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

Abstract Aim of the Study Long-gap esophageal atresia (LGEA) remains a surgical challenge. This study aimed to report the results of thoracoscopic esophageal axial internal traction in LGEA. Methods This multicenter observational study included retrospectively neonates who underwent primary thoracoscopic esophageal axial internal traction for LGEA between June 2017 and July 2018. LGEA was defined as the technical impossibility to perform a primary esophageal anastomosis. The Ethical Review Board of our institution approved the study. Main Results Eight neonates were included with a median gestational age at birth of 35 weeks [25; 37] and a median birth weight of 2266 g [890; 3800], 6 types I and 2 types II according to Ladd's classification. Initial median gap between 2 esophageal ends was 5 vertebral bodies [4.5; 7]. Internal traction was performed at a median age of 5 weeks of life [1; 17] with a median operative time of 87 minutes. Four patients required at least 2 internal traction procedures. After a mean traction time of 1.5 weeks [1; 13.5], esophageal anastomosis was successfully performed in 7 patients (5 thoracoscopies, 2 thoracotomies) with a median operative time of 165 minutes. One patient needed a colonic interposition. Five of these 7 patients required an esophageal endoscopic dilatation (median number: 4 [2; 6]). Median follow-up was 9.75 months [3; 16]. Conclusions Thoracoscopic esophageal axial internal traction for LGEA was a safe and feasible procedure that allowed an esophageal anastomosis in 7 of the 8 patients. Improvement of the procedure requires setting a common protocol concerning the timing of the first internal axial traction and the duration of traction before considering esophageal anastomosis.

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DOZ047.53: Esophageal balloon dilatation for strictures developing after esophageal atresia surgery

Diseases of the Esophagus ◽

10.1093/dote/doz047.53 ◽

2019 ◽

Vol 32 (Supplement_1) ◽

Author(s):

C U Durakbasa ◽

B Aksu ◽

E Uzun ◽

D Ugurlu ◽

S Aydoner ◽

...

Keyword(s):

Esophageal Atresia ◽

Balloon Dilatation ◽

Colonic Anastomosis ◽

Median Number ◽

Esophageal Replacement ◽

Replacement Surgery ◽

Anastomosis Site ◽

Esophageal Anastomosis ◽

Esophageal Balloon ◽

Target Pressure

Abstract Aim The aim of this study is to evaluate the results of esophageal balloon dilatation (BD) for strictures after esophageal atresia (EA) surgery. Methods Flexible endoscopic BD was done under fluoroscopic and manometric control. The balloon placed in the stricture was inflated by contrast. The target pressure and the diameter were decided in compliance with the manufacturer's directions as well as fluoroscopic guidance. The balloon was kept inflated for 3 minutes. Prospectively collected data over 10 years were retrospectively evaluated. Cure was defined as no need for dilatation during the last 12 months. Results A total of 79 patients with variable diagnoses underwent 481 BD. Forty (51%) had strictures which developed after EA surgery. They underwent 175 (36%) BD (P < 0.05). There were 21 males and 19 females. The atresia was distal fistula type in 31 (77.5%) patients and isolated EA in nine (22.5%). The BD was done for primary esophago-esophageal anastomosis site in 37 patients. The remaining three patients with long gap EA had undergone previous replacement surgery and the BD was done for the proximal esophago-colonic anastomosis. The median age at the time of the first BD was 14 months with 17 (43%) patients below the age of 1 year. The maximal inflation diameter varied between 5–20 mm. Esophageal BD catheters were used in all except two occasions where 5 mm ureteral balloons were used. The median number of BD was four (n = 1–15). Thirty-four (85%) patients underwent more than one BD. A transmural perforation was encountered in one occasion (0.6%) and the patient eventually underwent esophageal replacement surgery with an uneventful outcome. There was no mortality. Fundoplication was done in nine patients. Thirty-three patients (82.5%) were regarded as ‘cure’. Conclusion Esophageal BD is employed for strictures caused by a variety of reasons. Patients with EA comprise a substantial number of cases needing BD and have strictures less resistant to dilatation. The technique employed in this study is advantageous because it enables direct endoscopic visualization of the stricture and both gradual and controlled increase of the dilatation pressure. BD is safe and efficient yet there is a risk of esophageal perforation as in the other dilatation techniques.

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THORACOSCOPIC POSTERIOR TRACHEOPEXIE IN A NEWBORN WITH TRACHEOMALACIA AND ESOPHAGEAL ATRESIA

Russian Journal of Pediatric Surgery, Anesthesia and Intensive Care ◽

10.30946/2219-4061-2018-8-4-66-72 ◽

2019 ◽

Vol 8 (4) ◽

pp. 66-72

Author(s):

Yu. A. Kozlov ◽

A. A. Rasputin ◽

K. A. Kovalkov ◽

P. J. Baradieva ◽

Ch. B. Ochirov

Keyword(s):

Esophageal Atresia ◽

Pulmonary Ventilation ◽

Treatment Method ◽

Tracheal Lumen ◽

Esophageal Anastomosis ◽

Duration Of Surgery ◽

New Treatment ◽

Tracheal Collapse ◽

Thoracoscopic Procedure ◽

Complete Collapse

Introduction. Esophageal atresia is often accompanied by some form of tracheomalacia. Soon after birth, tracheal collapse can result in respiratory disturbances of various degrees – from mild to severe – requiring artifcial pulmonary ventilation. In this study, we describe the use of a new treatment method of tracheomalacia with posterior tracheopexie.Material and methods. A patient with tracheomalacia that developed against the background of esophageal atresia was presented in the study. A newborn boy of 2,720 g had a prenatally established diagnosis of esophageal atresia. The infant was born with the signs of respiratory disturbances. Following tracheoscopy, severe tracheomalacia was established with complete collapse of tracheal lumen. During the next thoracoscopic procedure, the trachea was fxed to the anterior longitudinal spinal ligament with several sutures.Results. Thoracoscopic posterior tracheopexie was performed prior to esophageal anastomosis. Overall duration of surgery was 85 minutes. Spontaneous breathing was restored at day 3 after the surgery. Tracheoscopy performed at day 10 after the surgery demonstrated a complete opening of the tracheal lumen.Conclusion. Promising results of the surgery prove that the procedure is eﬀective for the treatment of tracheomalacia. Moreover, more complex (aortopexy) recurrent surgeries can be prevented using this approach as posterior tracheopexie can be performed during the primary thoracoscopic correction of esophageal atresia.

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Management of patients with esophageal artesia with or without tracheoesophageal fistula, a 7 years experience

Annals of King Edward Medical University ◽

10.21649/akemu.v11i4.1081 ◽

2016 ◽

Vol 11 (4) ◽

Author(s):

Kifayat Khan ◽

Aamir Bilal ◽

Tahira Nishter ◽

Muhammad Shoaib Nabi ◽

Salim Saleem Shehzad Cheema

Keyword(s):

Esophageal Atresia ◽

Tracheoesophageal Fistula ◽

Tube Feeding ◽

Medical Institute ◽

Paediatric Surgery ◽

Term Outcome ◽

Tube Size ◽

Average Hospital ◽

Right Thoracotomy ◽

Esophageal Anastomosis

Objective: To see the short term outcome in patients treated for esophageal artesia with or without tracheo-esophageal fistula in our setup. Design: Descriptive and retrospective. Place and Duration: Department of Paediatric Surgery & Department of Cardiothoracic Surgery, Postgraduate Medical Institute, Lady Reading Hospital Peshawar from January 1998 to December 2004 with duration of 7 years. Materials and Methods: After diagnosis, patients were put on broad-spectrum intravenous antibiotics, intravenous fluids, vitamin K injection and throat suction in a normothermic environment. Diagnosis was established mainly on clinical grounds and supported by passing a big size nasogastric suction tube (size 10 Fr) through the mouth into the esophagus and taking a plain X-ray chest of the patient. After adequate preparation, through a right thoracotomy in 5th intercostals space, fistula repair and esophageal anastomosis was performed extrapleurally in patients with tracheoesophageal fistula while gastrostomy and ce rvical esophagostomy was performed in patients with pure esophageal atresia. Transanastomotic tube was passed as a nasogastric tube size 10 to act as a stent and later on used for tube feeding. Results: A total of 60 patients with esophageal artesia with or without tracheoesophageal fist ula were admitted. There were 40 males and 20 females. Age ranged from 1-7 days. Weight of the newborn patients was in the range of 2 - 3Kg. Four patients had cyanotic congenital heart disease, two were with imperforate anus and two with spina bifida. All patients had some form of bronchopneumonia due to aspiration of upper pouch contents out of whom 30 patients had severe pneumonia. Six patients left the hospital against medical advice and 6 patients died before operation. Forty-eight patients were operated. Esophagostomy and astrostomy was performed for pure esophageal atresia (10 Patients), while in 38 patients, a right thoracotomy in the 5" inter costal space with fistula ligation & esophageal anastomosis was performed. Three out of ten patients with pure esophageal atresia died, while eighteen patients with tracheoesophageal fistula died after surgery. Twenty-seven out of total 48 patients survived and were discharged to home after an average hospital stay of 7 days after surgery. Eleven patients were s een in follow up and treated accordingly. Conclusion: This study shows that majority of these patients presented late because of improper referral system.

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DOZ047.58: The familial occurrence of congenital esophageal atresia with or without a fistula is an extremely rare pathology

Diseases of the Esophagus ◽

10.1093/dote/doz047.58 ◽

2019 ◽

Vol 32 (Supplement_1) ◽

Author(s):

R Smigiel ◽

A Dzielendziak ◽

K Toczewski ◽

A Rozensztrauch ◽

M Bloch ◽

...

Keyword(s):

Esophageal Atresia ◽

Pediatric Surgery ◽

Oral Feeding ◽

Younger Child ◽

Congenital Esophageal Atresia ◽

Early Postoperative Complications ◽

Esophageal Anastomosis ◽

Child Patients ◽

Healthy Siblings ◽

The One

Abstract We report on two siblings (boy and girl), which were treated for congenital esophageal atresia with the fistula, at the Department of Pediatric Surgery and Urology in Wroclaw, at an interval of two years. These children have two healthy siblings. Both newborns were born on time (38 and 42 week of pregnancy). Prenatally hydramnios was observed in younger child. They were postnatally diagnosed with congenital esophageal atresia with a distal fistula. Newborns were operated on the second day of life. Bronchoscopy and right-sided thoracoscopy were performed. Both patients had a short-gap esophageal atresia with a distal fistula. The fistula was proximally closed with sutures and divided distally. Subsequently, the one-layered esophageal anastomosis was performed. There were no early postoperative complications. Both patients underwent two esophageal dilatations. Siblings are tolerating oral feeding. Occasionally, parents observe choking in the older child. Patients remain under the constant care of a pediatric surgery clinic. Moreover, children were evaluated by clinical geneticist and exome sequencing (WES) study on the base of DNA isolated from lymphocytes and esophageal tissues were performed in both siblings.

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COMBINATION OF ESOPHAGEAL ATRESIA WITH TRACHEOESOPHAGEAL FISTULA AND DUODENAL ATRESIA: TREATMENT ANALYSIS OF FIFTEEN PATIENTS

PEDIATRIA Journal named after G N SPERANSKY ◽

10.24110/0031-403x-2021-100-6-45-53 ◽

2021 ◽

Vol 100 (6) ◽

pp. 45-53

Author(s):

I.N. Khvorostov ◽

◽

N.K. Barova ◽

S.V. Minaev ◽

M.A. Akselrov ◽

...

Keyword(s):

Surgical Treatment ◽

Esophageal Atresia ◽

Gestational Age ◽

Tracheoesophageal Fistula ◽

Postoperative Mortality ◽

Duodenal Atresia ◽

Two Stage ◽

Results Of Treatment ◽

Esophageal Anastomosis ◽

Overall Mortality

The combination of duodenal atresia (DA) with esophageal atresia with tracheoesophageal fistula (EA-TEF) is a rare pathology, the frequency of which ranges from 1% to 6% of all cases of EA. Surgical treatment of the DA+EA-TEF combination always causes significant difficulties, primarily in determining the timing and stages of surgical correction. Objective of the study: to evaluate the results of treatment with a combination of DA+EA-TEF to determine the effective tactics of surgical treatment. Materials and methods of research: a retrospective, nonrandomized, uncontrolled, multicenter study was carried out. The work is based on the results of treatment of 15 newborns – 6 (40%) boys, 9 (60%) girls with a combination of DA+EA-TEF, who were treated in clinics of 6 university centers for pediatric surgery in the Russian Federation in 2015–2021. Simultaneous operations (SIMOPs) were performed in 10 (60%) patients, two-stage operations (TO) – in 5 (40%) newborns. The following criteria were taken into account: the period of antenatal (weeks) and postnatal (days) of establishing the diagnosis of obstruction of the gastrointestinal tract (GIT), gestational age (weeks), birth weight (g), weight at the time of surgery (g), type of concomitant pathology , sequence and methods of surgical treatment, terms of complete enteral feeding (days), outcomes of operations and reasons for unsatisfactory outcomes. The average gestational age of children who underwent SIMOPs was 35.1 weeks. (Q1 – 31.5, Q3 – 39; Me – 37; SD – 5.1; min/max – 25–40; 95% CI: 31.1–39.0) versus 29.8 weeks. at DO (Q1 – 29, Q3 – 30.5; Me – 30; SD – 1.0; min/max – 28–31; 95% CI: 28.4–31.6) did not differ statistically significantly (р=0.083). The mean body mass values did not have statistically significant differences (p=0.081) and amounted to 2224 g (Q1 – 1410, Q3 – 2930; Me – 2665; SD – 890.8; min/max – 760–3260; 95% CI: 1556–2926) for SIMOPs, versus 1322 g (Q1 – 1165, Q3 – 1450; Me – 1380; SD – 196; min/max – 980–1450; 95% CI: 1078.4–16565) in the TO group. Results: the average duration of SIMOPs was on average 144.4 min (Q1 – 125, Q3 – 155; Me – 147.5; SD – 22; min/max – 120–190; 95% CI: 1321–159.3), TO – 147.0 (Q1 – 125, Q3 – 172; Me – 140; SD – 33.4; min/max – 120–205; 95% CI: 126–178.6). The sequence of surgical correction of defects in SIMOPs in 8 (53%) patients consisted of thoracotomy, ligation of the TEF, direct anastomosis of the esophagus and the imposition of duodeno-duodenoanstomosis (DDA). In one case, DDA was selected as the first operation, which was supplemented with Kader gastrostomy followed by thoracotomy, ligation of the TEF and anastomosis of the esophagus after elongation according to I. Livaditis. In one patient, after thoracotomy and ligation of the TEF in connection with an insurmountable diastasis of the esophagus, a cervical esophagostomy (CE), duodenojejunoanastomosis (DEA) and a gastrostomy according to Kader were applied. In a two-stage correction (TO), the first operation in 3 patients was DDA (20%), supplemented in one case (7%) with Kader gastrostomy, and the second stage after 2 days performed thoracotomy with the elimination of TEF and EA. In 2 (13%) newborns, the first stage was thoracotomy, elimination of TEF and EA, followed by imposition of DDA 2 days later. In one case, due to an insurmountable diastasis of the esophagus after thoracotomy and ligation of the TEF, intrathoracic elongation of the esophagus according to Foker with delayed anastomosis of the esophagus (on the 7th day) and laparoscopic fundoplication according to Nissen (at 5 months) were performed. The duration of hospitalization did not statistically significantly depend on the chosen method for correcting the combination of DA+EA-TEF (p=0.79) and averaged 28.4 days for SIMOPs (Q1 – 16, Q3 –34.5; Me – 26; SD – 21.4; min/max – 5.0–79; 95% CI: 17.6–42.4), and for TOs – 27,2 days (Q1 – 21, Q3 – 33; Me – 28; SD – 7.1; min/max – 19–38; 95% CI: 27.2–33). In the group of patients with SIMOPs, 2 deaths (13%) were recorded on the 5th and 7th days after surgery due to progressive multiple organ failure and intractable pulmonary hypertension. In one case (7%), a lethal outcome was recorded 8 months after primary surgery due to progressive cardiovascular failure. Early postoperative mortality after SIMOPs was 20%, overall mortality was 30%. In the TO group, 3 (20%) deaths were recorded: 2 in the early postoperative period (on day 3 and day 19) and one at the age of 3 months of life. Early postoperative mortality after TO was 40%, overall mortality – 60%. Conclusion: it is preferable to choose the ligation of the TEF as the first operation and, if the child's condition allows, to impose an esophageal anastomosis and restore duodenal patency, followed by a nasogastric tube through the esophageal anastomosis into the stomach. If, after ligation of the TEF, the patient's cardiorespiratory status does not stabilize, it is possible to restore the patency of the esophagus and pass the probe into the stomach without imposing a gastrostomy, which will allow the patient to be further treated as an isolated DA, and the operation to restore the patency of the duodenum is delayed. In the presence of insurmountable diastasis, the use of esophageal elongation technology with subsequent delayed EA is justified.

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DOZ047.47: Flourish device for treatment of esophageal atresia

Diseases of the Esophagus ◽

10.1093/dote/doz047.47 ◽

2019 ◽

Vol 32 (Supplement_1) ◽

Author(s):

Bethany J Slater ◽

Mario Zaritzky

Keyword(s):

Esophageal Atresia ◽

Primary Anastomosis ◽

Distal Portion ◽

Contrast Study ◽

Anastomotic Leaks ◽

Magnetic Device ◽

Esophageal Anastomosis ◽

Long Gap Esophageal Atresia ◽

Cook Medical

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 < 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.

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