Magnetic compression anastomosis (magnamosis) in a porcine esophagus: Proof of concept for potential application in esophageal atresia.

BACKGROUND: Magnetic compression anastomosis (magnamosis) is the process of forming a sutureless anastomosis of the gastrointestinal tract using two magnetic Harrison rings. It has been shown to be effective in stomach, small bowel and colon, but has not been implemented in the esophagus. A pure esophageal atresia porcine model was developed to test the concept. METHODS: Five pigs weighing between 35 and 65 kg were used. In all pigs, a percutaneous endoscopic gastrostomy (PEG) tube was placed, and a right thoracotomy was performed. Esophageal atresia was simulated by transecting the esophagus with a cutting stapler, and magnets were placed endoscopically to approximate the two ends of the esophagus. In the first pig, the tissue within the magnetic ring was excised endoscopically to achieve immediate patency. In the second pig, approximation of the blind esophageal ends was reinforced with 3-4 externally-placed sutures but immediate patency was not performed. In the last three pigs, both external suture reinforcement and immediate patency were performed. The pigs survived for 10-14 days and received nutrition through PEG tube. At necropsy, an esophagram was performed, the specimen was explanted and a leak test was performed. RESULTS: The first pig died in the early postoperative period from a leak owing to separation of the magnets. The second pig died from aspiration before the anastomosis formed. The last three pigs survived until the study endpoint. The third pig had a contained leak owing to the staple line being placed between the magnets; this was not clinically significant. The last two pigs had well-formed anastomoses. Burst tests showed no leak when injecting saline up to 30 mmHg. CONCLUSION: Magnamosis is technically feasible for esophagoesophageal anastomoses. A survival model for pure esophageal atresia was developed and refined in pigs. Further work in this area may lead to clinical use in humans.

The management of newborns with esophageal atresia and right aortic arch: A systematic review or still unsolved problem.

AIM OF THE STUDY: The management of newborns with esophageal atresia (EA) and right aortic arch (RAA) is still an unsolved problem. This study provides a systematic review of epidemiology, diagnosis, management and short-term results of children with EA and RAA. MATERIALS AND METHODS: The PubMed database was searched for original studies on children with EA and RAA. In each study, data were extracted for the following outcomes: number of patients, associated anomalies, type of surgical repair, morbidity and mortality rate. RESULTS: Eight studies were selected, including 54 patients with EA and RAA. RAA was encountered in 3.6% of infants. Preoperative detection of RAA was reported in 7 of them. In these patients, primary anastomosis was achieved through the right approach in 3 (thoracotomy in 2 and thoracoscopy in 1) while the left approach was the primary choice in 4 (thoracotomy in 2 and thoracoscopy in 2). No significant differences were found between the right and left approaches with regard to leaks (P=0.89), strictures (P=1) or mortality (P=1). In 47/54 patients (87%) RAA was noted during right thoracotomy, and primary anastomosis was achieved through the same approach in 29 (61.7%); conversion to other approaches (left thoracotomy or esophageal substitution) was performed in 15 children (38.3%). No significant differences were found between primary left thoracotomy (LT) and LT after RT with regard to leaks (P=0.89), strictures (P=1) or mortality (P=1). CONCLUSIONS: Skills and preferences of the surgeon still guide the choice of surgical approach even when preoperatively faced with RAA. A multicenter, prospective randomized study is strongly required.

Thoracoscopic versus open repair of tracheoesophageal fistulas and rates of vocal cord paresis.

BACKGROUND/PURPOSE: The purpose of this study was to investigate the rates of vocal cord paresis/paralysis (VCP) in patients treated for esophageal atresia (EA) with and without fistula performed thoracoscopically versus open. METHODS: A retrospective review of EA cases performed from 2008 to 2014 in an integrated health care system was performed. RESULTS: A total of 31 cases of EA were performed by 6 surgeons at 4 different institutions. Seventeen cases were performed thoracoscopically, whereas 14 cases were performed open. In the thoracoscopic group, the average gestational age (weeks) of the patient was significantly higher 38.3 vs. 35.2 (p=0.016) as well as the average birth weight (grams) 2843 vs. 2079 (p=0.005). There was no difference in the postoperative length of stay, rates of anastomotic stricture, leak, or tracheomalacia. There were 10 cases of vocal cord paresis, 9 from the thoracoscopic group and one from the open group (p=0.007). Of the 10 cases of VCP, 6 were unilateral (left sided) and 4 were bilateral. Of the 10 cases, 6 resolved, 2 resulted in permanent paralysis, and 2 are currently still being evaluated. CONCLUSIONS: Thoracoscopic repair of EA appears to have higher rates of VCP. The results are thought to be from thoracoscopic dissection of the esophagus high into the thoracic inlet.

Oesophagogastric reconnection is possible.

INTRODUCTION: The first oesophagogastric dissociation was described by Bianchi in 1997 for the treatment of severe gastro-oesophageal reflux (GOR) in neurological patients to avoid serious respiratory complications. The dissociation leads to malabsorption and growth problems. We describe the first two cases of oesophagogastric reconnection long after lung growth. PATIENTS: Case no. 1 was a 12.7-year-old child with a history of type I oesophageal atresia. He required oesophagocoloplasty and gastric dissociation by the Bianchi procedure at the age of 3 months. He has oesophagogastric reconnection at 11 years old because he had a several macrocytic anaemia. Case no. 2 was also a 12-year-old boy, with an unlabelled multiple malformation syndrome with type I oesophageal atresia. He had an oesophagocoloplasty with gastric dissociation at the age of 3 months to protect his lungs. The reconnection was proposed at 10 years old because he developed multiple nutritional deficiencies and growth retardation. RESULTS: The two cases have no clinical symptom of reflux and their post-operative digestive contrasts are normal. Reconnection appears possible with or without preserving the Roux-en-Y loop. It improves absorption and corrects any vitamin deficiencies, allows the reconnected stomach to be monitored in terms of reflux and malignancy and enables enteral nutrition supplementation to be stopped. The possibility of reconnection after the Bianchi procedure therefore extends its indications, mostly in the case of oesophageal atresia complicated by severe GOR with pulmonary repercussions or tracheoesophageal cleft.

Atresia esofágica y fístula traqueoesofágica: evolución y complicaciones postquirúrgicas / Esophageal atresia and tracheoesophagic fistula: evolution and postsurgical complications

Esophageal atresia (EA) and tracheoesophageal fistula are congenital anomalies associated with respiratory and gastrointestinal morbidity. Objective: The aim of this study was to describe clinical characteristics of patients with EA and TEF during childhood, specially focused on respiratory and gastrointestinal complications. Methods: We reviewed the clinical charts from fifteen patients admitted to our hospital and who were followed locally between 1995 and 2007. Results: Gross classification distribution was: A: 0, B: 0, C: 12, D: 2, E: 1. Waterston distribution was Al: 6, B1: 1, B2: 4y C2: 4. Associated malformations to EA and TEF were 7/15. Main morbidity during the follow up period was: Recurrent pneumonia: 6/15, recurrent wheezing 12/15, tracheomalacia in 9/15 and apnea in one patient. Fistula re-opening in 3/15, Gastro esophageal reflux in 15/15 esophagic stenosis in 7/15. All patients were admitted to the hospital at least once during the follow up and in 12/15 of this were due to respiratory causes. Conclusions: EA and TEF after surgical repair have significant respiratory and gastrointestinal morbidity and frequent admission to the hospital during the first years of life.

La Atresia esofágica (AE) con o sin fístula traqueoesofágica (FTE) es una malformación congénita que se asocia a complicaciones respiratorias y digestivas. Objetivo: Describir las características de estos pacientes, su morbilidad respiratoria, digestiva y hospitalizaciones en su evolución a largo plazo. Materiales y Métodos: Se revisaron en forma retrospectiva 15 fichas de pacientes con diagnóstico de FTE evaluados por el equipo de Neumología Pediátrica de la Universidad Católica de Chile entre 1995 y 2007. Resultados: N = 15 pacientes, sexo masculino 9 diagnóstico el primer día de vida 13/15 pacientes. Clasificación de Gross: A= 0, B= 0, C= 12, D= 2, E= 1. Clasificación de Waterston Al: 6, Bl: 1, B2: 4 y C2: 4 Malformaciones asociadas: en 7/15. Complicaciones respiratorias: Neumonía recurrente 8/15, sibilancias recurrentes 12/15, Recurrencia de fístula: 3 /15 pacientes, Apnea: 1 paciente, Traqueomalacia (TM) (9/15). Complicaciones digestivas: Reflujo gastroesofágico 15/15, Estenosis esofágica: II15. Un paciente requirió cirugía de Nissen. Todos los pacientes se hospitalizaron en al menos una oportunidad y en el 12/15 la causa fue respiratoria. Conclusión: La FTE es una enfermedad de resolución quirúrgica con alta morbilidad respiratoria, digestiva y frecuentes hospitalizaciones en los primeros años de vida.

Evolución a largo plazo de 55 pacientes operados de atresia esofágica / Long-term development of 55 patients operated for esophageal atresia

Los pacientes operados de atresia esofágica constituyen un reto para los médicos involucrados en su seguimiento. Se realizó un estudio retrospectivo de las historias clínicas de 55 pacientes vivos después de operarse de atresia esofágica, en un período de 15 años, donde se evaluaron las complicaciones encontradas a largo plazo, con el objetivo de identificarlas y conocer su tratamiento. La presencia de reflujo gastroesofágico en 30 niños (54,54 por ciento), la dismotilidad esofágica en 28 (50,90 por ciento) y las manifestaciones respiratorias recurrentes en 26 pacientes (47,27 por ciento) fueron las más frecuentes, seguidas de las estenosis de la sutura en 11 (20 por ciento), retardo del crecimiento y desarrollo en 10 (18,18 por ciento) y la recurrencia de la fístula en 2 niños (3,63 por ciento). Se concluye que en el seguimiento a largo plazo de los pacientes operados de atresia esofágica se deben realizar el diagnóstico precoz y el tratamiento de múltiples complicaciones que definen su calidad de vida(AU)

Uso de magnetos en la reparación primaria de la atresia de esófago / Esophageal atresia: successful management with magnetic compression

Propósito. Evaluar la posibilidad de alargar los cabos esofágicos en niños y anastomosarlos mediante la utilización de magnetos a fin de reemplazar la cirugía o eventualmente facilitarla. Material y métodos. Tras evaluar a 6 niños entre 30 días y 17 meses de edad, se seleccionaron 5 de ellos con atresia esofágica para intentar la aplicación del método. El principal criterio de selección radicó en una separación entre cabos no mayor de 3 cm., dada la potencia de nuestro magneto, fabricado en USA según diseño realizado en nuestra institución. Resultados. Se logró la anastomosis en la totalidad de los pacientes en un promedio de 4,8 días de tratamiento (rango 2-7 días) y sin complicaciones intratratamiento salvo en un caso, en que se presentó un cuadro de sepsis que una vez tratado convencionalmente no impidió continuar con la aplicación. Conclusión. Esta experiencia inicial, si bien limitada, abre interesantes perspectivas para explorar alternativas al tratamiento quirúrgico de la atresia esofágica (AU)

Uso de magnetos en la reparación primaria de la atresia de esófago / Esophageal atresia: successful management with magnetic compression

Propósito. Evaluar la posibilidad de alargar los cabos esofágicos en niños y anastomosarlos mediante la utilización de magnetos a fin de reemplazar la cirugía o eventualmente facilitarla. Material y métodos. Tras evaluar a 6 niños entre 30 días y 17 meses de edad, se seleccionaron 5 de ellos con atresia esofágica para intentar la aplicación del método. El principal criterio de selección radicó en una separación entre cabos no mayor de 3 cm., dada la potencia de nuestro magneto, fabricado en USA según diseño realizado en nuestra institución. Resultados. Se logró la anastomosis en la totalidad de los pacientes en un promedio de 4,8 días de tratamiento (rango 2-7 días) y sin complicaciones intratratamiento salvo en un caso, en que se presentó un cuadro de sepsis que una vez tratado convencionalmente no impidió continuar con la aplicación. Conclusión. Esta experiencia inicial, si bien limitada, abre interesantes perspectivas para explorar alternativas al tratamiento quirúrgico de la atresia esofágica

High-dose omeprazole in esophagitis with stenosis after surgical treatment of esophageal atresia.

The authors describe 4 children with recurrent stenosis and persistent esophagitis after secondary repair of a long gap esophageal atresia. They underwent an esophageal reconstruction by elongation of the lesser gastric curvature according to Schärli at the age of 11 to 14 months. All had esophagitis grade III to IV (Savary-Miller classification), esophageal stenosis, and failure to thrive. Effective treatment of the esophagitis and prevention of stenosis consisted in high doses of omeprazole (1.9 to 2.5 mg/kg/d). After this treatment, the need for esophageal dilatation disappeared, and nutritional status normalized.

Nursing perspectives in the management of infants and children requiring thoracic surgery.

Nurses who care for infants and children undergoing thoracic surgery must function and make decisions which take into account a multiplicity of complex data. This necessitates a background of knowledge, skill and intuition which guides their nursing practice. The principles of holistic care in which the total needs of the infant and child are met within the context of the family are seen as an important approach to patient care. Selected perspectives in the care of infants with congenital and acquired thoracic anomalies are discussed, in particular infants with congenital diaphragmatic hernia and oesophageal atresia. The preparation of children for chest surgery and the postoperative nursing management are outlined and include aspects of pain management, physiotherapy and chest drain care.

Focal ectasia of the terminal bowel accompanying low anal deformities.

Three patients were treated at birth for low anal deformities and developed intractable constipation, not imputable to usual causes of rectal inertia. Barium enema, done the first time at ten days of age in one case, revealed focal ectasia of the terminal bowel, with a peculiar "balloon-like" aspect of the rectum. Optimal treatment includes resection of the terminal bowel down to the dentate line. Incidence of this anomaly in association with low anal deformities has been 5% in our series.