Esophageal and Airway Treatment Center | Esophageal atresia: Surgical aspects

Kamran A, Smithers CJ, Izadi SN, Staffa SJ, Zurakowski D, Demehri FR, Mohammed S, Shieh HF, Ngo PD, Yasuda J, Manfredi MA, Hamilton TE, Jennings RW, Zendejas B. Surgical Treatment of Esophageal Anastomotic Stricture After Repair of Esophageal Atresia. J Pediatr Surg. 2023 Dec;58(12):2375-2383. doi: 10.1016/j.jpedsurg.2023.07.014. Epub 2023 Jul 29. PMID: 37598047.

Surgery for refractory esophageal anastomotic stricture after EA repair is associated with inherent yet low morbidity and high rates of esophageal preservation. Surgical repair of non-refractory symptomatic AS at the time of another thoracic operation is associated with excellent outcomes.

Shieh HF, Hamilton TE, Manfredi MA, Ngo PD, Wilsey MJ, Yasuda JL, Zendejas B, Smithers CJ. Evolution of left-sided thoracoscopic approach for long gap esophageal atresia repair. J Pediatr Surg. 2023 Apr;58(4):629-632. doi: 10.1016/j.jpedsurg.2022.12.020. Epub 2022 Dec 22. PMID: 36707264.

This study reports on the evolution of our minimally invasive approach for children with long-gap esophageal atresia (LGEA). We highlight why lately we have preferentially chosen the left chest approach (as opposed to the more common right chest approach) as we believe it leads to less tracheomalacia and/or airway compression issues. This manuscript also highlights how there is not a one size fits all for LGEA but rather multiple potential pathways depending on the needs of each individual patient. 

Meisner JW, Kamran A, Staffa SJ, Mohammed S, Yasuda JL, Ngo P, Manfredi M, Zurakowski D, Jennings RW, Hamilton TE, Zendejas B. Qualitative features of esophageal fluorescence angiography and anastomotic outcomes in children. J Pediatr Surg. 2022 Jul 13:S0022-3468(22)00455-9. doi: 10.1016/j.jpedsurg.2022.07.007. Epub ahead of print. PMID: 35934523.

Blood supply (perfusion) is essential for an anastomosis to heal. Indocyanine green (ICG) is a substance that is commonly used to assess perfusion via fluorescence capture, but quality defining features are lacking. We established qualitative features of esophageal ICG perfusion assessments and developed an esophageal anastomotic scorecard to risk-stratify anastomotic outcomes. Our scoring system comprised of qualitative ICG perfusion features, tissue quality, and anastomotic tension can help risk-stratify esophageal anastomotic outcomes accurately.

Shieh HF, Jennings RW, Manfredi MA, Ngo PD, Zendejas B, Hamilton TE. Cautionary tales in the use of magnets for the treatment of long gap esophageal atresia. J Pediatr Surg. 2022 Oct;57(10):342-347. doi: 10.1016/j.jpedsurg.2021.11.002. Epub 2021 Nov 14. PMID: 34876292.

The use of magnets for the treatment of long gap esophageal atresia, or “magnamosis,” is associated with increased incidence of anastomotic strictures; however, little has been reported on other complications that may provide insight into refining selection criteria for appropriate use. We analyze three cases referred to us for treatment after attempted magnamosis with significant complications.

Foust AM, Zendejas B, Mohammed S, Meisner J, Zurakowski D, Staffa SJ, Jennings RW, Hamilton TE, Callahan MJ. Radiographic assessment of traction-induced esophageal growth and traction-related complications of the Foker process for treatment of long-gap esophageal atresia. Pediatr Radiol. 2022 Mar;52(3):468-476. doi: 10.1007/s00247-021-05228-z. Epub 2021 Nov 30. PMID: 34845501.

We demonstrate how chest radiography can estimate esophageal position and growth while on traction and is very useful in diagnosing certain traction system complications. Median daily radiographic esophageal growth rate for both segments was 2.2 mm. An increase of >12% between two sequential chest radiographs or >30% increase over the traction period in leading- to trailing-clip distance was found to be associated with traction system complications.

Thompson K, Zendejas B, Kamran A, Svetanoff WJ, Meisner J, Zurakowski D, Staffa SJ, Ngo P, Manfredi M, Yasuda JL, Jennings RW, Smithers CJ, Hamilton TE. Predictors of anti-reflux procedure failure in complex esophageal atresia patients. J Pediatr Surg. 2022 Jul;57(7):1321-1330. doi: 10.1016/j.jpedsurg.2021.08.005. Epub 2021 Aug 14. PMID: 34509283.

Anti-reflux procedures (ARP) in esophageal atresia (EA) patients can be challenging and prone to failure. These challenges become more evident with increasing complexity of EA. We sought to determine predictors of ARP failure in complex EA patients. We found that ARP fail in nearly one third of cases, though only half of failures require a reoperation. A Nissen fundoplication performed via laparotomy provided the lowest risk of ARP failure. Mesh reinforcement appears to decrease the risk of failure in half. 

Svetanoff WJ, Zendejas B, Hernandez K, Davidson K, Ngo P, Manfredi M, Hamilton TE, Jennings R, Smithers CJ. Contemporary outcomes of the Foker process and evolution of treatment algorithms for long-gap esophageal atresia. J Pediatr Surg. 2021 Dec;56(12):2180-2191. doi: 10.1016/j.jpedsurg.2021.02.054. Epub 2021 Feb 26. PMID: 33766420.

102 contemporary long-gap esophageal atresia patients treated from 2014–2020 were compared to 41 historical controls (2005 to <2014). With continued experience and technical refinements, the Foker process has evolved withim proved outcomes, less morbidity and maximal esophageal preservation.

Kamran A, Zendejas B, Meisner J, Choi SS, Munoz-San Julian C, Ngo P, Manfredi M, Yasuda JL, Smithers CJ, Hamilton TE, Jennings RW. Effect of Posterior Tracheopexy on Risk of Recurrence in Children after Recurrent Tracheo-Esophageal Fistula Repair. J Am Coll Surg. 2021 May;232(5):690-698. doi: 10.1016/j.jamcollsurg.2021.01.011. Epub 2021 Feb 5. PMID: 33556502.

In this study we evaluated the use of a posterior tracheopexy to effectively separate the suture lines of the trachea and esophageal repairs, which showed that in 62 patients there were zero recurrences.

Jo Svetanoff W, Zendejas B, Ngo P, Manfredi M, Hamilton TE, Jennings RW, Smithers CJ. The left-sided repair: An alternative approach for difficult esophageal atresia repair. J Pediatr Surg. 2021 May;56(5):938-943. doi: 10.1016/j.jpedsurg.2020.11.003. Epub 2020 Nov 13. PMID: 33248682.

Most esophageal atresia repairs are performed via the right chest. However, we describe several scenarios that may benefit from a left-sided repair, particularly for LGEA patients with a large leftward upper pouch or as a salvage pathway after a failed right chest approach, with similar outcomes to the right-sided approach.

Kamran A, Smithers CJ, Manfredi MA, Hamilton TE, Ngo PD, Zurakowski D, Jennings RW. Slide Esophagoplasty vs End-to-End Anastomosis for Recalcitrant Esophageal Stricture after Esophageal Atresia Repair. J Am Coll Surg. 2018 Jun;226(6):1045-1050. doi: 10.1016/j.jamcollsurg.2017.11.020. Epub 2017 Dec 7. PMID: 29224798.

 Comparison between two different types of esophageal anastomosis. Whenever feasible, a slide-type anastomosis offers an offset suture line which appears less likely to stricture. 

 Smithers CJ, Hamilton TE, Manfredi MA, Rhein L, Ngo P, Gallagher D, Foker JE, Jennings RW. Categorization and repair of recurrent and acquired tracheoesophageal fistulae occurring after esophageal atresia repair. J Pediatr Surg. 2017 Mar;52(3):424-430. doi: 10.1016/j.jpedsurg.2016.08.012. Epub 2016 Aug 31. PMID: 27616617.

Historically, most tracheo-esophageal fistulas (TEFs) have been lumped together. This study describes the different types of TEFs, proposes a classification system according to the underlying etiology of the TEF and proposes unique treatment strategies for each type of TEF.