Anastomotic
Leakage Following
Surgery for Esophageal
Atresia
By Sootiporn Chittmittrapap, Lewis Spitz, E.M. Kiely, and R.J. Brereton London, England 0 Of 199 neonates undergoing primary or delayed primary repair of esophageal atresia, 34 (17%) developed anastomotic leakage, 7 of which (3.5%) were major anastomotic disruptions. Infants with major leaks developed signs within 5 days and all required early reoperation, necessitating abandonment of the esophagus in 6. The remaining 27 were minor leaks demonstrated by water-soluble contrast studies and were successfully treated nonoperatively. Gastroesophageal reflux was unassociated with this complication but the use of braided silk sutures was associated with a significantly increased risk of anastomotic leakage when compared with polyglycolic acid (relative risk, 3.2) or polypropylene (relative risk, 2.6) sutures. Following anastomotic leakage there was a significantly increased risk (relative risk, 2.04) of subsequent esophageal stricture formation. Copyright c?1992 by W.B. Saunders Company INDEX WORDS: Esophageal atresia, esophageal tracheoesophageal fistula, anastomotic leakage.
leakage;
A
DVANCES IN neonatal surgery have contributed to improved survival rates of infants born with esophageal atresia (EA).‘32 Anastomotic leakage remains one of the most important causes of postoperative morbidity and mortality, and many factors have been implicated in its etiology.“4 These include the use of silk suture materials,” tension at the anastomotic site,” end-to-end anastomosis,8 and interference with the blood supply of the anastomosis from overvigorous dissection of the distal esophagus.’ This report presents an analysis of various risk factors contributing to anastomotic leakage derived from a review of the experience with EA during a recent period of 8 years at The Hospital for Sick Children, Great Ormond Street. MATERIALS AND METHODS Between January 1980 and December 1987, 253 neonates with EA were referred for surgical management. No operation was performed in 8 infants with multiple anomalies, 8 underwent gastrostomy alone and died, 38 underwent esophagostomy and gastrostomy for staged repair, 194 underwent primary repair, and 5 undetwent delayed primary repair. The records of the latter group of 199 infants were reviewed. All anastomotic complications including leakage, stricture formation, and recurrence of the tracheoesophageal fistula (TEF) were recorded and analyzed with respect to operative technique, outcome, and possible etiological risk factors. Details of anastomotic leakage are presented here, whereas details concerning stricture and recurrent fistula formation are the subjects of separate reports.“‘.” The xZ test was used for statistical analysis of the data. The standard approach to EA was directed toward primary repair in all patients whenever possible. A single layer, end-to-end anastomosis via an extrapleural approach was the most commonly used procedure in both primary and delayed primary repairs. A Journaloff’ediatric Surgery, Vol27, No
1
(January),
1992: pp 29-32
soft silastic transanastomotic tube was used in cases in which a gastrostomy was not performed. A small tube drain was left in the extrapleural space and connected to an underwater drainage system in the majority of cases. All operations were performed using endotracheal anesthesia and patients were extubated immediately postoperatively unless they had respiratory distress, associated cardiac anomalies, or marked tension at the anastomotic site. It has been our recent practice to electively ventilate for 5 days infants in whom marked tension was judged to be present at the anastomotic site at the time of esophageal repair.” This is reputed to prevent excessive movement that otherwise increases anastomotic tension, predisposing to disruption or leakage. For the first 5 to 10 days infants were fed by gastrostomy or transanastomotic tube. The volume and character of any material draining from the chest were regularly checked. A chest x-ray was performed in all infants with unexplained respiratory difficulties. Large amounts of mucus from the drain or the presence of a pneumothoraxihydrothorax on the chest film suggested significant anastomotic leakage. In the absence of clinical signs of anastomotic leakage, water-soluble contrast esophagograms were performed between the 5th and 7th postoperative days. If there was no demonstrable leak, oral feeding was commenced. The term “minor leakage” was used to indicate a small amount of extrapleural drainage and/or a small radiological leak. Affected infants were fed via the transanastomotic or gastrostomy tube and oral feeds were withheld until the esophagus had healed. A few infants with gross gastroesophageal reflux received parenteral nutrition. “Major leakage” referred to a large amount of drainage or a leak that caused respiratory symptoms associated with a large defect in the anastomosis. Major leaks tended to occur within a few days of operation and were generally diagnosed clinically rather than radiologically. Patients experiencing difficulties in swallowing (dysphagia, vomiting, or slow feeding), recurrent episodes of respiratory infections, or food bolus obstruction with a radiologically detected stricture that required dilatation were included in the “stricture” group. Patients admitted to hospital with the above symptoms, predominantly those with foreign body or food bolus obstruction, but who were shown at endoscopy to have a normal esophageal lumen were classified as being “undecided” with regard to stricture formation for the purposes of this paper. Gastroesophageal reflux was deemed to be present when detected on barium swallow and tracheomalacia was diagnosed at bronchoscopy under general anesthesia with spontaneous respiration.
RESULTS
Of the 199 patients, 34 (17%) had anastomotic leaks. All patients had type C anomalies’3 with a blind upper esophageal pouch and distal TEF and all had
From The Hospital for Sick Children, London. England. Date accepted: August 27. 1990. Address reprint requests to R.J. Brereton. MD. Institute of Child Health, 30 G&ford St, London WC1 N 1EH, England. Copyright o 1992 by W.B. Saunders Company 0022-346819212701-0003.00l0 29
30
CHlTTMllTRAPAP
undergone primary repair. Major leakage occurred in 7 (3.5%) patients, six of whom had total anastomotic dehiscence resulting in large amounts of saliva discharging through the chest drain. All of the infants in this group presented with respiratory distress within 5 days of operation and six underwent emergency cervical esophagostomy necessitating subsequent esophageal substitution either by gastric (5 cases) or colon interposition (1 case). At rethoracotomy, the 7th neonate was found to have a large defect in the anastomosis, which was successfully resutured. Minor leaks, diagnosed radiologically but unassociated with respiratory symptoms, developed in 27 infants, all of whom were successfully treated nonoperatively. Elective postoperative ventilation was undertaken in 26 patients, 2 of whom developed a minor leak and none had a major anastomotic disruption, whereas in the 173 not so treated 25 developed minor leaks and 7 had anastomotic disruption (P > .05, not a significant difference). The relationship between the suture material used for the anastomosis and the subsequent development of leakage is shown in Table 1. The proportion of patients with anastomotic leakage in whom silk sutures were used was significantly higher than the proportion in whom polyglycolic acid (P < .Ol) or polypropylene sutures (P < .05) were used. The relative risks of an anastomotic leak following the use of silk sutures were 3.2 compared with polyglycolic acid sutures and 2.6 compared with polypropylene sutures. There was no statistically significant difference between polyglycolic acid and polypropylene sutures. Polybutylated polyester sutures, now abandoned in favor of the latter materials, were used in 12 patients, 5 of whom suffered leakage, but the small number involved precludes worthwhile statistical analysis. Radiologically demonstrated gastroesphageal reflux was not associated with an increased rate of anastomotic leakage: 11 (17.5%) of 63 patients with Table 1. The Association Between the Suture Materiel Used for the Anastomosis and the Subsequent Development Anastomotic
of
Leakage
No. of Anastomoses
Suture Material
With Each
No. of
% of
suture
Leaking
Leaking
Material
Anastomoses
Anastomoses
Silk
30
10 (2)
33.3
Polyglycolic acid
76
6 (2)
10.3
Polypropylene
77
10 (2)
12.9
Polybutylated polyester
12
5 (1)
41.7
No data on suture material Total NOTE. The numbers
2 199
in parentheses
1 34 (7)
17.1 (3.5)
indicate those patients with
major leakage or total dehiscence ofthe anastomosis.
ET AL
Table 2. Anastomotic Leakage Related to Subsequent Stricture Formation “Undecided” Total
Leakage No leakage
Stricture
Stricture’
No Stricture”
34
6t
20 (71%)
8 (29%)
165
16
54 (36%)
95 (64%)
*P < .Ol. tSix
patients with disruption had the esophagus abandoned
and
subsequently underwent esophageal replacement.
gastroesophageal reflux had anastomotic leakage compared with 21 (17.2%) of 122 patients without reflux. The gastroesophageal junction was not adequately examined in 14 patients, 2 of whom had anastomotic leakage. Leakage occurred in 6 (14.6%) of 41 patients with tracheomalacia and in 27 (18.5%) of 146 without tracheomalacia (no statistically significant difference). Bronchoscopy was not performed in 12 patients, 1 of whom had anastomotic leakage. The risk of anastomotic stricture formation was significantly increased following anastomotic leakage (Table 2). Anastomotic leakage, including total disruption, did not directly result in the death of any of the affected infants, but 5 subsequently died of other causes. One infant died of complex cardiac anomalies associated with chromosomal abnormalities and another died of intraventricular hemorrhage. However, 3 infants died of the effects of recurrent TEF, which may have been produced by factors related to those causing anastomotic leakage. DISCUSSION
In this series of 253 neonates with EA there was an overall survival rate of 86%, increasing to 89% when infants with associated anomalies incompatible with life were excluded. In the 199 with an esophageal anastomosis, anastomotic complications were important causes of postoperative morbidity but none of the affected infants died directly from the effects of anastomotic leakage.‘~5 Depending on the criteria used for the definition and detection of leakage, the incidence varies widely from 4% to 36%.7-‘*‘4-‘6 Some studies have reported only “documented major” leaks that needed surgical intervention and did not include “controlled” or “localized” leaks demonstrated radiologically. Overall, the leak rate was 17%, with 3.5% of patients developing a major anastomotic disruption and there was some evidence that disruption could be prevented by elective artificial ventilation for 5 days.12 Many risk factors have been implicated in the pathogenesis of anastomotic leakage3-9 but statistical analysis of these various factors has been problematic because of the relatively small number of patients accumtilated during a short period in any one center. This study of a large number of cases collected over
ANASTOMOTIC
LEAKAGE AFTER EA REPAIR
31
an 8-year period enabled an analysis of several risk factors, but we accept that the statistical analyses must be treated with caution because patients were treated by several surgeons according to their personal preferences and were not randomized to various treatment groups in a matched, controlled, prospective study. From this review, the type of suture material used to construct the anastomosis was considered to play an important role in the development of leakage. Braided silk was associated with an increased incidence of leakage when compared with polyglycolic acid or polypropylene sutures. Sillen et alI6 reported a leak rate of 26% following repair of “no-gap” or “moderate-gap” EA using 5/O silk and a 100% leak rate in “long-gap” lesions; their overall leakage rate of 36% resembled our rate of 33% when silk was used for the repair. Gastroesophageal reflux has been reported to play an important role in the etiology of anastomotic stricture~.10.14.17 but was not an identifiable risk factor for anastomotic leakage in this series. Tracheomalacia did not predispose to anastomotic leakage. Other factors (eg, one-layer rather than two-layer anastomosis, end-to-end as opposed to end-to-side anastomosis, repair performed through a transpleural rather than an extrapleural approach, or repairs involving circular myotomy) have been related to the incidence of anastomotic leakage, but we were unable to evaluate these variables because the relevant operative techniques were rarely used in this center. An important risk factor is “tension” at the anastomotic site.18 We attempted to examine the influence of this factor but it proved impossible as we had no means of objectively measuring tension in the neonatal esophagus. A long-gap has been defined as a distance between the esophageal segments of more than 2 cm,“.lhirrespective of the size of the infant, and marked tension has been assumed to be present at the anastomosis performed in this situation. The leak rate in this group of infants has been reported to be 100%.h.‘hHowever, we would contend that the absolute length of the gap is an unreliable guide to tension
and in a series of infants varying in weight and size from less than 1 kg to over 3.5 kg, even when the gap between the two ends of the esophagus was more than 2 cm, sometimes we were able to fashion an anastomosis with little apparent tension after meticulous dissection and mobilization of both esophageal ends. Postoperative clinical assessment of the patients generally enabled the diagnosis of major anastomotic disruption to be made without difficulty. Symptoms and signs of respiratory distress usually developed during the second to fourth day after operation associated with large amounts of saliva or mucus exuding from the chest drain. Because severe respiratory distress developed in all patients with major disruption, all required urgent surgical intervention,‘4.‘yeither by rethoracotomy and repair or, more frequently, by proximal diversion with cervical esophagostomy and feeding gastrostomy, effectively abandoning the esophagus and necessitating its substitution either with whole stomach, gastric tube, jejunum, or colon. In this center, orthotopic gastric interposition was the most commonly used procedure during the last decade.2”.” Babies with minor leaks often appeared clinically well and the leak was undetected before routine esophagography on the 5th to 10th postoperative day.‘,15As a rule these patients could be successfully managed nonoperatively, with eventual spontaneous healing,lh although a few presented after the third day with tension pneumothorax requiring urgent drainage. The outcome of treatment of affected infants has been enhanced by early diagnosis and appropriate management, including the use of effective antibiotics, transanastomotic feeding, parenteral nutrition, and improved surgical techniques. Although minor leaks may be managed nonoperatively, early major leaks in small babies must be treated by urgent reoperation. ACKNOWLEDGMENT Dr Chittmittrapap wishes to thank Mr M.D. Stringer assistance in preparing this manuscript.
for his kind
REFERENCES 1. Brereton RJ, Zachary RB, Spitz L: Preventable death in oesphageal atresia. Arch Dis Child 53:276-283,1978 2. Spitz L, Kiely E, Brereton RJ: Esophageal atresia: Five year experience with 148 cases. J Pediatr Surg 22:103-108,1987 3. Randolph JG: Esophageal atresia and congenital stenosis, in Welch KJ, Randolph JG, Ravitch MM, et al (eds): Pediatric Surgery (ed 4). Chicago, IL, Year Book, 1986, pp 682-697 4. Cudmore RE: Oesophageal atresia and trachea-oesophageal fistula, in Rickham PP, Lister J, Irving IM (eds): Neonatal Surgery (ed 2). London, England, Buttenvorths, 1978, pp 189-208 5. Holder TM, Cloud DT, Lewis JE Jr, et al: Esophageal atresia
and tracheoesophageal fistula. A survey of its members by the Surgical Section of the American Academy of Pediatrics. Pediatrics 34:542-549,1964 6. Hagberg S, Rubenson A, Sillen U, et al: Management of long-gap esophagus: Experience with end-to-end anastomosis under maximal tension. Prog Pediatr Surg 19:88-92, 1986 7. O’Neill JA, Holcomb GW, Neblett WW: Recent experience with esophageal atresia. Ann Surg 195:739-745, 1982 8. Touloukian RJ: Long-term results following repair of esophageal atresia by end-to-side anastomosis and ligation of the tracheoesophageal fistula. J Pediatr Surg 16:983-988, 1981
32
CHlTTMllTRAPAP
9. Louhimo I, Lindahl H: Esophageal atresia: Primary results of 500 consecutively treated patients. J Pediatr Surg 18:217-229,1983 10. Chittmittrapap S, Spitz L, Kiely EM, et al: Anastomotic stricture following repair of esophageal atresia. J Pediatr Surg 25:508-511, 1990 11. Ghandour K, Spitz L, Brereton RJ, et al: Recurrent tracheoesophageal fistula: Experience with 24 patients. J Pediatr Child Health 26:89-91, 1990 12. MacKinley GA, Burtles R: Oesophageal atresia, paralysis and ventilation in management of wide gap. Pediatr Surg Int 210-12, 1987 13. Gross RE: Atresia of the esophagus, in The Surgery of Infancy and Childhood. Philadelphia, PA, Saunders, 1953,pp 75-102 14. Holder TM, Ashcraft KW: Developments in the care of patients with esophageal atresia and tracheoesophageal fistula. Surg Clin North Am 61:1051-1061,198l 15. Lundertse-Verloop
K, Tibboel D, Hazebrock FWJ, et al:
ET AL
Postoperative morbidity in patients with esophageal atresia. Pediatr Surg Int 2:2-5,1987 16. Sillen U, Hagberg S, Rubenson A, et al: Management of esophageal atresia: Review of 16 years’ experience. J Pediatr Surg 23:805-809,1988 17. Pieretti R, Shandling B, Stephens CA: Resistant esophageal stenosis associated with reflux after repair of esophageal atresia. A therapeutic approach. J Pediatr Surg 9:355-357, 1974 18. Howell CG, Davis JB Jr, Parrish RA: Primary repair of esophageal atresia. How long a gap? J Pediatr Surg 22:42-43, 1987 19. Martin LW, Alexander F: Esophageal atresia. Surg Clin North Am 65:1099-1113,1985 20. Spitz L: Gastric transposition via the mediastinal route for infants with long-gap esophageal atresia. J Pediatr Surg 19:149154,1984 21. Valente A, Brereton RJ, MacKersie A: Esophageal replacement with whole stomach in infants and children. J Pediatr Surg 22:913-917, 1987
Leakage Following
Surgery for Esophageal
Atresia
By Sootiporn Chittmittrapap, Lewis Spitz, E.M. Kiely, and R.J. Brereton London, England 0 Of 199 neonates undergoing primary or delayed primary repair of esophageal atresia, 34 (17%) developed anastomotic leakage, 7 of which (3.5%) were major anastomotic disruptions. Infants with major leaks developed signs within 5 days and all required early reoperation, necessitating abandonment of the esophagus in 6. The remaining 27 were minor leaks demonstrated by water-soluble contrast studies and were successfully treated nonoperatively. Gastroesophageal reflux was unassociated with this complication but the use of braided silk sutures was associated with a significantly increased risk of anastomotic leakage when compared with polyglycolic acid (relative risk, 3.2) or polypropylene (relative risk, 2.6) sutures. Following anastomotic leakage there was a significantly increased risk (relative risk, 2.04) of subsequent esophageal stricture formation. Copyright c?1992 by W.B. Saunders Company INDEX WORDS: Esophageal atresia, esophageal tracheoesophageal fistula, anastomotic leakage.
leakage;
A
DVANCES IN neonatal surgery have contributed to improved survival rates of infants born with esophageal atresia (EA).‘32 Anastomotic leakage remains one of the most important causes of postoperative morbidity and mortality, and many factors have been implicated in its etiology.“4 These include the use of silk suture materials,” tension at the anastomotic site,” end-to-end anastomosis,8 and interference with the blood supply of the anastomosis from overvigorous dissection of the distal esophagus.’ This report presents an analysis of various risk factors contributing to anastomotic leakage derived from a review of the experience with EA during a recent period of 8 years at The Hospital for Sick Children, Great Ormond Street. MATERIALS AND METHODS Between January 1980 and December 1987, 253 neonates with EA were referred for surgical management. No operation was performed in 8 infants with multiple anomalies, 8 underwent gastrostomy alone and died, 38 underwent esophagostomy and gastrostomy for staged repair, 194 underwent primary repair, and 5 undetwent delayed primary repair. The records of the latter group of 199 infants were reviewed. All anastomotic complications including leakage, stricture formation, and recurrence of the tracheoesophageal fistula (TEF) were recorded and analyzed with respect to operative technique, outcome, and possible etiological risk factors. Details of anastomotic leakage are presented here, whereas details concerning stricture and recurrent fistula formation are the subjects of separate reports.“‘.” The xZ test was used for statistical analysis of the data. The standard approach to EA was directed toward primary repair in all patients whenever possible. A single layer, end-to-end anastomosis via an extrapleural approach was the most commonly used procedure in both primary and delayed primary repairs. A Journaloff’ediatric Surgery, Vol27, No
1
(January),
1992: pp 29-32
soft silastic transanastomotic tube was used in cases in which a gastrostomy was not performed. A small tube drain was left in the extrapleural space and connected to an underwater drainage system in the majority of cases. All operations were performed using endotracheal anesthesia and patients were extubated immediately postoperatively unless they had respiratory distress, associated cardiac anomalies, or marked tension at the anastomotic site. It has been our recent practice to electively ventilate for 5 days infants in whom marked tension was judged to be present at the anastomotic site at the time of esophageal repair.” This is reputed to prevent excessive movement that otherwise increases anastomotic tension, predisposing to disruption or leakage. For the first 5 to 10 days infants were fed by gastrostomy or transanastomotic tube. The volume and character of any material draining from the chest were regularly checked. A chest x-ray was performed in all infants with unexplained respiratory difficulties. Large amounts of mucus from the drain or the presence of a pneumothoraxihydrothorax on the chest film suggested significant anastomotic leakage. In the absence of clinical signs of anastomotic leakage, water-soluble contrast esophagograms were performed between the 5th and 7th postoperative days. If there was no demonstrable leak, oral feeding was commenced. The term “minor leakage” was used to indicate a small amount of extrapleural drainage and/or a small radiological leak. Affected infants were fed via the transanastomotic or gastrostomy tube and oral feeds were withheld until the esophagus had healed. A few infants with gross gastroesophageal reflux received parenteral nutrition. “Major leakage” referred to a large amount of drainage or a leak that caused respiratory symptoms associated with a large defect in the anastomosis. Major leaks tended to occur within a few days of operation and were generally diagnosed clinically rather than radiologically. Patients experiencing difficulties in swallowing (dysphagia, vomiting, or slow feeding), recurrent episodes of respiratory infections, or food bolus obstruction with a radiologically detected stricture that required dilatation were included in the “stricture” group. Patients admitted to hospital with the above symptoms, predominantly those with foreign body or food bolus obstruction, but who were shown at endoscopy to have a normal esophageal lumen were classified as being “undecided” with regard to stricture formation for the purposes of this paper. Gastroesophageal reflux was deemed to be present when detected on barium swallow and tracheomalacia was diagnosed at bronchoscopy under general anesthesia with spontaneous respiration.
RESULTS
Of the 199 patients, 34 (17%) had anastomotic leaks. All patients had type C anomalies’3 with a blind upper esophageal pouch and distal TEF and all had
From The Hospital for Sick Children, London. England. Date accepted: August 27. 1990. Address reprint requests to R.J. Brereton. MD. Institute of Child Health, 30 G&ford St, London WC1 N 1EH, England. Copyright o 1992 by W.B. Saunders Company 0022-346819212701-0003.00l0 29
30
CHlTTMllTRAPAP
undergone primary repair. Major leakage occurred in 7 (3.5%) patients, six of whom had total anastomotic dehiscence resulting in large amounts of saliva discharging through the chest drain. All of the infants in this group presented with respiratory distress within 5 days of operation and six underwent emergency cervical esophagostomy necessitating subsequent esophageal substitution either by gastric (5 cases) or colon interposition (1 case). At rethoracotomy, the 7th neonate was found to have a large defect in the anastomosis, which was successfully resutured. Minor leaks, diagnosed radiologically but unassociated with respiratory symptoms, developed in 27 infants, all of whom were successfully treated nonoperatively. Elective postoperative ventilation was undertaken in 26 patients, 2 of whom developed a minor leak and none had a major anastomotic disruption, whereas in the 173 not so treated 25 developed minor leaks and 7 had anastomotic disruption (P > .05, not a significant difference). The relationship between the suture material used for the anastomosis and the subsequent development of leakage is shown in Table 1. The proportion of patients with anastomotic leakage in whom silk sutures were used was significantly higher than the proportion in whom polyglycolic acid (P < .Ol) or polypropylene sutures (P < .05) were used. The relative risks of an anastomotic leak following the use of silk sutures were 3.2 compared with polyglycolic acid sutures and 2.6 compared with polypropylene sutures. There was no statistically significant difference between polyglycolic acid and polypropylene sutures. Polybutylated polyester sutures, now abandoned in favor of the latter materials, were used in 12 patients, 5 of whom suffered leakage, but the small number involved precludes worthwhile statistical analysis. Radiologically demonstrated gastroesphageal reflux was not associated with an increased rate of anastomotic leakage: 11 (17.5%) of 63 patients with Table 1. The Association Between the Suture Materiel Used for the Anastomosis and the Subsequent Development Anastomotic
of
Leakage
No. of Anastomoses
Suture Material
With Each
No. of
% of
suture
Leaking
Leaking
Material
Anastomoses
Anastomoses
Silk
30
10 (2)
33.3
Polyglycolic acid
76
6 (2)
10.3
Polypropylene
77
10 (2)
12.9
Polybutylated polyester
12
5 (1)
41.7
No data on suture material Total NOTE. The numbers
2 199
in parentheses
1 34 (7)
17.1 (3.5)
indicate those patients with
major leakage or total dehiscence ofthe anastomosis.
ET AL
Table 2. Anastomotic Leakage Related to Subsequent Stricture Formation “Undecided” Total
Leakage No leakage
Stricture
Stricture’
No Stricture”
34
6t
20 (71%)
8 (29%)
165
16
54 (36%)
95 (64%)
*P < .Ol. tSix
patients with disruption had the esophagus abandoned
and
subsequently underwent esophageal replacement.
gastroesophageal reflux had anastomotic leakage compared with 21 (17.2%) of 122 patients without reflux. The gastroesophageal junction was not adequately examined in 14 patients, 2 of whom had anastomotic leakage. Leakage occurred in 6 (14.6%) of 41 patients with tracheomalacia and in 27 (18.5%) of 146 without tracheomalacia (no statistically significant difference). Bronchoscopy was not performed in 12 patients, 1 of whom had anastomotic leakage. The risk of anastomotic stricture formation was significantly increased following anastomotic leakage (Table 2). Anastomotic leakage, including total disruption, did not directly result in the death of any of the affected infants, but 5 subsequently died of other causes. One infant died of complex cardiac anomalies associated with chromosomal abnormalities and another died of intraventricular hemorrhage. However, 3 infants died of the effects of recurrent TEF, which may have been produced by factors related to those causing anastomotic leakage. DISCUSSION
In this series of 253 neonates with EA there was an overall survival rate of 86%, increasing to 89% when infants with associated anomalies incompatible with life were excluded. In the 199 with an esophageal anastomosis, anastomotic complications were important causes of postoperative morbidity but none of the affected infants died directly from the effects of anastomotic leakage.‘~5 Depending on the criteria used for the definition and detection of leakage, the incidence varies widely from 4% to 36%.7-‘*‘4-‘6 Some studies have reported only “documented major” leaks that needed surgical intervention and did not include “controlled” or “localized” leaks demonstrated radiologically. Overall, the leak rate was 17%, with 3.5% of patients developing a major anastomotic disruption and there was some evidence that disruption could be prevented by elective artificial ventilation for 5 days.12 Many risk factors have been implicated in the pathogenesis of anastomotic leakage3-9 but statistical analysis of these various factors has been problematic because of the relatively small number of patients accumtilated during a short period in any one center. This study of a large number of cases collected over
ANASTOMOTIC
LEAKAGE AFTER EA REPAIR
31
an 8-year period enabled an analysis of several risk factors, but we accept that the statistical analyses must be treated with caution because patients were treated by several surgeons according to their personal preferences and were not randomized to various treatment groups in a matched, controlled, prospective study. From this review, the type of suture material used to construct the anastomosis was considered to play an important role in the development of leakage. Braided silk was associated with an increased incidence of leakage when compared with polyglycolic acid or polypropylene sutures. Sillen et alI6 reported a leak rate of 26% following repair of “no-gap” or “moderate-gap” EA using 5/O silk and a 100% leak rate in “long-gap” lesions; their overall leakage rate of 36% resembled our rate of 33% when silk was used for the repair. Gastroesophageal reflux has been reported to play an important role in the etiology of anastomotic stricture~.10.14.17 but was not an identifiable risk factor for anastomotic leakage in this series. Tracheomalacia did not predispose to anastomotic leakage. Other factors (eg, one-layer rather than two-layer anastomosis, end-to-end as opposed to end-to-side anastomosis, repair performed through a transpleural rather than an extrapleural approach, or repairs involving circular myotomy) have been related to the incidence of anastomotic leakage, but we were unable to evaluate these variables because the relevant operative techniques were rarely used in this center. An important risk factor is “tension” at the anastomotic site.18 We attempted to examine the influence of this factor but it proved impossible as we had no means of objectively measuring tension in the neonatal esophagus. A long-gap has been defined as a distance between the esophageal segments of more than 2 cm,“.lhirrespective of the size of the infant, and marked tension has been assumed to be present at the anastomosis performed in this situation. The leak rate in this group of infants has been reported to be 100%.h.‘hHowever, we would contend that the absolute length of the gap is an unreliable guide to tension
and in a series of infants varying in weight and size from less than 1 kg to over 3.5 kg, even when the gap between the two ends of the esophagus was more than 2 cm, sometimes we were able to fashion an anastomosis with little apparent tension after meticulous dissection and mobilization of both esophageal ends. Postoperative clinical assessment of the patients generally enabled the diagnosis of major anastomotic disruption to be made without difficulty. Symptoms and signs of respiratory distress usually developed during the second to fourth day after operation associated with large amounts of saliva or mucus exuding from the chest drain. Because severe respiratory distress developed in all patients with major disruption, all required urgent surgical intervention,‘4.‘yeither by rethoracotomy and repair or, more frequently, by proximal diversion with cervical esophagostomy and feeding gastrostomy, effectively abandoning the esophagus and necessitating its substitution either with whole stomach, gastric tube, jejunum, or colon. In this center, orthotopic gastric interposition was the most commonly used procedure during the last decade.2”.” Babies with minor leaks often appeared clinically well and the leak was undetected before routine esophagography on the 5th to 10th postoperative day.‘,15As a rule these patients could be successfully managed nonoperatively, with eventual spontaneous healing,lh although a few presented after the third day with tension pneumothorax requiring urgent drainage. The outcome of treatment of affected infants has been enhanced by early diagnosis and appropriate management, including the use of effective antibiotics, transanastomotic feeding, parenteral nutrition, and improved surgical techniques. Although minor leaks may be managed nonoperatively, early major leaks in small babies must be treated by urgent reoperation. ACKNOWLEDGMENT Dr Chittmittrapap wishes to thank Mr M.D. Stringer assistance in preparing this manuscript.
for his kind
REFERENCES 1. Brereton RJ, Zachary RB, Spitz L: Preventable death in oesphageal atresia. Arch Dis Child 53:276-283,1978 2. Spitz L, Kiely E, Brereton RJ: Esophageal atresia: Five year experience with 148 cases. J Pediatr Surg 22:103-108,1987 3. Randolph JG: Esophageal atresia and congenital stenosis, in Welch KJ, Randolph JG, Ravitch MM, et al (eds): Pediatric Surgery (ed 4). Chicago, IL, Year Book, 1986, pp 682-697 4. Cudmore RE: Oesophageal atresia and trachea-oesophageal fistula, in Rickham PP, Lister J, Irving IM (eds): Neonatal Surgery (ed 2). London, England, Buttenvorths, 1978, pp 189-208 5. Holder TM, Cloud DT, Lewis JE Jr, et al: Esophageal atresia
and tracheoesophageal fistula. A survey of its members by the Surgical Section of the American Academy of Pediatrics. Pediatrics 34:542-549,1964 6. Hagberg S, Rubenson A, Sillen U, et al: Management of long-gap esophagus: Experience with end-to-end anastomosis under maximal tension. Prog Pediatr Surg 19:88-92, 1986 7. O’Neill JA, Holcomb GW, Neblett WW: Recent experience with esophageal atresia. Ann Surg 195:739-745, 1982 8. Touloukian RJ: Long-term results following repair of esophageal atresia by end-to-side anastomosis and ligation of the tracheoesophageal fistula. J Pediatr Surg 16:983-988, 1981
32
CHlTTMllTRAPAP
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