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ORIGINAL ARTICLE
Year : 2016  |  Volume : 21  |  Issue : 1  |  Page : 24-27
 

Role of feeding jejunostomy in major anastomotic disruptions in esophageal atresia: A pilot study


Department of Pediatric Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India

Date of Web Publication17-Dec-2015

Correspondence Address:
Monika Bawa
Department of Pediatric Surgery, Advanced Pediatric Center, Post Graduate Institute of Medical Education and Research, Chandigarh - 160 012
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-9261.165843

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   Abstract 

Aims: To investigate the role of feeding jejunostomy (FJ) in patients of esophageal atresia with anastomotic leak (AL) to decrease the degree of gastroesophageal reflux (GER) and its effect on anastomotic healing. Materials and Methods: Twenty neonates, with major AL and severe GER after primary repair were managed with decompressing gastrostomy and transgastric FJ and analyzed prospectively. Results: Male to female ratio was 1.7:1. Mean birth weight was 2.2 kg. Anastomotic gap ranged from 0 to 4 cm. The amount of leak was more than 20% of nasogastric feeds. Gastrostomy and FJ was done on an average of the 12 th postoperative day, after observing the general condition, chest tube output, lung expansion, and ventilatory requirement. There was a drastic reduction in chest tube output and lung expanded in all patients. Average hospital stay was 36 days (8-80 days). Sixty percentage patients were discharged successfully on FJ. Esophagogram demonstrated healing and leak free patency after an average of 1.5 months. GER was noted in seven patients, four developed stricture, and one had pseudodiverticulum in follow-up. Conclusion: Decompressing gastrostomy and FJ can be an alternative to managing major ALs. It helps in healing of anastomotic dehiscence and in preserving the native esophagus.


Keywords: Anastomotic leak, feeding jejunostomy, gastrostomy, native esophagus, tracheoesophageal fistula


How to cite this article:
Bawa M, Menon P, Mahajan JK, Peters NJ, Saurabh G, Rao K. Role of feeding jejunostomy in major anastomotic disruptions in esophageal atresia: A pilot study . J Indian Assoc Pediatr Surg 2016;21:24-7

How to cite this URL:
Bawa M, Menon P, Mahajan JK, Peters NJ, Saurabh G, Rao K. Role of feeding jejunostomy in major anastomotic disruptions in esophageal atresia: A pilot study . J Indian Assoc Pediatr Surg [serial online] 2016 [cited 2019 Sep 18];21:24-7. Available from: http://www.jiaps.com/text.asp?2016/21/1/24/165843



   Introduction Top


The anastomotic complications after primary repair of esophageal atresia (EA) are well recognized and can significantly increase the morbidity. [1],[2],[3],[4] The management options for an anastomotic leak (AL) vary from conservative management to reoperation. A major AL may require esophageal diversion that leads to discarding of the native esophagus. To retain the native esophagus, a redo anastomosis with or without vascularized flaps or a conservative approach with adequate nutritional supplementation have all been described in the literature, [1],[2],[5],[6] however, the reported success of conservative treatment is quite variable. [5],[7] There is no controversy regarding the conservative management of minor leaks, but the management strategies for major anastomotic disruptions are still not standardized.

Gastroesophageal reflux is associated with a significant number in patients of EA and is one of the factors preventing the closure of AL leading to failure of conservative treatment. We performed transgastric feeding jejunostomy (FJ) with decompressing gastrostomy in patients of EA with anastomotic dehiscence and studied its effect on healing.


   Materials And Methods Top


From January 2006 to October 2012, 20 consecutive neonates with major AL, fulfilling the inclusion criteria, were prospectively studied. All the leaks were identified in the chest tubes and these patients were managed with a decompressing gastrostomy and transgastric FJ. Transgastric FJ was used for enteral nutrition, and none of the patients received total parenteral nutrition (TPN).

In our study, a major leak was defined as the presence of either more than 20% of the total nasogastric feeds draining out through the intercostal drain or <20% of total nasogastric feeds with chest complications (pneumothorax, persistent collection, and lung collapse), increase in ventilatory parameters and worsening general condition of the neonate.

Patients with a major leak who developed pneumothorax or persistent collections were considered for insertion of a second intercostal chest drain (ICD). The patients with high ICD output draining more than 20% of the feeds and those with continuing chest complications underwent gastrostomy and FJ and formed the subjects of this report [Figure 1]. The patients with a minor leak and those who improved with a second ICD were excluded from the study.
Figure 1: Algorithm for management of major anastomotic leak

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A transgastric FJ was done by selecting an area in the body of the stomach as is done for gastrostomy. A hole was created within a purse string suture through which a Malecot's catheter of suitable size and a 6 Fr infant feeding tube were introduced. The Malecot's catheter was kept inside the stomach while the feeding tube was guided across the duodenum into the jejunum. The purse string was tightened, and the stomach was fixed to the abdominal wall in a watertight manner at the exit of the tubes. A gastrostomy tube was used for decompression while the jejunostomy was used for feeding purpose. The objectives of the study were to analyze the effect of FJ and gastrostomy in terms of decrease in the chest tube output, improvement of lung complications, change in parameters of ventilation, and subsequent anastomotic healing.

The study was approved by the Institute Ethics Committee.


   Results Top


Over a period of 6 years, 20 patients with major anastomotic dehiscence were analyzed. Male to female ratio was 1.7:1. The birth weight of patients ranged from 1.6 to 3.3 kg (mean-2.2 kg). The anastomotic gap ranged from 0 to 4 cm (mean-2.2 cm). All patients underwent primary end to end anastomosis of the esophagus (Vicryl 5-0) with ligation of fistula and 15 patients required mobilization of the lower pouch also.

As per the management protocol, after primary repair, the patients were nursed in head up position, and the feeds were started by transanastomotic feeding tube on 2 nd postoperative day in all the patients, except two who had associated jejunal and rectal atresia. AL was clinically noted in all these patients from 3 rd to 5 th postoperative day with chest tube showing evidence of saliva. All the patients of AL were managed conservatively, and the feeding was continued through the nasogastric tube. The contents of the leak were saliva mixed with feeds, and the amount was more than 20% of nasogastric feeds in all the patients. The first chest drain was effective in 75% of the patients, whereas a second ICD was required in the remaining 25% (5/20) for persistent pneumothorax or collection.

On an average, the patients underwent gastrostomy and FJ on the 12 th postoperative day (range 8-15 days) after an adequate trial of conservative management. After FJ and gastrostomy, the condition of lungs improved gradually in 53% of patients (8/15) with single chest tube over next 8-10 days who could then be extubated. The rest of the patients required prolonged ventilation due to persistent high chest tube output, and associated heart and gastrointestinal diseases. There was a gradual reduction in chest tube output and improvement in the condition of chest in these patients also. On an average, the postoperative ventilation was required for 25 days (14-51 days).

Enteral nutrition could be started through the jejunostomy in two-thirds (14/20) of the patients on the 2 nd postoperative day. Three patients (15%) had jejunostomy tube-related complications. Two of them had bowel perforation with jejuno-cutaneous fistula and expired. The third one had severe peritubal excoriation and was managed conservatively and discharged. The average hospital stay was 36 days (range 18-80 days).

Twelve out of 20 (60%) patients were discharged successfully on FJ. Esophagogram demonstrated healing of the anastomosis and leak free patency after an average of 1.5 months (range 1-3 months) when oral feeds could be instituted.

There were a total of eight deaths (40%). Of the patients who died, six could not be started on feeds. Of these six, two developed jejuno-cutaneous fistulas as a complication of jejunal intubation, two necrotizing enterocolitis and one each had associated jejunal and rectal atresia. Remaining two patients had severe associated congenital heart anomalies.

In the follow-up, gastroesophageal reflux was noted in seven patients, and six of them had a resolution of the reflux over next 2 years. Four patients developed stricture, out of which two were amenable to multiple dilatations, but the other two required resection of the strictured segment and end to end anastomosis. One had a rare complication of pseudo-diverticulum that required excision [Figure 2].
Figure 2: Contrast study showing a pseudodiverticulum

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   Discussion Top


The overall incidence of AL age after surgical repair of EA is around 15-17% but major leakage is approximately 3.5%. [7] The main factors held responsible for anastomotic dehiscence are the use of certain suture materials such as silk, devascularization secondary to extensive dissection, excess tension on the sutures, small and friable lower segment, technically poor suturing techniques, and inaccurate mucosal apposition. [1],[3],[4] Current management of ALs depends on the clinical condition of the patient and the extent of leak. [4]

It is important to determine whether the leak is "major" or "minor" as the approach to management will differ. Chittmittrapap et al. labeled involvement of more than one-fourth circumference of the esophagus as a major leak. [8] Chavin et al. reported 11 cases of ALs, seven of which were considered "major" involving 15-85% of the circumference of anastomosis. [6] D'Urzo et al. described more than 4 mm dehiscence as major. [4] In contrast to the above-mentioned studies, we defined the of degree of AL as major or minor based not only on chest tube output but also the presence or absence of pneumothorax, chest collection, and lung collapse.

Major leaks usually occur in early postoperative period (<48 h) and may require additional procedures such as rethoracotomy or esophageal diversion to tide over the situation. [7],[9] However, minor leaks detected on the "routine" contrast study on 5-7 th day postoperatively usually heal spontaneously, with or without strictures. [7] When anastomotic dehiscence occurs, the choice between surgical and conservative management can be difficult.

We propose a comprehensive management protocol for major leaks as detailed in [Figure 1]. Initially, a conservative approach was advised as long as the lungs were maintained in an expanded state although this required careful and prolonged monitoring. Inability to prevent lung complications and deliver adequate enteral nutrition via nasogastric route necessitated surgical intervention. In addition, TPN is required for these patients, which has its own short and long-term complications and availability may be an issue in developing countries. [1] None of our patients received TPN due to financial constraints.

However, many a times, the decision to abandon the "wait-and-see" approach and reoperate is both complex and crucial. [4] Some authors advice early thoracotomy and reanastamosis, with good results. [10] In most cases, the recently operated friable tissue is further jeopardized by being constantly in contact with salivary and possibly gastric juices from the leak. This condition precludes reanastomosis. [2],[7] Another approach to manage major ALs involves a cervical esophagostomy and gastrostomy followed by gastric, colonic, or jejunal interposition at an appropriate time, like a staged procedure. Apart from abandoning the native esophagus, consequences of interposition grafts such as poor motility, severe gastric reflux and the tenuous nature of the blood supply especially in jejunal grafts make these less than ideal. [1],[2],[7] Primary gastric pull up in patients with ALs has also been described [1],[2] but is not feasible, most of the times, due to sepsis, and poor general condition. Use of anticholinergic medications, to reduce the drain output, during the conservative approach has also been described recently. [5]

None of the above-mentioned approaches have turned out to be ideal and free of complications. With this background, we describe an innovative addition in the form of an FJ with gastrostomy, which is feasible in an acute setting without rendering the native esophagus unusable in future. Our results even though not very encouraging show significant improvement in a subset of patients who did not require esophageal replacement after major AL. The advantages of gastrostomy and FJ over other procedures are manifold. First, it is less time consuming and requires less anesthesia time in the friable, septic cohort of patients with major AL. Second, the native esophagus is preserved. Furthermore, gastrostomy drainage in the early period helps in decreasing the reflux which is an aggravating factor for AL. Third; an ability to institute early enteral feedings is a major advantage which could be done in the majority of our patients. This improved the overall well-being, avoided complications of parenteral nutrition and provided breast milk during this crucial period.

The presence of jejunostomy and gastrostomy tubes is not free from complications. Nonavailability of silastic tubes which are more suitable for jejunostomy forced us to use simple nasogastric tubes although these are likely to become hard with the passage of time. Many complications such as accidental dislodgment of the tube, bowel perforation with peritonitis, and a jejunocolic fistula formation have been described in the literature and were noted in our patients as well. [1],[2]

In the initial part of the study, the decision for doing FJ was delayed as it was based on lung condition and chest tube output. There was a tendency to continue conservative management in the presence of good lung condition even with persistent chest tube drainage. In the later part of study, the patients underwent the procedure at an earlier stage as a result of the experience gained and showed better outcomes. We do not claim that this procedure is an ideal way of managing major anastomotic dehiscence but can be considered in a septic cohort of patients who would otherwise end up with an esophageal replacement. It can also be considered at centers, which cannot provide long-term TPN. Although many of our patients required secondary procedures to normalize the esophageal tube, yet they had the benefit of native esophagus.


   Conclusion Top


The mainstay of treatment of most esophageal AL after tracheoesophageal fistula repair includes adequate chest drainage, treatment of infection, observation, and maintenance of proper nutrition. Protocolized treatment can lead to better results, avoiding the therapeutic dilemmas, and delay in interventional decisions. Gastrostomy and FJ are feasible in this crucial period and may help in salvaging the native esophagus.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Gupta DK, Sharma S. Esophageal atresia: The total care in a high-risk population. Semin Pediatr Surg 2008;17:236-43.  Back to cited text no. 1
    
2.
Gupta DK, Sharma S, Arora MK, Agarwal G, Gupta M, Grover VP. Esophageal replacement in the neonatal period in infants with esophageal atresia and tracheoesophageal fistula. J Pediatr Surg 2007;42:1471-7.  Back to cited text no. 2
    
3.
Upadhyaya VD, Gopal SC, Gangopadhyaya AN, Gupta DK, Sharma S, Upadyaya A, et al. Role of fibrin glue as a sealant to esophageal anastomosis in cases of congenital esophageal atresia with tracheoesophageal fistula. World J Surg 2007;31:2412-5.  Back to cited text no. 3
    
4.
D'Urzo C, Buonuomo V, Rando G, Pintus C. Major anastomotic dehiscence after repair of esophageal atresia: Conservative management or reoperation? Dis Esophagus 2005;18:120-3.  Back to cited text no. 4
    
5.
Mathur S, Vasudevan SA, Patterson DM, Hassan SF, Kim ES. Novel use of glycopyrrolate (Robinul) in the treatment of anastomotic leak after repair of esophageal atresia and tracheoesophageal fistula. J Pediatr Surg 2011;46:e29-32.  Back to cited text no. 5
    
6.
Chavin K, Field G, Chandler J, Tagge E, Othersen HB. Save the child's esophagus: Management of major disruption after repair of esophageal atresia. J Pediatr Surg 1996;31:48-51.  Back to cited text no. 6
    
7.
Spitz L. Oesophageal atresia. Orphanet J Rare Dis 2007;2:24.  Back to cited text no. 7
    
8.
Chittmittrapap S, Spitz L, Kiely EM, Brereton RJ. Anastomotic leakage following surgery for esophageal atresia. J Pediatr Surg 1992;27:29-32.  Back to cited text no. 8
    
9.
Zhao R, Li K, Shen C, Zheng S. The outcome of conservative treatment for anastomotic leakage after surgical repair of esophageal atresia. J Pediatr Surg 2011;46:2274-8.  Back to cited text no. 9
    
10.
Spitz L. Esophageal atresia. Lessons I have learned in a 40-year experience. J Pediatr Surg 2006;41:1635-40.  Back to cited text no. 10
    


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