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The novel application of an emerging device for salvage of primary repair in high-risk complex esophageal atresia

      Highlights

      • What is currently known about this topic?.
      • Magnetic compression anastomoses can be created for endoscopic primary repair of esophageal atresia (EA) with favorable outcomes.
      • What new information is contained in this article?.
      • An esophageal magnetic compression anastomosis device is used for salvage of primary repair in 2 surgically and medically complex EA patients. Two operative approaches are reported: totally endoscopic and a novel hybrid approach.

      Abstract

      Introduction

      Preservation of native esophagus is a tenet of esophageal atresia (EA) repair. However, techniques for delayed primary anastomosis are severely limited for surgically and medically complex patients at high-risk for operative repair. We report our initial experience with the novel application of the Connect-EA, an esophageal magnetic compression anastomosis device, for salvage of primary repair in 2 high-risk complex EA patients. Compassionate use was approved by the FDA and treating institutions.

      Operative Technique

      Two approaches using the Connect-EA are described – a totally endoscopic approach and a novel hybrid operative approach. To our knowledge, this is the first successful use of a hybrid operative approach with an esophageal magnetic compression device.

      Outcomes

      Salvage of delayed primary anastomosis was successful in both patients. The totally endoscopic approach significantly reduced operative time and avoided repeat high-risk operation. The hybrid operative approach salvaged delayed primary anastomosis and avoided cervical esophagostomy.

      Conclusion

      The Connect-EA is a novel intervention to achieve delayed primary esophageal repair in complex EA patients with high-risk tissue characteristics and multi-system comorbidities that limit operative repair. We propose a clinical algorithm for use of the totally endoscopic approach and hybrid operative approach for use of the Connect-EA in high-risk complex EA patients.

      Key Words

      Abbreviations:

      CXR (Chest x-ray), EA (Esophageal atresia), EMCA (Esophageal magnetic compression anastomosis), POD (Post-operative day)
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      References

        • Dingemann C.
        • Eaton S.
        • Aksnes G.
        • et al.
        ERNICA consensus conference on the management of patients with long-gap esophageal atresia: perioperative, surgical, and long-term management.
        Eur J Pediatr Surg. 2020; https://doi.org/10.1055/s-0040-1713932
        • Friedmacher F.
        • Puri P.
        Delayed primary anastomosis for management of long-gap esophageal atresia: a meta-analysis of complications and long-term outcome.
        Pediatr Surg Int. 2012; 28: 899-906https://doi.org/10.1007/s00383-012-3142-2
        • Zani A.
        • Cobellis G.
        • Wolinska J.
        • et al.
        Preservation of native esophagus in infants with pure esophageal atresia has good long-term outcomes despite significant postoperative morbidity.
        Pediatr Surg Int. 2016; 32: 113-117https://doi.org/10.1007/s00383-015-3821-x
        • Conforti A.
        • Morini F.
        • Bagolan P.
        Difficult esophageal atresia: trick and treat.
        Semin Pediatr Surg. 2014; 23: 261-269https://doi.org/10.1053/j.sempedsurg.2014.09.006
        • Svetanoff W.J.
        • Zendejas B.
        • Hernandez K.
        • et al.
        Contemporary outcomes of the Foker process and evolution of treatment algorithms for long-gap Esophageal Atresia.
        J Pediatr Surg. 2021; https://doi.org/10.1016/j.jpedsurg.2021.02.054
        • Etchill E.W.
        • Giuliano K.A.
        • Boss E.F.
        • et al.
        Association of operative approach with outcomes in neonates with esophageal atresia and tracheoesophageal fistula.
        J Pediatr Surg. 2021; https://doi.org/10.1016/j.jpedsurg.2021.04.006
        • Friedmacher F.
        • Kroneis B.
        • Huber-Zeyringer A.
        • et al.
        Postoperative complications and functional outcome after esophageal atresia repair: results from longitudinal single-center follow-Up.
        J Gastrointest Surg. 2017; 21: 927-935https://doi.org/10.1007/s11605-017-3423-0
        • Powell L.
        • Frawley J.
        • Crameri J.
        • et al.
        Oesophageal atresia: are "long gap" patients at greater anesthetic risk?.
        Paediatr Anaesth. 2018; 28: 249-256https://doi.org/10.1111/pan.13336
        • Baird R.
        • Lal D.R.
        • Ricca R.L.
        • et al.
        Management of long gap esophageal atresia: a systematic review and evidence-based guidelines from the APSA outcomes and evidence based practice committee.
        J Pediatr Surg. 2019; 54: 675-687https://doi.org/10.1016/j.jpedsurg.2018.12.019
        • Lal D.R.
        • Gadepalli S.K.
        • Downard C.D.
        • et al.
        Challenging surgical dogma in the management of proximal esophageal atresia with distal tracheoesophageal fistula: outcomes from the Midwest Pediatric Surgery Consortium.
        J Pediatr Surg. 2018; 53: 1267-1272https://doi.org/10.1016/j.jpedsurg.2017.05.024
      1. Tambucci R., Angelino G., De Angelis P., et al. Anastomotic Strictures after Esophageal Atresia Repair: incidence, Investigations, and Management, Including Treatment of Refractory and Recurrent Strictures. Front Pediatr. 2017;5:120. doi:10.3389/fped.2017.00120.

        • 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: 869-873https://doi.org/10.1007/s00383-016-3931-0
        • Chumfong I.
        • Lee H.
        • Padilla B.E.
        • et al.
        Esophagoesophagopexy technique for assisted fistulization of esophageal atresia.
        Pediatr Surg Int. 2018; 34: 63-69https://doi.org/10.1007/s00383-017-4164-6
        • Janek K.
        • Meagher D.
        • Goodwin C.
        Suture fistula revisited for long gap esophageal atresia.
        J Pediatr Surg. 2019; 54: 600-603https://doi.org/10.1016/j.jpedsurg.2018.10.100
        • Zaritzky M.
        • Ben R.
        • Johnston K.
        Magnetic gastrointestinal anastomosis in pediatric patients.
        J Pediatr Surg. 2014; 49: 1131-1137https://doi.org/10.1016/j.jpedsurg.2013.11.002
        • Slater B.J.
        • Borobia P.
        • Lovvorn H.N.
        • et al.
        Use of magnets as a minimally invasive approach for anastomosis in esophageal atresia: long-term outcomes.
        J Laparoendosc Adv Surg Tech A. 2019; 29: 1202-1206https://doi.org/10.1089/lap.2019.0199
        • Graves C.E.
        • Co C.
        • Hsi R.S.
        • et al.
        Magnetic Compression Anastomosis (Magnamosis): first-In-Human Trial.
        J Am Coll Surg. 2017; 225 (e1. doi:S1072-7515(17)31701-5): 676-681
        • Muensterer O.J.
        • Sterlin A.
        • Oetzmann von Sochaczewski C.
        • et al.
        An experimental study on magnetic esophageal compression anastomosis in piglets.
        J Pediatr Surg. 2019; (doi:S0022-3468(19)30336-7)
        • Sterlin A.
        • Evans L.
        • Mahler S.
        • et al.
        An experimental study on long term outcomes after magnetic esophageal compression anastomosis in piglets.
        J Pediatr Surg. 2021; https://doi.org/10.1016/j.jpedsurg.2021.09.032
        • Muensterer O.J.
        • Evans L.L.
        • Sterlin A.
        • et al.
        Novel device for endoluminal esophageal atresia repair: first-in-human experience.
        Pediatrics. 2021; https://doi.org/10.1542/peds.2020-049627
        • Okuyama H.
        • Tazuke Y.
        • Ueno T.
        • et al.
        Learning curve for the thoracoscopic repair of esophageal atresia with tracheoesophageal fistula.
        Asian J Endosc Surg. 2018; 11: 30-34https://doi.org/10.1111/ases.12411
        • Petroze R.T.
        • Puligandla P.S.
        Preoperative cardiopulmonary evaluation in specific neonatal surgery.
        Semin Pediatr Surg. 2019; 28: 3-10https://doi.org/10.1053/j.sempedsurg.2019.01.002
        • van der Zee D.C.
        • van Herwaarden M.Y.A.
        • Hulsker C.C.C.
        • et al.
        Esophageal atresia and upper airway pathology.
        Clin Perinatol. 2017; 44: 753-762https://doi.org/10.1016/j.clp.2017.08.002
        • Shieh H.F.
        • Jennings R.W.
        Long-gap esophageal atresia.
        Semin Pediatr Surg. 2017; 26: 72-77https://doi.org/10.1053/j.sempedsurg.2017.02.009
        • Stadil T.
        • Koivusalo A.
        • Svensson J.F.
        • et al.
        Surgical treatment and major complications Within the first year of life in newborns with long-gap esophageal atresia gross type A and B - a systematic review.
        J Pediatr Surg. 2019; 54: 2242-2249https://doi.org/10.1016/j.jpedsurg.2019.06.017
        • Gallo G.
        • Zwaveling S.
        • Van der Zee D.C.
        • et al.
        A two-center comparative study of gastric pull-up and jejunal interposition for long gap esophageal atresia.
        J Pediatr Surg. 2015; 50: 535-539https://doi.org/10.1016/j.jpedsurg.2014.05.026
        • Lee H.Q.
        • Hawley A.
        • Doak J.
        • et al.
        Long-gap oesophageal atresia: comparison of delayed primary anastomosis and oesophageal replacement with gastric tube.
        J Pediatr Surg. 2014; 49: 1762-1766https://doi.org/10.1016/j.jpedsurg.2014.09.017
        • Campos J.
        • Tan Tanny S.P.
        • Kuyruk S.
        • et al.
        The burden of esophageal dilatations following repair of esophageal atresia.
        J Pediatr Surg. 2020; 55: 2329-2334https://doi.org/10.1016/j.jpedsurg.2020.02.018
        • 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 (doi:S0022-3468(16)30597-8): 1245-1251
        • Spitz L.
        Esophageal atresia. Lessons I have learned in a 40-year experience.
        J Pediatr Surg. 2006; 41: 1635-1640https://doi.org/10.1016/j.jpedsurg.2006.07.004
        • Marinho A.S.
        • Saxena A.K.
        Thoracoscopic esophageal atresia repair: outcomes analysis between primary and staged procedures.
        Surg Laparosc Endosc Percutan Tech. 2020; 31: 363-367https://doi.org/10.1097/sle.0000000000000895
        • Kovesi T.
        • Rubin S.
        Long-term complications of congenital esophageal atresia and/or tracheoesophageal fistula.
        Chest. 2004; 126: 915-925https://doi.org/10.1378/chest.126.3.915
        • Bagolan P.
        • Valfrè L.
        • Morini F.
        • et al.
        Long-gap esophageal atresia: traction-growth and anastomosis - before and beyond.
        Dis Esophagus. 2013; 26: 372-379https://doi.org/10.1111/dote.12050
        • Stringel G.
        • Lawrence C.
        • McBride W.
        Repair of long gap esophageal atresia without anastomosis.
        J Pediatr Surg. 2010; 45: 872-875https://doi.org/10.1016/j.jpedsurg.2010.02.003
        • Lovvorn H.N.
        • Baron C.M.
        • Danko M.E.
        • et al.
        Staged repair of esophageal atresia: pouch approximation and catheter-based magnetic anastomosis.
        J Pediatr Surg Case Rep. 2014; 2: 170-175https://doi.org/10.1016/j.epsc.2014.03.004
      2. Dorman R.M., Vali K., Harmon C.M., et al. Repair of esophageal atresia with proximal fistula using endoscopic magnetic compression anastomosis (magnamosis) after staged lengthening. Pediatric surgery international. 2016;32:525–8. doi:10.1007/s00383-016-3889-y.

        • Wolfe E.
        • Zidane M.
        • Hancock B.J.
        • et al.
        Magnamosis for esophageal atresia is associated with anastomotic strictures requiring an increased number of dilatations.
        J Pediatr Surg. 2020; 55: 821-823https://doi.org/10.1016/j.jpedsurg.2020.01.022
        • Ellebaek M.B.B.
        • Qvist N.
        • Rasmussen L.
        Magnetic compression anastomosis in long-gap esophageal atresia gross type a: a case report.
        European J Pediatr Surg Rep. 2018; 6 (e37-e9)https://doi.org/10.1055/s-0038-1649489
        • Shieh H.F.
        • Jennings R.W.
        • Manfredi M.A.
        • et al.
        Cautionary tales in the use of magnets for the treatment of long gap esophageal atresia.
        J Pediatr Surg. 2021; https://doi.org/10.1016/j.jpedsurg.2021.11.002