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Delayed primary anastomosis for esophageal atresia: 18 months' to 11 years' follow-up
1Children's Research Centre, Our Lady's Hospital for Sick Children, Dublin, Ireland.
Insights
Delayed primary anastomosis is a feasible treatment for isolated esophageal atresia in infants, preserving the patient's own esophagus. Aggressive management of gastroesophageal reflux is recommended for improved outcomes.
Area of Science:
- Pediatric Surgery
- Gastroenterology
- Neonatology
Background:
- Isolated esophageal atresia (EA) presents significant surgical challenges.
- Early management strategies for EA have evolved over time.
- Delayed primary anastomosis (DPA) offers a potential alternative to immediate repair.
Purpose of the Study:
- To evaluate the feasibility and outcomes of delayed primary anastomosis for isolated esophageal atresia.
- To assess the long-term results of DPA in a consecutive series of infants.
- To identify complications and recommend management strategies for EA.
Main Methods:
- Retrospective review of 11 consecutive infants with isolated EA managed with initial gastrostomy and DPA.
- Assessment of esophageal gap, age at anastomosis, and postoperative complications.
- Long-term follow-up including clinical evaluation, barium swallow, and growth parameters.
Main Results:
- DPA was performed at a mean age of 13 weeks (range, 6-20 weeks) with a mean esophageal gap of 3.2 cm.
- Anastomotic leaks occurred in 3/11 infants, managed conservatively.
- Anastomotic strictures developed in 8/11 patients, with 7 requiring dilatations and 1 needing resection.
- At follow-up (18 months to 11 years), 7/10 survivors ate normally; 3 had swallowing difficulties due to strictures, reflux, or hiatus hernia.
Conclusions:
- Delayed primary anastomosis is a viable surgical approach for isolated esophageal atresia.
- While DPA can preserve the native esophagus, anastomotic strictures and reflux are significant long-term concerns.
- A proactive approach to managing gastroesophageal reflux is crucial for optimizing outcomes in these patients.
Abstract:
In 1977 we started treating babies with isolated esophageal atresia by delayed primary anastomosis and in 1981 reported our early experience in five cases treated between 1977 and 1979. Since 1979, 11 further consecutive cases have been managed by initial gastrostomy followed by delayed primary esophageal anastomosis. Their mean gestation was 35 weeks (range, 28 to 40 weeks) and mean birth weight was 2,040 g (range, 1,140 to 2,720 g). The esophageal gap between the two ends when assessed initially at fluoroscopy ranged from 2.2 to 4.5 cm (mean, 3.2 cm). Age at delayed primary anastomosis ranged from 6 to 20 weeks. Anastomotic leak occurred in three babies in the immediate postoperative period and all were successfully managed conservatively. Eight of the 11 patients developed anastomotic strictures; seven cases required 1 to 5 esophageal dilatations. One patient who did not respond to multiple esophageal dilatations required resection of an esophageal stricture. One patient died at 15 months of age of unrelated causes. The 10 surviving patients have been followed-up from 18 months to 11 years. At follow-up, seven patients were eating normally. Three patients had swallowing difficulties and all three were found to have esophageal strictures on barium swallow, two of them also had gross esophageal reflux and hiatus hernia. The height and weight in the 10 patients varied from 3rd centile to 75th centile. Delayed primary anastomosis is feasible in cases of isolated esophageal atresia and the patient's own esophagus is the best. A more aggressive approach should be applied to gastroesophageal reflux in these patients.