Anatomic Thoracoscopic Repair of Esophageal Atresia

Abstract

BackgroundThe thoracoscopic approach to repair esophageal atresia (EA) with tracheoesophageal fistula (TEF) provides excellent view, allowing the most skillful surgeons to spare the azygos vein by performing the esophageal anastomosis over (on the right side) the azygos vein. Seeking the most anatomic repair, we started to perform the esophageal anastomosis underneath (on the left side) the azygos vein: anatomic thoracoscopic repair of esophageal atresia (ATREA). We aim to compare results of ATREA with the classic thoracoscopic repair.MethodsDuring the last 4 years, in our center, all infants with EA with distal TEF were operated by thoracoscopy sparing the azygos vein. According to the surgical technique, two groups were created: Group A—treated with ATREA and Group B—treated with classic thoracoscopic repair over (on the right side) the azygos vein. We retrospectively collected data regarding features of the newborn (gestational age, gender, karyotype changes, associated anomalies, birth weight), surgery (operative technique, operative time, and surgical complications), hospitalization (duration of mechanical ventilation, thoracic drainage, time for the first feeding, time of admission, and early complications) and follow-up [tracheomalacia, gastroesophageal reflux disease (GERD), anastomotic stricture, recurrence of fistula].ResultsGroup A had seven newborns and Group B had four newborns. There were no statistically significant differences between both groups concerning the evaluated variables on surgery, hospitalization, and follow-up. Nevertheless, in Group A, there was an infant with a right aortic arch where ATREA was particularly useful as it avoided that the azygos vein and the aortic arch were left compressed in between the esophagus and trachea. Postoperatively, one patient of Group B had a major anastomotic leak with empyema requiring surgical re-intervention. During follow-up, anastomotic stricture requiring esophageal dilation occurred with similar rates in both groups. In Group B, one patient had severe and symptomatic tracheomalacia requiring aortopexy and severe GERD requiring fundoplication. No patients developed recurrent fistula.ConclusionThe ATREA is feasible in the great majority of patients with EA with TEF without compromising long-term results and might be particularly useful for those infants with malformations of the cardiac venous return vessels and/or major aortic malformations.

Comparison of ligation versus preservation of azygous vein in primary repair of esophageal atresia with tracheoesophageal fistula in neonates.

“…In the light of results of the present study, it can be advocated that in future practice azygous vein should be saved during primary repair of EA so as to minimize the risk of post-operative anastomotic leak with its associated morbidity and mortality. [16][17][18] Limitations of the Study: The results of the present study are reliable due to strict exclusion criteria and stratification of effect modifiers. However, there is a limitation to the present study and that is its limited sample size of 180 patients which produced insignificant difference upon stratification of results.…”

The trachea, a missed organ in esophageal atresia complex: Evolution of a thoracoscopic approach

“…It is believed that higher rate of rTEFs might be attributed to the operative technique used especially when the anastomotic lines of esophagus and trachea are opposing, as in most of our rTEF patients, who had anastomoses done without intervening tissue aps. Therefore, anastomosis on the left side of the azygos might be regarded as a risk factor, thus tissue ap as azygos vein is usually preferred by many surgeons [12][13][14]. Moreover, missed anastomotic leak may have developed and healed before being clinically and radiologically detected.…”

The Dysfunctional Immune System in Common Variable Immunodeficiency Increases the Susceptibility to Gastric Cancer

“…A recent study demonstrated that gastric cancer risk is not significantly increased in patients with IgA deficiency [ 15 ]. Isolated case reports of gastric cancer have been reported in young patients with X-linked hypogammaglobulinaemia [ 41 , 42 , 43 , 44 ], but the increase of gastric cancer risk in this population has not been demonstrated yet. Abnormalities in the innate immune system and T cells, rather than immunoglobulin deficiencies, could be relevant for gastric cancer pathogenesis in CVID patients.…”