Advertisement

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

      Abstract

      Purpose

      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.

      Methods

      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.

      Results

      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 >24 h were used in 193 patients (66%) with no difference in rates of infection, shock or death when compared to antibiotic use ≤24 h (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.

      Conclusion

      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 24 h 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.

      Study type

      Treatment study.

      Level of evidence

      III.

      Key words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Journal of Pediatric Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Lal D.R.
        • Gadepalli S.K.
        • Downard C.D.
        • et al.
        Perioperative management and outcomes of esophageal atresia and tracheoesophageal fistula.
        J Pediatr Surg. 2017; 52: 1245-1251
        • Hirschl R.B.
        • Minneci P.
        • Gadepalli S.
        • et al.
        Development of a multi-institutional clinical research consortium for pediatric surgery.
        J Pediatr Surg. 2017; 52: 1084-1088
        • Harris P.A.
        • Taylor R.
        • Thielke R.
        • et al.
        Research electronic data capture (REDCap)—a metadata-driven methodology and workflow process for providing translational research informatics support.
        J Biomed Inform. 2009; 42: 377-381
        • Chittmittrapap S.
        • Spitz L.
        • Kiely E.M.
        • et al.
        Anastomotic stricture following repair of esophageal atresia.
        J Pediatr Surg. 1990; 25: 508-511
        • McKinnon L.J.
        • Kosloske A.M.
        Prediction and prevention of anastomotic complications of esophageal atresia and tracheoesophageal fistula.
        J Pediatr Surg. 1990; 25: 778-781
        • Sweed Y.
        • Bar-Maor J.A.
        • Shoshany G.
        Insertion of a soft silastic nasogastric tube at operation for esophageal atresia: a new technical method.
        J Pediatr Surg. 1992; 27: 650-651
        • Spitz L.
        Esophageal atresia and tracheoesophageal fistula in children.
        . 1993; 5: 347-352
        • Patel S.B.
        • Ade-Ajayi N.
        • Kiely E.M.
        Oesophageal atresia: a simplified approach to early management.
        Pediatr Surg Int. 2002; 18: 87-89
        • Alabbad S.I.
        • Ryckman J.
        • Puligandla P.S.
        • et al.
        Use of transanastomotic feeding tubes during esophageal atresia repair.
        J Pediatr Surg. 2009; 44: 902-905
        • Yurtcu M.
        • Toy H.
        • Arbag H.
        • et al.
        Surgical management with or without a nasogastric tube in esophageal repairs.
        Int J Pediatr Otorhinolaryngol. 2012; 76: 104-106
        • Borruto F.A.
        • Impellizzeri P.
        • Montalto A.S.
        • et al.
        Thoracoscopy versus thoracotomy for esophageal atresia and tracheoesophageal fistula repair: review of the literature and metaanalysis.
        Eur J Pediatr Surg. 2012; 22: 415-419
        • Thakkar H.S.
        • Cooney J.
        • Kumar N.
        • et al.
        Measured gap length and outcomes in oesophageal atresia.
        J Pediatr Surg. 2014; 49: 1343-1346
        • Hagander L.
        • Muszynska C.
        • Arnbjornsson E.
        • et al.
        Prophylactic treatment with proton pump inhibitors in children operated on for oesophageal atresia.
        Eur J Pediatr Surg. 2012; 22: 139-142
        • Allin B.
        • Knight M.
        • Johnson P.
        • et al.
        Outcomes at one-year post anastomosis from a national cohort of infants with oesophageal atresia.
        PLoS One. 2014; 9e106149
        • Okata Y.
        • Maeda K.
        • Bitoh Y.
        • et al.
        Evaluation of the intraoperative risk factors for esophageal anastomotic complications after primary repair of esophageal atresia with tracheoesophageal fistula.
        Pediatr Surg Int. 2016; 32: 869-873
        • Guillet R.
        • Stoll B.J.
        • Cotten C.M.
        • et al.
        Association of H2-blocker therapy and higher incidence of necrotizing enterocolitis in very low birth weight infants.
        Pediatrics. 2006; 117: e137-e142
        • Orenstein S.R.
        • Hassall E.
        • Furmaga-Jablonska W.
        • et al.
        Multicenter, double-blind, randomized, placebo-controlled trial assessing the efficacy and safety of proton pump inhibitor lansoprazole in infants with symptoms of gastroesophageal reflux disease.
        J Pediatr. 2009; 154: 514-520.e4
        • Tleyjeh I.M.
        • Abdulhak A.B.
        • Riaz M.
        • et al.
        The association between histamine 2 receptor antagonist use and Clostridium difficile infection: a systematic review and meta-analysis.
        PLoS One. 2013; 8e56498
        • Nylund C.M.
        • Eide M.
        • Gorman G.H.
        Association of Clostridium difficile infections with acid suppression medications in children.
        J Pediatr. 2014; 165: 979-984.e1
        • St Peter S.D.
        • Calkins C.M.
        • Holcomb III, G.W.
        The use of biosynthetic mesh to separate the anastomoses during the thoracoscopic repair of esophageal atresia and tracheoesophageal fistula.
        J Laparoendosc Adv Surg Tech A. 2007; 17: 380-382
        • Takemoto R.C.
        • Lonner B.
        • Andres T.
        • et al.
        Appropriateness of twenty-four-hour antibiotic prophylaxis after spinal surgery in which a drain is utilized: a prospective randomized study.
        J Bone Joint Surg Am. 2015; 97: 979-986
        • Park Y.Y.
        • Kim C.W.
        • Park S.J.
        • et al.
        Influence of shorter duration of prophylactic antibiotic use on the incidence of surgical site infection following colorectal cancer surgery.
        Ann Coloproctol. 2015; 31: 235-242