Surgical options in retrosternal oesophageal reconstruction.

BACKGROUND: Retrosternal oesophageal reconstructions with collar anastomoses can become necessary when the stomach is either unavailable for oesophageal replacement, or orthotopic reconstruction is deemed impractical. Our aim was to analyse our results regarding technical approaches and outcomes. MATERIALS AND METHODS: All patients undergoing primary and secondary oesophageal retrosternal reconstructions with collar anastomoses at our centre (2019-2023) were retrospectively analysed and individual surgical reconstruction options were presented. RESULTS: Overall, twelve patients received primary (n = 5; 42.7%) or secondary (n = 7; 58.3%) reconstructions; ten with colonic interposition and two with gastric pull-up. Male/female ratio was 4:8; median age 66 years (30-87). Charlson-Comorbidity-Score (CCS) was 5 (1-7); 8/12 patients (67%) had ASA-classification score ≥ 3. We observed no conduit necrosis, but one patient (8.3%) with a leakage of the oesophago-colonostomy which was successfully treated by endoscopic vacuum therapy. Four patients (33.3%) acquired nosocomial pneumonia. Additional drainages for pleural fluid collections were necessary in three patients (25%). Overall comprehensive-complication-index (CCI) was 26.2 (0-44.9). Length-of-stay (LOS) was 22 days median (15-40). There was no 90-days mortality. Overall, CCI during the follow-up (FU) period at median 26 months (16-50) was 33.7 (0-100). 10 out of 12 patients were on sufficient oral nutrition at 12 months FU. CONCLUSION: Primary and secondary oesophageal retrosternal reconstructions encompass diverse entities and typically requires tailored decision-making. These procedures, though rare, are feasible with acceptable complication rates and positive functional outcomes when performed in experienced hands.

Update on aortopexy and posterior tracheopexy for tracheomalacia in patients with esophageal atresia.

Despite improving the survival after repair of esophageal atresia (EA), the morbidity of EA repair remains high. Specifically, tracheomalacia (TM) is one of the most frequent complications of EA repair. Continuous positive airway pressure is generally applied for the treatment of TM. However, surgical intervention is required against an apparent life-threatening event or inability to perform extubation for a long period. According to our review, most cases of TM showed symptom improvement after aortopexy. The ratio of the trachea's lateral and anterior-posterior diameter at the brachiocephalic artery crossing the trachea, which reflects the compression of the trachea by the brachiocephalic artery, is a good indicator of aortopexy. Our finding suggests that most TM cases associated with EA may not be caused by tracheal fragility alone, but may involve blood vessel compression. Posterior tracheopexy (PT) is also an effective treatment for TM. Recently, open or thoracoscopic PT was able to be performed simultaneously with EA repair. In many cases, aortopexy or PT is a safe and effective surgical treatment for TM with EA. Other surgical procedures, such as external stenting, should be considered for patients with diffuse-type TM for whom aortopexy and PT appear relatively ineffective.

Methods of quality assurance in multicenter trials in laparoscopic fundoplication for gastroesophageal reflux disease.

BACKGROUND: Operative performance may affect the internal and external validity of randomized trials. The aim of this study was to review the use of surgical quality assurance mechanisms of published trials on laparoscopic anti-reflux surgery, with the objective to appraise their internal (research quality) and external validity (applicability to the clinical setting). METHODS: Building upon a previous systematic review and network meta-analysis published by the authors, Medline, Embase, AMED, CINAHL, CENTRAL, and OpenGrey databases were searched for randomized control trials comparing different methods of laparoscopic anti-reflux surgery for the management of gastroesophageal disease. Quality assurance in individual studies was appraised using a specified framework addressing surgeon accreditation, procedure standardization, and performance monitoring. RESULTS: In total, 2276 articles were screened to obtain 43 publications reporting 29 randomized controlled trials. Twenty-five out of 43 (58.1%) articles reported the number of participating centers and surgeons involved. Additionally, only 21/43 (48.8%) of articles reported consistent use of a bougie, while 23/43 (53.5%) of articles reported consistent division of the short gastric arteries during fundoplication. Surgical experience and credentials were stated in half of the studies. Standardization of the technique was reported in almost 70% of cases, whereas operative notes or video was submitted in one fourth of the studies. Monitoring of the operative performance during the trial was not documented in most of the trials (62%). CONCLUSION: Surgical quality assurance in randomized trials on laparoscopic anti-reflux surgery is insufficient, which does not allow appraisal of the internal and external validity of this research. With improved reporting, trials assessing the use of laparoscopic anti-reflux surgery will enable surgeons to make informed treatment decisions to enhance patient care in the surgical management of GERD.

Reoperative surgery after magnetic sphincter augmentation.

Reoperative surgery following magnetic sphincter augmentation (MSA) is rare. The clinical indications include the removal of MSA for dysphagia, the recurrence of reflux, or the issues of erosion. Diagnostic evaluation follows that of patients with recurrent reflux and dysphagia following surgical fundoplication. Procedures following the complications of MSA can be performed in a minimally invasive fashion, either endoscopically or robotic/laparoscopically, with good clinical outcomes.

Is magnetic sphincter augmentation indicated in patients with laryngopharyngeal reflux?

Up to 30% of patients with gastroesophageal reflux disease (GERD) suffer from laryngopharyngeal reflux (LPR) with symptoms, as chronic cough, laryngitis, or asthma. Besides life-style modifications and medical acid suppression, laparoscopic fundoplication is an established treatment option. Treatment-related side effects after laparoscopic fundoplication have to be weighted against LPR symptom control in 30-85% of patients after surgery. Magnetic sphincter augmentation (MSA) is described as an effective alternative to fundoplication for surgical treatment of GERD. However, evidence on the efficacy of MSA in patients with LPR is very limited. Preliminary data on the results of MSA treating LPR symptoms in patients with acid and weakly acid reflux are promising; showing comparable results to laparoscopic fundoplication by providing the potential of decrease side effects.

Use of magnetic sphincter augmentation as an adjunct procedure in paraesophageal hernia repair.

Magnetic sphincter augmentation (MSA) is an anti-reflux procedure with comparable outcomes to fundoplication, yet its use in patients with larger hiatal or paraesophageal hernias has not been widely reported. This review discusses the history of MSA and how its utilization has evolved from initial Food and Drug Administration (FDA) approval in 2012 for patients with small hernias to its contemporary use in patients with paraesophageal hernias and beyond.

Achalasia Treatment. Robotic Approach or Laparoscopy?

Background: Nowadays the question persists whether to choose the endoscopic or surgical method as the first treatment of choice for achalasia. Another debate topic is about the differences between the outcomes of the two approaches of minimally invasive surgical treatment and their feasibility. Material and Methods: This retrospective observational study included 193 patients with achalasia treated between 2008 and 2021. The patients were divided into 2 groups (A and B): 152 with minimally invasive heller myotomy (HM), and 41 with pneumatic dilation (PD). Patients surgically treated were then subdivided into robotic group (RG) and laparoscopic group (LG). Results: The recurrence rate was significantly higher in PD group (Ã?2 = 16.81, DF = 1, p 0.0001), with a success rate of 63,4%, comparing with 92,7% in HM group. No significant difference was obtained between the 2 groups concerning symptom relief on patients successfully treated. The success rate was comparable between the robotic and laparoscopic groups (p = 1). Significant difference was obtained in length of hospital stay between the 2 groups, with a mean of 4.78 +-1.59 days in the RG and, respectively, 5.52 +-2.1 days in the LG (t = 2.40, DF = 124.34, p = 0.0177). Postprocedural esophagitis rates were higher in patients with no fundoplication (6 out of 37 - 16.2%) and in patients treated with pneumatic dilation (4 out of 26 - 15.4%) than in patients with fundoplication (4 out of 46 - 8.5%). Conclusion: The present study indicates that surgery may be a better choice in fit patients for the treatment of achalasia. The procedure has a better success rate, even if the long-term outcomes are comparable in patients successfully treated. The success rate and long-term results were comparable between laparoscopy and robotic surgery.

[The first experience of fluorescent angiography with indocyanine green in primary esophagoplasty with gastric conduit in patients with malignant tumors of the esophagus]. / Pervyi opyt flyuorestsentnoi angiografii s indotsianinom zelenym pri pervichnoi ezofagoplastike zheludochnym steblem u bol'nykh so zlokachestvennymi opukholyami pishchevoda.

OBJECTIVE: To evaluate the possibilities of intraoperative indocyanine green fluorescein angiography (ICG technology) in primary esophagoplasty by gastric conduit in patients with malignant tumors of the esophagus. MATERIAL AND METHODS: The study included 74 patients. Depending on the localization of the tumor in the esophagus, a Lewis-type or McKeown-type operation was performed. The retrospective group (surgery without the use of ICG technology) included 53 patients who underwent surgery from 2015 to 2020 years.The prospective group (surgery with the use ICG technology) included 21 patients operated on from 2021 to 2023 years. ICG technology was used to assess microcirculation in the gastric conduit during esophagoplasty, as well as to identify the right gastroepiploic artery. RESULTS: The ICG fluorescein angiography technique for assessing microcirculation in the gastric conduit was a simple and easily reproducible procedure. Perfusion of the gastric conduit was regarded as satisfactory in 16 (76%) cases, unsatisfactory in 5 (24%) cases, which required resection of the distal part of the conduit. All cases of poor perfusion were in patients with narrow gastric conduit and neck anastomosis location (McKeown-type operation). Anastomotic leakages occurred in 8 (15%) patients in the retrospective group, 4 (19%) patients in the prospective group (p>0.05). In 4 out of 5 cases of poor gastric conduit perfusion, anastomotic leaks occurred. Immediate postoperative results in the compared groups were also comparable. The use of ICG technology in 5 (45%) cases out of 11, when laparoscopic mobilization of the stomach was performed, helped to visualize the right gastroepiploic artery, which is the main source of blood supply to the formed gastric conduit. The use of ICG technology in 3 patients with a compromised gastrostomy stomach demonstrated the absence of significant microcirculation disorders in the stomach wall. CONCLUSION: The first experience of using fluorescein angiography with ICG in primary esophagoplasty by gastric conduit in patients with malignant tumors of the esophagus demonstrated the safety, simplicity and availability of this technique. An objective assessment of the effectiveness of the application of ICG technology requires the accumulation of experience.

Adverse events associated with transoral incisionless fundoplication (TIF) for chronic gastroesophageal reflux disease: a MAUDE database analysis.

BACKGROUND: Transoral incisionless fundoplication (TIF) has been used for treating chronic gastroesophageal reflux disease (GERD) refractory to medical therapy. We aim to investigate the complications associated with TIF using a national database. METHODS: We analyzed post-marketing surveillance data from the FDA Manufacturer and User Facility Device Experience (MAUDE) database from Jan 2011 through Jan 2021. RESULTS: During the study period, approximately 95 event cases reported to the FDA. Approximately 131 patient complications were identified. The number of adverse events declined from 2011 to 2016 (R2 = 0.96) but increased from 2016 to 2020 (R2 = 0.99). The most common adverse event was perforation (19.8%), followed by laceration 17.6%, bleeding (9.2%), and pleural effusion (9.2%). The most common patient complications were treated using endoscopic clips (12.3%), chest tube or drain insertion (12.3%), use of endoscopic retriever device (11.1%), esophageal stent (8.6%), and emergent or open surgery (11.1%). CONCLUSIONS: Adverse events from TIF range from mild to severe. Further research is needed to develop approaches aimed at reducing patient risks.

Fundoplication in children with esophageal atresia: preoperative workup and outcome.

Up to 45% of esophageal atresia (EA) patients undergo fundoplication during childhood. Their esophageal dysmotility may predispose to worse fundoplication outcomes compared with patients without EA. We therefore compared fundoplication outcomes and symptoms pre- and post-fundoplication in EA patients with matched patients without EA. A retrospective review of patients with- and without EA who underwent a fundoplication was performed between 2006 and 2017. Therapeutic success was defined as complete sustained resolution of symptoms that were the reason to perform fundoplication. Fundoplication indications of 39 EA patients (49% male; median age 1.1 [0.1-17.0] yrs) and 39 non-EA patients (46% male; median age 1.3 [0.3-17.0] yrs) included respiratory symptoms, brief resolved unexplained events, typical symptoms of gastroesophageal reflux disease, recurrent strictures and respiratory problems. Post-fundoplication, therapeutic success was achieved in 5 (13%) EA patients versus 29 (74%) non-EA patients (P<0.001). Despite therapeutic success, all 5 (13%) EA patients developed postoperative sustained symptoms/complications versus 12 (31%) non-EA patients. Eleven (28%) EA patients versus 3 (8%) non-EA patients did not achieve any therapeutic success (P=0.036). Remaining patients achieved partial therapeutic success. EA patients suffered significantly more often from postoperative sustained dysphagia (41% vs. 13%; P=0.039), gagging (33% vs. 23%; P<0.001) and bloating (40% vs. 17%; P=0.022). Fundoplication outcomes in EA patients are poor and EA patients are more susceptible to post-fundoplication sustained symptoms and complications compared with patients without EA. The decision to perform fundoplication in EA patients with proven gastroesophageal reflux disease needs to be made with caution after thorough multidisciplinary evaluation.

Outcome of esophageal atresia: inborn versus outborn patients.

Esophageal atresia (EA) is a rare congenital disease which is usually not of the detected prenatally. Due to the lack of prenatal diagnosis, some newborns with EA are born outside of specialized centers. Nevertheless, centralized care of EA has been proposed, even if a clear volume-outcome association in EA management remains unconfirmed. Furthermore, whether outcomes differ between outborn and inborn patients with EA has not been systematically investigated. Therefore, this single-center, retrospective study aimed to investigate EA management and outcomes with a special focus on inborn versus outborn patients. The following data were extracted from the medical records of infants with EA from 2009 to 2019: EA type, associated anomalies, complications, and long-term outcome. Patients were allocated into inborn and outborn groups. Altogether, 57 patients were included. Five patients were excluded (referral before surgery, loss of data, death before surgery [n = 1], and incorrect diagnosis [diverticulum, n = 1]). Among all patients, the overall survival rate was 96%, with no mortalities among outborn patients. The overall hospitalization period was shorter for outborn patients. The median follow-up durations were 3.8 years and 3.2 years for inborn and outborn patients, respectively. Overall, 15% of patients underwent delayed primary anastomosis (long-gap atresia [n = 4] and other reasons [n = 4]). Early complications included three anastomotic leakages and one post-operative fistula; 28% of patients developed strictures, which required dilatation, and 38% of patients showed relevant gastroesophageal reflux, which required fundoplication, without any differences between the groups. The two groups had comparable low mortality and expected high morbidity with no significant differences in outcome. The outborn group showed nonsignificant trends toward lower morbidity and shorter hospitalization periods, which might be explained by the overall better clinical status.

Recommendations for endoscopic surveillance after esophageal atresia repair in adults.

BACKGROUND: Endoscopic surveillance of adults with esophageal atresia is advocated, but the optimal surveillance strategy remains uncertain. This study aimed to provide recommendations on appropriate starting age and intervals of endoscopic surveillance in adults with esophageal atresia. METHODS: Participants underwent standardized upper endoscopies with biopsies. Surveillance intervals of 3-5 years were applied, depending on age and histopathological results. Patient's age and time to development of (pre)malignant lesions were calculated. RESULTS: A total of 271 patients with esophageal atresia (55% male; median age at baseline endoscopy 26.7 (range 15.6-68.5) years; colon interposition n = 17) were included. Barrett's esophagus was found in 19 (7%) patients (median age 32.3 (17.8-56.0) years at diagnosis). Youngest patient with a clinically relevant Barrett's esophagus was 20.9 years. Follow-up endoscopies were performed in 108 patients (40%; median follow-up time 4.6 years). During surveillance, four patients developed Barrett's esophagus but no dysplasia or cancer was found. One 45-year-old woman with a colon interposition developed an adenoma with high-grade dysplasia which was radically removed. Two new cases of esophageal carcinoma were diagnosed in patients (55 and 66 years old) who were not under surveillance. One of them had been curatively treated for esophageal carcinoma 13 years ago. CONCLUSIONS: This study shows that endoscopic screening of patients with esophageal atresia, including those with a colon interposition, can be started at 20 years of age. Up to the age of 40 years a surveillance interval of 10 years appeared to be safe. Endoscopic surveillance may also be warranted for patients after curative esophageal cancer treatment.

Development and validation of a novel 3D-printed simulation model for open oesophageal atresia and tracheo-oesophageal fistula repair.

BACKGROUND: The role of simulation training in paediatric surgery is expanding as more simulation devices are designed and validated. We aimed to conduct a training needs assessment of UK paediatric surgical trainees to prioritise procedures for simulation, and to validate a novel 3D-printed simulation model for oesophageal atresia and tracheo-oesophageal fistula (OA-TOF) repair. METHODS: A questionnaire was sent to UK trainee paediatric surgeons surveying the availability and utility of simulation. The operation ranked as most useful to simulate was OA-TOF repair. 3D-printing techniques were used to build an OA-TOF model. Content, face and construct validity was assessed by 40 paediatric surgeons of varying experience. RESULTS: Thirty-four paediatric surgeons completed the survey; 79% had access to surgical simulation at least monthly, and 47% had access to paediatric-specific resources. Perceived utility of simulation was 4.1/5. Validation of open OA-TOF repair was conducted by 40 surgeons. Participants rated the model as useful 4.9/5. Anatomical realism was scored 4.2/5 and surgical realism 3.9/5. The model was able to discriminate between experienced and inexperienced surgeons. CONCLUSION: UK paediatric surgeons voted OA-TOF repair as the most useful procedure to simulate. In response we have developed and validated an affordable 3D-printed simulation model for open OA-TOF repair.

Colon patch esophagoplasty for esophageal strictures refractory to multi-modal treatment revisited.

INTRODUCTION/PURPOSE: Esophageal strictures due to caustic ingestion (CI) may require repeat esophageal dilations and dilation adjuvants, including local anti-fibrinogenic injection therapy, stent placement, and radial stricture incisions. Refractory strictures require surgical intervention. Pedicled colon patch esophagoplasty (CPE) may avoid the morbidity associated with total esophageal replacement, although reports of its use are limited. Indications and outcomes for CPE in patients undergoing repeat esophageal stricture dilations following caustic ingestion are described according to our local experience and literature reports. MATERIALS AND METHODS: A retrospective review of indications for surgical management of esophageal strictures to tertiary pediatric surgical services between 2015 and 2020 focused on patients undergoing CPE. English-language literature (PubMed, Google Scholar, and Scopus) describing CPE was also reviewed. RESULTS: Eight (12%) out of 65 patients with esophageal strictures requiring 7 or more esophageal dilations with poor response underwent surgical stricture management over a 6 year period, which included stricture resection and re-anastomosis in 2 patients, total esophageal replacement with colon graft in 2 patients, gastric pull-up in 1 patient, and CPE in 3 patients. The patients undergoing CPE were aged 3-8 years and had 17 to more than 25 dilations following caustic ingestion over a 2-5 year period. One patient had a 4 cm stricture; the other 2 had strictures 7 cm in length. A transverse colon patch based on the middle and left colic vessels was utilized in all three, with the vascular pedicle placed retrogastrically via the esophageal hiatus and the patch inlay esophagoplasty concluded via right thoracotomy. Post-operative contrast studies showed near-normal anatomy, and the patients could tolerate full oral diets. During a 9-36 month follow-up period, only 2 patients required dilations of a proximal anastomotic stricture at 1 and 5 months postoperatively. One patient required additional proximal stricturoplasty with advancement of the original graft across the stricture via a cervical surgical approach. CONCLUSION: Colon patch esophagoplasty to restore esophageal luminal continuity and allow a normal diet should be considered for refractory esophageal strictures. CPE had excellent functional outcomes in our 3 patients and should be considered in selected cases instead of total esophageal replacement.

RESULTS OF PREVENTIVE METHODS OF OCCURRENCE CERVICAL ANASTOMOTIC COMPLICATIONS IN ESOPHAGOPLASTY.

OBJECTIVE: The aim: The aim of the study was to improve the results of surgical treatment in patients with corrosive esophageal strictures using the designed comprehensive surgical management program in esophagoplasty to decrease cervical anastomotic complications. PATIENTS AND METHODS: Materials and methods: The results of surgical treatment of 116 patients with esophageal strictures were studied. 45 patients had post-burn corrosive strictures, 17 - postoperative corrosive strictures, 10 - peptic strictures due to reflux esophagitis and 44 patients - esophageal cancer. All patients were divided into two groups: the control group, consisting of 55 patients who underwent conventional surgical treatment of corrosive esophageal strictures during 2005-2011, and experimental group involving 61 patients operated on during 2012- 2020, in whom an individual approach to the choice of surgical method was applied using diagnostic and treatment algorithm as well as the designed surgical management program. RESULTS: Results: In early postoperative period the proportion of specific and non-specific complications was significantly lower in experimental group as compared to the control group: cervical anastomotic leak - 16.36 % versus 4.392 %; strictures of cervical anastomosis - 20.0% versus 6.56 % (p<0.05). There were six postoperative deaths - four in the control group and two in experimental group. CONCLUSION: Conclusions: To prevent the development of cervical anastomotic complications and mortality in esophagoplasty proper therapeutic approach with consideration of all prognostic criteria and risk factors should be chosen and designed surgical management program should be applied.

The Features of Stomach Vascularisation Pattern and Their Impact on Oesophageal Reconstruction with a Gastric Pull-up.

Regardless of the reconstruction surgery used, the fundamental concepts of visceral reconstruction are based on the vascular support needed for the substituting graft. The vascular factor is the main element of any reconstruction technique, as an underlying condition for the visceral material stretch and, along with other factor, for the suture safety. In the case of the stomach, a consistent vascular flow and the minimal vascular anatomy variations are the first theoretical argument. A second argument is based on the intraparietal vascular network features allowing for supplementing visceral perfusion as the blood flow is stopped in one or more pediculi. Graft hypoperfusion is, however, a potential cause of failure, and the most frequently invoked complication is, therefore, a high risk of anastomosis fistulae. A series of modern techniques - arteriography data for the pre-operative vascular reconstruction or Doppler laser fluorometry intraoperative assessments, graft oximetry, laser speckle (spot) scan or the use of indocyanine green staining (ICG) - represent methods of early determination of the gastric graft perfusion/microperfusion quality used in reducing such risks. The doubts regarding the gastric perfusion mandate the use of vascular augmentation techniques. If such techniques are not used, the final outcome is uncertain and difficult to correct.

Intraoperative Right Colic Graft Ischemia, Followed by Delayed Oesophagoplasty Including an Ileo-Transverse Anastomosis and the Cervical Revascularisation of the Ileum: Case Report.

The ischemic complications during the isolation of the substituting oesophageal graft placement and after its placement may lead to graft necrosis and to the need to find a different reconstructive procedure. The most frequent reports of graft necroses occur in the days following the reconstruction. We are presenting the case of a 27-y.o. with full dysphagia as a result of caustic stenosis, in whose case the oesophageal reconstruction was abandoned following the irreversible ischemia of the right colic graft during the vascular isolation, followed by right-side hemicolectomy and ileo-transverse anastomosis. 4 years post the ingestion of a caustic substance and 2 years post the right colic graft ischemic necrosis, we performed an oesophageal reconstruction using a pediculated, cervically revascularized, ileo-colic graft on the left colic vessels. The graft's particularity is that is formed from left and transverse colon and ileum portions, including the ileo-transverse anastomosis performed 2 years prior to the oesophageal reconstruction.

Gastric Pull-up: A Back-up Surgical Solution in the Treatment of Large Hiatal Hernias.

The laparoscopic treatment of the hiatal hernias is nowadays the standard procedure. However, due to the volume and the age of the affliction, there are some situations in which the classical approach is indicated. The latter is associated with specific risks. The appearance of some intra-operatory incidents or accidents could lead to changes in the tactics and the techniques, moreover the abandon of the classical procedure and the use of alternative solutions. These procedures are meant to solve the case with minimum negative effects on the patient. This article presents the case of a 62 year-old female patient, diagnosed with a large type II hiatal hernia on which the surgical team had to intervene through a median xypho-umbilical laparotomy. During the attempt to perform the Nissen procedure, the irreversible lesion of the abdominal esophagus occurred, the esophageal wall having already suffered because of the esophagitis. This led to the restoring of the gastric continuity using the gastric pull-up technique and a cervical anastomosis. The remaining esophagus was removed during the second procedure, 3 moths later. The immediate and the late evolution of the patient was excellent.

Repair, Reconstruct, or Divert: Fate of the Perforated Esophagus.

OBJECTIVES: The aim of this study was to determine differences in esophageal perforation populations undergoing different advanced interventions for perforated esophagus and identify predictors of treatment outcomes. SUMMARY BACKGROUND DATA: Contained esophageal perforation can often be managed expectantly, but uncontained perforation is uniformly fatal without invasive intervention. Treatment options for the latter range from simple endoscopic control through advanced intervention. Clinical presentation varies greatly and directs which intervention is most appropriate. METHODS: From 1996 to 2017, 335 patients were treated for esophageal perforation, and 166 for advanced interventions: 74 primary repair with tissue flap (repair), 26 esophagectomy and gastric pull-up (resection), and 66 esophagectomy and immediate diversion with planned delayed reconstruction (resection-diversion). Patient characteristics, clinical presentation, operative outcomes, and survival were abstracted. Pittsburgh Severity Scores (PSS) were retrospectively calculated. Random survival forest analysis was performed for 90-day mortality and competing risks for reconstruction after resection-diversion. RESULTS: Repair and resection patients had lower PSS than resection-diversion patients (3 vs 3 vs 6, respectively). Ninety-day mortality for repair, resection, and resection-diversion was 11% vs 7.7% vs 23%, and 5-year survival was 71% vs 63% vs 47%. Risk of death after resection-diversion was highest within 1 year, but 52% of patients had reconstruction of the upper alimentary tract within 2 years. CONCLUSIONS: Several advanced interventions exist for critically ill patients with uncontained esophageal perforation. Repair and organ preservation are always preferred; however, patients at extremes of illness might best be treated with resection-diversion, with the understanding that the competing risk of death may preclude eventual reconstruction.

Evaluation of Gastroesophageal Reflux Disease 1 Year after Esophageal Atresia Repair: Paradigms Lost from a Single Snapshot?

OBJECTIVE: To analyze the findings of both multichannel intraluminal impedance with pH (MII-pH) and endoscopy/histopathology in children with esophageal atresia at age 1 year, according to current recommendations for the evaluation of gastroesophageal reflux disease (GERD) in esophageal atresia. STUDY DESIGN: We retrospectively reviewed both MII-pH and endoscopy/histopathology performed in 1-year-old children with esophageal atresia who were followed up in accordance with international recommendations. Demographic data and clinical characteristics were also reviewed to investigate factors associated with abnormal GERD investigations. RESULTS: In our study cohort of 48 children with esophageal atresia, microscopic esophagitis was found in 33 (69%) and pathological esophageal acid exposure on MII-pH was detected in 12 (25%). Among baseline variables, only the presence of long-gap esophageal atresia was associated with abnormal MII-pH. Distal baseline impedance was significantly lower in patients with microscopic esophagitis, and it showed a very good diagnostic performance in predicting histological changes. CONCLUSIONS: Histological esophagitis is highly prevalent at 1 year after esophageal atresia repair, but our results do not support a definitive causative role of acid-induced GERD. Instead, they support the hypothesis that chronic stasis in the dysmotile esophagus might lead to histological changes. MII-pH may be a helpful tool in selecting patients who need closer endoscopic surveillance and/or benefit from acid suppression.