Tailored endoscopic treatment of tracheo-oesophageal fistula using preoperative holographic assessment and a cardiac septal occluder.

Devices originally designed for closure of cardiac septal defects have also been proposed for the treatment of acquired tracheo-oesophageal fistula (TOF). Choosing the right occluder device to match TOF size and shape is essential for a tailored treatment. We report the successful endoscopic closure of a post-radiotherapy TOF using preprocedural CT scan with holographic three-dimensional reconstruction and an Amplatzer atrial septal device. Complete TOF sealing was achieved with resolution of respiratory symptoms, and the patient was maintaining his ability to eat at 4-month follow-up.

Assessment of the Concerns of Caregivers of Children with Repaired Esophageal Atresia-Tracheoesophageal Fistula Related to Feeding-Swallowing Difficulties.

The study aimed to assess concerns of caregivers of children with EA-TEF related to feeding-swallowing difficulties, compare the concerns according to type of atresia and repair time, and investigate its relationship with time to start oral feeding. Caregivers accompanying 64 children with EA-TEF were included. Age, sex, type of atresia, repair time, and time to start oral feeding were noted. Parents completed the Turkish version of the Feeding/Swallowing Impact Survey (T-FS-IS) to assess the concerns of caregivers related to feeding-swallowing difficulties. The T-FS-IS has three subscales including daily activities, worry, and feeding difficulties. The median age of patients was 3 (min = 1, max = 12) years, of which 57.8% were male. 43.8% of cases were isolated-EA, and 56.3% were EA-distal TEF. 57.8% of cases received early repair, and 42.2% had delayed repair. The median time to start oral feeding was 4 weeks (min = 1, max = 128). The mean scores of daily activities, worry, feeding difficulties, and total score from the T-FS-IS were 2.43 ± 1.18, 2.73 ± 1.28, 2.10 ± 0.97, and 2.44 ± 1.09, respectively. Caregivers of children with isolated-EA reported more problems in total score and all subscales of the T-FS-IS than EA-distal TEF (p < 0.01). Caregivers of children who received delayed repair reported more problems in total score and all subscales of the T-FS-IS than children with early repair (p < 0.05). Moderate to strong correlations were found between the T-FS-IS and time to start oral feeding (p < 0.01, r = 0.55-0.65). This study suggests that caregivers of children with isolated-EA and/or delayed repair and/or delay in oral intake may have higher concerns related to feeding-swallowing difficulties.

Neonatal surgery in low- vs. high-volume institutions: a KID inpatient database outcomes and cost study after repair of congenital diaphragmatic hernia, esophageal atresia, and gastroschisis.

BACKGROUND/PURPOSE: The volume-outcome relationship and optimal surgical volumes for repair of congenital anomalies in neonates is unknown. METHODS: A retrospective study of infants who underwent diaphragmatic hernia (CDH), gastroschisis (GS), and esophageal atresia/tracheoesophageal fistula (EA/TEF) repair at US hospitals using the Kids' Inpatient Database 2009-2012. Distribution of institutional volumes was calculated. Multi-level logistic/linear regressions were used to determine the association between volume and mortality, length of stay, and costs. RESULTS: Total surgical volumes were 1186 for CDH, 1280 for EA/TEF, and 3372 for GS. Median case volume per institution was three for CDH and EA/TEF, and four for GS. Hospitals with annual case volumes ≥ 75th percentile were considered high volume. Approximately, half of all surgeries were performed at low-volume hospitals. No clinically meaningful association between volume and outcomes was found for any procedure. Median cost was greater at high- vs. low-volume hospitals [CDH: $165,964 (p < 0.0001) vs. $104,107, EA/TEF: $85,791 vs. $67,487 (p < 0.006), GS: $83,156 vs. $72,710 (p < 0.0009)]. CONCLUSIONS: An association between volume and outcome was not identified in this study using robust outcome measures. The cost of care was higher in high-volume institutions compared to low-volume institutions. LEVEL OF EVIDENCE: III.

Utilizing stricture indices to predict dilation of strictures after esophageal atresia repair.

BACKGROUND: Anastomotic stricture is the most common postoperative complication in infants undergoing repair of esophageal atresia with or without tracheoesophageal fistula (EA/TEF). Stricture indices (SIs) are used to predict infants at risk for stricture requiring dilation. We sought to determine the most accurate SI and optimal timing for predicting anastomotic dilation. MATERIALS AND METHODS: A retrospective study of infants undergoing repair of EA/TEF between 2008 and 2013 was performed. Esophagrams were used to calculate four SIs (upper pouch esophageal anastomotic stricture index [U-EASI], lower pouch esophageal anastomotic stricture index [L-EASI], lateral SI, and anterior/posterior SI). The best performing SI was identified. Logistic regression analysis was performed to determine if a first or second esophagram SI threshold was associated with dilation. A receiver operating characteristic curve measured the accuracy of the model using SIs to predict dilation. RESULTS: Of 45 EA/TEF infants included, 20 (44%) had postoperative strictures requiring dilation. As the best performing SI, logistic regression analysis showed that U-EASI as a continuous variable was predictive of dilation (P = 0.03) but was not significant at U-EASI ≤ 0.37. However, U-EASI ≤ 0.37 was associated with needing earlier dilation. On second esophagram (median, 38 days), U-EASI of ≤0.39 was significantly associated with dilation (OR: 7.8, 95% CI: 1.05-57.58, P = 0.04). The area under the receiver operating characteristic curve of the U-EASI model controlling for days to esophagram demonstrated improved predictive ability from first (AUC 0.73) to second esophagram (AUC 0.81). CONCLUSIONS: Calculation of the SI utilizing a U-EASI ≤ 0.39 on the delayed esophagram is associated with future anastomotic dilation. A multi-institutional study is necessary to confirm the predictive ability of the U-EASI.

Preliminary Study of Video-Based Pediatric Endoscopic Surgical Skill Assessment Using a Neonatal Esophageal Atresia/Tracheoesophageal Fistula Model.

PURPOSE: Thoracoscopic esophageal atresia/tracheoesophageal fistula (EA/TEF) repair in neonates is technically difficult because of the small working space and fragility of tissues. This study aimed to show the construct validity of the neonatal EA/TEF simulator by video-based assessment of endoscopic suturing skill. MATERIALS AND METHODS: A rapid-prototyped neonatal chest model with an artificial esophagus model similar to the actual neonatal esophagus was developed. Forty pediatric surgeons performed an endoscopic intracorporeal suturing task and a knot-tying task using the model, and a questionnaire survey was administered. Each task was video recorded and assessed using two skill assessment methods (the 29-point checklist method and the error assessment sheet method). The task completion time and the number of manipulations were measured. RESULTS: With regard to experience in performing thoracoscopic TEF repair, the experienced surgeons (ESs, ≥3 EA/TEF repair experiences, n = 6) were significantly superior to the inexperienced surgeons (ISs, <3 experiences, n = 34) in all metrics. Upon comparison by the pediatric Endoscopic Surgical Skill Qualification (ESSQ) status, there were no significant differences in all metrics between the ESSQ-qualified (n = 15) and nonqualified (n = 25) surgeons. The qualified ESs (n = 6) were significantly superior to the qualified ISs (n = 9) in all metrics. CONCLUSION: Video-based endoscopic surgical skill assessment using the neonatal EA/TEF simulator could differentiate ESs from ISs. The construct validity of the simulator was demonstrated, and the simulator would be useful especially for practicing thoracoscopic EA/TEF procedures.

Assessment of Clinical Symptoms and Multichannel Intraluminal Impedance and pH Monitoring in Children After Thoracoscopic Repair of Esophageal Atresia and Distal Tracheoesophageal Fistula.

BACKGROUND: Motility disturbances of the esophagus and gastroesophageal reflux disease (GERD) are observed frequently in children after repair of congenital esophageal atresia with distal tracheoesophageal fistula (EA/TEF). Recently, in many pediatric surgical centers, thoracoscopic repair was introduced, which theoretically would change the postoperative course. OBJECTIVES: The goal of the study was to assess physical development, disease symptoms, and GERD symptom frequency in children who underwent thoracoscopic surgery of congenital EA/TEF. MATERIAL AND METHODS: The study comprised 22 children (14 boys and 8 girls), aged 16 to 79 months (average age 47.3 months) after surgery of EA/TEF. Clinical symptoms and physical development were analyzed. In 19 children, multichannel intraluminal esophageal impedance connected with pH-metry (MII/pH) was performed. In 11 patients, esophagogastroduodenoscopy with a histological study of mucosa samples was done. RESULTS: The most frequent symptoms were dysphagia, belching, cough and recurrent bronchitis. In 31.5% of the children, body mass deficiency was observed and in 28.6%, low body mass and short stature. Prematurity was present in half of the patients. Depending on the result of the MII/pH study, the children were divided into two groups: 10 children with GERD and 9 children without diagnosis of gastroesophageal reflux. In the 10 with GERD, acid reflux was diagnosed in 9 and non-acid reflux was diagnosed in one. MII/pH demonstrated statistically significant differences in the number of reflux episodes, reflux index, bolus exposure index, mean time of esophageal exposure and acid exposure and mean acid clearance time in children with GERD in comparison to children without this disease. In 36.4% of children who underwent endoscopy, esophagitis was diagnosed, esophageal stricture in 18% and gastric metaplasia in 9.1%. CONCLUSIONS: In children who underwent corrective thoracoscopic surgery of EA/TEF, GERD caused by motility disorders of the esophagus was frequently observed. These children require constant monitoring and early treatment of the complication.

Validation of an inanimate low cost model for training minimal invasive surgery (MIS) of esophageal atresia with tracheoesophageal fistula (AE/TEF) repair.

UNLABELLED: We present the results of the validation of an inanimate model created for training thoracoscopic treatment of esophageal atresia with lower tracheoesophageal fistula (EA/TEF). MATERIALS AND METHODS: We used different domestic materials such as a piece of wood (support), corrugated plastic tubes (PVC) of different sizes to simulate ribs, intercostal spaces, trachea and spine and tubular latex balloons to simulate the esophagus and lungs to make the basic model. This device was inserted into the thoracic cavity of a rubber dummy simulating a 3kg newborn with a work area volume of 50ml. The model was designed taking into account the experience of doing this procedure in neonates. The cost of the materials used was 50 US$. Regular video endoscopic equipment and 3mm instruments were used. Thirty-nine international faculty or pediatric surgeons attending hands on courses with different levels of training in minimal invasive surgery (MIS) repair of EA/TEF performed the procedure in the model. We compared the performance of the practitioners with their experience in thoracoscopic repair of EA. A Likert-type scale was used to evaluate results. Previous experience in MIS, anatomical appearance of the model, surgical anatomy compared to a real patient, and utility as a training method were analyzed. We also used a checklist to assess performance. We evaluated: number of errors and types of injuries, quality of the anastomosis, and duration of procedure. To analyze the results we used a T-test, chi-square test and Excel® database to match up some results. RESULTS: Thirty-nine questionnaires were completed. Seven surgeons were experts (≥30 TEF/EA repairs as surgeon), 10 had intermediate level of experience (5 to 29 repairs as surgeon) and 22 were beginners (less than 5 repairs). To simplify the analysis we divided the respondents into low experience LE (<5 real procedures-beginners; n=22) and high experience HE (intermediate, 10; and experts, 7; n=17). In relation to the anatomical characteristics of the model, 94.48% (n=37) respondents considered that the model has a high degree of similarity or good similarity; in relation to surgical anatomy 88.2% (n=34) respondents considered that the model has a high degree of similarity or good similarity; 87.17% (n=34) respondents considered that the model can generate a good amount of skills and/or can generate great majority of skills to EA/TEF repair; and 12.82% (n=5) respondents consider that it can generate some skills or a few skills, only in relation to trocar placement, one of the surveyed items. The number of errors was 29±7 SD (20 to 51) for the low experience group (LE) and 9±6 SD (1 to 20) for the high experience group (HE) (P value<0.0001). Time in minutes was significantly lower in the HE group (40±9 SD; 26 to 58min), in relation with LE (81±19 SD; 49 to 118min) (P<0.0001, T-test). Deficient or incomplete anastomosis also showed differences: 7 (32%) in the LE group and 1 (6%) in the HE group (P = 0.04, chi-square test). We saw a correlation between the previous experience of the surgeon and their performance in the model considering operating time, quality of anastomosis and peripheral tissue damage. According to the suggestions registered in the questionnaires, we have now improved the model. We have also started using it in a scenario to simulate the whole neonatal MIS operative room setting and team work.

Weekday vs. weekend repair of esophageal atresia and tracheoesophageal fistula.

PURPOSE: We hypothesize that weekend esophageal atresia and tracheoesophageal fistula (EA/TEF) repair has worse outcomes compared to procedures performed on weekdays. METHODS: Kids' Inpatient Database (1997-2009) was searched for EA/TEF in infants admitted at <8days of life. Cases were limited to patients who underwent repair during their hospitalization. Risk-adjusted multivariate analysis (MVA) compared complications, mortality, and resource utilization (length of stay [LOS] total charges [TC]) between weekday and weekend procedures. RESULTS: Overall, 861 EA/TEF cases with known day of repair were identified. Cohort survival was 96%. On risk-adjusted MVA, complication rates were higher with EA/TEF repair on a weekend (OR: 2.2) compared to a weekday. Additionally, complications (OR: 6.5) and LOS (OR: 9.3) were found to be higher among African American children compared to Caucasians. LOS was higher in patients with Medicaid (OR: 2.4) and repairs performed at non-teaching hospitals (OR: 3.2). Weekend vs. weekday procedure had no significant effect on mortality or resource utilization. CONCLUSION: By risk-adjusted MVA, increased complication rates for EA/TEF are seen in patients undergoing repair on weekends compared to weekdays. Additionally, African American children experienced higher complication rates compared to Caucasians. LOS after repair varies according to race, payer status, and hospital characteristics.

[Esophageal Atresia Repair - Can We Influence the Schedule?]. / Ösophagusatresie und tracheoösophageale Fistel - ist der Zeitpunkt der Versorgung steuerbar?

UNLABELLED: The treatment of newborns with esophageal atresia (EA) and tracheoesophageal fistula (TEF) is associated with a great logistic effort. The aim of the presented study was to analyse the possibility to influence the time of surgery. MATERIAL AND METHOD: Data from 30 neonates with EA and TEF regarding the date and mode of birth, biometric data and preoperative acid-base and blood gas values were collected retrospectively. The newborns were divided into two subgroups: birth between Monday and Thursday ("week"), and birth from Friday to Sunday ("weekend"). RESULTS: We observed a seasonal peak of births in November/December. The rate of prenatal ultrasound detection of polyhydramnions was 40%. In 14 of 16 cases with Caesarean section, maternal or foetal problems predicted the date and mode of delivery. In both groups, most newborns had an unimpaired postnatal adaptation. There were no significant differences regarding biometry. Delivery at the weekend was associated with later surgical repair (second vs. first day of life). Repeated estimations of acid-base and blood gas parameters over a median time span of 13 hours revealed a stable situation with a trend to normalisation. DISCUSSION: The time of birth is multifactorial and, in most cases, can neither be predicted nor influenced. Stable respiratory and metabolic parameters in the majority of patients allow a surgical intervention within a limited time frame during the first days of life. CONCLUSION: As it is hardly possible to plan the surgical procedure, an experienced team as well as neonatal intensive care facilities and operation room access must be available throughout the week.

Evaluation of Three Sources of Validity Evidence for a Synthetic Thoracoscopic Esophageal Atresia/Tracheoesophageal Fistula Repair Simulator.

PURPOSE: Thoracoscopic esophageal atresia (EA)/tracheoesophageal fistula (TEF) repair is technically challenging. We have previously reported our experiences with a high-fidelity hybrid model for simulation-based educational instruction in thoracoscopic EA/TEF, including the high cost of the tissue for these models. The purposes of this study were (1) to create a low-cost synthetic tissue EA/TEF repair simulation model and (2) to evaluate the content validity of the synthetic tissue simulator. MATERIALS AND METHODS: Review of the literature and computed tomography images were used to create computer-aided drawings (CAD) for a synthetic, size-appropriate EA/TEF tissue insert. The inverse of the CAD image was then printed in six different sections to create a mold that could be filled with platinum-cured silicone. The silicone EA/TEF insert was then placed in a previously described neonatal thorax and covered with synthetic skin. Following institutional review board-exempt determination, 47 participants performed some or all of a simulated thoracoscopic EA/TEF during two separate international meetings (International Pediatric Endosurgery Group [IPEG] and World Federation of Associations of Pediatric Surgeons [WOFAPS]). Participants were identified as "experts," having 6-50 self-reported thoracoscopic EA/TEF repairs, and "novice," having 0-5 self-reported thoracoscopic EA/TEF repairs. Participants completed a self-report, six-domain, 24-item instrument consisting of 23 5-point rating scales and one 4-point Global Rating Scale. Validity evidence relevant to test content and response processes was evaluated using the many-facet Rasch model, and evidence of internal structure (interitem consistency) was estimated using Cronbach's alpha. RESULTS: A review of the participants' ratings indicates there were no overall differences across sites (IPEG versus WOFAPS, P=.84) or experience (expert versus novice, P=.17). The highest observed averages were 4.4 (Value of Simulator as a Training Tool), 4.3 (Physical Attributes-chest circumference, chest depth, and intercostal space), and 4.3 (Realism of Experience-fistula location). The lowest observed averages were 3.5 (Ability to Perform-closure of fistula), 3.7 (Ability to Perform-acquisition target trocar sites), 3.8 (Physical Attributes-landmark visualization), 3.8 (Ability to Perform-anastomosis and dissection of upper pouch), and 3.9 (Realism of Materials-skin). The Global Rating Scale was 2.9, coinciding with a response of "this simulator can be considered for use in neonatal TEF repair training, but could be improved slightly." Material costs for the synthetic EA/TEF inserts were less than $2 U.S. per insert. CONCLUSIONS: We have successfully created a low-cost synthetic EA/TEF tissue insert for use in a neonatal thoracoscopic EA/TEF repair simulator. Analysis of the participants' ratings of the synthetic EA/TEF simulation model indicates that it has value and can be used to train pediatric surgeons, especially those early in their learning curve, to begin to perform a thoracoscopic EA/TEF repair. Areas for model improvement were identified, and these areas will be the focus for future modifications to the synthetic EA/TEF repair simulator.

A case for early bronchoscopic airway assessment after disc battery ingestion.

Disc battery ingestion in children is becoming increasingly common with the proliferation of small battery-powered electronic devices. In the case of esophageal impaction, the likelihood and severity of complications are proportionate to the time between ingestion and removal. Tracheo-esophageal fistulae (TOF) are a recognized complication and can be life-threatening. We describe an interesting case of disc battery ingestion with delayed recognition of a TOF. We document the tracheal mucosal healing process of a large airway defect and describe the role of bronchoscopy in guiding the timing of surgical intervention. This case highlights the important role of early bronchoscopic assessment in management of these patients.

A standardised investigative strategy prior to revisional oesophageal surgery in children: High incidence of unexpected findings.

BACKGROUND/PURPOSE: Revisional oesophageal reconstructive surgery carries uncommon and unusual risks related to previous surgery. To provide maximum anatomical detail and facilitate successful outcome, we report a standardised pre-operative investigative strategy for all such patients. METHODS: Prospective 8-month cohort study following the introduction of this strategy. All patients underwent high resolution thoracic contrast CT scan and micro-laryngo-bronchoscopy by a paediatric ENT surgeon in addition to upper gastrointestinal contrast study, oesophagoscopy, and echocardiogram. RESULTS: Seven children (median age 5.6 months [range 2.2-60]) completed the pathway. Four were referred with recurrence of a previously divided tracheo-oesophageal fistula (3 congenital, 1 acquired) and 3 (all with oesophagostomy) for oesophageal replacement for congenital isolated oesophageal atresia (OA, n=1) and failed repair of OA with distal TOF with wide gap (n=2). Overall, unanticipated findings were demonstrated in 6/7 children and comprised severe tracheomalacia and right main bronchus stenosis requiring aortopexy (n=1), vocal cord palsy (n=2), extensive mediastinal rotation (n=1), proximal tracheal diverticulum (n=1), severe subglottic stenosis requiring airway reconstruction (n=1), proximal tracheal diverticulum (n=1), right sided aortic arch (n=1) and left sided aortic arch (previously reported to be right sided, n=1). CONCLUSIONS: This standardised approach for this complex group of patients reveals a high incidence of unexpected anatomical and functional anomalies with significant surgical and possible medico-legal implications. We recommend these investigations during the pre-operative work-up prior to all revisional oesophageal surgery.

[Preliminary results of percutaneous tracheotomies]. / Résultats préliminaires des trachéotomies percutanées.

OBJECTIVES: Percutaneous tracheotomy (PT) is an alternative to surgical tracheotomy (ST). We describe our procedure and discuss the current status of PT through a retrospective study of our first 30 cases. MATERIAL AND METHODS: Thirty patients had a PT between October 2006 and March 2008 in the intensive care units of Caen University Hospital (France). Twenty-eight were done with the Ciaglia Blue Rhino (CBR) and two with the Percutwist. Each PT was endoscopically guided. We retrospectively collected preoperative data and most of the intraoperative as well as early postoperative complications. RESULTS: No death was reported with the PT application. Twenty-two (73.3%) PTs had neither preoperative nor early postoperative complications. Eight complications were observed, half preoperative and half early postoperative. The most frequent complication was minor bleeding in three cases (10%), the most important one was the intraoperative appearance of a tracheoesophageal fistula with the CBR. DISCUSSION: The principal advantages of PT are safety attributable to simultaneous endoscopic guidance as well as shorter operative time and lower cost in comparison with the ST technique. CONCLUSION: PT is a safe and valid alternative procedure to ST. Initially performed by intensivists, it should be part of the ENT/head and neck surgeon's repertory as the upper airway specialist.

Long-term assessment of the treatment of recurrent tracheoesophageal fistula with fibrin glue associated with diathermy.

PURPOSE: Recurrent tracheoesophageal fistula (RTF) is a serious common complication of the surgical treatment of esophageal atresia. We report the results of our technique of bronchoscopic treatment of RTF with fibrin glue (Tissucol), with a follow-up of over 1 decade. METHODS: A retrospective review between 1993 and 2004 was conducted, including all patients diagnosed with RTF and treated bronchoscopically with Tissucol, with over 1 year of follow-up. The procedure was implemented under general anesthesia using a rigid neonatal bronchoscope. A magnification chamber and previous diathermia using a urethral catheter were used in the latter 4 patients. The fibrin glue was injected through a clear catheter. The number of endoscopic sessions per patient was limited to 3. RESULTS: Seven patients were treated, with evidence of fistular closure in 6 (85%). One patient with satisfactory results, but a follow-up of 4 months, was not included. The age at bronchoscopy ranged from 14 to 20 days (mean, 16.7 days), and a total of 12 sessions were required (mean, 1.7). In the latter 4 patients, diathermia was associated with good results in all and a lower number of sessions (mean, 1.5). All patients were evaluated clinically and radiologically, and a control endoscopy was performed in 4 patients. The follow-up lasted from 2 to 11 years (mean, 7.4 years). CONCLUSIONS: Because we started to use Tissucol (1994), other authors have reported successful isolated cases, but a relatively large series and a long-term follow-up were lacking. We consider that the success of the procedure depends on several technical factors such as an early diagnosis, before epithelium is formed in the fistula, and the use of initial diathermia, associated in the latter 4 patients. The results obtained with 85% success with a follow-up over 1 year show that the fibrin adhesive is the reference substance for the treatment of RTF; we recommend its endoscopic application associated with diathermia as initial measure.

Fístula traqueoesofágica en H: reporte de un caso y revisión de la literatura / H-Type tracheoesophageal fistula: report of case and review of th literature

Se informa el primer paciente operado en el Hospital de Especialidades del Instituto Hondureño de Seguridad Social con una fístula traqueoesofágica en H. La cirugía consistió en una toracotomía posterolateral derecha con resección de la fístula y reparación del esófago y la traquea. La fístula traqueoesofágica en H es una anormalidad congénita rara que constituye únicamente el 4% de todos los tipos de malformaciones congénitas de esófago. El diagnóstico puede realizarse al nacimiento pero en ocaciones este pasa desapercibido y se manifiesta como una neumopatía crónica como en el presente caso, constituyendo el diagnóstico un verdadero reto para los médicos tratantes...

Transanastomotic feeding tubes in repair of esophageal atresia.

To avoid the need for a gastrostomy and parenteral nutrition during the 7- to 10-day healing period after esophageal anastomosis, the authors modified their technique for esophageal atresia repair to include placement of a transanastomotic feeding tube. A SILASTIC transanastomotic feeding tube and early enteral nutrition was used for 19 of 23 consecutively treated patients after repair of esophageal atresia and tracheoesophageal fistula. One of the 19 patients had recurrent fistula and another had an anastomotic leak. Five patients had significant gastroesophageal reflux (noted on barium esophagram), and four had strictures that required dilatation. Parenteral nutrition was necessary for only two patients. The authors conclude that transanastomotic feeding tubes and early enteral nutrition are safe and effective, reduce costs, and do not appear to increase the incidence of anastomotic leaks, strictures, or gastroesophageal reflux.

Esophageal stricture following esophageal atresia repair: endoscopic assessment and dilation.

A retrospective review from 1981 to 1986 was made of 51 neonates who were treated for congenital esophageal atresia at the Royal Alexandra Hospital for Children, Sydney, Australia. Thirty of the 51 had primary repair and 15 (50%) developed esophageal stricture requiring one or more dilations. Stricture dilations were performed with open-tube rigid esophagoscopes, rigid telescopes, and Jackson dilators. The number of dilations performed until the patient was asymptomatic ranged from 1 to 12 (mean 4.5). The minimal follow-up time was 4 years. There was one esophageal perforation with full recovery following conservative management. One child died of septicemia caused by continued aspiration of unknown cause. A surprising finding, contrary to other reports, was the stricture formation did not appear to be related to the size of the "gap" found at the time of esophageal repair. Gastroesophageal reflux, however, was an important factor. We conclude that esophageal stricture following repair of tracheoesophageal atresia can be satisfactorily and relatively safely managed by direct vision antegrade endoscopic dilation using graduated dilators, although treatment may be prolonged and repeated. New esophagoscopes and dilators, in graduated sizes and designed for pediatric use, are recommended. The technique of esophageal dilation in infants is described in detail. Pediatric laryngobronchoesophagologists will become more involved in the care of infants born with esophageal atresia with or without tracheoesophageal fistula.

[Value of myotomy of the lower constrictor in surgery of tracheo-esophageal puncture]. / Valoración de la miotomía del constrictor inferior en la cirugía de la punción traqueoesofágica.

The importance of the inferior myotomy for speech restoration in total laryngectomized patients following not only primary techniques (speech restoration by tracheo-esophageal puncture during total laryngectomy) but also secondary punctures, is well documented. In this paper, the results obtained by manometric studies applied to 25 patients divided into two groups are shown (the first group) (15 patients) following primary techniques, and the second one (10 patients) following secondary punctures. We observe a sphincter pressure decreasing after secondary myotomy in those patients which previously presented dysphagia, prostheses breaking or intermittent speech, therefore considering the inferior constrictor myotomy as of great value in speech rehabilitation.