Long-Gap Esophageal Atresia

Bagolan, Pietro; Conforti, Andrea; Morini, Francesco

doi:10.1007/978-3-319-27443-0_31

Cited by 1 publication

(6 citation statements)

References 11 publications

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“…It can be measured in centimeters or vertebral bodies. Some authors define 2 or 3 or 3.5 cm as a cutoff point; others classify the gap into short (1 cm), intermediate (2.5–3 cm), and long (>3 cm); others recommend an esophageal replacement if the gap exceeds the length of six vertebral bodies ( 13 ).…”

Section: Incidence and Risk Factorsmentioning

confidence: 99%

“…The surgical attitude toward AE repair has changed over the last decades, with an increased rate of early primary esophageal repair and a respective reduction of delayed primary repair and esophageal replacement ( 29 ). This changing may be attributed to several factors: improved neonatal care allows children to be in a better condition to survive early definitive surgery; moreover, increased understanding and specialized training of neonatal surgeons has made primary esophageal reconstruction achievable in most long-gap patients ( 13 ). A direct consequence of primary anastomosis in long-gap AE is anastomotic tension, which in turn contributes to AS, as widely reported in retrospective analysis ( 5 – 11 ).…”

Section: Incidence and Risk Factorsmentioning

confidence: 99%

“…Nonetheless, with meticulous handling of the esophageal ends, preservation of the blood supply, and care to include the mucosa in each and every suture of the anastomosis, strictures can be kept to a minimum ( 24 ). Surgical techniques of esophageal lengthening, which have been used to achieve a primary anastomosis, may facilitate the reduction of anastomotic tension ( 13 ). The Kimura advancement technique may be applied only to the upper esophageal pouch and consists on multistage extra thoracic esophageal elongation of the proximal esophagus by moving the cutaneous stoma progressively further down the anterior chest wall ( 13 , 30 ).…”

Section: Incidence and Risk Factorsmentioning

confidence: 99%

“…Surgical techniques of esophageal lengthening, which have been used to achieve a primary anastomosis, may facilitate the reduction of anastomotic tension ( 13 ). The Kimura advancement technique may be applied only to the upper esophageal pouch and consists on multistage extra thoracic esophageal elongation of the proximal esophagus by moving the cutaneous stoma progressively further down the anterior chest wall ( 13 , 30 ). Foker technique involves extensive mobilization of both upper and lower pouches and the placement of sutures in both segments, which are brought out to the skin surface and progressively pulled in the following days until a primary repair is possible ( 13 , 30 – 32 ).…”

Section: Incidence and Risk Factorsmentioning

confidence: 99%

“…Despite the identification of multiple risk factors for ASs, such as long-gap EA with consequent anastomotic tension, postoperative anastomotic leak, and gastroesophageal reflux disease (GERD) ( 3 , 5 – 11 ), prevention strategies with intraoperative techniques and/or postoperative treatments have failed to decrease the incidence of ASs over time ( 12 ). Traction and growth surgical techniques are considered a good system to induce esophageal growth and elongation, therefore facilitating anastomosis with less tension ( 13 ). The possible role of these procedures in preventing AS formation has to be clarified.…”

Section: Introductionmentioning

confidence: 99%

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Anastomotic Strictures after Esophageal Atresia Repair: Incidence, Investigations, and Management, Including Treatment of Refractory and Recurrent Strictures

et al. 2017

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Improved surgical techniques, as well as preoperative and postoperative care, have dramatically changed survival of children with esophageal atresia (EA) over the last decades. Nowadays, we are increasingly seeing EA patients experiencing significant short- and long-term gastrointestinal morbidities. Anastomotic stricture (AS) is the most common complication following operative repair. An esophageal stricture is defined as an intrinsic luminal narrowing in a clinically symptomatic patient, but no symptoms are sensitive or specific enough to diagnose an AS. This review aims to provide a comprehensive view of AS in EA children. Given the lack of evidence-based data, we critically analyzed significant studies on children and adults, including comments on benign strictures with other etiologies. Despite there is no consensus about the goal of the luminal diameter based on the patient’s age, esophageal contrast study, and/or endoscopy are recommended to assess the degree of the narrowing. A high variability in incidence of ASs is reported in literature, depending on different definitions of AS and on a great number of pre-, intra-, and postoperative risk factor influencing the anastomosis outcome. The presence of a long gap between the two esophageal ends, with consequent anastomotic tension, is determinant for stricture formation and its response to treatment. The cornerstone of treatment is endoscopic dilation, whose primary aims are to achieve symptom relief, allow age-appropriate capacity for oral feeding, and reduce the risk of pulmonary aspiration. No clear advantage of either balloon or bougie dilator has been demonstrated; therefore, the choice is based on operator experience and comfort with the equipment. Retrospective evidences suggest that selective dilatations (performed only in symptomatic patients) results in significantly less number of dilatation sessions than routine dilations (performed to prevent symptoms) with equal long-term outcomes. The response to dilation treatment is variable, and some patients may experience recurrent and refractory ASs. Adjunctive treatments have been used, including local injection of steroids, topical application of mitomycin C, and esophageal stenting, but long-term studies are needed to prove their efficacy and safety. Stricture resection or esophageal replacement with an interposition graft remains options for AS refractory to conservative treatments.

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Section: Incidence and Risk Factorsmentioning

confidence: 99%