Outcome of primary repair in extremely and very low-birth-weight infants with esophageal atresia/distal tracheoesophageal fistula.

The optimal surgical management of extremely (ELBW) and very low-birth-weight (VLBW) neonates with esophageal atresia and distal tracheoesophageal fistula (EA/TEF) (Gross type C) is still debated. The aim of this study was to evaluate the surgical outcome of primary repair in these patients and compare it to ≥1500g neonates. Medical records of neonates with repaired EA from 2002 to 2016 were reviewed. 4 ELBW, 7 VLBW, and 24 ≥1500g infants had type C EA/TEF and underwent primary repair. Anastomotic leakage occurred in 0% ELBW, 0% VLBW and 8.3% ≥1500g patients and anastomotic stricture in 25% ELBW, 28.5% VLBW and 37.5% ≥1500g patients. 50% ELBW, 14.2% VLBW and 20.8% ≥1500g patients underwent secondary fundoplication. One patient of the VLBW group and one patient of the ≥1500g group died postoperatively of causes not related to EA/TEF. In extremely and very low-birth-weight neonates with type C EA/TEF surgical outcome after primary repair is comparable to the outcome in ≥1500g neonates. Primary repair can be performed in most of these patients and staged repair can be restricted to unstable patients. Treatment study level III.

Schmidt A ，Obermayr F ，Lieber J ，Gille C ，Fideler F ，Fuchs J ... -  《-》

Esophageal atresia/tracheoesophageal fistula in very low-birth-weight neonates: improved outcomes with staged repair.

Petrosyan M ，Estrada J ，Hunter C ，Woo R ，Stein J ，Ford HR ，Anselmo DM ... -  《-》

Outcome of esophageal atresia/tracheoesophageal fistula in extremely low birth weight neonates (<1000 grams).

Zani A ，Wolinska J ，Cobellis G ，Chiu PP ，Pierro A ... -  《-》

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 ... -  《-》

Perioperative management and outcomes of esophageal atresia and tracheoesophageal fistula.

Esophageal atresia/tracheoesophageal fistula (EA/TEF) is a rare congenital anomaly lacking contemporary data detailing patient demographics, medical/surgical management and outcomes. Substantial variation in the care of infants with EA/TEF may affect both short- and long-term outcomes. The purpose of this study was to characterize the demographics, management strategies and outcomes in a contemporary multi-institutional cohort of infants diagnosed with EA/TEF to identify potential areas for standardization of care. A multi-institutional retrospective cohort study of infants with EA/TEF treated at 11 children's hospitals between 2009 and 2014 was performed. Over the 5year period, 396 cases were identified in the 11 centers (7±5 per center per year). All infants with a diagnosis of EA/TEF made within 30days of life who had surgical repair of their defect defined as esophageal reconstruction with or without ligation of TEF within the first six months of life were included. Demographic, operative, and outcome data were collected and analyzed to detect associations between variables. Prenatal suspicion or diagnosis of EA/TEF was present in 53 (13%). The most common anatomy was proximal EA with distal TEF (n=335; 85%) followed by pure EA (n=27; 7%). Clinically significant congenital heart disease (CHD) was present in 137 (35%). Mortality was 7.5% and significantly associated with CHD (p<0.0001). Postoperative morbidity occurred in 62% of the population, including 165 (42%) cases with anastomotic stricture requiring intervention, anastomotic leak in 89 (23%), vocal cord paresis/paralysis in 26 (7%), recurrent fistula in 19 (5%), and anastomotic dehiscence in 9 (2%). Substantial variation in practice across our institutions existed: bronchoscopy prior to repair was performed in 64% of cases (range: 0%-100%); proximal pouch contrast study in 21% (0%-69%); use of interposing material between the esophageal and tracheal suture lines in 38% (0%-69%); perioperative antibiotics ≥24h in 69% (36%-97%); and transanastomotic tubes in 73% (21%-100%). Contemporary treatment of EA/TEF is characterized by substantial variation in perioperative management and considerable postoperative morbidity and mortality. Future studies are planned to establish best practices and clinical care guidelines for infants with EA/TEF. Type of study: Treatment study. Level IV.

Lal DR ，Gadepalli SK ，Downard CD ，Ostlie DJ ，Minneci PC ，Swedler RM ，Chelius T ，Cassidy L ，Rapp CT ，Deans KJ ，Fallat ME ，Finnell SME ，Helmrath MA ，Hirschl RB ，Kabre RS ，Leys CM ，Mak G ，Raque J ，Rescorla FJ ，Saito JM ，St Peter SD ，von Allmen D ，Warner BW ，Sato TT ，Midwest Pediatric Surgery Consortium ... -  《-》