delayed primary anastomosis for management of long-gap

7/28/2019 Delayed Primary Anastomosis for Management of Long-gap

1/43

Delayed primary anastomosis for

management of long-gapesophageal atresia: a meta-analysis of

complications

and long-term outcomeFlorian Friedmacher , Prem Puri

Pediatric Surgery International Sept 2012


2/43

INTRODUCTION


3/43

Esophageal atresia

Esophageal atresia (EA) relatively common

congenital malformation of unknown etiology

incidence 1 in 3,500 live births

PURE EA WITHOUT TEF

uncommon variant

8 % of all incidence of 1 in 40,000 live births


4/43

Factors responsible for increased

survival rates in recent years

Improvements in prenatal diagnosis

advances in surgery, pediatric anesthesia,

Neonatal intensive care

parenteral nutrition


5/43

Delayed primary anastomosis

high incidence of prematurity

additional anomalies

long-gap esophageal atresia (LGEA)


6/43

Long gap esophageal atresia

surgical management a

major challenge

no. of innovative

techniques introducedto reduce the distance

between upper and

lower esophageal

segments to allow an

anastomosis


7/43

1981, Puri et al reported

Spontaneous growth & hypertrophy of the

esophageal segments in LGEA occur at a rate

faster than overall somatic growth in the

absence of any form of mechanical stretching.


8/43

First measurement of gap

between upper & lower

esophageal segment by using

radiopaque bougies at 3 weeksof age.

gap ~ 5 vertebral bodies long.

esophageal gap

significantly reduced in

the same patient at 14

weeks of age


9/43

Observations of Puri et al, 1981

STIMULI TO SUCH NATURAL GROWTH:

swallowing reflex

reflux of gastric contents into the lower

esophageal pouch

MAXIMAL NATURAL GROWTH of the esophageal

segments: the first 812 weeks therefore IDEAL TIME for delayed primary

anastomosis (DPA): 12 weeks of age


10/43

Consensus among most pediatric surgeons :

conservation of the native esophagus

associated with the best postoperative results

Last 3 decades : DPA recognised as the ideal

procedure in the majority of cases for

esophageal reconstruction in LGEA


11/43

objective of the study

to investigate the complications & long-term

outcome in patients with LGEA managed by

DPA based on a meta-analysis of the published

literature.


12/43

MATERIALS AND METHODS


13/43

Sources & literature search

Systematic literature search to identifyarticles reporting cases of LGEA managed byDPA.

Common electronic databases : MEDLINE,EMBASE, ISI Web of ScienceSM & theCochrane Library searched in December 2011

No language or publication date restrictions

Duplicated articles were deleted.


14/43

Excluded from the study

Articles not containing originalresearch data ( letters, editorials,

commentaries & reviews)

Articles not giving adequate

information regarding complicationrates and outcome excluded.


15/43

Data extraction

Unblinded , standardized full-text assessment

of relevant articles independently performed

by both authors (F.F. and P.P.).

Data was extracted into electronic datasheet


16/43

Data extracted from each participating

article

first author

publication year,

sample size

follow-up time &

mortality rate

STUDYCHARACTERISTICS

gestational age

birth weight, type of LGEA &

additional congenital anomalies

PATIENTCHARACTERISTICS


17/43

Outcome analysis

primary outcome : complication rates.

COMPLICATIONS:

Anastomotic leaks / strictures

symptomatic gastroesophageal reflux (GER)

dysphagia, esophagitis

recurrent fistula / aspiration pneumonia

growth retardation &

Barretts metaplasia


18/43

postoperativeinterventions(drainage,dilatation, reoperation

and replacement).

SECONDARYOUTCOMES


19/43

Statistical analysis

Each specificcomplicationrecorded as:

no. of patientswith that

complicationDIVIDED BY thetotal number ofpatients in thecohorts that

presented data onthat specific

complication

Cumulativemeta-

analysis

calculation of

incidenceswith a 95 %confidenceinterval(CI)

for eachspecific

complication

Statistical

differencesconsidered

significant fora p value


20/43

RESULTS


21/43

Literature search results

total of223

articles

removalof 117

duplicates

106 titles,key words

&abstractsreviewed.

46articles

metinclusioncriteria &examined

2 articlesreferred

to resultsof alreadyselectedarticles,excluded

data from44 studies

from1981-2010,

included


22/43

Characteristics of included studies

Total no. managed by DPA= 451(range 1-74 per study)

Most common variants :

Pure EA [194/451, 43.0 %]

LGEA with distal TEF [252/451, 55.9 %], Rare variant: LGEA with prox TEF [5/451,

1.1%]


23/43

Data about LGEA

PREOPERATIVE GAP LENGTH :

13 studies :mean of 3.6 cm (range 1.97.0) or 4.5 vertebral bodies (range1.58.0)

7 studies : mean of 1.3 cm ( range 0.5-3.

TIME UNTIL DPA:

36 studies, mean of 11.9 weeks (range 0.554.0 weeks).

CIRCULAR MYOTOMY to reduce the distance between the 2 esophageal segments

reported in 14 studies.FOLLOW-UP TIME

27 studies, mean of 5.5 years (range 0.527.0 years).


24/43

incidence of

each specific complication

Anastomotic leaks 62/216 (95 % CI 22.935.3)

Anastomotic strictures 155/272 (95 % CI 50.962.9)

Symptomatic GER 131/274 (95 % CI 41.853.9)

Esophagitis 14/38 (95 % CI 22.354.0)

Dysphagia 12/77 (95 % CI 8.726.0)

Recurrent fistula 12/137 (95 % CI 4.815.1),

Recurrent aspiration pneumonia 6/25 (95 % CI10.245.5)

Growth retardation 21/108 (95 % CI 12.728.

Barretts metaplasia 4/30 (95 % CI 4.31.6).

Mortality 34 /332 (95 % CI 7.314.)


25/43

observations

RELATIVE RISK FOR ANASTOMOTIC STRICTURES significantly higher inpts with previous anastomotic leaks (RR 2.4, 95 % CI 1.93.0;p


26/43

Incidence of postoperative

interventions

Drainage/reoperation for anastomotic leaks: 25/109 (95% CI 15.732.2)

Dilatation : 129/253 (95% CI 44.757.3)

Resection & reanastomosis for strictures: 26/121 (95% CI 14.830.1)

Fundoplication for symptomatic GER: 94/262 (95% CI 30.142.1)

Esophageal replacement after DPA: 13/92 (95 % CI 8.023.3)


27/43

DISCUSSION


28/43

Overview of complications and long-termoutcome in newborns with LGEA managed byDPA of the available patient cohorts published

so far. Based on this data, it is recommended to

perform a DPA when the patient is 34months old.

At this age, the distance between the twoends usually is


29/43

Anastomotic leaks

Generally pts kept in the hospital until DPA

could be performed

In most of the studies, early complications

after DPA : anastomotic leaks

Mostly minor, subsided spontaneously on TPN


30/43

Esophageal stricture

Presence of a previous anastomotic leak one

of the most important risk factors in stricture

formation.

Persistent esophageal strictures mainly in

association with symptomatic GER.

Most of the strictures responded to periodic

dilatations


31/43

Symptomatic GER

Symptomatic GER present after DPA: requiresaggressive approach

~ 30 % of patients required a fundoplication in

1st year after surgical repair of their LGEA dueto symptomatic GER or persistent strictures.

Risk for esophagitis higher in patients with

symptomatic GER. Severe esophagitis caused by symptomatic

GER rarely after DPA : required fundoplication


32/43

Other complications

INCIDENCE OF DYSPHAGIA AFTER DPA : low

Patients with dysphagia usually had symptomaticGER or associated strictures on contrast studies.

RECURRENT ASPIRATION PNEUMONIAuncommon after DPA

NEED FOR ESOPHAGEAL REPLACEMENT FORUNSATISFACTORY RESULTS AFTER DPA : relatively

rare and only necessary in a few patients havingno lower esophageal segment or only a nub of alower esophageal segment


33/43

SURVIVAL RATE after DPA ~ 90 %

Long-term follow-up studies showed: majority

having NORMAL GROWTH ANDDEVELOPMENT

Continued long-term follow-up with regularendoscopic surveillance protocols: potentialRISK OF BARRETTS METAPLASIA


34/43

Disadvantages

Prolonged hospital stay

Constant threat of aspiration pneumonia

These factors must be balanced against reducedlong-term morbidity in a child who should have anormal life expectancy

&against the disadvantages of esophagealreplacement.


35/43

CONCLUSIONS


36/43

DPA provides good long-term functional results.

High incidence of GER and associated strictures requiresearly intervention to prevent feeding problems due tostricture & esophagitis

Long-term follow-up is recommended because of thepotential risk of Barretts metaplasia


37/43

REFERENCES


38/43

The surgical approach to esophageal atresia repair

and the management of long-gap atresia: results of a

survey.Ron O, De Coppi P, Pierro A.

Semin Pediatr Surg. 2009 Feb;18(1):44-9

Most surgeons repair < or =2 LGEA/ year.

LGEA should be managed by a limited number

of surgeons at each center.

Little consensus on the definition of or theoptimum technique for repair of long-gap OA.

h l d h l


39/43

Long gap esophageal atresia and esophageal

replacement: moving toward a separation?Bagolan P, Iacobelli Bd Bd, De Angelis P, di Abriola GF, Laviani R, Trucchi A, Orzalesi M

J Pediatr Surg. 2004 Jul;39(7):1084-90

19cases classified as long gap (> or =3 cm), allunderwent primary or shortly delayed repair

CONCLUSIONS:

(1) long gap EA could be treated successfully withprimary repair and anastomosis

(2) Strictures & GER represent the most frequentpostoperative problem, but additional procedures

required seem "acceptable" to maintain the patient'sown esophagus and avoid replacement

(3) esophageal substitution in long gap EA should bereserved for cases in which a previous attempt ofesophageal reconstruction failed


40/43

Long gap esophageal atresia: an Australian experience.Al-Shanafey S, Harvey J.

J Pediatr Surg. 2008 Apr;43(4):597-601

103 pts with EA , 17 (16%) of them were defined asLGEA, with mean gap of 5 cm (SD, 1cm).

CONCLUSIONS:

LGEA a surgical challenge.

Mortality high secondary to associated anomalies.

no consensus among APS regarding defn of LGEA

general consensus of APS: the preservation of the

patient's own esophagus should be attempted beforeconsidering the use of an esophageal replacement.


41/43

Repair of long-gap esophageal atresia: gastric conduits


42/43

p g g p p g gmay improve outcomea 20-year single center

experienceCatherine J. Hunter, Mikael Petrosyan, Meghan E. Connelly,Nam X. Nguyen

Pediatr Surg Int. 2009 December; 25(12): 10871091.

Surgeons expertise and patients anatomy shouldbe considered when selecting appropriateoperation for LEA.

Although native esophagus generally preferred,associated with a high rate of stricture.

Although study limited by numbers, pts with

gastric conduits found to have lower complicationrates and no conduit ischemia.

gastric transposition may be favored as an initialreconstructive option.


43/43

THANK YOU

delayed primary anastomosis for management of long-gap

Documents