Airway Epithelial Cultures of Children with Esophageal Atresia as a Model to Study Respiratory Tract Disorders.

Esophageal atresia (EA) is a rare birth defect in which respiratory tract disorders are a major cause of morbidity. It remains unclear whether respiratory tract disorders are in part caused by alterations in airway epithelial cell functions such as the activity of motile cilia. This can be studied using airway epithelial cell culture models of patients with EA. Therefore, the aim of this study was to evaluate the feasibility to culture and functionally characterize motile cilia function in the differentiated air-liquid interface cultured airway epithelial cells and 3D organoids derived from nasal brushings and bronchoalveolar lavage (BAL) fluid from children with EA. We demonstrate the feasibility of culturing differentiated airway epithelia and organoids of nasal brushings and BAL fluid of children with EA, which display normal motile cilia function. EA patient-derived airway epithelial cultures can be further used to examine whether alterations in epithelial functions contribute to respiratory disorders in EA.

Bacterial Colonization of the Lower Airways in Children With Esophageal Atresia.

BACKGROUND: Esophageal atresia (EA) is most often accompanied by some degree of tracheomalacia (TM), which negatively influences the airway by ineffective clearance of secretions. This can lead to lower airway bacterial colonization (LABC), which may cause recurrent respiratory tract infections (RTIs). This study aims to evaluate the prevalence and specific pathogens of LABC in EA patients. METHODS: A 5-year retrospective single-site cohort study was conducted including all EA patients that had undergone an intraoperative bronchoalveolar lavage (BAL) during various routine surgical interventions. Concentrations of greater than 10 cfu were considered evidence of LABC. RESULTS: We recruited 68 EA patients, of which 12 were excluded based on the exclusion criteria. In the remaining 56 patients, a total of 90 BAL samples were obtained. In 57% of the patients, at least 1 BAL sample was positive for LABC. Respiratory symptoms were reported in 21 patients at the time of the BAL, of which 10 (48%) had LABC. Haemophilus influenzae (14%) and Staphylococcus aureus (16%) were most frequently found in the BAL samples. The number of respiratory tract infections and the existence of a recurrent fistula were significantly associated with LABC ( P = 0.008 and P = 0.04, respectively). CONCLUSIONS: This is the first study showing that patients with EA have a high prevalence of bacterial colonization of the lower airways which may be a leading mechanism of severe and recurrent respiratory complications.

Safety and Feasibility of Indocyanine Green Fluorescence Angiography in Pediatric Gastrointestinal Surgery: A Systematic Review.

BACKGROUND: Although ICG-FA may be valuable in assessing anastomotic perfusion, reliable data on its use in pediatric gastrointestinal surgery is lacking. This systematic review analyzes whether ICG is useful for intestinal perfusion assessment in pediatric gastrointestinal surgery and safe to use in neonates. METHODS: Systematic searches of PubMed, EMBASE & MEDLINE and CENTRAL were performed (last conducted December 6, 2021). The main inclusion criteria were (1) use of ICG for intestinal perfusion assessment and (2) use of ICG in young infants. Exclusion criteria were lack of an English or Dutch full-text and MINORS quality score <60%. Data was presented in overview tables. The usefulness in pediatric gastrointestinal surgery was assessed by surgical outcome. Safety of ICG in neonates was assessed by complication or adverse event occurrence. RESULTS: Regarding intestinal perfusion assessment, four studies were included, reporting 45 patients (median age 1.5 years). ICG was considered useful for anastomotic blood flow evaluation and intraoperative determination of resection length. Regarding ICG safety in neonates, eight studies were included, reporting 46 infants (median age 24.9 days), of which 18 neonates. All but one studies reported the absence of complications or adverse events. Two studies reported subcutaneous dye retention, which fully disappeared within two weeks. CONCLUSION: Although the number of available studies is small, ICG might be useful for intraoperative intestinal perfusion assessment, perhaps even more than conventional clinical assessment. Furthermore, its safety profile looks promising in neonates. Larger prospective studies are necessary to confirm these assumptions and seem warranted given the safety profile. LEVELS OF EVIDENCE: Since this is a systematic review, a Level of Evidence for clinical studies cannot be determined for this manuscript.

Primary Posterior Tracheopexy in Esophageal Atresia Decreases Respiratory Tract Infections.

Background: Esophageal atresia (EA) is often accompanied by tracheomalacia (TM). TM can lead to severe respiratory complaints requiring invasive treatment. This study aims to evaluate if thoracoscopic primary posterior tracheopexy (PPT) can prevent the potential sequelae of TM in patients with EA. Methods: A cohort study including all consecutive EA patients treated between 2014 and July 2019 at the Wilhelmina Children's Hospital was conducted. Two groups were distinguished: (group 1) all EA patients born between January 2014 and December 2016 and (group 2) all EA patients born between January 2017 and July 2019, after introduction of PPT. In the latter group, PPT was performed in EA patients with moderate (33-66%) or severe (67-100%) tracheomalacia, seen during preoperative bronchoscopy. Group differences were assessed using the Fisher's exact test for bivariate variables and the Mann-Whitney U-test for continuous variables. Results: A total of 64 patients were included in this study (28 patients in group 1; 36 patients in group 2). In group 2, PPT was performed in 14 patients. Respiratory tract infections (RTIs) requiring antibiotics within the first year of life occurred significantly less in group 2 (61 vs. 25%, p = 0.004). Brief resolved unexplained events (BRUEs) seemed to diminish in group 2 compared to group 1 (39 vs. 19%, p = 0.09). Conclusion: Thoracoscopic primary posterior tracheopexy decreases the number of respiratory tract infections in EA patients. The clinical impact of reducing RTIs combined with the minimal additional operating time and safety of PPT outweighs the risk of overtreatment.

Thoracoscopic Repair of Esophageal Atresia.

Background: Esophageal atresia (EA) is a rare congenital malformation of the esophagus. Surgical treatment is required to restore the continuity of the esophagus. This can be performed through thoracotomy. However, an increasing number of hospitals is performing minimal invasive surgery (MIS). In this article, we describe the technique of thoracoscopic repair of EA in neonates in more detail and show the outcome of a patient cohort operated by young pediatric surgeons in training. Methods: Between 2014 and 2019 correction was performed in 64 EA type C patients at the UMC Utrecht, Wilhelmina Children's Hospital, mainly by young pediatric surgeons in training. Results: All patients were corrected through MIS, 3 days after birth. The median operation duration was 181 (127-334) minutes. Nasogastric tube feeding was started on the first postoperative day, and oral feeding 6 days postop. Postoperative complications included leakage (14.1%), stenosis (51.1%), and recurrent tracheoesophageal fistula (7.8%). Conclusion: Thoracoscopic repair of EA can be performed safely, with good outcome and all the benefits of MIS. However, it remains a challenging procedure and should be performed only in pediatric centers with a vast experience in MIS, especially when training young pediatric surgeons. These centers must have access to a multidisciplinary team of neonatologists, pediatric anesthesiologists, surgeons, and ENT specialists to ensure the best possible care in hemodynamic, respiratory, and cerebral monitoring and gastrointestinal and developmental outcome.

Childhood outcome after correction of long-gap esophageal atresia by thoracoscopic external traction technique.

BACKGROUND: Thoracoscopic external traction technique (TTT) is a relatively new surgical intervention for patients with long-gap esophageal atresia (LGEA) that preserves the native esophagus. The major accomplishment with TTT is that esophageal repair can be achieved within days after birth. This study evaluates the childhood outcome in LGEA patients treated with TTT, including gastrointestinal outcome, nutritional status and Health-Related Quality of Life (HRQoL). METHODS: A cohort study including all LGEA patients that underwent TTT between 2006-2017 was conducted. Patients and/or their parents were invited to fill out questionnaires regarding reflux symptoms and HRQoL. RESULTS: TTT was successful in 11/13 patients (85%). Esophageal anastomosis was accomplished at a median age of 12 days (range 7-138), first oral feeding was started at a median of 16 days postoperatively (range 5-37). All patients required multiple dilatations and 10 patients required anti-reflux surgery. At median follow-up of seven years, five patients reported mild and one moderate reflux complaints. All patients but one reached age-appropriate oral diet. Most patients (80%) were within normal growth range. Overall HRQoL was comparable to healthy controls. CONCLUSION: TTT provides acceptable results in childhood. Oral feeding can be started as soon as two weeks postoperatively. Almost all patients are able to eat an age-appropriate oral diet. Overall HRQoL was comparable to healthy controls.

ERNICA Consensus Conference on the Management of Patients with Long-Gap Esophageal Atresia: Perioperative, Surgical, and Long-Term Management.

INTRODUCTION: Evidence supporting best practice for long-gap esophageal atresia is limited. The European Reference Network for Rare Inherited Congenital Anomalies (ERNICA) organized a consensus conference on the management of patients with long-gap esophageal atresia based on expert opinion referring to the latest literature aiming to provide clear and uniform statements in this respect. MATERIALS AND METHODS: Twenty-four ERNICA representatives from nine European countries participated. The conference was prepared by item generation, item prioritization by online survey, formulation of a final list containing items on perioperative, surgical, and long-term management, and literature review. The 2-day conference was held in Berlin in November 2019. Anonymous voting was conducted via an internet-based system using a 1 to 9 scale. Consensus was defined as ≥75% of those voting scoring 6 to 9. RESULTS: Ninety-seven items were generated. Complete consensus (100%) was achieved on 56 items (58%), e.g., avoidance of a cervical esophagostomy, promotion of sham feeding, details of delayed anastomosis, thoracoscopic pouch mobilization and placement of traction sutures as novel technique, replacement techniques, and follow-up. Consensus ≥75% was achieved on 90 items (93%), e.g., definition of long gap, routine pyloroplasty in gastric transposition, and avoidance of preoperative bougienage to enable delayed anastomosis. Nineteen items (20%), e.g., methods of gap measurement were discussed controversially (range 1-9). CONCLUSION: This is the first consensus conference on the perioperative, surgical, and long-term management of patients with long-gap esophageal atresia. Substantial statements regarding esophageal reconstruction or replacement and follow-up were formulated which may contribute to improve patient care.

Gastro-esophageal Reflux After Laparoscopic Gastrostomy Placement in Children.

OBJECTIVES: Gastrostomy placement is frequently performed in pediatric patients who require long-term enteral tube feeding. Evidence on the influence of gastrostomy placement on gastro-oesophageal reflux disease has been inconsistent. The aim of this study was to investigate the influence of gastrostomy on gastro-oesophageal reflux. METHODS: A prospective, longitudinal cohort study was performed including 50 patients who underwent laparoscopic gastrostomy between May 2012 and April 2014. Before and 3 months after surgery 24-hour multichannel intraluminal impedance pH monitoring was performed and caregivers filled out reflux symptom questionnaires. RESULTS: Gastro-oesophageal reflux symptoms were present in a comparable number of patients before (44%) and after gastrostomy placement (40%; P = 0.73). Twenty-five of the patients (50%) underwent both the preoperative and postoperative tests and were included in impedance-pH analysis. Acid exposure time (percentage of time with pH below 4) did not change significantly after gastrostomy placement: from 6.2% (3.0-18.1) to 6.1% (2.6-14.9). The number of reflux episodes did not significantly change, for either liquid [mean difference 4.3 (-4.5 to 13.2)] or mixed liquid-gas reflux [mean difference 2.0 (-9.3 to 13.3)]. Before gastrostomy placement, 18 out of 25 patients had pathological reflux (72%) on pH-impedance measurement. In 4 patients, pathological reflux dissolved, whereas 4 patients newly developed pathological reflux. A low preoperative weight-for-height percentile was associated with increased acid exposure after gastrostomy placement. CONCLUSIONS: Overall, gastrostomy placement was not associated with an increase in acid exposure on 24-hour multichannel intraluminal impedance pH monitoring. Similarly, the prevalence of gastro-oesophageal reflux-related symptoms did not change after gastrostomy.

Health-related quality of life in children after laparoscopic gastrostomy placement.

INTRODUCTION: A gastrostomy placement (GP) is an established treatment to provide enteral feeding in pediatric patients with feeding difficulties aiming to improve nutritional status and health-related quality of life (HRQoL). The aim of this study was to evaluate HRQoL in children with severe feeding difficulties who have undergone GP. MATERIALS AND METHODS: A cross-sectional study was performed including 128 patients who had undergone laparoscopic GP (2004-2011). HRQoL was evaluated using the validated Pediatric Quality of Life 4.0 Inventory. Multiple regression analysis was performed to identify predictors of HRQoL. RESULTS: After a mean follow-up of 4.0 years (interquartile range 2.9-6.2) after GP, mean HRQoL was 53.0 out of 100 (standard deviation 21.1). HRQoL was significantly lower in children with neurologic impairment, with a mean difference of -21.4 points between neurologically impaired and neurologically normal children (p < 0.001). HRQoL was also lower in children with cardiac disease (-19.0 points; p = 0.01) and in children with a history of previous gastrointestinal surgery (-15.2 points; p = 0.03). Feeding through a gastrojejunostomy tube (-33.0 points; p = 0.01) and higher age at the time of operation (-1.2 points per year; p = 0.03) were also associated with lower HRQoL. GP-related complications requiring reintervention were associated with lower HRQoL, although this association was not statistically significant (p = 0.06). CONCLUSIONS: Children with severe feeding difficulty, who have undergone GP, have significantly lower HRQoL compared to a healthy pediatric population. Neurologic impairment, cardiac disease, a history of gastrointestinal surgery, older age, and the need for jejunal feeding through the gastrostomy were predictive of even lower HRQoL.

The Effect of Gastrostomy Placement on Health-Related Quality of Life in Children.

BACKGROUND AND PURPOSE: A gastrostomy placement (GP) aims to improve nutritional status and health-related quality of life (HRQoL) in children who require long-term enteral tube feeding. We evaluated the effect of GP on HRQoL. METHODS: A prospective, longitudinal cohort study was performed including patients referred for laparoscopic GP. Children and/or caregivers were asked to fill out the validated PedsQL™ questionnaire before and 3 months after surgery. The aim was to compare preoperative with postoperative HRQoL and to identify predictors of HRQoL. RESULTS: Fifty patients were included with a median age of 3.4 years (interquartile range 1.4-5.6). After GP, total HRQoL did not significantly increase (p = 0.30). However, psychosocial health significantly increased: 55.8 (standard deviation ±20.8) to 61.2 (±19.6; p = 0.03) on a 100-point scale. This was mainly owing to an increase in social HRQoL: 58.2 (±32.3) to 68.3 (±27.9; p = 0.04). HRQoL both before and after GP was significantly lower in children with neurologic impairment (p < 0.0005). However, neurologic impairment did not influence the effect of surgery on HRQoL (p = 0.66). Low preoperative body mass index was a predictor for improvement in HRQoL after GP. CONCLUSIONS: After GP in children, psychosocial HRQoL improved significantly. This was mainly owing to an improvement in social HRQoL. LEVEL OF EVIDENCE: IV.

Thoracoscopic posterior tracheopexy during primary esophageal atresia repair: a new approach to prevent tracheomalacia complications.

BACKGROUND: Esophageal atresia (EA) is usually accompanied by some form of tracheomalacia (TM). During the early phases in life, excessive dynamic collapse of the trachea can cause a wide spectrum of symptoms ranging from mild complaints to apparent life-threatening events (ALTE's) or brief resolved unexplained events (BRUE's). Therapeutic strategies for severe TM include aortopexy to lift the anterior weakened cartilaginous rings or posterior tracheopexy of the floppy membranous tracheal intrusion. In this study, we describe the development of a new approach in which the posterior tracheopexy is performed directly during the primary thoracoscopic correction of EA. METHODS: In 2017, all nine consecutive EA patients with trachea-esophageal fistula underwent a rigid tracheo-bronchoscopy (RTB) evaluation during induction of anesthesia prior to the thoracoscopic EA repair. A floppy posterior membrane was diagnosed in four patients. During the subsequent thoracoscopic procedure, the posterior membranous trachea was fixed to the anterior longitudinal spinal ligament with non-absorbable sutures. Then, the anastomosis was made between the two esophageal pouches. RESULTS: On preoperative RTB, two patients had a severe (70-90%) mid-tracheal collapse of the pars membranacea and two patients had a moderate (33-40%) mid-tracheal collapse. Thoracoscopic posterior tracheopexy with two or three sutures was possible in all four patients, prior to the formation of the esophageal anastomosis. Median time per suture was 6 min (range 4-12 min). All operative procedures were uneventful. A median follow-up of 6 months (range 4-9 months) revealed that all patients showed further recovery without any TM symptoms or ALTE/BRUE. CONCLUSIONS: This is the first report that introduces a new approach to thoracoscopic posterior tracheopexy during primary EA repair. We believe that this technique can prevent the potentially deleterious sequelae of mild to severe TM that may complicate the lives of EA patients. Also, a second, sometimes complex surgical procedure can be prevented as the posterior tracheopexy is performed during the primary thoracoscopic EA correction. LEVEL OF EVIDENCE: IV.

Neonatal brain oxygenation during thoracoscopic correction of esophageal atresia.

BACKGROUND: Little is known about the effects of carbon dioxide (CO2) insufflation on cerebral oxygenation during thoracoscopy in neonates. Near-infrared spectroscopy can measure perioperative brain oxygenation [regional cerebral oxygen saturation (rScO2)]. AIMS: To evaluate the effects of CO2 insufflation on rScO2 during thoracoscopic esophageal atresia (EA) repair. METHODS: This is an observational study during thoracoscopic EA repair with 5 mmHg CO2 insufflation pressure. Mean arterial blood pressure (MABP), arterial oxygen saturation (SaO2), partial pressure of arterial carbon dioxide (paCO2), pH, and rScO2 were monitored in 15 neonates at seven time points: baseline (T0), after anesthesia induction (T1), after CO2-insufflation (T2), before CO2-exsufflation (T3), and postoperatively at 6 (T4), 12 (T5), and 24 h (T6). RESULTS: MABP remained stable. SaO2 decreased from T0 to T2 [97 ± 3-90 ± 6 % (p < 0.01)]. PaCO2 increased from T0 to T2 [41 ± 6-54 ± 15 mmHg (p < 0.01)]. pH decreased from T0 to T2 [7.33 ± 0.04-7.25 ± 0.11 (p < 0.05)]. All parameters recovered during the surgical course. Mean rScO2 was significantly higher at T1 compared to T2 [77 ± 10-73 ± 7 % (p < 0.05)]. Mean rScO2 levels never dropped below a safety threshold of 55 %. CONCLUSION: The impact of neonatal thoracoscopic repair of EA with insufflation of CO2 at 5 mmHg was studied. Intrathoracic CO2 insufflation caused a reversible decrease in SaO2 and pH and an increase in paCO2. The rScO2 was higher at anesthesia induction but remained stable and within normal limits during and after the CO2 pneumothorax, which suggest no hampering of cerebral oxygenation by the thoracoscopic intervention. Future studies will focus on the long-term effects of this surgery on the developing brain.

Brain oxygenation during laparoscopic correction of hypertrophic pyloric stenosis.

BACKGROUND: Concern remains about the safety of carbon dioxide (CO2) pneumoperitoneum (PP) in young infants having surgery for pyloric stenosis via laparoscopy. Interests here mainly focus on possible jeopardized organ perfusion and in particular brain oxygenation with possible adverse neurodevelopmental outcomes. The aim of this study was to investigate the intraoperative effects of CO2 gas PP on cerebral oxygenation during laparoscopic surgery for hypertrophic pyloric stenosis in young infants. PATIENTS AND METHODS: In this single-center prospective observational study, we investigated brain oxygenation in 12 young infants receiving laparoscopic pyloromyotomy with CO2 PP, with a pressure of 8 mm Hg and a flow rate of 5 L/minute. Intraoperative hemodynamic parameters and transcranial near-infrared spectroscopy to assess regional cerebral oxygen saturation (rScO2) were monitored continuously during the whole procedure. Parameters were analyzed in four intervals: before insufflation (T0), during (start [T1] and end [T2]), and after cessation (T3) of the CO2 PP. RESULTS: Blood pressure and end-tidal CO2 (etCO2) increased during the procedure: mean arterial pressure, 35±5 mm Hg at T0 to 43±9 mm Hg at T2; etCO2, 35±4 mm Hg at T0 to 40±3 mm Hg at T3. The rScO2 remained stable throughout the whole anesthetic period. In none of the patients did the rScO2 drop below the safety threshold of 55% (rScO2, 68±14% at T0 to 71±9% at T3). CONCLUSIONS: Our results indicate that a laparoscopic procedure with a CO2 PP of 8 mm Hg can be performed under safe anesthetic conditions in the presence of gradually increasing blood pressure and etCO2 without altering regional brain oxygenation levels.

The effects of CO2-insufflation with 5 and 10 mmHg during thoracoscopy on cerebral oxygenation and hemodynamics in piglets: an animal experimental study.

OBJECTIVE: To evaluate the effect of CO2-insufflation with 5 and 10 mmHg on cerebral oxygenation and hemodynamics in neonates. BACKGROUND: An increasing percentage of surgical interventions in neonates are performed by minimal invasive techniques. Recently, concerns have been raised regarding a decrease of cerebral oxygenation in neonates during thoracoscopy as a result of CO2-insufflation. METHODS: This was an animal experimental study. Piglets were anesthetized, intubated, ventilated, and surgically prepared for CO2-insufflation. Insufflation was done with 5 or 10 mmHg CO2 during 1 h. Arterial saturation (SaO2), heart rate (HR), mean arterial blood pressure (MABP), and cerebral oxygenation (rScO2) were monitored. CFTOE, an estimator of cerebral oxygen extraction ((SaO2 - rScO2)/SaO2)), was calculated. Arterial blood gases were drawn every 15': pre (T0), during (T1-T4) and after CO2-insufflation (T5). RESULTS: Ten piglets (4 kg) were randomized for 5 (P5) and 10 (P10) mmHg CO2-insufflation. Two P10 piglets needed resuscitation after insufflation, none P5. Linear mixed-effect modeling of paCO2, pH, and SaO2 showed that values were dependent on time and time squared (p < 0.001) but were not different between the 5 and 10 mmHg groups. Analysis demonstrated significant changes over time in heart rate and MABP between the 5 and 10 mmHg groups, with a significant higher heart rate and lower blood pressure in the 10 mmHg group (p < 0.001). For rScO2 and cFTOE, no group differences could be demonstrated, but a significant effect of time was found: rScO2 increased and cFTOE decreased (p < 0.001). CONCLUSIONS: Insufflation of CO2 during thoracoscopy with 10 mmHg caused more severe hemodynamic instability and seems to be related with a decrease of cerebral perfusion as represented by a higher oxygen extraction. CO2-insufflation of 5 mmHg for thoracoscopy seems to have no adverse effects on cerebral oxygenation.

Carbon dioxide gas pneumoperitoneum induces minimal microcirculatory changes in neonates during laparoscopic pyloromyotomy.

BACKGROUND: Little is known about the direct effect of pneumoperitoneum (PP) on microcirculation and its influence on the quality of tissue perfusion. This study aimed to investigate the intraoperative effects of carbon dioxide (CO2) gas PP on microcirculation density and perfusion in neonates receiving laparoscopic surgery for hypertrophic pyloric stenosis. METHODS: In a single-center observational study, the oral microcirculation in 12 neonates receiving laparoscopic pyloromyotomy was investigated. Intraoperative hemodynamic parameters, intermittent buccal mucosa capillary density measurements (pre- and postoperative), and continuous intraoperative sublingual microcirculation measurements (i.e., vessels with a diameter <25 µm) of total vessel density, perfused vessel density, proportion of perfused blood vessels, blood vessel diameters (BVd), and microvascular flow index were obtained before (at baseline), during, and after PP insufflation for all patients using sidestream dark-field imaging for the duration of the complete surgical procedure. RESULTS: With the exception of a significantly elevated end-tidal CO2 (34 ± 4-40 ± 8 mmHg; p < 0.05 vs before [baseline], one-way analysis of variance [ANOVA]) during intraoperative insufflation, no significant differences were found between time points for the intraoperative hemodynamic parameters. Pre- and postoperative buccal capillary density showed no significant changes in mucosal perfusion. Analysis of continuous intraoperative sublingual microcirculation parameters exhibited a statistically significant increase in BVd during insufflation (8.8 ± 2.4-9.3 ± 2.5 µm; p < 0.05, one-way ANOVA) and a significant decrease after exsufflation (8.2 ± 2.3 µm; p < 0.01 vs during insufflation and p < 0.05 vs baseline, one-way ANOVA, respectively). No other significant differences were found between time points for the remaining microcirculatory parameters. CONCLUSION: The installation of CO2 gas PP during laparoscopic pyloromyotomy procedures regulates microcirculatory perfusion by inducing changes in microvascular diameters but does not alter microcirculation density in neonates.

Learning curve of thoracoscopic repair of esophageal atresia.

BACKGROUND: Thoracoscopic repair of esophageal atresia is considered to be one of the more advanced pediatric surgical procedures, and it undoubtedly has a learning curve. This is a single-center study that was designed to determine the learning curve of thoracoscopic repair of esophageal atresia. METHODS: The study involved comparison of the first and second five-year outcomes of thoracoscopic esophageal atresia repair. RESULTS: The demographics of the two groups were comparable. There was a remarkable reduction of postoperative leakage or stenosis, and recurrence of fistulae, in spite of the fact that nowadays the procedure is mainly performed by young staff members and fellows. CONCLUSIONS: There is a considerable learning curve for thoracoscopic repair of esophageal atresia. Centers with the ambition to start up a program for thoracoscopic repair of esophageal atresia should do so with the guidance of experienced centers.

The influence of the CO2 pneumoperitoneum on a rat model of intestinal anastomosis healing.

BACKGROUND: The CO(2) pneumoperitoneum, which is used for laparoscopic surgery, causes local and systemic effects in patients. Concern arises about what the pressurized anoxic environment of the CO(2) pneumoperitoneum has on intestinal healing. Earlier experimental work showed a negative correlation between intestinal healing and the applied intra-abdominal pressure. To further elucidate this, we developed a rat model, in which enterotomy healing can be compared after open or laparoscopic surgery. Possible mechanisms of injury, such as impaired neoangiogenesis or injury through hypoxia-induced pathways were studied. METHODS: A new experimental mechanically ventilated rat model was developed. An enterotomy was made and closed via laparotomy (group I) or laparoscopy under CO(2) pressures of 5 mmHg (group II) or 10 mmHg (group III). Intestinal healing was tested in vivo after 1 week by bursting-pressure analysis. The effect of the operative procedure on neoangiogenesis was tested by counting factor VIII positive vessels in biopsies of the perianastomotic granulation tissue after 1 week. Intestinal anoxia was tested by quantifying HIF-1α protein levels in intestinal biopsies, taken before the enterotomy closure. RESULTS: The bursting pressures were significantly lower after laparoscopic surgery at 10 mmHg CO(2) pneumoperitoneum (group III) compared with rats that had undergone open surgery (group I) or laparoscopic surgery at 5 mmHg CO(2) pneumoperitoneum (group II). There was no significant quantitative difference between the three groups in the neoangiogenesis nor was there a difference in the amount of HIF-1α measured in the intestinal biopsies. CONCLUSIONS: We developed a surgical model that is well fitted to study the effects of pneumoperitoneum on intestinal healing. With this model, we found further evidence of CO(2) pressure-dependant hampered intestinal healing. These differences could not be explained by difference in neoangiogenesis nor local upregulation of hypoxic factors.

An infected urachal cyst--a rare diagnosis in a child with acute abdominal pain.

UNLABELLED: A 2-year-old girl who presented with acute abdominal pain and spiking fever was diagnosed with an infected urachal cyst. Ultrasonography aided the diagnosis and the urachal remnant was removed successfully through a single laparoscopic procedure. Treatment is through removal of the complete structure, to prevent malignant degeneration in adulthood. CONCLUSION: Urachal cysts may cause abdominal complaints when infected. Although rare, they should be added to the differential diagnosis of acute abdominal pain in the paediatric patient, as this case illustrates.

A novel technique for risk calculation of anastomotic leakage after thoracoscopic repair for esophageal atresia with distal fistula.

PURPOSE: This study was designed to determine the risk of anastomotic leakage after thoracoscopic repair for esophageal atresia by digitally measuring the length of the proximal esophagus and distance of carina to proximal esophagus. METHODS: With the use of Picture Archiving and Communication System (PACS), the length of the proximal esophagus from the top of the first thoracic vertebra was measured on the preoperative chest x-ray, as well as the distance from the carina to the proximal esophagus. The chest x-rays of 27 neonates, born with esophageal atresia with distal fistula, were examined. Furthermore, the tapes from the procedures were reviewed. Statistical analysis was performed with the t test for equality of means by using SPSS 12.0.1 for Windows. RESULTS: Both groups were comparable, and there was a statistical significant difference in both length of the proximal esophagus (p < 0.023) and distance of carina to proximal esophagus (p < 0.022) in patients who did and did not leak postoperatively. There seems to be a tendency toward a shorter proximal esophagus in recent years that was not obvious earlier. CONCLUSIONS: The digital measurement of the length of the proximal esophagus (M < 7 mm) and distance of carina to proximal esophagus (M > 13.5 mm) with the use of PACS gives a good risk calculation for postoperative leakage.

Thoracoscopic elongation of the esophagus in long gap esophageal atresia.

Long gap esophageal atresia in which a primary anastomosis cannot be achieved remains a challenge. Elongation of the esophagus by traction on the 2 ends has been previously described. With the advent of thoracoscopic repair of esophageal atresia, there have thus far been no reports of thoracoscopic repair of long gap esophageal atresia. This paper describes the first successful repair of long gap esophageal atresia by thoracoscopic traction of the 2 esophageal ends and delayed thoracoscopic anastomosis.