has a channel for feeds. Placement is done under fluoroscopy with anesthesia or sedation. Daily chest radiographs are obtained until union of the magnets occur. Successful anastomosis is identified by saliva in the gastrostomy catheter, feeds in the esophageal catheter, or with a contrast study. One day after confirmation, the magnets may be removed. When the catheters are aligned, the magnets attract. Once the magnets have connected, the tissue between them sloughs off while the outer rim heals establishing the anastomosis. The Flourish device may be particularly useful in patients in whom additional operations are not ideal such as those with congenital anomalies or who have undergone previous operations or complications.

Magnetic Anastomosis as a Minimally Invasive Treatment for Esophageal Atresia

Esophageal atresia without fistula is a rare congenital abnormality for which treatment historically required a surgical repair. A new minimally invasive procedure with US Food and Drug Administration–approved Humanitarian Device Exemption has now emerged as a possible treatment option in place of, or in conjunction with, surgical repair for infants with esophageal atresia. This procedure uses magnets placed under fluoroscopic guidance to create an anastomosis between the stomach and the esophagus. In this article, we will review a new magnetic anastomosis catheter-based system, describing how the procedure is performed as well as the reported outcomes and potential complications of this approach. We will highlight a recent case of a patient who underwent the procedure.

TREATMENT OF PATIENTS WITH ESOPHAGEAL ATRESIA AND RIGHT AORTIC ARCH

Right-sided (right, in dextral position) aortic arch (RAA) is recorded in approximately 5% of esophageal atresia (EA) patients. This vascular abnormality may complicate the surgical treatment of EA and is still an unsolved problem in pediatric surgery. Conventional methods for determining the anatomy of the aortic arch do not always provide accurate data, which can lead to thoracotomy on the side of the aortic arch. Skills and preferences of the surgeon still determine the choice of surgical approach in EA patients with RAA. For most experienced surgeons, to make anastomosis of the esophagus in patients with RAA from right access is not so difficult. However, in EA patients with RAA, combined with the vascular ring, left-sided thoracotomy can make the final combined reconstruction technically simpler. In this scientific review, we sought to determine the prevalence rate of RAA in the population of EA patients, the level of pre-operative evaluation of this vascular anomaly, and the existing surgical strategies that consist in choosing the optimal side for access to the esophagus.

A new approach on treatment of esophageal atresia

Esophageal atresia is a rare congenital malformation affecting one in every 3500 live births. Treatment consists in surgical ligation of the fistula and esophageal anastomosis of the two pouches by conventional thoracotomy or by thoracoscopic approach. In recent years, uniportal videoassisted thoracic surgery has been a revolution in thoracic surgery but it had never been used for treatment of congenital pathologies like esophageal atresia. We have used this technique for the treatment of two newborns with this condition. We made a reparation with fistula ligation and end-to-end anastomosis, video-assisted using one only incision. We have excellent results with this technique. A larger list of patients and an increased surgical experience is needed but this can be a new and appropriated alternative in the reparation of esophageal atresia-tracheoesophageal fistula. Keywords: children, esophageal atresia, neonates, uniportal video-assisted thoracic surgery

Using a Miniature Stapler to Divide a Mucosal Bridge at the Anastomosis after Gastric Pull-up for Iatrogenic Tracheoesophageal Fistula.

We report the first use of a miniature stapler to divide a mucosal bridge at the gastroesophageal junction after complex esophageal atresia (EA) repair. A 4-year-old girl was referred to our center after treatment of EA elsewhere. On our initial enodoscopy, a large iatrogenic tracheoesophageal fistula had formed, prompting us to perform a tracheoplasty and gastric interposition. One year after recovery, she had dysphagia with solid food. Upon endoscopy, a mucosal bridge was noted at the gastroesophageal anastomosis. This bridge was divided under endoscopy using a 5 mm miniature stapler. No complications were noted. Upon follow-up, she had no more complaints with solid food. Our report shows that the mucosal bridges may cause dysphagia after EA repair and can be safely divided using a miniature stapler.