Perioperative management of esophageal atresia/tracheo‐esophageal fistula: An analysis of data of 101 consecutive patients

Abstract

Background The perioperative management of esophageal atresia/tracheo‐esophageal fistula by open or thoracoscopic approach can be complicated by metabolic derangements. Little is known, however, about the severity of derangements of vital and metabolic parameters in the perioperative period. Aim The aim of this study is to describe the perioperative courses of vital and metabolic parameters in 101 consecutive neonates undergoing surgical repair of esophageal atresia type C. Method In a retrospective cohort study, we extracted all data from the electronic anesthetic and medical charts of patients who underwent esophageal atresia type C repair within 30 days of life (2007‐2017). We distinguished three types of surgery: primary open, primary thoracoscopic, and primary thoracoscopic surgery converted to open surgery. Descriptive analysis was applied. Results The charts of 117 patients were reviewed: data of 101 were included. The perioperative anesthetic management was not standardized; various methods and medications were used for anesthesia induction and maintenance. Intraoperative blood gas analysis data of 72 patients were available and showed derangements regardless of type of surgery. The median pH‐value decreased to 7.21 [IQR 7.14‐7.30] and a pH‐value below 7.20 was found in 29 patients; in four cases below 7.0, with the lowest value 6.83. The median PaCO2 reached an upper level of 7.5kPa [IQR 5.8‐9.2]; in 13 cases above 10.0kPa, with a peak value of 25.8kPa. These high PaCO2 levels fluctuated with lowest measured PaCO2 of median 5.6 [IQR 4.5‐6.6], with the lowest value 2.8kPa. The median PaO2 level reached an upper level of 16.9kPa [IQR 11.8‐25.7], in 22 cases above 20.0kPa, with a peak value of 50.0kPa. These high levels fluctuated with lowest measured PaO2 levels of median 8.3kPa [IQR 6.73‐10.5]; the lowest PaO2 value was 4.7 kPa. Conclusion Open and thoracoscopic correction of esophageal atresia were associated with periods of severe metabolic derangements. These events need to be taken into account for the evaluation of esophageal atresia (surgical) care and in evaluations of short‐ and long‐term outcomes.

Short and mid-term results of thoracoscopic surgery for esophageal atresia in low birth weight infants:A single-center clinical experience

“…Hypercapnia is one of the pathological conditions that are likely to occur in neonatal thoracoscopic surgery,especially in neonates with severe pneumonia before surgery or premature infants with pulmonary dysplasia [8,9].In 2017,James K and others pointed out that carbon dioxide insu ation during thoracoscopic surgery may cause hemodynamic changes,such as hypotension and tachycardia.In addition,the establishment of a thoracoscopic pneumothorax may result in decreased blood oxygen saturation [7,10].Finally,the absorption of CO2 by the pleura can lead to hypercapnia,the most serious consequence of which is metabolic acidosis.However,the proposed ventilation strategy for permissive hypercapnia solved this problem for clinicians.When using thoracoscopic surgery, choose a CO2 arti cial pneumothorax pressure of 4-6 mmHg,which has less impact on the vital signs of newborns, is not easy to cause lung collapse,and also ensures a certain amount of chest operation space.There was no signi cant difference in the use time of the ventilator between the thoracoscopy group and the thoracotomy group,which may be related to the use of ventilation strategies for permissive hypercapnia during the thoracoscopy group to reduce lung compression.At the same time,pay attention to pneumonia before operation, clarify whether there is tracheomalacia,pay attention to lung management during operation,and select the appropriate surgical position,which will help improve the anesthesia tolerance of children [11].While ensuring that the surgical eld of vision is not disturbed,the blood oxygen uctuation is maintained at about 90%.…”

Mitochondrial Oxygen Monitoring During Surgical Repair of Congenital Diaphragmatic Hernia or Esophageal Atresia: A Feasibility Study

“…CDH neonates are a challenge for clinicians to manage due this altered physiology. In EA neonates, the physiology is less affected by the congenital anomaly itself, but requires complex surgery with major intrathoracic manipulation which highly affects the neonatal physiology ( 31 ). In these children, our preliminary results suggest that monitoring mitochondrial oxygenation might register changes in neonatal physiology which could not have been observed using standard monitoring devices.…”

Primary repair of esophageal atresia is followed by multiple diagnostic and surgical procedures.

“…These 18 infants underwent in total 151 procedures besides primary EA repair (151 out of 542). The median number of procedures was 6 [4][5][6][7][8][9][10][11][12][13][14] , which is significantly higher than that in infants without VACTERL (p = 0.031). Fourteen of the 18 infants underwent procedures in the first year of life besides primary EA repair, a median number of 4 [2-9] .…”