Secondary Esophageal Surgery Following Repair of Esophageal Atresia With Distal Tracheoesophageal Fistula N . A . M y e r s , S . W . Beasley, and A . W . A u l d i s t

Melbourne, Australia Q During the period 1948 through 1988, 498 patients with esophageal atresia and distal tracheoesophageal fistula w e r e admitted to the Royal Children's Hospital, Melbourne. Fifty patients had a second operative procedure on the esophagus, for anastomotic stricture (30), recurrent fistula (15), both (4), and a postmyotomy diverticulum (1). During the same period, nine patients underwent esophageal replacement and 33 patients a Nissen fundoplication. Improvements in the technique of esophageal anastomosis, and in recent years the use of fundoplication to correct gastroesophageal reflux have led to a marked reduction in the need for secondary surgery to the esophagus after repair of esophageal atresia. Esophageal replacement is rarely required in esophageal atresia and distal tracheoesophageal fistula. One-layer end-to-end esophageal anastomosis using interrupted sutures resulted in the lowest rate of recurrent fistula and anastomotic stricture. 9 1990 by W.B. Saunders Company.

Table 1. Indications for Surgery No. of Patients Anastomotic stricture Recurrent fistula Tracheoesophageal Esophagobronchial Stricture and recurrent tracheoesophageal fistula Postmyotomy diverticulum

30* 15 13 t 2 4 1

*Three patients with stricture had further resection for stricture. t T w o patients with recurrent tracheoesophageal fistula had a second recurrence of the fistula.

RESULTS

MATERIALS AND METHODS

There were 584 patients with EA and/or TEF admitted during the review period, of which 498 had EA with distal fistula. In 47 infants, no definitive surgery was undertaken as part of the policy of selective nontreatment. In 50 of the remainder (11%), a second operative procedure to the esophagus was performed and five of these required a third procedure, the indications for which are summarized in Table 1. During this period, 33 patients had a Nissen fundoplication and nine patients required esophageal replacement (for long gap in four, anastomotic disruption in three, perforation of the upper pouch in one, 7 and lower esophageal stenosis in one). Anastomotic stricture was the most common indication for further surgery to the esophagus (Table 1). Patients with stricture (Fig 1) had feeding difficulties or dysphagia as their major symptom. In babies the first symptom was often "slow feeding" and regurgitation with or without cyanotic episodes. Each patient had several dilatations prior to resection of the stricture. Resection was performed when it became evident

A combined prospective and retrospective study of all patients with EA and distal TEF admitted to the Royal Children's Hospital, Melbourne, during the 41-year period until December 1988 was undertaken. The data were originally collected prospectively by one of the authors (N.A.M.) and supplemented by review of the hospital case notes. All data were analyzed on a Hewlett Packard 3000 Series 68 computer using SPSS (Statistical Package for Social Services). Where relevant, the radiology was reviewed, and the patients contacted and reexamined. Although less common variants of EA (atresia without fistula, 4 atresia with an upper pouch or double fistula, 5 and " H " fistula without atresia 6) may require secondary surgery, they were not included in the study. Nor does the paper address endoscopic procedures or procedures to the esophagus that were part of a deliberately staged management plan.

From the Department of General Surgery, Royal Children's Hospital, Melbourne, Australia. Supported in part by the Oesophageal Atresia Research Auxilliary and the Royal Children's Hospital Research Foundation, Melbourne, Australia. Presented at the 22nd Annual Meeting of the Pacific Association of Pediatric Surgeons, Portland and Sun River, Oregon, May 22-26, 1989. Address reprint requests to N.A. Myers. AM, FRACS, Department of General Surgery, Royal Children's Hospital, Parkville, Victoria 3052, Australia. 9 1990 by W.B. Saunders Company. 0022-3468/90/2507-0017503.00/0

INDEX WORDS: Esophageal atresia; esophageal stricture; recurrent tracheoesophageal fistula; gastroesophageal reflux; postmyotomy diverticulum.

L T H O U G H the literature contains several large

A series of patients with esophageal atresia (EA) and distal tracheoesophageal fistula (TEF), 1-3 these do not specifically address the question of secondary operative procedures to the esophagus after repair of EA. In this report we have examined the complications of repaired EA and distal TEF that have required secondary surgical intervention to the esophagus, with specific reference to anastomotic stricture and recurrent TEF. Less common indications for secondary esophageal surgery (esophagobronchial fistulae and postLivaditis myotomy diverticulum) are also described.

Journal of Pediatric Surgery, Vol 25, No 7 (,July), 1990: pp 773-777

773

774

MYERS, BEASLEY, AND AULDIST 30 ..c:O

25 20

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I

D..rr '

1948-52

Fig 3. tion.

I

1953-57 1958-62 1963-67 1968-72 1973-77 1978-82 1983-87 Period(years)

Treatment of gastroesophageal reflux by fundoplica-

The majority of patients with recurrent TEF (Figs 4 and 5) had coughing and spluttering episodes with feeding, usually associated with cyanosis. Occasionally the recurrent fistula was an incidental finding on x-ray Fig 1. A severe anastomotic stricture that did not respond to repeated dilatation.

that the dilatation program had failed. In more than half, the patients were less than 12 months of age (Fig 2). In recent years, patients with significant gastroesophageal reflux and esophageal stricture have had an antireflux procedure performed as initial management of their stricture; resection of the stricture is not usually necessary (Fig 3).

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o n.. w t~ z

5

0

0-1

1-2 AGE

i

2-5

I1 5-10

(Years)

Fig 2. Age at operation for esophagealstricture after repair of esophageal atresia and distal tracheoesophageal fistula,

Fig 4. Anastomotic leak showing early pseudodiverticulum that subsequently produced a recurrent tracheoesophageal fistula.

SECONDARY ESOPHAGEAL SURGERY

775

mediastinum. At 2 years of age he developed a severe febrile illness and right upper lobe consolidation secondary to a communication between the esophagus and the right upper lobe of the bronchus (Fig 7). Segmental lobectomy and closure of the esophagobronchial fistula communication was performed. In the second patient, there was a communication between the esophagus and left lower lobe. This patient, who had a right aortic arch, also had a staged repair; the first thoracotomy was on the right side and the second on the left. A circular myotomy of both esophageal segments was required to achieve an anastomosis that subsequently leaked into the mediastinum, and he developed an esophagobronchial fistula. At surgery, the fistula was divided and part of the left lower lobe was resected. The patient with a postmyotomy diverticulum had progressive dysphagia with cough. 8 Five patients required a third procedure (Table 2), three of which were for stricture. Forty-nine patients survived; the one death occurred in a patient with a complex cardiac abnormality. The relationship of the complications to the type of esophageal anastomosis is shown in Fig 8. The lowest rate of recurrent T E F and anastomotic stricture occurred after one layer end-toend anastomoses. DISCUSSION Secondary surgery to the esophagus is performed for complications of EA repair, the two most common of which are esophageal stricture and recurrent TEF. Anastomotic esophageal strictures are the most common late postoperative complication requiring surgery (Table 1). We now know that they are frequently associated with, and in many patients the result of, gastroesophageal reflux. 9 However, this has not always been realized, as is evident from the experience docu-

Fig 5. fistula.

Same patient as in Fig 4. Recurrent tracheoesophageal

I-Z UJ m h-

8-

10

(Years)

Fig 6. Age at presentation of recurrent tracheoesophageal fistula a f t e r repair of esophageal atrasia and distal tracheoesophageal fistula.

776

MYERS, BEASLEY, AND AULDIST

Table 2. Patients Requiring Multiple Additional Procedures to the Esophagus: The Age at Which the Secondary Procedures Were Performed Secondary Esophageal Surgery 1St Procedure Stricture

3 weeks

2rid Procedure 6 months

3 years

5 years

3 yea~s

13 years

Recurrent tracheoesophageal fistula

1 month

6 months

6 weeks

8 months

require resection is consistent with our current experience, but this contrasts markedly with the approach adopted before the relationship of strictures with gastroesophageal reflux was recognized, that if a stricture did not respond to dilatation, it was resected. Recurrent T E F is the second well-recognized complication of EA repair) 3 In our experience, recurrence of a T E F is more likely to occur if there has been leak from the anastomosis and following end-to-side anastomosis (Fig 8). Now that the end-to-side anastomosis has been abandoned and there have been improvements in the technique of end-to-end anastomosis, including minimal mobilization of the lower esophageal segment, there has been a reduction in the incidence of recurrent TEF. The lowest rate of recurrent fistula occurs after one-layer end-to-end anastomosis. When it is suspected, the diagnosis can be confirmed radiologically in the same way as for a congenital H fistula. 6 Treatment involves division of the fistula, which is usually performed through a thoracotomy. Spontaneous closure of a recurrent fistula is unlikely and there would seem to be little merit in deferring reoperation. Given that it is impossible to draw definite conclusions from a study that incorporates many varied 40 35

Fig 7.

Esophageobronchial fistula (to right upper lobe).

mented in this paper. As recently as 1967, Keshishian and Cox 1~contended that periodic dilatation is all that is necessary for most strictures, although occasionally a second operation for a stricture at the anastomotic site is required. Recognition of the role of gastroesophageal reflux in the pathogenesis of strictures at the level of the anastomosis has led to the realization that control of gastroesophageal reflux is essential in the treatment of these strictures. 9,H This has led to a substantial increase in the number of antireflux operations performed following repair of EA (Fig 3). Holder's assertion 12 that it is now rare that a stricture will

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Sleeve

Anastomosis

Staged

Repair

End-To-Side Anastomosis

One Layer End-To-End Anastomosis

Anastomotic Type

Fig 8. Incidence of anastomostic stricture and recurrent tracheoesophageal fistula according to type of anastomosis. [~. Recurrent tracheoesophageal fistula; lB. anastomotic stricture requiring resection.

SECONDARY ESOPHAGEAL SURGERY

777

surgical approaches and techniques, it is our belief that the following factors may be important in the development of esophageal stricture and recurrent TEF. (1) Gastroesophageal reflux is a potent cause of anastomotic stricture. Successful treatment of an esophageal stricture due to gastroesophageal reflux necessitates correction of that reflux; repeated esophageal dilatation alone will be ineffective in the long-term if reflux persists. (2) The staged approach to repair of EA overall has a higher morbidity, and in particular, a higher incidence of esophageal stricture (Fig 8). (3) The end-to-side esophageal anastomosis has an unac-

ceptably high incidence of recurrent TEF; in our experience this occurred in 11.4% compared with 4.1% after an end-to-end anastomosis (Fig 8). (4) Excessive dissection and mobilization of the esophagus, particularly the lower esophageal segment, may cause anastomotic complications due to ischemia. (5) A one-layer end-to-end anastomosis using interrupted absorbable sutures has few anastomotic complications. ACKNOWLEDGMENTS

We are grateful to Judith Hayes and Elizabeth Vorrath for typing the manuscript, and to Jocelyn Brady, Research Assistant.

REFERENCES

1. Louhimo i, Lindahl H: Oesophageal atresia: Primary results of 500 consecutively treated patients. J Pediatr Surg 18:217-229, 1983 2. Holder TM, Cloud DT, Lewis JE, et al: Esophageal atresia and tracheo-esophageal fistula, a survey of its members by the Surgical Section of the American Academy of Pediatrics. Pediatrics 34:542549, 1964 3. Beasley SW, Shann FA, Myers NA, et al: Developments in the management of oesophageal atresia and tracheo-oesophageal fistulas. Med J Aust 150:501-503, 1989 4. Myers NA, Beasley SW, Auldist AW, et al: Oesophageal atresia without fistula--Anastomosis or replacement? Pediatr Surg Int 2:216-222, 1987 5. Auldist AW, Cass D: Oesophageal atresia with upper pouch fistula. Pediatr Surg Int 2:212-215, 1987 6. Myers NA, Egami K: Congenital tracheo-oesophageal fistula. The "H" or " N " fistula. Pediatr Surg Int 2:198-211, 1987 7. Wright VM, Noblett HR: A complication of continuous upper

pouch suction in esophageal atresia. J Pediatr Surg 13:369-370, 1978 8. Taylor RG, Myers NA: The management of a post-Livaditis procedure oesophageal diverticulum. Pediatr Surg Int (in press) 9. 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 10. Keshishian JM, Cox PA: Esophageal stricture at anastomotic site following repair of tracheo-esophageal fistula. J Thorac Cardiovasc Surg 53:754-756, 1967 11. Leendertse-Verloop K, Tibboel D, Hazebroek FWJ, et al: Postoperative morbidity in patients with esophageal atresia. Pediatr Surg Int 2:2-5, 1987 12. Holder TM: Esophageal atresia and tracheo-esophageal fistula, in Ashcraft KW, Holder TM (eds): Pediatric Esophageal Surgery. Philadelphia, PA, Grune & Stratton, 1986 13. Ein SH, Stringer DA, Stephens CA, et al: Recurrent tracheoesophageal fistulas: Seventeen-year review. J Pediatr Surg 18:436441, 1983

Secondary esophageal surgery following repair of esophageal atresia with distal tracheoesophageal fistula.

During the period 1948 through 1988, 498 patients with esophageal atresia and distal tracheoesophageal fistula were admitted to the Royal Children's H...
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