Repair of Esophageal Atresia With Trache Esophageal Fistula Through Modified Transpleural Approach by Delivering Lung Out of Main Wound

Abstract

ABSTRACT

Objectives: To assess the morbidity, mortality, operation time, and postoperative complications in the present modified transpleural (MTP) approach with the conventional extrapleural (EP) approach in esophageal atresia (EA) with tracheoesophageal fistula (TEF).

Design: Longitudinal randomized case control study.

Setting: Pediatrics Surgery Department of a tertiary care hospital.

Study period: November 2009 to December 2011.

Participants: Neonates above 1.5 kg body weight with EA and TEF.

Results: Sex ratio is 7:3 (male and female). In total, 40% had associate anomalies. Duration of operation in MTP approach from 90 to 110 min (mean duration 98.6 min) where as in EP approach from 120 to 130 min (mean duration 121.4 min). All 3(15% wound infections were in EP group. A total of 3 develops right sided pneumothorax with 2 in MTP and 1 in EP approach group. In total, 10% (2) in MTP approach group and 5% (1) in EP group expired. Leakage in anastomotic site was seen in 2(10%) each in both the groups. Six developed stricture, out of which 4 in EP group, 2 in MTP group.

Conclusion: MTP approach is less time consuming, possess less hindrance during operation. Postoperative complications are comparable. Mortality is higher in MTP group than EP group, may be because of associated lethal co morbidity.

Keywords

Esophageal atresia (EA)tracheoesophageal fistula (TEF)extrapleural (EP) approach modified transpleural (MTP) approach

Introduction

Esophageal atresia (EA) with tracheoesophageal fistula (TEF) is one of the most challenging surgical problem in neonates. The overall incidence is approximately 1 in 3500 to 4500 livebirths.¹ The estimated incidence of EA in India is 18 000 per year.² The commonest is EA with distal TEF.³

Other congenital anomalies are frequently associated with EA and TEF like cardiovascular anomalies, VACTREL anomalies, gastro-intestinal, genitourinary, and limb anomalies. Other less frequent conditions like tracheomalacia, spina-bifida, and exomphalus are also associated anomalies.²

In 1939, almost simultaneously, Dr William Ladd of Boston and Dr Logan Levin of St. Paul got the first complete surgical success.⁶ In 1941, Dr Cameroon Height of An Arbor performed first successful primary anastomosis.⁷ Since that time due to improved pediatric nursing care and anesthetic technique, intensive care units, better ventilator support, better antibiotics, and suture materials, the results have improved dramatically.

There have been many approaches for repair of TEF + EA like conventional extrapleural (EP) approach,⁸ transpleural route,^{9, 11, 22} end to side anastomosis,¹² thoracoscopic repair of TEF + EA,²¹ and more recently efforts like tissue engineering. The result of repair of TEF + EA depends upon birth weight, associated congenital anomaly, underlying pneumonia, and more importantly duration of surgery that has direct bearing on postoperative morbidity and mortality.^{16, 17} Most advocate EP approach but it has certain disadvantages as follows.

Retraction of lung and mediastinum causing difficulty in operation in deeper areas

Frequent interruption of surgery for ventilation by anesthetist

Hypoxemia

Increased operation time

Survival following repair of TEF + EA varies from 24% to 75% in different groups.^8-10 The comorbid conditions especially pneumonia worsen the survival rate. As because of availability of better antibiotics, suture materials, anesthetic drugs, EP, and transpleural approaches in experienced hands produce comparable results. In this study, a different maneuver to the usual steps is added in transpleural approach,^11-13 which only makes the dissection and anastomosis easy and reduces the operative time.

This maneuver is a modification of transpleural approach¹¹ in which the 3 lobes of right lung are delivered into the main wound one after another and retracted by a tape made of wet gauze that is held just distal to hilum. The following are the advantages of this maneuver.

It brings the mediastinal structures more superficial to the wound.

Allows the surgeon to complete the dissection and the anastomosis of the esophageal ends without interruption.

The anesthesiologist is at ease as he/she can watch the lobes being inflated all the time along with oxygen saturation above 95%.

Postoperative lung problems are fewer as operation is smooth and reduce the operative time.

Aims and Objectives

The present study is carried out to assess the morbidity, mortality, ease of operation, and postoperative complications in this modification of transpleural approach and compare it with conventional EP approach.

Materials and Methods

This study is a prospective study conducted over a period of 2 years from November 2009 to December 2011 at the Department of Paediatric Surgery of S.V.P Post Graduate Institute of Paediatric, SCB Medical College and Hospital, Cuttack. A total of 20 cases were enlisted for the study and the cases are selected arbitrarily on alternate basis for modified transpleural (MTP) and EP approach.

Subjected for Study

The patients with classical EA with distal TEF (Type C) managed by primary anastomosis were enrolled for the study.

Criteria for Inclusion

All patients with EA with distal TEF having birth weight 1.5 kg or more.

Exclusion Criteria

The patients who had a body weight less than 1.5 kg, major cyanotic cardiac disease, other type of EA (Type A, B, D, E) and long atresia were excluded from this study.

Preoperative Assessment

All patients were subjected to detailed history and a thorough clinical examination. Attention was given to find out the associated anomalies. All patients were kept nil per orally with intravenous fluid containing an adequate glucose concentration (ie, 10% glucose) and prophylactic broad-spectrum antibiotics (eg, ampicillin, gentamycin).

The neonate is kept warm by using an incubator or overhead warmer and is positioned supine in the Fowler position, with the head elevated by approximately 45°. A 10F feeding tube is placed nasally or orally well into the upper pouch and is connected to a continuous suction device. Every 30 min, the tube is checked for patency.

Laboratory tests like Hb%, serum electrolytes, serum bilirubin, plain X-ray showing recoiling of feeding tube, infantogram to detect vertebral/limb anomaly, ultrasonography for other congenital anomaly and echocardiography were preformed.

The parents were fully briefed about the nature of the congenital anomaly. Their consent for treatment was obtained, and the discussion with them was documented in appropriate details on the baby’s medical record.

Plan of Surgery

All the patients were undergone primary oesophagoesophageal anastomosis under general anesthesia. Duration of operation (starting from skin incision up to wound closure), type of operation (MTP/EP), intraoperative complication were noted.

Postoperative Care

Postoperatively the intubated neonate is transported to the neonatal intensive care unit. The endotracheol tube should remain until weaning from ventilation is ensured, usually after 1 to 2 days. Antibiotics are continued until the chest drain is removed.

Chest radiography is obtained first and third postoperative day for possibility of pneumothorax. Under water seal bag of chest tube and wound were evaluated by the surgeon every day for any discharge and wound infection. Oral feed started at the eighth postoperative day of surgery, if there is no feature of leakage of anastomosis. A contrast study was done in cases suspicion of leakage of anastomosis before beginning oral feeding. The patients were discharged after removing the chest tube.

Follow-up Assessment

In the follow-up, patients were assessed at 1 month, 3 months, and thereafter at yearly intervals. Assessment was made for child’s general condition, growth, healing at the surgical site, swallowing functions, and respiratory issues.

Statistical Analysis

Since it is a small case-controlled study, percentage was used in assessing most of the results. Pearson chi square test is used to determine statistical significance. A P-value <.05 was taken as significant.

Observation and Results

During the 2 years period total number of indoor patients were 3456, out of which 39 cases were EA with or without TEF. Out of it 20 cases were enrolled in this study and treated.

Among 20 cases that underwent primary esophageal anastomosis, 11 cases (55%) present from third to fifth day of life, whereas 3 cases (15%) presented during first day of life and rest of the cases presented late (average eight day). The cases presented late had lower respiratory tract infection.

Average birth weight in this study is 2.35 kg. Only 3 cases were having birth weight more than 3 kg, whereas 5 cases were having birth weight less than 2 kg. Rest of the cases had birth weight between 2 and 3 kg.

Sex Incidence

The sex incidence in this study showed male preponderance. A total of 14 cases (70%) are males, whereas only 6 cases (30%) were females.

Associated Anomalies

Among the 20 cases enrolled in this study 8 cases (40%) had associated anomalies. Most commonly associated anomalies were gastrointestinal (3 cases, 15%), cardiovascular (2 cases, 10%), 1 case of hypospadias, 1 case of limb anomaly, and 1 case of cleft palate.

Out of 20 cases arbitrary selection was done on alternate basis for MTP and extapleural approach. Duration of operation was significantly shorter in the modified transpleural group. The mean duration of operation in the EP group was 121.4 min (range from 120 to 130 min), whereas in this MTP approach, it was 98.6 min (range from 90 to 110 min).

Postoperative Complications

Among 20 cases operated, 3 cases (15%) had wound infection, all of whom were in EP group and all are managed conservatively. Three patients (15%) developed right sided pneumothorax; 2(10%) of whom were in MTP group and 1 (5%) was in EP group. 1 patient died due to prolonged hypoxia in MTP group. The other 2 cases were managed by tube thoracostomy.

Four patients (20%) developed leakage of anastomosis, 2 of whom were in EP group and 2 were in MTP group. There was no significant statistical difference in the rate of anastomotic leakage between the 2 surgical techniques. In total 2 patients, 1 from EP group, and 1 from MTP group, developed major anastomotic leakage and died in account of aspiration pneumonia, hypoalbuminemia, and sepsis.

Six patients (30%) developed stricture, of whom 4 patients (20%) were from EP group and 2 patients (10%) were in MTP group. All patients responded to gum-elastic bougie dilation except 1 case that required stricturoplasty.

Three patients (15%) died after surgery, 2 (10%) of whom were in MTP group, and 1 (5%) was in EP group.

Two patients received total parenteral nutrition, 1 patient died on the course due to major anastomotic leak in transpleural group. Patients started orally at an average 13.8 days (range from 8 to 15 days) postoperatively, of whom EP group started at 13.3 days, whereas in transpleural group, started at 14.3 days. There is no significant statistical differences between 2 groups.

Two patient of associated high anorectal malformation had transverse loop colostomy. One patient of jejunal atresia underwent resection and end to end anastomosis.

Among the 10 cases who had undergone MTP approaches, 7 cases (70%) were in regular follow-up, whereas in EP group 7 patients (70%) were in regular follow-up. A total of 1 case (10%) in MTP group and 2 patients (20%) in EP group were lost to follow-up after first month checkup.

Duration of hospital stay ranged from 10 to 40 days with a mean of 15.8 days. A total of 5 patients stayed more than 20 days in the hospital. The reason for prolonged hospital stay was postoperative morbidity and subsequent TPN therapy.

Discussion

In the past, the mortality following repair of EA with TEF rate was very high because of nonavailability of advanced care units, experienced anesthetists, better anesthetic drugs, neonatal surgical care, suture materials, and more importantly better antibiotics. Now the scenario is different as because of advance intensive care units for newborn, experienced anesthetists, better surgical approach, and better knowledge about the pathophysiology of TEF with EA.¹

In this study, it is concluded that transpleural approach with taking out right lung out of main wound is well comparable with the conventional EP approach and this approach has the following advantages.

It brings the mediastinal structures more superficial to wound.

Allows the surgeon to complete the dissection and the anastomosis of the esophageal ends without interruption.

The anesthesiologist is at ease as he/she can watch the lobes being inflated all the time along with oxygen saturation above 95%.

Postoperative lung problems are fewer as operation is smooth.

Reduced operative time.

Though there are not many studies in this MTP approach. Jadhav et al¹¹ published a large series with this procedure. There are other studies¹³ done with comparable results between EP and transpleural approaches for treatment of TEF with EA.

Prematurity is still a major problem for developing countries. Additional physiological handicaps in these babies are the increased susceptibility to sepsis and the low survival among the preterms. Therefore, it does not indicate failure of operative technique used rather it is a result owing to multiple of factors.¹⁴

Male to female ratio in the present series is 2.33:1, which is showing male preponderance. These findings are similar to other studies in India.^{1, 15} The probable cause might be the fewer enrolments attributed to low importance being given to female child in our society. In most series studied abroad, sex incidence is nearly equal.²

Associated anomalies were found in 8 cases (40%). According to other studies they reported 60%, 47%, 59% associate anomalies.^16-18

A total of 4 of 20 patients developed leakage of anastomosis (20%). Among these 4 patients 2 patients had major leak. Both died due to aspiration pneumonia, hypoproteinemia, and sepsis. The patient died in the MTP group had associated cardiovascular anomaly. There was no significant statistical difference in the leakage of anastomosis between both surgical techniques. Similarly other also reported anastomotic leak in 20% to 25% cases.^{18, 19} Sarin et al²⁰ reported poor results with anastomotic leaks with only 20% survival rate among the leak group.

In this study, out of 20 cases who underwent primary repair, 6 patients (30%) developed stricture of whom 4 patients (20%) were from EP group and 2 patients (10%) are in MTP group. The incidence of stricture development is significantly lower in the MTP group. The results are well comparable to other studies having 18%, 17% stricture.^{4, 18}

In this study, 3 patients (15%) developed right sided pneumothorax; 2 of whom were in MTP group and 1 was in EP group. One patient died due to prolonged hypoxia in MTP group. The other 2 cases were managed by tube thoracostomy. The rate of pneumothorax was higher in MTP group. Others described the rate of pneumothorax is 20% and 14% in their studies.^{13, 20}

The operative time in this study had statistically significant difference between both the groups. The operative time in the MTP group was considerably reduced. The average MTP operative time was 98.6 min, whereas the mean duration of operation in the EP group was 121.4 min.

The shortest “skin to skin” operation in MTP group was for 56 min and 6 operations in the MTP group were performed in less than 100 min. Koop et al¹³ studied a large series with retropleural operative time of 2 h and 4 min, while in transpleural group it was 1 h and 40 min. Similarly, Shahman et al²³ mentioned EP operative time was 135.3 min, while transpleural operative time was 102.33 min.

In the present study, 17(85%) out of 20 patients survived following repair of EA with TEF as compared with 80%, 36%, 35% to 50% survival rate in the other series conducted in India.²⁰ Among the total 3 cases who died in which 2 patients died in MTP group and 1 patient was in conventional EP group. The 2 patients in MTP group probably died because both the cases had associated cardiovascular anomalies as well as low birth weight and may not be due to the technique itself. According to Shahman et al,²³ there were no significant differences in mortality rates between the surgical techniques.

The popularity of the EP approach instead of transpleural approach is due to more possibility of emphysema followed by anastomotic leakage in the transpleural approach. Another significant problem in transpleural approach is increased rate of pneumothorax according to Shahman et al.²³ In this series there are 2 cases of pneumothorax in MTP group out of which 1 expired and the other managed with tube thoracostomy. As because of availability of better antibiotic and with aid of tube thoracostomy and respiratory physiotherapy, this problem can be handled.

Table 1.

Comparison of Duration of Surgery in Different Studies

Present Series (min)		Koop et al (min), ¹³ Year 1954		Shahnam et al (min), ²³ Year 2009
Extrapleural Group	Modified Transpleural Group	Extrapleural Group	Transpleural Group	Extrapleural Group	Transpleural Group
121.4	98.6	124	100	135.3	102.33

This study also showed that group A and B (according to Waterston classification) were of comparable outcome with other series,¹ but survival in group C are lower as compared with other studies for which the reason might be the higher incidence of lower birth weight, delayed diagnosis, low socioeconomic status, and lack of advanced neonatological backup.

Treatment of EA with tracheoesophageal fistula by this MTP approach is better comparable with conventional EP approach. Complication seen in this study does not show any significant difference with conventional EP approach. It had certain advantages like duration of surgery is significantly low, it brings the mediastinal structures more superficial to wound, which made the anastomosis easy and without interruption. The results in this MTP approach is very much encouraging and well comparable with conventional EP approach, and this approach permits increased facility of surgery with shorter duration; hence, it is recommended as a proper technique of surgery for neonates with esophageal atresia with TEF.

Conclusion

In conclusion, the MTP approach in comparison to the conventional EP approach is less time consuming, easier fistula identification, and esophageal anastomosis. Possess less hindrance during intraoperative ventilation. Postoperative complications are comparable with the EP approach, however in this small series, mortality rate is higher than conventional the EP approach. It is recommended that the MTP approach is an alternate and better technique for repair of TEF in a new born.

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Gadadhar Sarangi

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