delayed primary anastomosis for management of long-gap
TRANSCRIPT
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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
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INTRODUCTION
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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
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Factors responsible for increased
survival rates in recent years
Improvements in prenatal diagnosis
advances in surgery, pediatric anesthesia,
Neonatal intensive care
parenteral nutrition
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Delayed primary anastomosis
high incidence of prematurity
additional anomalies
long-gap esophageal atresia (LGEA)
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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
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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.
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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
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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
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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
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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.
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MATERIALS AND METHODS
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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.
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Excluded from the study
Articles not containing originalresearch data ( letters, editorials,
commentaries & reviews)
Articles not giving adequate
information regarding complicationrates and outcome excluded.
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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
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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
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Outcome analysis
primary outcome : complication rates.
COMPLICATIONS:
Anastomotic leaks / strictures
symptomatic gastroesophageal reflux (GER)
dysphagia, esophagitis
recurrent fistula / aspiration pneumonia
growth retardation &
Barretts metaplasia
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postoperativeinterventions(drainage,dilatation, reoperation
and replacement).
SECONDARYOUTCOMES
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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
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RESULTS
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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
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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%]
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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).
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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.)
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observations
RELATIVE RISK FOR ANASTOMOTIC STRICTURES significantly higher inpts with previous anastomotic leaks (RR 2.4, 95 % CI 1.93.0;p
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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)
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DISCUSSION
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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
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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
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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
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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
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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
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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
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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.
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CONCLUSIONS
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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
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REFERENCES
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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
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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
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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.
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Repair of long-gap esophageal atresia: gastric conduits
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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.
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