Dave R Lal1, Samir K Gadepalli2, Cynthia D Downard3, Daniel J Ostlie4, Peter C Minneci5, Ruth M Swedler6, Thomas H Chelius7, Laura Cassidy8, Cooper T Rapp6, Deborah Billmire9, Steven Bruch2, R Carland Burns9, Katherine J Deans5, Mary E Fallat3, Jason D Fraser10, Julia Grabowski11, Ferdynand Hebel11, Michael A Helmrath12, Ronald B Hirschl2, Rashmi Kabre11, Jonathan Kohler4, Matthew P Landman9, Charles M Leys4, Grace Z Mak13, Jessica Raque3, Beth Rymeski12, Jacqueline M Saito14, Shawn D St Peter10, Daniel von Allmen12, Brad W Warner14, Thomas T Sato6. 1. Division of Pediatric Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI. Electronic address: dlal@chw.org. 2. Section of Pediatric Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI. 3. Division of Pediatric Surgery, Hiram C. Polk, Jr., M.D. Department of Surgery, University of Louisville, Louisville, KY. 4. Division of Pediatric Surgery, Department of Surgery, University of Wisconsin, Madison, WI. 5. Center for Surgical Outcomes Research, The Research Institute at Nationwide Children's Hospital, Department of Surgery, University of Ohio, Columbus, OH. 6. Division of Pediatric Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI. 7. Division of Epidemiology, Institute for Health and Society, Medical College of Wisconsin, Milwaukee, WI. 8. Division of Pediatric Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI; Division of Epidemiology, Institute for Health and Society, Medical College of Wisconsin, Milwaukee, WI. 9. Division of Pediatric Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN. 10. Division of Pediatric Surgery, Department of Surgery, Children's Mercy Hospital, Kansas City, MO. 11. Division of Pediatric Surgery, Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL. 12. Division of Pediatric Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH. 13. Section of Pediatric Surgery, Department of Surgery, The University of Chicago Medicine and Biologic Sciences, Chicago, IL. 14. Division of Pediatric Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO.
Abstract
PURPOSE: Perioperative management of infants with esophageal atresia and tracheoesophageal fistula (EA/TEF) is frequently based on surgeon experience and dogma rather than evidence-based guidelines. This study examines whether commonly perceived important aspects of practice affect outcome in a contemporary multi-institutional cohort of patients undergoing primary repair for the most common type of esophageal atresia anomaly, proximal EA with distal TEF. METHODS: The Midwest Pediatric Surgery Consortium conducted a multicenter, retrospective study examining selected outcomes on infants diagnosed with proximal EA with distal TEF who underwent primary repair over a 5-year period (2009-2014), with a minimum 1-year follow up, across 11 centers. RESULTS: 292 patients with proximal EA and distal TEF who underwent primary repair were reviewed. The overall mortality was 6% and was significantly associated with the presence of congenital heart disease (OR 4.82, p=0.005). Postoperative complications occurred in 181 (62%) infants, including: anastomotic stricture requiring intervention (n=127; 43%); anastomotic leak (n=54; 18%); recurrent fistula (n=15; 5%); vocal cord paralysis/paresis (n=14; 5%); and esophageal dehiscence (n=5; 2%). Placement of a transanastomotic tube was associated with an increase in esophageal stricture formation (OR 2.2, p=0.01). Acid suppression was not associated with altered rates of stricture, leak or pneumonia (all p>0.1). Placement of interposing prosthetic material between the esophageal and tracheal suture lines was associated with an increased leak rate (OR 4.7, p<0.001), but no difference in the incidence of recurrent fistula (p=0.3). Empiric postoperative antibiotics for >24h were used in 193 patients (66%) with no difference in rates of infection, shock or death when compared to antibiotic use ≤24h (all p>0.3). Hospital volume was not associated with postoperative complication rates (p>0.08). Routine postoperative esophagram obtained on day 5 resulted in no delayed/missed anastomotic leaks or a difference in anastomotic leak rate as compared to esophagrams obtained on day 7. CONCLUSION: Morbidity after primary repair of proximal EA and distal TEF patients is substantial, and many common practices do not appear to reduce complications. Specifically, this large retrospective series does not support the use of prophylactic antibiotics beyond 24h and empiric acid suppression may not prevent complications. Use of a transanastomotic tube was associated with higher rates of stricture, and interposition of prosthetic material was associated with higher leak rates. Routine postoperative esophagram can be safely obtained on day 5 resulting in earlier initiation of oral feeds. STUDY TYPE: Treatment study. LEVEL OF EVIDENCE: III.
PURPOSE: Perioperative management of infants with esophageal atresia and tracheoesophageal fistula (EA/TEF) is frequently based on surgeon experience and dogma rather than evidence-based guidelines. This study examines whether commonly perceived important aspects of practice affect outcome in a contemporary multi-institutional cohort of patients undergoing primary repair for the most common type of esophageal atresia anomaly, proximal EA with distal TEF. METHODS: The Midwest Pediatric Surgery Consortium conducted a multicenter, retrospective study examining selected outcomes on infants diagnosed with proximal EA with distal TEF who underwent primary repair over a 5-year period (2009-2014), with a minimum 1-year follow up, across 11 centers. RESULTS: 292 patients with proximal EA and distal TEF who underwent primary repair were reviewed. The overall mortality was 6% and was significantly associated with the presence of congenital heart disease (OR 4.82, p=0.005). Postoperative complications occurred in 181 (62%) infants, including: anastomotic stricture requiring intervention (n=127; 43%); anastomotic leak (n=54; 18%); recurrent fistula (n=15; 5%); vocal cord paralysis/paresis (n=14; 5%); and esophageal dehiscence (n=5; 2%). Placement of a transanastomotic tube was associated with an increase in esophageal stricture formation (OR 2.2, p=0.01). Acid suppression was not associated with altered rates of stricture, leak or pneumonia (all p>0.1). Placement of interposing prosthetic material between the esophageal and tracheal suture lines was associated with an increased leak rate (OR 4.7, p<0.001), but no difference in the incidence of recurrent fistula (p=0.3). Empiric postoperative antibiotics for >24h were used in 193 patients (66%) with no difference in rates of infection, shock or death when compared to antibiotic use ≤24h (all p>0.3). Hospital volume was not associated with postoperative complication rates (p>0.08). Routine postoperative esophagram obtained on day 5 resulted in no delayed/missed anastomotic leaks or a difference in anastomotic leak rate as compared to esophagrams obtained on day 7. CONCLUSION: Morbidity after primary repair of proximal EA and distal TEFpatients is substantial, and many common practices do not appear to reduce complications. Specifically, this large retrospective series does not support the use of prophylactic antibiotics beyond 24h and empiric acid suppression may not prevent complications. Use of a transanastomotic tube was associated with higher rates of stricture, and interposition of prosthetic material was associated with higher leak rates. Routine postoperative esophagram can be safely obtained on day 5 resulting in earlier initiation of oral feeds. STUDY TYPE: Treatment study. LEVEL OF EVIDENCE: III.
Authors: Carolina Pinzon-Guzman; Sreedhara Sangadala; Katherine M Riera; Evgenya Y Popova; Elizabeth Manning; Won Jae Huh; Matthew S Alexander; Julia S Shelton; Scott D Boden; James R Goldenring Journal: J Clin Invest Date: 2020-08-03 Impact factor: 14.808