Prophylactic
Extrapleural Chest Drainage Following Esophageal Atresia: Is it Necessary? By W.A. McCallion,
R.J. Hannon,
Belfast, Northern 6 In a review of 110 cases of esophageal atresia (EA) and tracheoesophageal fistula (TEF), 15 patients (13.6%) developed anastomotic leakage. All patients had extrapleural surgical exposure and prophylactic extrapleural chest drainage (PEPCD). Despite this precaution, all patients with anastomotic leaks developed a pneumothorax with or without a pleural effusion. This required insertion of an additional drain in 12 (80%) cases. PEPCDfollowing repair of EA and TEF does not appear to prevent pneumothorax or pleural effusion when anastomotic leakage occurs. Copyright o 1992 by W. B. Saunders Company INDEX WORDS: tula.
Esophageal
atresia; tracheoesophageal
fis-
E
XTRAPLEURAL surgical exposure of the posterior mediastinum has been considered superior to the transpleural route for the repair of esophageal atresia (EA) and tracheoesophageal fistula (TEF).’ Prophylactic extrapleural chest drainage (PEPCD) has become routine despite the absence of scientific evidence to justify its use. It is thought that this reduces morbidity by permitting escape of fluid and gas through the tube in the event of an anastomotic leak thus avoiding an intrapleural or extrapleural collection. The object of this retrospective survey was to determine whether drainage does have this effect. MATERIALS
AND METHODS
The hospital records of 110 consecutive cases of EA and TEF were reviewed. Fifteen (13.6%) anastomotic leaks were diagnosed, 13 following primary and 2 following secondary esophageal repair. In all cases extrapleural surgical exposure and PEPCD were used with undetwater seal chest drains (Argyle FGlO or 12) in 14 cases and an open corrugated drain in 1. The tip of the drainage tube was placed within 10 mm of the anastomosis within the extrapleural space. Anastomotic leakage was suspected if the general condition of the patient deteriorated postoperatively associated with tachypnea and signs of a right-sided pneumothorax and pleural effusion. Leakage was confirmed radiologically in 14 cases. In the remaining case, gas and saliva were evacuated when an additional postoperative chest drain was inserted. None of the remaining 95 patients had evidence of esophageal anastomotic leakage. RESULTS Anastomotic leaks were diagnosed between the first and fifth postoperative days (mean, day 2). All
Journaloffediatric
Surgery, Vol27, No 5 (May), 1992: p 561
Repair of
and V.E. Boston
Ireland
patients had deteriorated clinically and chest x-rays taken during this period showed a right-sided pneumothorax in each of the 15 cases. There were 5 tension pneumothoraces and 5 right-sided pleural effusions. Saliva and gas were noted to have drained from the PEPCD in only 7 of 15 (46.7%). The collection of gas and or fluid in the chest caused sufficient clinical deterioration to necessitate the insertion of an additional drain in 12 patients (80%). Anastomotic leakage was managed conservatively in 11 cases and surgically by repeat thoracotomy in 4. There was one recurrent fistula and no leak-related deaths. DISCUSSION
These data indicate that in all cases in which anastomotic failure occurred following repair of EA and TEF, gas and or fluid collected in the right hemithorax despite a PEPCD. Only 46.7% were noted to have drained and in the majority (80%) this drainage was so inadequate that clinical deterioration occurred necessitating the insertion of an additional chest drain. Both the type and position of the PEPCD should have been adequate to clear any leaked gas or liquid and the reason for this not occuring in most cases is uncertain. Because prophylactic extrapleural chest drainage does not appear to prevent collections in the chest following anastomotic failure, it is difficult to justify its continued routine use. REFERENCE 1. Holder TM: Transpleural versus retropleural approach for repair of tracheoesophageal fistula. Surg Clin North Am 44:14331439,1964
From the Department of Paediatric Surgeery,Royal Belfast Hospital for Sick Children, Beffast, Northern Ireland. Date accepted: February 28, 1991. Address reprint requests to V.E. Bo.yton, MD, FRCS, FRCSI, Consultant Paediatric Surgeon, Royal Belfast Hospital for Sick Children, Falls Rd, Belfast BT12 6B.5 Northem Ireland. Copyright o 1992 by W.B. Saunders Company 0022-3468/9212705-0006$03.OOiO
561
Extrapleural Chest Drainage Following Esophageal Atresia: Is it Necessary? By W.A. McCallion,
R.J. Hannon,
Belfast, Northern 6 In a review of 110 cases of esophageal atresia (EA) and tracheoesophageal fistula (TEF), 15 patients (13.6%) developed anastomotic leakage. All patients had extrapleural surgical exposure and prophylactic extrapleural chest drainage (PEPCD). Despite this precaution, all patients with anastomotic leaks developed a pneumothorax with or without a pleural effusion. This required insertion of an additional drain in 12 (80%) cases. PEPCDfollowing repair of EA and TEF does not appear to prevent pneumothorax or pleural effusion when anastomotic leakage occurs. Copyright o 1992 by W. B. Saunders Company INDEX WORDS: tula.
Esophageal
atresia; tracheoesophageal
fis-
E
XTRAPLEURAL surgical exposure of the posterior mediastinum has been considered superior to the transpleural route for the repair of esophageal atresia (EA) and tracheoesophageal fistula (TEF).’ Prophylactic extrapleural chest drainage (PEPCD) has become routine despite the absence of scientific evidence to justify its use. It is thought that this reduces morbidity by permitting escape of fluid and gas through the tube in the event of an anastomotic leak thus avoiding an intrapleural or extrapleural collection. The object of this retrospective survey was to determine whether drainage does have this effect. MATERIALS
AND METHODS
The hospital records of 110 consecutive cases of EA and TEF were reviewed. Fifteen (13.6%) anastomotic leaks were diagnosed, 13 following primary and 2 following secondary esophageal repair. In all cases extrapleural surgical exposure and PEPCD were used with undetwater seal chest drains (Argyle FGlO or 12) in 14 cases and an open corrugated drain in 1. The tip of the drainage tube was placed within 10 mm of the anastomosis within the extrapleural space. Anastomotic leakage was suspected if the general condition of the patient deteriorated postoperatively associated with tachypnea and signs of a right-sided pneumothorax and pleural effusion. Leakage was confirmed radiologically in 14 cases. In the remaining case, gas and saliva were evacuated when an additional postoperative chest drain was inserted. None of the remaining 95 patients had evidence of esophageal anastomotic leakage. RESULTS Anastomotic leaks were diagnosed between the first and fifth postoperative days (mean, day 2). All
Journaloffediatric
Surgery, Vol27, No 5 (May), 1992: p 561
Repair of
and V.E. Boston
Ireland
patients had deteriorated clinically and chest x-rays taken during this period showed a right-sided pneumothorax in each of the 15 cases. There were 5 tension pneumothoraces and 5 right-sided pleural effusions. Saliva and gas were noted to have drained from the PEPCD in only 7 of 15 (46.7%). The collection of gas and or fluid in the chest caused sufficient clinical deterioration to necessitate the insertion of an additional drain in 12 patients (80%). Anastomotic leakage was managed conservatively in 11 cases and surgically by repeat thoracotomy in 4. There was one recurrent fistula and no leak-related deaths. DISCUSSION
These data indicate that in all cases in which anastomotic failure occurred following repair of EA and TEF, gas and or fluid collected in the right hemithorax despite a PEPCD. Only 46.7% were noted to have drained and in the majority (80%) this drainage was so inadequate that clinical deterioration occurred necessitating the insertion of an additional chest drain. Both the type and position of the PEPCD should have been adequate to clear any leaked gas or liquid and the reason for this not occuring in most cases is uncertain. Because prophylactic extrapleural chest drainage does not appear to prevent collections in the chest following anastomotic failure, it is difficult to justify its continued routine use. REFERENCE 1. Holder TM: Transpleural versus retropleural approach for repair of tracheoesophageal fistula. Surg Clin North Am 44:14331439,1964
From the Department of Paediatric Surgeery,Royal Belfast Hospital for Sick Children, Beffast, Northern Ireland. Date accepted: February 28, 1991. Address reprint requests to V.E. Bo.yton, MD, FRCS, FRCSI, Consultant Paediatric Surgeon, Royal Belfast Hospital for Sick Children, Falls Rd, Belfast BT12 6B.5 Northem Ireland. Copyright o 1992 by W.B. Saunders Company 0022-3468/9212705-0006$03.OOiO
561
