Revisional surgery for recurrent tracheoesophageal fistula and anastomotic complications after repair of esophageal atresia in 258 infants.

We assessed the occurrence and outcome of major reoperations following repair of esophageal atresia with or without tracheoesophageal fistula (TOF). Major outcome measures were survival, preservation of native esophagus, and long-term esophageal function. Hospital charts of 258 consecutive patients treated for esophageal atresia from 1980 to 2013 were reviewed. Forty-two (16%) patients required a total of 57 reoperations after primary repair (n=37) or esophageal reconstruction (n=5). The indications were anastomotic leakage (n=17), anastomotic rupture after endoscopic dilatation (n=5), recurrent tracheoesophageal fistula (TOF) (n=12), undiagnosed proximal TOF (n=3), recalcitrant anastomotic stricture (n=11, primary anastomosis 9, reconstruction 2), undetected proximal fistula (n=3), and inadvertently perforated jejunal graft (n=1). Anastomotic leakage and rupture after dilatation were treated with rethoracotomy and suture and recurrent or undetected TOF by open repair. Strictures not manageable with repeated dilatations were resected and esophageal ends reanastomosed (n=10) or bridged with jejunum graft (n=1). Five (12%) patients required further reoperations, two after recurrent TEF (reocclusion n=1, reconstruction with gastric tube n=1), two after stricture operations (re-resection n=1, resuture after leakage n=1), and one after recurrent dilatation-related rupture. Mortality was 4/42 (10%). Two patients died of recurred leakage or TOF and two of unrelated cause. Of 38 survivors, 35 retained their native or initially reconstructed esophagus, and 3 had secondary reconstruction. After a median follow-up of 23 (range 0.6-32) years, 35 (95%) patients have acceptable esophageal function. Three patients remained dependent on gastrostomy feedings. Anastomotic and TOF complications required a substantial number of reoperations, including esophageal reconstructions. Over 90% of the patients survived with a functioning native or reconstructed esophagus.

Koivusalo AI ，Pakarinen MP ，Lindahl HG ，Rintala RJ ... -  《-》

Categorization and repair of recurrent and acquired tracheoesophageal fistulae occurring after esophageal atresia repair.

Recurrent trachea-esophageal fistula (recTEF) is a frequent (5%-10%) complication of congenital TEF (conTEF) and esophageal atresia (EA) repair. In addition, postoperative acquired TEF (acqTEF) can occur in addition to or even in the absence of prior conTEF in the setting of esophageal anastomotic complications. Reliable repair often proves difficult by endoluminal or standard surgical techniques. We present the results of an approach that reliably identifies the TEF and facilitates airway closure as well as repair of associated tracheal and esophageal problems. Retrospective review of 66 consecutive patients 2009-2016 (55 referrals and 11 local) who underwent repair via reoperative thoracotomy or cervicotomy for recTEF and acqTEF (IRB P00004344). Our surgical approach used complete separation of the airway and esophagus, which reliably revealed the TEF (without need for cannulation) and freed the tissues for primary closure of the trachea and frequently resection of the tracheal diverticulum. For associated esophageal strictures, stricturoplasty or resection was performed. Separation of the suture lines by rotational pexy of the both esophagus and the trachea, and/or tissue interposition were used to further inhibit re-recurrence. For associated severe tracheomalacia, posterior tracheopexy to the anterior spinal ligament was utilized. The TEFs were recurrent (77%), acquired from esophageal leaks (26%), in addition to persistent or missed H-type (6%). Seven patients in this series had multiple TEFs of more than one category. Of the acqTEF cases, 6 were esophagobronchial, 10 esophagopulmonic, 2 esophagotracheal (initial pure EA cases), and 2 from a gastric conduit to the trachea. Upon referral, 18 patients had failed endoluminal treatments; and open operations for recTEF had failed in 18 patients. Significant pulmonary symptoms were present in all. During repairs, 58% were found to have a large tracheal diverticulum, and 51% had posterior tracheopexy for significant tracheomalacia. For larger esophageal defects, 32% were treated by stricturoplasty and 37% by segmental resection. Rotational pexy of the trachea and/or esophagus was utilized in 62% of cases to achieve optimal suture line separation. Review with a mean follow-up of 35months identified no recurrences, and resolution of pulmonary symptoms in all. Stricture treatment required postoperative dilations in 30, and esophageal replacement in 6 for long strictures. There was one death. This retrospective review of 66 patients with postoperative recurrent and acquired TEF following esophageal atresia repair is the largest such series to date and provides a new categorization for postoperative TEF that helps clarify the diagnostic and therapeutic challenges for management.

Smithers CJ ，Hamilton TE ，Manfredi MA ，Rhein L ，Ngo P ，Gallagher D ，Foker JE ，Jennings RW ... -  《-》

Location of TEF at the carina as an indicator of long-gap C-type esophageal atresia.

Koivusalo A ，Suominen J ，Rintala R ，Pakarinen M ... -  《-》

Management of recurrent tracheoesophageal fistula after esophageal atresia and follow-up.

Recurrent tracheoesophageal fistula (rTEF) is a complex complication after the repair of esophageal atresia (EA) and remains a challenge because of difficulties in preoperative management and the substantial rates of mortality and morbidity after reoperation. By reviewing a single institution's experience in the management of rTEF and assessing the outcome, we aimed to provide an optimal approach for managing rTEF and to evaluate growth and feeding problems after reoperations. The medical records of 35 patients with rTEF treated at a single institution from June 2012 to December 2015 were reviewed, and follow-up data were collected from all survivors. The diagnosis of rTEF was made using a modified esophagram in 32 of 35 patients. Before reoperation, all patients received continuous aspiration to prevent reflux and aspiration pneumonia by placing two nasogastric tubes at the level of the fistula and into the stomach, and they received enteral nutrition through a jejunal feeding tube. Thirty-five patients received a total of 41 reoperations, including 12 operations of fistula resection, 28 reanastomosis, and 1 esophageal replacement. The incidence of postoperative anastomotic leak (AL), anastomotic stricture (AS), and repeat recurrences was 40.0%, 17.1%, and 11.4%, respectively. The mortality rate was 8.6%. All survivors achieved full oral intake. Mid-term follow-up (median of 18 months) revealed that 7 (21.9%) presented prolonged meal time, 6 (18.8%) had feeding refusal, 8 (25.0%) experienced coughing during feeding, and 7 (21.9%) had vomiting during feeding. According to the growth data, 5 survivors (15.6%) presented with growth retardation, including stunting (n = 1), wasting (n = 2), and underweight (n = 2). The modified esophagram is an effective and reliable method for diagnosing rTEF. Optimized preoperative management and surgical techniques lead to a satisfactory outcome. Nevertheless, nutritional evaluation and feeding guidance by a nutritionist after reoperation are recommended.

Wang J ，Zhang M ，Pan W ，Wu W ，Yan W ，Cai W ... -  《-》

Challenging surgical dogma in the management of proximal esophageal atresia with distal tracheoesophageal fistula: Outcomes from the Midwest Pediatric Surgery Consortium.

Perioperative management of infants with esophageal atresia and tracheoesophageal fistula (EA/TEF) is frequently based on surgeon experience and dogma rather than evidence-based guidelines. This study examines whether commonly perceived important aspects of practice affect outcome in a contemporary multi-institutional cohort of patients undergoing primary repair for the most common type of esophageal atresia anomaly, proximal EA with distal TEF. The Midwest Pediatric Surgery Consortium conducted a multicenter, retrospective study examining selected outcomes on infants diagnosed with proximal EA with distal TEF who underwent primary repair over a 5-year period (2009-2014), with a minimum 1-year follow up, across 11 centers. 292 patients with proximal EA and distal TEF who underwent primary repair were reviewed. The overall mortality was 6% and was significantly associated with the presence of congenital heart disease (OR 4.82, p=0.005). Postoperative complications occurred in 181 (62%) infants, including: anastomotic stricture requiring intervention (n=127; 43%); anastomotic leak (n=54; 18%); recurrent fistula (n=15; 5%); vocal cord paralysis/paresis (n=14; 5%); and esophageal dehiscence (n=5; 2%). Placement of a transanastomotic tube was associated with an increase in esophageal stricture formation (OR 2.2, p=0.01). Acid suppression was not associated with altered rates of stricture, leak or pneumonia (all p>0.1). Placement of interposing prosthetic material between the esophageal and tracheal suture lines was associated with an increased leak rate (OR 4.7, p<0.001), but no difference in the incidence of recurrent fistula (p=0.3). Empiric postoperative antibiotics for >24h were used in 193 patients (66%) with no difference in rates of infection, shock or death when compared to antibiotic use ≤24h (all p>0.3). Hospital volume was not associated with postoperative complication rates (p>0.08). Routine postoperative esophagram obtained on day 5 resulted in no delayed/missed anastomotic leaks or a difference in anastomotic leak rate as compared to esophagrams obtained on day 7. Morbidity after primary repair of proximal EA and distal TEF patients is substantial, and many common practices do not appear to reduce complications. Specifically, this large retrospective series does not support the use of prophylactic antibiotics beyond 24h and empiric acid suppression may not prevent complications. Use of a transanastomotic tube was associated with higher rates of stricture, and interposition of prosthetic material was associated with higher leak rates. Routine postoperative esophagram can be safely obtained on day 5 resulting in earlier initiation of oral feeds. Treatment study. III.

Lal DR ，Gadepalli SK ，Downard CD ，Ostlie DJ ，Minneci PC ，Swedler RM ，Chelius TH ，Cassidy L ，Rapp CT ，Billmire D ，Bruch S ，Burns RC ，Deans KJ ，Fallat ME ，Fraser JD ，Grabowski J ，Hebel F ，Helmrath MA ，Hirschl RB ，Kabre R ，Kohler J ，Landman MP ，Leys CM ，Mak GZ ，Raque J ，Rymeski B ，Saito JM ，St Peter SD ，von Allmen D ，Warner BW ，Sato TT ，Midwest Pediatric Surgery Consortium ... -  《-》