Secondary esophageal surgery following repair of esophageal atresia with distal tracheoesophageal fistula

During the period 1948 through 1988, 498 patients with esophageal atresia and distal tracheoesophageal fistula were admitted to the Royal Children's Hospital, Melbourne. Fifty patients had a second operative procedure on the esophagus, for anastomotic stricture (30), recurrent fistula (15), both (4), and a postmyotomy diverticulum (1). During the same period, nine patients underwent esophageal replacement and 33 patients a Nissen fundoplication. Improvements in the technique of esophageal anastomosis, and in recent years the use of fundoplication to correct gastroesophageal reflux have led to a marked reduction in the need for secondary surgery to the esophagus after repair of esophageal atresia. Esophageal replacement is rarely required in esophageal atresia and distal tracheoesophageal fistula. One-layer end-to-end esophageal anastomosis using interrupted sutures resulted in the lowest rate of recurrent fistula and anastomotic stricture.     

Anastomotic stricture following repair of esophageal atresia

Anastomotic strictures developed in 74 (37.2%) of 199 patients undergoing primary or delayed primary repair of esophageal atresia with or without tracheoesophageal fistula. Significant predisposing factors included the use of braided silk sutures (relative risk 1.72 and 1.49, compared with polyglycolic acid and polypropylene sutures), the presence of gastroesophageal reflux and leakage of the anastomosis (relative risk 2.29 and 2.04, respectively). Tracheomalacia, personnel factors, and recurrent fistula did not affect the rate of stricture formation. Seventy-one patients responded to dilatation alone, whereas three required stricture resection or esophageal substitution. All three patients requiring surgical intervention and 14 requiring five or more dilatations developed symptoms within the first 6 months after esophageal anastomosis. Antireflux surgery was carried out in 19 (25.7%) of the 74 patients.     

Recent experience with esophageal atresia.

A nine-year experience with esophageal atresia of all types is described with current diagnostic and therapeutic approaches and long-term results. During this time, 53 neonates with esophageal atresia and tracheoesophageal fistula had a 93% survival, with four deaths in risk group C. Temporary postoperative morbidity related to the anastomosis occurred in ten patients. All patients had some disturbance in esophageal motility. While all have been studied for gastroesophageal reflux, only five had significant reflux, and four required fundoplication. Five patients with isolated esophageal atresia survived staged repair, and an additional five patients with H-type fistulae survived primary repair, including one with a long tracheoesophageal cleft. Despite the fact that 45% of the 63 patients had significant associated anomalies, initial survival was 93.5% and late survival 91%. Long-term functional results were generally satisfactory.     

Problems associated with a Nissen fundoplication following tracheoesophageal fistula and esophageal atresia repair

Gastroesophageal reflux is frequently associated with esophageal atresia and tracheoesophageal fistula repair. Following unsuccessful medical treatment, 14 (45%) of 31 patients underwent a Nissen fundoplication. Five of these 14 patients had prolonged dysphagia requiring supplemental gastrostomy feeding. Four of these five patients underwent postoperative manometry and extended pH monitoring, which revealed a normal lower-esophageal sphincter pressure (greater than 15 mm Hg), normal pH results, and marked esophageal dysmotility. The fundoplication creates a mechanical obstruction for those patients with a dyskinetic esophagus who cannot generate the pressure to open the "new sphincter". To avoid this complication, antireflux surgery should be deferred, if possible, in those patients with severe gastroesophageal reflux and marked esophageal motility abnormalities.     

Prevention of gastroesophageal reflux using nissen fundoplication in the staged repair of esophageal atresia with distal tracheoesophageal fistula

To prevent the reflux of gastric contents into the bronchial tree through the tracheoesophageal fistula in patients with esophageal atresia with tracheoesophageal fistula, Nissen fundoplication was performed in the first-stage repair of staged operations. After elimination of the pulmonary complication, a correction of esophageal atresia and tracheoesophageal fistula was successfully performed through the extrapleural route at the age of 16 days. Thus, because Nissen fundoplication is simple to perform and effective in preventing gastroesophageal reflux, this procedure is considered to be useful in the staged repair of esophageal atresia with tracheoesophageal fistula.     

Prevention of gastroesophageal reflux using Nissen fundoplication in the staged repair of esophageal atresia with distal tracheoesophageal fistula

To prevent the reflux of gastric contents into the bronchial tree through the tracheoesophageal fistula in patients with esophageal atresia with tracheoesophageal fistula, Nissen fundoplication was performed in the first-stage repair of staged operations. After elimination of the pulmonary complication, a correction of esophageal atresia and tracheoesophageal fistula was successfully performed through the extrapleural route at the age of 16 days. Thus, because Nissen fundoplication is simple to perform and effective in preventing gastroesophageal reflux, this procedure is considered to be useful in the staged repair of esophageal atresia with tracheoesophageal fistula.     

Lower esophageal sphincter dysfunction in esophageal atresia: nocturnal regurgitation and aspiration pneumonia

The association between lower esophageal sphincter (LES) incompetence, gastroesophageal reflux, and recurrent pneumonia in patients who have undergone successful repair of esophageal atresia (EA) and tracheoesophageal fistula is demonstrated in this study. The efficacy of esophageal manometric examination in the evaluation of the LES in young children after EA repair is documented. This study also provides evidence that infants and children with LES incompetence associated with EA may have LES responsiveness to bethanechol. Once established by manometry, this responsiveness may be used to manage the patient until surgical repair would be advantageous.     

Development of an adenocarcinoma of the esophagus 22 years after primary repair of a congenital atresia

Esophageal cancer development after previous atresia repair is extremely rare in young patients. We present the clinical course of a patient who developed an adenocarcinoma of the esophagus at the age of 22 years, after repair of a tracheoesophageal fistula with esophageal atresia in the neonatal period. She developed a stricture of the esophageal anastomosis requiring frequent dilatations. Six years after an antireflux procedure because of a difficult treatable severe gastroesophageal reflux, an advanced adenocarcinoma was detected at the site of the end-to-end anastomosis of the previous atresia.     

Thirty-five-year institutional experience with end-to-side repair for esophageal atresia

HYPOTHESIS: End-to-side repair (ES) with ligation of the tracheoesophageal fistula (TEF) reduces the risks of stricture and gastroesophageal reflux disease requiring operation compared with the end-to-end repair of esophageal atresia and distal TEF. DESIGN: Case series with institutional and historical control subjects. SETTING: Referral children's hospital. PATIENTS: One hundred thirty-four infants diagnosed as having esophageal atresia and distal TEF between June 30, 1968, and July 1, 2003. INTERVENTIONS: Ninety-six infants having ES and 38 having end-to-end repair. MAIN OUTCOME MEASURES: Patients were studied for overall survival, surgical complications, and well-being during the first year of life. RESULTS: Survival was 95% vs 90% (patients undergoing ES vs end-to-end repair). Complications included anastomotic leak, 8% vs 13%; recurrent TEF, 7% vs 3%, with only 1 recurrence in the last 28 patients having ES; anastomotic stricture (requiring dilatation), 5% vs 13%; gastroesophageal reflux disease requiring operation, 6% vs 18%; and esophageal dysmotility, which was present following nearly all ES and end-to-end procedures. Tracheomalacia-related respiratory symptoms following ES decreased from 50% to 11% at 1 year of age. Age-appropriate diet following ES was achieved in 93% by 1 year; 5% experienced occasional dysphagia or choking episodes. CONCLUSIONS: The ES operation is accompanied by a reduced rate of stricture and gastroesophageal reflux disease requiring operation compared with end-to-end repair. Earlier concerns regarding an unacceptable risk of recurrent TEF were not substantiated.     

Long-term esophageal function following repair of esophageal atresia.

Primary repair of esophageal atresia restores gastrointestinal continuity, but does not ensure normal esophageal function. To date 22 patients, six to 32 (average 15) years after repair of their esophageal atresias, have been evaluated by personal interview and esophageal manometrics and acid reflux testing. Previous barium swallow examinations had demonstrated varying degrees of anastomotic narrowing (12 patients), abnormal esophageal motor function (11 patients), gastroesophageal reflux (two patients), and hiatal hernia (one patient). Ten patients experience intermittent dysphagia for solid foods. Seven have typical symptoms of gastroesophageal reflux. Esophageal function tests including manometry and intraesophageal pH recording, have demonstrated varying abnormalities of esophageal motility in 21 patients and moderate to severe gastroesophageal reflux in 13. Two patients have required reconstruction of the esophagogastric junction for control of severe reflux esophagitis. The unexpected high incidence of gastroesophageal reflux in these patients, coupled with their abnormal esophageal motility which impairs normal acid clearing, renders them more prone to reflux esophagitis. Careful long-term evaluation for gastroesophageal reflux and its complications is indicated following primary repair of esophageal atresia. Evaluation of esophageal function with intraesophageal pressure and pH recordings is a far more sensitive indicator of esophageal physiology than the barium swallow examination.     

A more than 25-year experience with end-to-end versus end-to-side repair for esophageal atresia

End-to-end anastomosis has become the standard technique for repair of esophageal atresia with distal tracheoesophageal fistula. End-to-side anastomosis with ligation of the fistula in continuity has also been advocated. For over 25 years both methods have been used in this hospital. The purpose of this report is to compare retrospectively the results obtained with these two techniques. Between 1962 and 1988, 111 neonates underwent repair of esophageal atresia and distal tracheoesophageal fistula. 74 patients had an end-to-end repair and 37 had end-to-side anastomosis with fistula ligation, according to the surgeons' preference. There were no significant differences between the two groups with respect to preoperative variables and Waterston classification. There was a significantly increased incidence of fistula recanalization (22% v 3%, P = .003) and mortality directly related to the esophageal atresia (16% v 3%, P = .03) in the end-to-side group versus the end-to-end group. The end-to-end group had a significantly higher incidence of gastroesophageal reflux. Logistic regression analysis showed that the end-to-side repair was associated with a greater overall mortality. We conclude that the end-to-end repair appears to be a safer procedure than the end-to-side technique.     

Heterotopic gastric mucosa of the upper esophagus following repair of esophageal atresia with tracheoesophageal fistula

A term female newborn underwent uncomplicated repair of esophageal atresia with tracheoesophageal fistula (type C) then coarctation of the aorta. Subsequently, she developed symptomatic esophageal strictures, which required serial dilations. In addition, she suffered feeding intolerance from esophageal dysmotility and gastroesophageal reflux disease, necessitating Nissen fundoplication with gastrostomy. At 6 years of age, surveillance esophagogastroduodenoscopy revealed mild stenosis and heterotopic gastric mucosa of the upper esophagus at the level of the anastomosis. This is the second report of heterotopic gastric mucosa of the upper esophagus at the level of the anastomosis following repair of esophageal atresia with tracheoesophageal fistula.     

Esophageal atresia without distal tracheoesophageal fistula: high incidence of proximal fistula

Background

This retrospective study was performed to test our suspicion that the incidence of esophageal atresia with proximal fistula in our institution is much higher than is generally reported.

Methods

The charts of all patients with esophageal atresia and/or tracheoesophageal fistula admitted in the period 1982 to 2000 were analyzed. The type of atresia and/or tracheoesophageal fistula was noted, and the relative incidence was calculated and compared with the relative incidence in a cumulative series of 3492 patients taken from 9 published studies.

Results

In the period under study, 123 patients with esophageal atresia and/or tracheoesophageal fistula were identified. The relative incidence of esophageal atresia without distal fistula was statistically not different (10.6% in the present series against 8.49% in the reference group). A statistically significant difference in the relative incidence of esophageal atresia with proximal fistula, however, was found: 5.69% in the present series against 1.05% in the reference group (P < .0001). Looking at the subgroup of patients without a distal fistula, more than half of the patients did have a proximal fistula.

Conclusions

The relative incidence of esophageal atresia with proximal fistula in this series of children with esophageal atresia and/or tracheoesophageal fistula is significantly higher than reported in the literature. This is on the account of the subgroup of patients without a distal fistula in which the incidence of a proximal fistula is more than 50%. Especially in this subgroup, the existence of a proximal fistula should be ruled out preoperatively.     

Thoracoscopic repair for esophageal pulmonary fistula after esophageal atresia repair

BackgroundEsophageal pulmonary fistula is a special type of acquired tracheoesophageal fistula that occurs after esophageal atresia/tracheoesophageal fistula repair. Thoracotomy is the surgical repair method currently in use, but postoperative outcomes are unclear. Therefore, we aimed to explore the preliminary safety, effectiveness, and feasibility of thoracoscopic surgical repair of esophageal pulmonary fistula.MethodsWe retrospectively collected data from all patients with esophageal atresia/tracheoesophageal fistula at Beijing Children's Hospital from January 2017 to October 2021, and the clinical characteristics of patients with esophageal pulmonary fistula were analyzed. Clinical information was recorded, and follow-up was performed.ResultsSeven patients (five boys and two girls) were diagnosed as esophageal pulmonary fistula. All patients underwent multiple esophageal surgeries and had esophageal strictures before surgical repair. Clinical manifestations included cough, expectoration, and recurrent pneumonia. Esophagography indicated the location of the fistula with a 100% positive rate, while the positive rate of flexible bronchoscopy and chest computed tomography was 57% (4/7) and 43% (3/7), respectively. Surgical repair was achieved using thoracoscopy with an average operation time of 172 min. All patients developed esophageal strictures, four of which had refractory esophageal strictures and underwent esophageal dilations ranged from 5 to 56 times before this surgery, but anastomotic leakage or acquired esophageal pulmonary fistulas were absent post-surgery. After a median follow-up of 22 months, all patients survived, and the symptoms were well controlled.ConclusionsEsophageal pulmonary fistula is a rare complication of atresia/tracheoesophageal fistula repair. Thoracoscopic surgery is still possible even after previous multiple surgeries in the chest with significant complications and satisfactory results can be achieved in the short term.Level of EvidenceLevel III     

Prediction and prevention of anastomotic complications of esophageal atresia and tracheoesophageal fistula

We analyzed our experience with 64 infants with esophageal atresia (EA) and tracheoesophageal fistula (TEF), to determine the possibility of prediction and prevention of anastomotic complications (leak, stricture, and recurrent TEF). In most of the infants, the anatomical level of the fistula was documented preoperatively by bronchoscopy. The level of the fistula, in turn, correlated with the esophageal anatomy at thoracotomy, ie, carinal fistulas had a wide gap between esophageal pouches, whereas midtracheal or cervical fistulas had a minimal gap. Major anastomotic complications were defined as leak requiring reoperation, symptomatic strictures requiring four or more dilatations, or a recurrent TEF. The complication rates wre: leak (major and minor), 21%; major stricture, 15%; and recurrent TEF, 5%. Major complications occurred in 42% (11/26) of infants with wide gaps, compared with 8% (3/36) of infants with minimal gaps. Route of repair (transpleural or retropleural) made no difference in incidence of anastomotic complications. No infant died of an anastomotic complication. Survival was 100% for Waterston A and B infants, 83% for Waterston C, and 90% overall. Severe gastroesophageal reflux, requiring Nissen fundoplication, was more common among infants with wide gaps than those with minimal gaps (32% v 3%). The most important pathogenetic factor, present in 79% (11/14) of major anastomotic complications, was anastomotic tension, determined by the gap between esophageal pouches, and predicted by preoperative bronchoscopy. Thus the bronchoscopic finding of a carinal fistula signals the need for technical measures that may limit anastomotic morbidity, such as myotomy, patching the anastomosis, retropleural approach, or delayed repair. Assuming precise technique and gentle handling of tissues, the anatomy of the anomaly determines the anastomotic morbidity of EA and TEF.     

Esophageal atresia and achalasialike esophageal dysmotility

A 14-year-old boy presented with regurgitation, malnutrition, and chronic lung insufficiency with a history of successful repair of esophageal atresia and tracheoesophageal fistula in the newborn period. Barium swallow and manometry results showed achalasia. Hellar operation with antireflux procedure resulted in complete symptomatic relief. Histology and immunohistochemistry including PGP9.5, MAP5, cKit, and nNOS of myotomy specimen showed intact innervation. Although esophageal dysmotility after esophageal atresia repair usually is caused by gastroesophageal reflux and incoordination of peristalsis, the possibility of achalasia should also be considered, because a casual relationship between esophageal atresia and achalasia may exist.     

Etiology and management of respiratory complications after repair of esophageal atresia with tracheoesophageal fistula.

This article reviews the cause and management of respiratory symptoms after repair of esophageal atresia with tracheoesophageal fistula (TEF). Postoperative respiratory symptoms developed in 31 (46%) of 68 patients and included apnea and bradycardia, respiratory arrest, aspiration, and recurrent pneumonia. The respiratory symptoms were initially attributed to gastroesophageal reflux (GER) in 20 patients (64%), tracheomalacia in 4 patients (13%), recurrent TEF in 4 patients (13%), and anastomotic stricture in 3 patients (10%). Three patients with GER and the three patients with a stricture were initially managed nonoperatively. The remaining 25 patients underwent surgical correction of the underlying cause of the respiratory symptoms. Despite aggressive management of this problem, 14 (45%) of these 31 patients had persistent or recurrent respiratory symptoms. Although GER is the most common cause of respiratory complications in patients who have undergone prior TEF repair, other factors are often responsible for these symptoms and should not be overlooked.     

食管功能检查的临床应用

目的 探讨食管腔内压力测定和２４小时食管ｐＨ监测在临床的应用价值。方法 用上述食管功能检查方法对：（１）胃食管反流性疾病采用内、外科不同治疗方法的比较：（２）鉴别食管源性胸痛;（３）评价抗酸药物的作用;以及（４）胆囊切除术后胃食管功能监测等。结果 通过食管功能检查完成了对上述四项内容的验证和评价,取得了良好的效果。结论 食管腔内压力测定和２４小时食管ｐＨ监测是诊断食管功能性疾病是最敏感和特异的检查     

Radiologic evaluation of the esophagus: methods and value in motility disorders and GERD

The barium esophagram is an essential component in the workup of a patient with dysphagia and gastroesophageal reflux disease, especially when considering antireflux surgery or after such surgery. The examination requires a flexible approach with an emphasis on the motility portion of the examination. When properly performed, the examination should identify the following: normal or impaired esophageal emptying; normal or abnormal motility; the presence and type of hiatal hernia; the presence of a distal stricture or mucosal ring; and in many instances, the presence of gastroesophageal reflux. In patients after antireflux surgery, the examination should identify the following: normal of impaired esophageal emptying; normal or abnormal motility; the location, tightness, and length of the fundoplication; the presence of a recurrent hernia; and the presence of gastroesophageal reflux.     

Obesity and Gastro-esophageal Acid Reflux: Physiopathological Mechanisms and Role of Gastric Bariatric Surgery

Background: Controversial findings about the relationships between obesity and gastro-esophageal reflux have been reported, as well as about the effects of weight loss and bariatric surgery on reflux. The aims of this study were to evaluate esophageal motility and gastro-esophageal acid circadian patterns in obese patients and to test the effects of vertical banded gastroplasty (VBG) on these parameters. Methods: 14 obese subjects (BMI 36-53 kg/m²), 4 men, 10 women, 27-61 years old, admitted for elective bariatric surgery, underwent clinical evaluation, upper endoscopy, esophageal manometry and gastroesophageal pH monitoring. Evaluations were repeated 6 to 12 months after gastric surgery that consisted of a VBG (7 patients), accompanied in the other 7 patients with an anti-reflux procedure (fundoplication). Manometric and pH-metric findings in the obese patients were compared with a normal-weight control group before and after the two different surgical treatments. Results: Gastro-esophageal reflux was significantly more frequent in obese (57.1%) than in control group (7.1%). Esophageal motility in obese subjects was not different from controls. After VBG alone, we found a reduction in basal lower esophageal sphincter (LES) pressure and an increase of acid reflux. When VBG was accompanied by fundoplication, basal LES pressure increased and acid reflux frequency decreased. Conclusions: Obesity is associated with gastroesophageal reflux. VBG reduced weight, but not gastro-esophageal acid reflux. Therefore, in our population, this operation cannot be considered as an antireflux procedure.