Simultaneous type III congenital esophageal atresia and patent ductus arteriosus in a low-weight patient: A case report

BACKGROUND We report a low-birth-weight child(1.8 kg)with neonatal type III congenital esophageal atresia(CEA)combined with symptomatic patent ductus arteriosus(PDA).After comprehensive evaluation,esophageal anastomosis was performed on postnatal day 11 after excluding surgical contraindications,and arterial catheter ligation was performed at the same time.Concurrent surgery for CEA combined with PDA has not been clearly reported in the literature.CASE SUMMARY We report a 6-day-old female child with type III CEA and PDA.The patient presented with foam at the mouth after birth,cough and shortness of breath after feeding.At another hospital,she was considered to have neonatal pneumonia,neonatal jaundice and congenital heart disease and transferred to our hospital.After iodine oil radiography of the esophagus and echocardiography we con-firmed diagnosis of CEA and PDA.The diameter of the PDA was 8 mm,with obvious left to right shunting.We performed right rear extrapleural orificium fistula ligation and esophageal anastomosis,and ligation of PDA via left axilla straight incision after 5 d of hospitalization.The operations were successful,and the incision healed after 12 d,and the patient was discharged.We re-examined the patient 1 mo after surgery.She did not vomit when she ate rice flour.Esophageal angiography showed no stricture of the anastomotic stoma.The patient weighed 3.2 kg.CONCLUSION For CEA patients with multiple risk factors,comprehensive,timely and accurate diagnosis and evaluation,and early treatment may improve prognosis.

Primary repair of esophageal atresia Gross type C via thoracoscopic magnetic compression anastomosis:Is it the best option?

Magnetic compression anastomosis is a promising treatment option for patients with complex esophageal atresia;but,at the present time,should not be the first therapeutic option in those cases where the surgeon can perform a primary anastomosis of the two ends of the esophagus with acceptable tension.

Primary repair of esophageal atresia gross type C via thoracoscopic magnetic compression anastomosis:A case report

BACKGROUND Esophageal atresia(EA)is a life-threatening congenital malformation in newborns,and the traditional repair approaches pose technical challenges and are extremely invasive.Therefore,surgeons have been actively investigating new minimally invasive techniques to address this issue.Magnetic compression anastomosis has been reported in several studies for its potential in repairing EA.In this paper,the primary repair of EA with magnetic compression anastomosis under thoracoscopy was reported.CASE SUMMARY A full-term male weighing 3500 g was diagnosed with EA gross type C.The magnetic devices used in this procedure consisted of two magnetic rings and several catheters.Tracheoesophageal fistula ligation and two purse strings were performed.The magnetic compression anastomosis was then completed thoracoscopically.After the primary repair,no additional operation was conducted.A patent anastomosis was observed on the 15th day postoperatively,and the magnets were removed on the 23rd day.No leakage existed when the transoral feeding started.CONCLUSION Thoracoscopic magnetic compression anastomosis may be a promising minimally invasive approach for repairing EA.

Graft dilatation and Barrett’s esophagus in adults after gastric pullup and jejunal interposition for long-gap esophageal atresia

BACKGROUND Esophageal replacement(ER)with gastric pull-up(GPU)or jejunal interposition(JI)used to be the standard treatment for long-gap esophageal atresia(LGEA).Changes of the ER grafts on a macro-and microscopic level however,are unknown.AIM To evaluate long-term clinical symptoms and anatomical and mucosal changes in adolescents and adults after ER for LGEA.METHODS A cohort study was conducted including all LGEA patients≥16 years who had undergone GPU or JI between 1985-2003 at two tertiary referral centers in the Netherlands.Patients underwent clinical assessment,contrast study and endoscopy with biopsy.Data was collected prospectively.Group differences between JI and GPU patients,and associations between different outcome measures were assessed using the Fisher’s exact test for bivariate variables and the Mann-Whitney U-test for continuous variables.Differences with a P-value<0.05 were considered statistically significant.RESULTS Nine GPU patients and eleven JI patients were included.Median age at follow-up was 21.5 years and 24.4 years,respectively.Reflux was reported in six GPU patients(67%)vs four JI patients(36%)(P=0.37).Dysphagia symptoms were reported in 64%of JI patients,compared to 22%of GPU patients(P=0.09).Contrast studies showed dilatation of the jejunal graft in six patients(55%)and graft lengthening in four of these six patients.Endoscopy revealed columnar-lined esophagus in three GPU patients(33%)and intestinal metaplasia was histologically confirmed in two patients(22%).No association was found between reflux symptoms and macroscopic anomalies or intestinal metaplasia.Three GPU patients(33%)experienced severe feeding problems vs none in the JI group.The median body mass index of JI patients was 20.9 kg/m^(2) vs 19.5 kg/m^(2) in GPU patients(P=0.08).CONCLUSION The majority of GPU patients had reflux and intestinal metaplasia in 22%.The majority of JI patients had dysphagia and a dilated graft.Follow-up after ER for LGEA is essential.

Early Morbidity and Perioperative Course of Neonates with Esophageal Atresia and Tracheoesophageal Fistula in a Tertiary Pediatric Surgical Center

Background: The management of infants (infs.) with esophageal atresia and tracheoesophageal fistula (EA ± TEF) is demanding and complex. The aim of this study was to evaluate early morbidity, the timing of surgery, and the results of surgery. Patients and Method: We collected data of 30 consecutive infs. treated for EA ± TEF between 2006 and 2014. Results: The median gestational age was 38 weeks (12 preterm), and the median Birth Weight (BW) was 2660 g (4 infs. had a BW 1500 g). The median Apgar score at 10 minutes was 10 (range 7 - 10). The median umbilical artery pH (UapH) was 7.30. According to the Spitz classification, 19 infs. were group 1, 9 infs. were group 2, and 2 infs. were group 3. Surgical repair was performed in 29 cases (25 EA;4 isolated TEF). Once the infs. arrived at the pediatric surgery department, surgery was postponed overnight in 11 cases. The duration of postoperative (p.o.) mechanical ventilation was significantly shorter for operations performed on day 2 after delivery. Twenty-four infs. (83%) underwent surgery within 2 days after delivery, and 5 infs. had later surgery. Chest drains (p.o.) for pneumothorax were inserted in 6 infs. (21%), and gastrostomy was performed in 6 cases (21%). No re-thoracotomy was required. The median length of hospital stay was 17.5 days (6 to 120). The incidence of p.o. mortality was 1 in 29 (3%). Discussion: The majority of the infs. presented growth retardation (indicated by low birth weight) and a stable immediate postnatal course. The data from this study support the concept of early but not emergent surgery for the majority of infs. with EA ± TEF. However, a remarkable rate of perioperative morbidity must be taken into account. Conclusion: Surgery for EA ± TEF can be performed safely during the first postnatal days with exception of very unstable preterm infants.

Gastroesophageal reflux disease in pediatric esophageal atresia:Assessment of clinical symptoms and pH-impedance data

BACKGROUND Esophageal atresia(EA)is the most common congenital anomaly of the gastrointestinal tract.Gastroesophageal reflux disease(GERD)is a frequent and lifelong problem in these patients.GERD can be asymptomatic and the incidence of esophageal gastric and intestinal metaplasia(Barrett’s esophagus)is increased in adults with EA compared with the general population.Timely and accurate diagnosis of GERD is important to reduce long-term problems and this may be achieved by pH-impedance testing.AIM To assess symptoms and pH-impedance data in children after EA,in order to identify their specific features of GERD.METHODS This study was conducted from November 2017 to February 2020 and involved 37 children who had undergone EA via open surgical repair(51.35%boys,48.65%girls;age range:1-14 years,median:4.99 years).GERD diagnosis was made based on multichannel intraluminal impedance/pH study and two groups were established:EA without GERD,n=17;EA with GERD,n=20.A control group was established with 66 children with proven GERD(68.18%boys,31.82%girls;median age:7.21 years),composed of a nonerosive reflux disease(referred to as NERD)group(n=41)and a reflux esophagitis group(n=25).Upper gastrointestinal endoscopy with a mucosal esophageal biopsy was performed on all patients.RESULTS The most frequently observed symptom in EA patients with GERD and without GERD was cough(70%and 76.5%respectively).The number of patients with positive symptom association probability in the EA groups was significantly larger in the EA without GERD group(P=0.03).In the control reflux esophagitis group,prevalence of gastrointestinal symptoms was significantly higher than in the NERD group(P=0.017).For both EA groups,there was strong correlation with index of proximal events(IPE)and total proximal events(EA with GERD:0.96,P<0.001;EA without GERD:0.97,P<0.001)but level of IPE was significantly lower than in GERD patients without any surgical treatment(P<0.001).Data on distal mean nocturnal baseline impedance were significantly different between the EA with GERD group(P<0.001)and the two control groups but not between EA without GERD and the two control groups.CONCLUSION Mean nocturnal baseline impedance may have diagnostic value for GERD in EA children after open surgical repair.IPE might be an additional parameter of pHimpedance monitoring.

Detection of reflux-symptom association in children with esophageal atresia by video-pH-impedance study

BACKGROUND Children with esophageal atresia(EA)have risk of gastroesophageal reflux disease(GERD),suggesting reflux monitoring for prompt management.AIM To evaluate GERD in children with EA and specific symptom association from combined Video with Multichannel Intraluminal Impedance and pH(MII-pH)study.METHODS Children diagnosed with EA with suspected GERD and followed up at King Chulalongkorn Memorial Hospital between January 2000 and December 2018 were prospectively studied.All underwent esophagogastroduodenoscopy with esophageal biopsy and Video MII-pH study on the same day.Symptoms of GERD which included both esophageal and extra-esophageal symptom were recorded from video monitoring and abnormal reflux from MII-pH study based on the statement from the European Paediatric Impedance Group.Prevalence of GERD was also reported by using histopathology as a gold standard.Endoscopic appearance was recorded using Los Angeles Classification and esophagitis severity was graded using Esohisto criteria.RESULTS Fifteen children were recruited with age of 3.1(2.2,9.8)years(40%,male)and the common type was C(93.3%).The symptoms recorded were cough(75.2%),vomiting(15.2%),irritability or unexplained crying(7.6%)and dysphagia(1.9%)with the symptom-reflux association of 45.7%,89%,71%and 0%,respectively.There were abnormal endoscopic appearance in 52.9%,esophagitis in 64.7%and high reflux score in 47.1%.Video MII-pH study has high diagnostic value with the sensitivity,specificity and accuracy of 72.7%,100%and 82.4%,respectively.CONCLUSION Prevalence of GERD in children with EA was high.Video MII-pH study to detect GERD in children with EA had high diagnostic value with the trend of specific symptom association.

Endoscopic Detection and Surgical Repair of Congenital Tracheo-Esophageal-Fistula(TEF)±Esophageal Atresia(EA)

Purpose: This study was performed to evaluate the management of tracheoesophageal fistula (TEF) ± esophageal atresia (EA) under the guidance of preoperative tracheo-bronchoscopy (TrSc). Methods: Between 2007 and July 2014, a total of 26 consecutive newborns who underwent rigid TrSc for suspected TEF were identified. All associated charts and operation reports were retrospectively analyzed. Results: Distal TEF with EA (Gross C) predominated (n = 18). Furthermore, we managed 2 infants with proximal and distal TEF (Gross D) and 4 infants with isolated TEF (Gross E). In our hands, TrSc was feasible in infants with a birth weight above 1300 g. Twenty-five fistulas were identified by endoscopy in 23 patients. In one infant with a birth weight below 1000 g, an attempt to perform TrSc was interrupted, and urgent TEF closure was required. Fistula site at the carina was associated with a high rate of esophageal anastomosis under tension. During surgery, proximal TEF and isolated TEF were safely approached via right cervicotomy (n =5). Conclusion: This study supports the routine use of rigid TrSc at the time of surgery. Rigid TrSc allowed the surgical team to identify the number and location of TEFs, and the incidence of side effects was low.

Comparison of neonatal tolerance to thoracoscopic and open repair of esophageal atresia with tracheoesophageal fistula

Background Advances in minimally invasive surgical techniques and neonatal intensive care for neonates have allowed for repair of the neonatal esophageal atresia with tracheoesophageal fistula （EA/TEF） to be approached endoscopically. However, thoracoscopic surgery in children is still performed in only a few centers throughout the world. The aim of this study was to compare the neonatal tolerance to the thoracoscopic repair （TR） and the open repair （OR） and also to discuss anesthetic management in thoracoscopic procedure. Methods We performed a prospective study enrolling newborns diagnosed with EA with distal TEF （type C） receiving the repair surgery between June 2009 and January 2012 in our institution. Data collected included the newborns＇ gestational age and weight at the time of the operation, operative time, parameters of intraoperative mechanical ventilation, oxygenation, end-tidal carbon dioxide （ETCO2）, and analysis of blood gases. Time to extubation and length of stay were also recorded. Results Intravenous induction with muscle paralysis followed by pressure-control ventilation and tracheal intubation regardless of the position of the fistula can be performed uneventfully in EA/TEF newborns with no additional airway anomalies and large, pericarinal fistulas in our experiences. The thoracoscopic approach appeared to take longer than the open approach. During the procedure of repair, hypercarbia and acidosis developed immediately 1 hour after pneumothorax in both groups. CO2 insufflation did have additional influence on the respiratory function of the newborns in the TR group; values of PaCO2 and ETCO2 were higher in the TR group but the difference did not reach statistical significance. By the end of the procedure, values of PaCO2 and ETCO2 returned to the baseline levels while pH did not, but all parameters made no difference in the two groups. Besides, time to extubation was shorter in the TR group. Conclusions Thoracoscopic repair of EA/TEF is comparable to the open repair, and is believed to be safe and tolerable in selected patients. A wider range of neonates may be acceptable for thoracoscopic EA/TEF repair with increasinQ surQical experience.

Partial gastric pull-up in the treatment of patients with long-gap esophageal atresia

Background:This study was to analyze outcomes of long-gap esophageal atresia(LGEA)treated with partial gastric pull-up(PGP)into the thorax.Methods:The medical records of all children who had undergone PGP for LGEA from 1999 to 2012 were reviewed.Preoperative data,initial postoperative course,complications,time to full oral nutrition,follow-up diagnostics and nutritional status were assessed.Results:Nine children who had undergone PGP were followed up for a mean period of 6.2±3.1 years.Their median gestational age was 37+2 weeks,and mean birth weight 2462±658 g.Eight children were primarily treated with a gastrostomy,their mean age at PGP was 11.4+10.9 weeks and mean weight was 4484+1966 g.Their mean operation time was 199+51 minutes.Leakage was an early postoperative complication in three children,one of whom had a consecutive stricture resection.Late complications were stenosis(n=7)and gastro-esophageal reflux(n=5).The general status of the children was judged as"good"or"very good"on the last presentation.The median percentile of the body-mass-index was 25.Gastroscopy at 3.7±3.2 years after the operation revealed a grade I esophagitis in two children.There was no death in this group of children.Conclusions:Because of its high complication rate,partial gastric pull-up cannot be recommended as an alternative for the treatment of LGEA at present.A final judgment could be made on the basis of a comparative study.

Diagnose and treatment for Type D congenital esophageal atresia with tracheoesophageal fistula

Importance:Type D esophageal atresia(EA)with tracheoesophageal fistula(TEF)is characterized by EA with both proximal and distal TEFs.It is a rare congenital anomaly with a very low incidence.Objective:To investigate diagnostic and treatment strategies for this rare condition.Methods:We retrospectively reviewed the clinicopathological features of patients with EA/TEF treated at our institution between January 2007 and September 2021.Results:Among 386 patients with EA/TEF,14(3.6%)had type D EA/TEF.Only two patients were diagnosed with proximal TEF preoperatively.Seven patients were diagnosed intraoperatively.Five patients were missed for diagnosis during the initial surgery but was later confirmed by bronchoscopy.During the neonatal period,seven patients underwent a one-stage repair of proximal and distal TEF via thoracoscopy or thoracotomy.Due to missed diagnosis and other reasons,the other 7 patients underwent two-stage surgery for repair of the proximal TEF,including cervical incision and thoracoscopy.Ten of the 14 patients experienced postoperative complications including anastomotic leakage,pneumothorax,esophageal stricture,and recurrence.Patients who underwent one-stage repair of distal and proximal TEF during the neonatal period showed a higher incidence of anastomotic leak(4/7).In contrast,only one of seven patients with two-stage repair of the proximal TEF developed an anastomotic leak.Interpretation:Type D EA/TEF is a rare condition,and proximal TEFs are easily missed.Bronchoscopy may aim to diagnose and determine the correct surgical approach.A cervical approach may be more suitable for repairing the proximal TEF.

Endoscopic vacuum assisted closure therapy for esophagopericardial fistula in a 16-year-old male:A case report

BACKGROUND Esophagopericardial fistula(EPF)is a rare,life-threatening condition with limited scientific literature and no established management guidelines.This case report highlights a successful multidisciplinary approach and the innovative use of endoscopic vacuum assisted closure(endoVAC)therapy in treating this complex condition.CASE SUMMARY A 16-year-old male with a history of esophageal atresia and colon interposition presented with progressive chest pain,fever,and dyspnea.Imaging revealed an EPF with associated pleural and pericardial effusions.Initial management with an esophageal stent failed,prompting the use of an endoVAC system.The patient underwent multiple endoVAC device changes and received broad-spectrum antibiotics and nutritional support.The fistula successfully closed,and the patient recovered,demonstrating no new symptoms at a 6-month follow-up.CONCLUSION EndoVAC therapy can effectively manage EPF,providing a minimally invasive treatment option.

针刺治疗食管闭锁伴气管食管瘘术后吞咽困难1例

A 5-month plus 2-week-old male infant underwent esophageal atresia(EA)with tracheoesophageal fistula(TEF)repair,dysphagia gradually aggravated after EA repair,the patient occurred frequent choke and cough,vomiting aroused in the case of eating a little faster,anorexia and impatience were manifested.Based on the history of preterm birth,clinical symptoms and signs,chest CT,and barium swallow radiography of digestive tract,the patient was clearly diagnosed with EA/TEF(IIIA).Dysphagia soon followed after thoracoscopic surgery,he was diagnosed as dysphagia.Acupuncture was applied at bilateral Fēngchí(风池GB20),Liánquán(廉泉CV23),Tiāntū(天突CV 22),Zhōngwǎn(中脘CV12)and bilateral Zúsānlí(足三里ST36).The needles were retained for 20 min per session,treatments were scheduled on Monday,Wednesday and Friday of each week,three times a week,the duration was 4 weeks.After acupuncture treatment,the patient basically had no choke,cough,anorexia and impatience.The total time of food intake was significantly shortened than before.Except for special food restrictions,the modified functional oral intake scale was evaluated as level 6.Acupuncture might be a beneficial option for the treatment of complications after EA repair.