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Post-operative ventilation strategies after surgical repair in neonates with esophageal atresia: A retrospective cohort study

  • Domenico Umberto De Rose
    Correspondence
    Corresponding author at: Neonatal Intensive Care Unit, Medical and Surgical Department of Fetus - Newborn – Infant, “Bambino Gesù” Children's Hospital IRCCS, Piazza S. Onofrio 4 – 00165 Rome, Italy.
    Affiliations
    Neonatal Intensive Care Unit, Medical and Surgical Department of Fetus - Newborn – Infant, “Bambino Gesù” Children's Hospital IRCCS, Rome, Italy

    PhD course in Microbiology, Immunology, Infectious Diseases, and Transplants (MIMIT), University of Rome “Tor Vergata”, Rome, Italy
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  • Francesca Landolfo
    Affiliations
    Neonatal Intensive Care Unit, Medical and Surgical Department of Fetus - Newborn – Infant, “Bambino Gesù” Children's Hospital IRCCS, Rome, Italy
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  • Paola Giliberti
    Affiliations
    Neonatal Intensive Care Unit, Medical and Surgical Department of Fetus - Newborn – Infant, “Bambino Gesù” Children's Hospital IRCCS, Rome, Italy
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  • Alessandra Santisi
    Affiliations
    Neonatal Intensive Care Unit, Medical and Surgical Department of Fetus - Newborn – Infant, “Bambino Gesù” Children's Hospital IRCCS, Rome, Italy
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  • Claudia Columbo
    Affiliations
    Neonatal Intensive Care Unit, Medical and Surgical Department of Fetus - Newborn – Infant, “Bambino Gesù” Children's Hospital IRCCS, Rome, Italy
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  • Andrea Conforti
    Affiliations
    Newborn Surgery Unit, Medical and Surgical Department of Fetus - Newborn – Infant, “Bambino Gesù” Children's Hospital IRCCS, Rome, Italy

    Congenital Esophageal Disorders Unit, Medical and Surgical Department of Fetus - Newborn – Infant, “Bambino Gesù” Children's Hospital IRCCS, Rome, Italy
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  • Maria Paola Ronchetti
    Affiliations
    Neonatal Intensive Care Unit, Medical and Surgical Department of Fetus - Newborn – Infant, “Bambino Gesù” Children's Hospital IRCCS, Rome, Italy
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  • Annabella Braguglia
    Affiliations
    Congenital Esophageal Disorders Unit, Medical and Surgical Department of Fetus - Newborn – Infant, “Bambino Gesù” Children's Hospital IRCCS, Rome, Italy
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  • Andrea Dotta
    Affiliations
    Neonatal Intensive Care Unit, Medical and Surgical Department of Fetus - Newborn – Infant, “Bambino Gesù” Children's Hospital IRCCS, Rome, Italy
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  • Irma Capolupo
    Affiliations
    Neonatal Intensive Care Unit, Medical and Surgical Department of Fetus - Newborn – Infant, “Bambino Gesù” Children's Hospital IRCCS, Rome, Italy
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  • Pietro Bagolan
    Affiliations
    Newborn Surgery Unit, Medical and Surgical Department of Fetus - Newborn – Infant, “Bambino Gesù” Children's Hospital IRCCS, Rome, Italy

    Neonatal Sub-Intensive Care Unit and Follow-up, Medical and Surgical Department of Fetus - Newborn – Infant, “Bambino Gesù” Children's Hospital IRCCS, Rome, Italy

    Department of Systems Medicine, University of Rome “Tor Vergata”, Rome, Italy
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      HIGHLIGHTS

      • What is currently known about this topic?
        Concerns have been addressed about a higher risk of anastomotic leak and mediastinitis in neonates operated on for EA/TEF who required non-invasive ventilation after extubation in previous studies, with contrasting results.
      • What new information is contained in this article?
        Post-operative non-invasive respiratory support could be safely used in EA/TEF infants without a significant increase in risk of anastomotic leak.
        This should be considered especially in preterm infants in which a prolonged invasive ventilation contribute to the development of bronchopulmonary dysplasia and therefore it should be carefully shifted to non-invasive ventilation as soon as possible, using low pressures and, if necessary, a mild sedation.

      ABSTRACT

      Background

      Infants affected by Esophageal atresia (EA) with or without tracheoesophageal fistula (TEF) may require non-invasive ventilation (NIV) in the post-operative period after elective extubation, especially if born preterm. The aim of the paper is to evaluate the role of different ventilation strategies on anastomotic complications, specifically on anastomotic leak (AL).

      Materials and Methods

      Retrospective single Institution study, including all consecutive neonates affected by EA with or without TEF in a 5-year period study (from 2014 to 2018). Only infants with a primary anastomosis were included in the study. All infants were mechanically ventilated after surgery and electively extubated after 6–7 days. The duration of invasive ventilation was decided on a case-by-case basis after surgery, based on the pre-operative esophageal gap and intraoperative findings. The need for non-invasive ventilation (NCPAP, NIPPV, and HHHFNC) after extubation and extubation failure with the need for mechanical ventilation in the post-operative period were assessed. The primary outcome evaluated was the rate of anastomotic leak.

      Results

      102 EA/TEF infants were managed in the study period. Sixty-seven underwent primary anastomosis. Of these, 29 (43.3%) were born preterm. Patients who required ventilation (n = 32) had a significantly lower gestational age as well as birthweight (respectively p = 0.007 and p = 0.041). 4/67 patients had an AL after surgical repair, with no statistical differences among post-operative ventilation strategies.

      Conclusion

      We found no significant differences in the rate of anastomotic leak (AL) according to post-operative ventilation strategies in neonates operated on for EA/TEF.

      Keywords

      Abbreviations:

      AL (anastomotic leak), EA/TEF (esophageal atresia with or without tracheoesophageal fistula), HHHFNC (heated humidified high-flow nasal cannulas), IQR (interquartile range), LGEA (Long gap EA), MV (mechanical ventilation), NCPAP (nasal continuous positive airway pressure), NICU (Neonatal Intensive Care Unit), NIPPV (nasal intermittent positive pressure ventilation), NIV (non-invasive ventilation), PEEP (positive end-expiratory pressure), SB (spontaneous breathing), SD (standard deviation)
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