The dilemma after an unforeseen aortic arch anomalies at thoracoscopic repair of esophageal atresia: Is curtailing surgery still a necessity?

BACKGROUND AND OBJECTIVE: There are several forms of relevant epi-aortic branching anomalies, and perhaps that is why different views as to the best approach have been reported. To help resolve this dilemma, we examined the unforeseen arch anomalies found at thoracoscopic repair of esophageal atresia and the outcomes. METHODS: In a retrospective cohort, all consecutive patients who were thoracoscopically approached for esophageal atresia over a 5-year period with unforeseen aortic/epi-aortic branching were identified and grouped. Thoracoscopic views, operative interventions, and outcomes were studied. RESULTS: A total of 121 neonates were thoracoscopically approached for EA, of whom 18 cases with aberrant aortic architecture were selected. Four (3%) cases were diagnosed on a preoperative echocardiography as a right-sided aortic arch, whereas unforeseen anomalous anatomies were reported in 14 cases (11.6%): left aortic arch with an aberrant right subclavian artery (ARSA) (n = 10), right-sided aortic arch with an aberrant left subclavian artery (ALSA) (n = 3), and mirror-image right arch (n = 1). Single postoperative mortality was reported among the group with left arch and ARSA (10%), whereas all the cases with right arch and ALSA died. CONCLUSIONS: In all, 11.6% of the studied series exhibited unexpected aberrant aortic architecture, with higher complication rates in comparison to the typical thoracoscopic repairs. For EA with left aortic arch and ARSA, the primary esophageal surgery could safely be completed. Meanwhile, curtailing surgery-after ligating the TEF-to get advanced imaging is still advised for both groups with the right arch due to the significant existence of vascular rings.

Laparoscopic Resurrection of an Old Technique: A New Approach for Total Urogenital Separation and Rectal Pull-Through in Patients with Long Common Channel Cloacal Malformation.

Background and Aims: Before the significance of urethral length was highlighted in patients with cloacal malformation, total urogenital mobilization using a posterior sagittal approach was recommended for common channel (CC) length <3 cm, those >3 cm it was followed by urogenital separation. However, many urologists are advocating that the urethral length rather than length of the CC should influence the choice of operation. It is also recommended that total urogenital mobilization should be avoided in patients with short urethral length as intraoperative decision to shift to urogenital separation will risk devascularization of the urethra, advocating total urogenital separation (TUS) from the start; the later technique was deemed difficult using open approach. We describe our experience with laparoscopic TUS and rectal pull-through in patients with cloacal malformation. Methods: Six patients were operated for a period of 3 years from December 2017 to July 2021; they underwent laparoscopic TUS and rectal pull-through. Preoperative investigations included cystoscopy, genitogram, and MRI pelvis and abdominal ultrasound. IRB approval has been obtained from research ethical committee at Cairo University. Results: Six female patients born with single perineal opening had colostomy at birth. Age during the second operation ranged from 1 to 4 years. Length of the CC ranged between 2 and 5 cm. Proximal urethral length ranged between 0.5 and 1.5 cm and vaginal depth >3 cm. Average operative time was 4.25 hours. Postoperative period was 1-5 days and uneventful. On the long-term follow-up. No patient developed urethrovaginal fistula and one patient developed vaginal stenosis. All patients had no urinary problems, dry over 4-hour interval, voiding spontaneously, and had normal kidney functions. Conclusions: Laparoscopic urogenital separation, as well as vaginal and rectal pull-through for cloacal malformation, is feasible in cloacal malformation providing anatomical repair.

Outcome of thoracoscopic repair of type-C esophageal atresia: a single-center experience from North Africa.

Thoracoscopic repair of esophageal atresia is gaining popularity worldwide attributable to availability and advances in minimally invasive instruments. In this report, we presented our experience with thoracoscopic esophageal atresia/tracheoesophageal fistula (EA/TEF) repair in our tertiary care institute. A prospective study on short-gap type-C EA/TEF was conducted at Cairo University Specialized Pediatric Hospital between April 2016 and 2018. Excluded were cases with birth weight < 1500 gm, inability to stabilize physiologic parameters, or major cardiac anomalies. The technique was standardized in all cases and was carried out by operating team concerned with minimally invasive surgery at our facility. Primary outcome evaluated was successful primary anastomosis. Secondary outcomes included operative time, conversion rate, anastomotic leakage, recurrent fistula, postoperative stricture, and time till discharge. Over the inclusion period of this study, 136 cases of EA/TEF were admitted at our surgical NICU. Thoracoscopic repair was attempted in 76 cases. In total, 30 cases were pure atresia/long gap type-C atresia and were excluded from the study. Remaining 46 cases met the inclusion criteria and were enrolled in the study. Mean age at operation was 8.7 days (range 2-32), and mean weight was 2.6 Kg (range 1.8-3.6). Apart from five cases (10.8%) converted to thoracotomy, the mean operative time was 108.3 minutes (range 80-122 minute). A tension-free primary anastomosis was possible in all thoracoscopically managed cases (n = 41) cases. Survival rate was 85.4% (n = 35). Anastomotic leakage occurred in seven patients (17%). Conservative management was successful in two cases, while esophagostomy and gastrostomy were judged necessary in the other for five. Anastomotic stricture developed in five cases (16.6%) of the 30 surviving patients who kept their native esophagus. Despite the fact that good mid-term presented results may be due to patient selection bias, thoracoscopic approach proved to be feasible for management of short-gap EA/TEF. Authors of this report believe that thoracoscopy should gain wider acceptance and pediatric surgeons should strive to adopt this procedure.

Short-term Effects of Mitomycin C Infiltration for Caustic Oesophageal Strictures in Children.

OBJECTIVES: The aim of this study was to investigate the efficacy and safety of endoscopic local infiltration of mitomycin C (MMC) after oesophageal dilation for children suffering from refractory postcorrosive oesophageal stricture (OS). METHODS: Children referred to Cairo University Specialized Paediatric Hospital with refractory postcorrosive OS during the period from March 2016 to August 2017 were included in this study. MMC was infiltrated endoscopically at the stricture site by the end of the dilation session. The measured outcomes were dysphagia score (DS) and periodic dilation index (PDI). RESULTS: During the inclusion period of the presented study, 17 children met the inclusion criteria. There were 7 boys and 10 girls. During the follow-up period, an average of 3.8 dilation sessions with MMC infiltration per case were performed, using a total dose of 1 mg each session. The median follow-up period was 9.5 months. The median DS improved from DS 3 before application of MMC to DS 0 at the last follow-up (P < 0.001). Additionally, the median PDI declined from 1 to 0.75 after MMC application (P = 0.052). Sixteen cases (94%) became dysphagia free after 6 months. Seven patients experienced postdilation minor bleeding that was spontaneously resolved, not triggering blood transfusion. There were no infiltration-related complications in the included series. CONCLUSION: Stricture-site MMC endoscopic infiltration by the end of a dilation session proved to be safe and effective in improving the DS and PDI.

Laparoscopic Diamond Antroduodenostomy for Postcorrosive Pyloric Cicatrization: A Novel Approach.

BACKGROUND: Traditionally, Billroth I procedure or bypass gastrojejunostomy were the recommended approaches for management of postcorrosive complete gastric outlet obstruction (GOO), whereas Heineke Mickulicz pyloroplasty was recommended for moderate mucosal injury with partial cicatrization. In this study, laparoscopic diamond antroduodenostomy was carried out as an alternative minimally invasive approach for cases with pyloric cicatricial obstruction. PATIENTS AND METHODS: Between January and December 2017, children who were referred to Pediatric Surgery Department, Cairo University Hospital, with GOO as a consequence of caustic liquid ingestions were included in this study. Laparoscopic diamond antroduodenostomy was performed for the presented cases. RESULTS: Through the year 2017, 5 cases were approached with laparoscopic diamond antroduodenostomy. Isolated pyloric cicatrization was evident in 4 cases, whereas synchronous insult to thoracic esophagus and pylorus was manifest in the fifth case. Laparoscopic feeding jejunostomy completed the procedure for the case with esophageal stricture. Contrast study-24 hour postoperatively-assured no radiological leaks in the presented cases, where enteral feeding was gradually commenced, and patients discharged home a day later. After a mean follow-up of 13.5 months, neither recurrence of obstructive symptoms nor dumping was displayed. Cosmetic outlook inherent to the minimally invasive approach was appreciated by the parents. CONCLUSION: Laparoscopic diamond antroduodenostomy is a feasible approach for management of postcorrosive pyloric obstruction. It allowed early enteral feeding, with no dumping symptoms, in addition to the fundamental advantages of minimally invasive surgery. A bigger series and longer follow-up is recommended to verify the reported results.