|Year : 2011 | Volume
| Issue : 2 | Page : 50-53
Esophageal atresia and tracheoesophageal fistula: Effect of pleural cover on anastomotic dehiscence
Money Gupta, JK Mahajan, Monika Bawa, KLN Rao
Department of Pediatric Surgery, Advanced Pediatrics Center, Post Graduate Institute of Medical Education and Research, Chandigarh, India
|Date of Web Publication||18-Mar-2011|
J K Mahajan
Department of Pediatric Surgery, Advanced Pediatrics Center, Post Graduate Institute of Medical Education and Research, Chandigarh 160 012
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: A significant number of esophageal atresia and tracheoesophageal fistula patients have long gaps and a high propensity to leak. Anastomotic leak in esophageal atresia is associated with a significant morbidity and mortality. Aim : In a prospective randomized trial, we analyzed the risk factors leading to anastomotic dehiscence and studied the effect of pleural wrap as an additional vascular cover around the esophageal anastomosis. Materials and Methods: Forty patients were divided into two groups A and B randomly. In 20 patients of group A, pleural wrap was utilized for covering the anastomosis and in 20 patients of group B, no such wrap was utilized. Results: Both the groups were comparable regarding age, sex, weight, gap length, tension at anastomosis and the hospital stay. The overall leak rate was 25% (10/40) in both the groups. The leak rate was not significantly different in two groups whenever a gap length was less than 2 cm or more than 3 cm. However, for a gap length of 2-3 cm, the leak rate in group A was 18% (2/11) and in group B was 50% (4/8) (P = 0.05). Thirty percent (3/10) of patients, whose anastomosis was under tension, leaked in group A as compared to 75% (6/8) in group B patients (P = 0.001). Conclusions: Use of pleural wrap was associated with less anastomotic dehiscence in patients with moderate gap esophageal atresia (2-3 cm) especially when the anastomosis was under tension.
Keywords: Anastomotic dehiscence, esophageal atresia, pleural wrap, tracheoesophageal fistula
|How to cite this article:|
Gupta M, Mahajan J K, Bawa M, Rao K. Esophageal atresia and tracheoesophageal fistula: Effect of pleural cover on anastomotic dehiscence. J Indian Assoc Pediatr Surg 2011;16:50-3
|How to cite this URL:|
Gupta M, Mahajan J K, Bawa M, Rao K. Esophageal atresia and tracheoesophageal fistula: Effect of pleural cover on anastomotic dehiscence. J Indian Assoc Pediatr Surg [serial online] 2011 [cited 2020 Jul 6];16:50-3. Available from: http://www.jiaps.com/text.asp?2011/16/2/50/78130
| Introduction|| |
Prognosis of the patients with esophageal atresia and tracheoesophageal fistula (EA and TEF) depends on the weight of the patient, day of presentation, associated anomalies and the ventilator dependence. , Esophageal gap length, anatomy of the defect and the physiological status are other factors affecting the therapy and outcome. The complications of esophageal anastomosis in primary repair are major or minor leaks, recurrent TEF and significant strictures. Depending upon the criteria used for the definition of leakage, the incidence varies widely from 4 to 36%. ,,, Anastomotic leak rate as reported in several Indian series varies from 16 to 35%. ,, Leak rate in long gap EA and TEF has been reported to be 100%.  Mortality rates after the anastomotic leak, however, are very high in developing as well as in the developed countries.  Hence the anastomotic leak, will most directly influence the outcome.
Although, there are reports using pleura as a reinforcement cover in esophageal perforations and recurrent TEF,  yet, there are no controlled studies available in the literature on the use of pleural wrap in EA. In this prospective randomized trial, we studied the effect of pleural wrap as an additional cover around the esophageal anastomosis.
| Materials and Methods|| |
This study was carried out prospectively in patients of EA and distal TEF undergoing corrective surgery over a period of 2 years. The study comprised of 40 consecutive patients of EA and distal TEF, randomized by computer generated tables into two groups - A and B - once the patient had met the inclusion criteria for the study. The inclusion criteria were weight more than 2 kg, full-term gestation, less than 3-days old at presentation and ability to maintain adequate oxygen saturation preoperatively without mechanical ventilation.
Group A - It consisted of 20 patients in whom, a pleural wrap was utilized for covering the esophageal anastomosis.
Group B - It comprised of 20 patients in whom, no additional cover was provided for the esophageal anastomosis.
After a right posterolateral thoracotomy and ligation of the azygous vein, the lower pouch fistula was delineated. In order to measure the gap between the upper and lower pouches, the anesthetist minimally stretched the upper pouch with a stiff red rubber catheter, introduced through oral route and the distance between the stretched upper pouch and the lower pouch prior to the fistula division was measured. After full mobilization of the upper pouch, additional mobilization of the lower pouch was also done for the long gaps. Circular myotomy was not done in any of the cases. The repair was completed using the conventional operative steps with 5/0 Vicryl sutures. All the patients were operated by similar grade surgeons who made an assessment of the anastomotic tension and recorded the findings in the operation chart.
After completion of the anastomosis, a pleural flap was harvested from the parietal pleura, which had been reflected from the chest wall. A posteriorly based flap of the pleura was used to encircle the esophageal anastomosis and a superior and an inferior suture of 5/0 Vicryl kept it in place [Figure 1]. The opened up parietal pleura stayed as such with drainage of the pleural cavity with a chest drain.
|Figure 1: Pleura (small arrow) being wrapped around the esophageal anastomosis (big arrow)|
Click here to view
Postoperative ventilation was used whenever indicated. Nasogastric feeding was started after 48 h. Anastomotic healing was checked by indirect parameters like clinical examination of the chest, respiratory rate, ventilator parameters for the ventilated patients, chest tube inspection and the radiological examination of the chest. A contrast swallow was performed on the fifth postoperative day and the oral feeds commenced once a leak-free anastomosis of the esophagus was established. The anastomotic leak was categorized as major or minor. When small amount of the contrast leaked into the chest tube without clinical deterioration and soiling of the pleural cavity, it was considered to be a minor leak. The leak was considered to be major, when most of the contrast entered the chest cavity with a clinical evidence of mediastinitis and sepsis. Statistical analysis was done by Chi-square test and Fisher's exact test. The Institute ethical committee had approved the study.
| Results|| |
Mean age at presentation in group A was 1.85 days as compared to 1.75 days in group B. Various parameters in the two groups were comparable and are summarized in [Table 1]. Out of 40 patients, 15 (37.5%) patients in both the groups had associated anomalies. The associated anomalies were cardiac (8), gastrointestinal (3), urological (2), and vertebral (2). The overall leak rate was 25% (10/40) in both the groups whereas it was 20% (4/20) in group A as compared to 30% (6/20) in group B. The gap lengths were categorized as short (<2 cm), moderate (2-3 cm) and long (>3 cm). , In patients with gap length less than 2 cm, none of the patients in either of the groups leaked. In patients, with gap between 2 and 3 cm, the leak rate in group A was 18.2% (2/11) as compared to 50% (4/8) in group B (P<0.05). With gap length more than 3 cm, the leak rate in group A was 40% (2/5) as compared to 50% (2/4) in group B ( p0 <0.5) [Table 2]. The leak was major in 25% (1/4) of the patients in group A as compared to 66.6% (4/6) major leaks in group B (P < 0.524). All the cases of anastomotic dehiscence including the major leaks were managed conservatively. There was no difference in terms of days of ventilation and hospital stay in patients with major and minor leaks in either group.
As per the assessment of the operating surgeon, 50% (10 out of 20) of the patients in group A had anastomotic tension as compared to 40% (8 out of 20) in group B. Out of 10 patients in group A with esophageal anastomosis under tension, 3 patients (30%) had anastomotic leak as compared to 75% (6 out of 8) leak rate in group B (P<0.001).
Eight patients (8/20, 40%) in group A and 7 patients (7/20, 35%) in group B underwent lower pouch mobilization. With lower pouch mobilization, 37.5% (3/8) patients in group A had anastomotic leak as compared to 57.1% (4/7) group B patients, however the difference was not statistically significant.
Postoperative ventilation was required for 15 patients in group A and 14 patients in group B. Sixteen out of 40 patients (40%) required ventilator support for more than 10 days. The requirement of ventilator support was related to the presence or absence of anastomotic leak. Ninety percent of the patients (9/10) who leaked required postoperative ventilation as compared to 66.6% (20/30) of the patients who did not leak. However the mean duration of ventilation and hospital stay were not significantly different in patients with anastomotic leak (16.22 days, range 3-30 days and 30.66 days, range 14-59 days) as compared to the patients who did not leak (13.5 days, range 1-30 days and 25.55 days, range 9-55 days). The patients were followed up for a mean period of one year after their discharge from the hospital. In the follow-up, one patient each in groups A and B who had major anastomotic leak, developed anastomotic stricture which was amenable to dilatations and did not require any other surgical procedure.
| Discussion|| |
Since the first successful repair of EA and TEF in 1941 by Haight, the outcome has gradually improved.  Although the overall mortality has declined; anastomotic leakage and its complication still continue to occur. Main determinant of the prognosis of patients of EA and TEF is anastomotic leak which in turn is influenced by the anastomotic tension. , Other causes could be lower pouch mobilization, gap length, impaired vascular supply of the ends due to excessive mobilization and use of silk sutures. , The definition for gap length has been quite variable. Dudley considered a gap length of over 2 cm as a long gap and found it to be a factor for increased incidence of anastomotic leak. ,
As reported by other workers, we also found the gap length to be a significant factor in predicting leak rate. , Overall leak rate in our series was 25%, similar to other reported Indian series. ,, However, in the gap length between 2 and 3 cm, only 18.2% patients in group A had anastomotic leak as compared to 50% incidence of anastomotic leak in group B. The pleural wrap, being a vascular reinforcement for the anastomosis, probably sealed small potential leak points caused by miniature suture holes in the esophagus. This could be the reason for the leak to be mainly minor in the group A patients. However, additional cover improved leak rates only marginally in gap lengths more than 3 cm and these being minor leaks more often than in patients without any protective cover [Table 2]. Greater tension in longest gap patient may lead to bigger potential leak points, which may not get completely occluded by the pleural cover. The report of Brown et al. showed a leak rate of 31% in patients of long gap and 25% in the intermediate gap lengths.  Similar results were shown in a series by Sharma et al., who reported leak rate of 32% for long gap lengths. 
Tension on anastomosis is also considered a significant factor in predicting the leak rate. , In our patients, the leak rate in group A was less even in the presence of tension, probably, because of the additional supplementary cover of the pleura. Lower pouch mobilization is in itself a risk factor, however it did not always increase the chances of anastomotic leak. ,
Some other risk factors associated with increased incidence of anastomotic dehiscence such as increased age at presentation, weight at presentation, associated anomalies and postoperative ventilation have also been described in the literature ,, and been implicated to a variable extent. ,, Although technical expertise is one of the factors affecting outcome in EA and TEF, but it may be difficult to evaluate. We analyzed the risk of anastomotic leakage associated with each factor and found that the anastomotic tension, lower pouch mobilization and gap length were the significant risk factors predisposing to anastomotic leak [P<0.002 (odds ratio = 21 and CI = 2.08-513), 0.024 (odds ratio = 6.42 and CI = 1.08-42.62) and 0.019, respectively) [Table 3].
Use of pleura as a wrap was also described by Grillo in esophageal perforations.  It is easy to harvest and technically easy to use. Pleura is a mesothelial layer like peritoneum and it acts as an additional vascular cover over the anastomosis. Although, the use of pleura led to the repair of EA and TEF becoming transpleural but the route of approach did not influence mortality and morbidity of the surgical procedure , as well as made no difference in the incidence of complications. 
The results are to be viewed in the context of some limitations of this study. Though, assessment of anastomotic tension, gap length and surgeons' technique have an element of subjectivity and may lack uniformity yet the prospective nature of the study and control of the patient related factors lend validity to the results. However, for a more reproducible outcome, an extended study with more number of patients is required.
| Conclusions|| |
Anastomotic tension is a significant risk factor for dehiscence in the repair of EA. Use of pleural wrap was associated with less anastomotic dehiscence in patients with moderate gap EA and TEF (2-3 cm) as well as it decreased the magnitude of the leakage.
| References|| |
|1.||Spitz L. Esophageal Atresia: Past, present, and future: J Pediatr Surg 1996;31:19-25. |
|2.||Choudhury SR, Ashcraft KW, Sharp RJ, Murphy JP, Snyder CL, Sigalet DL. Survival of patients with esophageal atresia: Influence of birth weight, cardiac anomaly, and late respiratory complications. J Pediatr Surg 2001;36:1419-21. |
|3.||Chittmittrapap S, Spitz L, Kiely EM, Brereton RJ. Anastomotic leakage following surgery for esophageal atresia. J Pediatr Surg 1992;27:29-32. |
|4.||Sharma AK, Kothari SK, Goel D, Sharma SB, Aggrawal LD, Chaturvedi V. Morbidity and mortality with reference to gap between two segments in esophageal atresia. J Indian Assoc Pediatr Surg 1997;2:67-70. |
|5.||Tripathy PK, Rao KLN, Chowdhary SK, Menon P, Mahajan JK, Samujh R et al. Lower pouch mobilization in long gap esophageal atresia: J Indian Assoc Pediatr Surg 2004;9:172-8. |
|6.||McKinnon LJ, Kosloske AM. Prediction and prevention of anastomotic complication of esophageal atresia and tracheosophageal fistula. J Pediatr Surg 1990;25:778-81. |
|7.||Bendi G, Chowdhary SK, Rao KL. Esophageal atresia with tracheoesophageal fistula - An audit. J Indian Assoc Pediatr Surg 2004;9:126-30. |
|8.||Gouge TM, Depan HJ, Spencer FC. Experience with the Grillo pleural wrap procedure in 18 patients with perforation of the thoracic esophagus. Ann Surg 1989;209:612-7. |
|9.||Hands LJ, Dudley NE. A comparison between gap length and Waterston classification as guides to mortality and morbidity after surgery for esophageal atresia. J Pediatr Surg 1986;21:404-6. |
|10.||Brown AK, Tam PK. Measurement of gap length in esophageal atresia: A simple predictor of outcome. J Am Coll Surg 1996;182:41-5. |
|11.||Nagaya M, Kato J, Niimi N, Tanaka S, Iio K. Proposal of a novel method to evaluate anastomotic tension in esophageal atresia with a distal tracheoesophageal fistula. Pediatr Surg Int 2005;21:780-5. |
|12.||Tsao KJ, Lee H. Extrapleural thoracoscopic repair of esophageal atresia and tracheoesophageal fistula. Pediatr Surg Int 2005;21:308-10. |
|13.||Bhatnagar V, Agarwala S, Bajpai M, et al. Results of treatment of esophageal atresia. J Indian Assoc Pediatr Surg 1997;2:55-9. |
|14.||Gangopadhyay AN, Apte AV, Mongha VK. Is retropleural drainage necessary after definitive repair of esophageal atresia and tracheoesophageal fistula? J Indian Assoc Pediatr Surg 2003;8:86-90. |
|15.||Farkash U, Lazar L, Erez I, Gutermacher M, Freud E. The distal pouch in esophageal atresia- to dissect or not to dissect, that is the question. Eur J Pediatr Surg 2002;12:19-23. |
|16.||Mohan NV, Rajamani G, Kumaran V, Krishnamurty P, Raghupathy R. Prognostic indices in esophageal atresia with tracheoesophageal fistula. J Indian Assoc Pediatr Surg 1999;4:23-30. |
|17.||Eradi B, Narasimhan KL, Rao KL, Grover A, Samujh R, Chowdhary SK et al. Waterston: Classification revisited - Its relevance in developing countries. J Indian Assoc Pediatr Surg 2003;8:58-64. |
|18.||Hick LM, Mansfeld PB. Esophageal atresia and tracheoesophageal fistula: Review of thirteen years experience. J Thorac Cardiovasc Surg 1981;81:358-63. |
[Table 1], [Table 2], [Table 3]