| Congenital esophageal atresia is a severe developmental malformation of digestive system, and also is one of typical neonatal surgical diseases requiring emergency treatment. The incidence of the disease is1/3000-1/4000abroad. There are still many problems in its diagnosis, treatment during the peri-operative phase, management of postoperative complications and follow-up in our country, making gaps at home and abroad. Even in children’s medical centers of domestic big or medium-size cities, a standard therapy mode is in demand. Nowadays, how to improve cure rate, minimize the trauma, and reduce the incidence of complications becomes the same goal of pediatric surgeons at home and abroad.With the improvement of early diagnosis, neonatal anesthesia technique and surgical therapy, peri-operative intensive care and nutrition support, the cure rate of congenital esophageal atresia has increased in China recently. However, there exist numerous straits and debates among case combined with other complex malformations, long-gap type or low-birth-weight situation. Moreover, clinical research is hard to carry out in a deep-going way due to small sample size and heterogeneity of cases. This study intends to review93cases with congenital esophageal atresia admitted to our department from October1995to October2013. Clinical data are collected retrospectively, and analyzed in accordance with all aspects of preoperative condition, surgical procedures, nutrition support and follow-up, etc. A series of key points and puzzle problems are discussed and summarized. Results as follows:●Preoperative condition and prognosis1. A total survival rate was89%(83/93). Male and female survival rate was91.8%and84.4%respectively; survival rate of preterm infants was91.7%(vs term infants88.9%); survival rate of low birth weight infants was92.3%(vs normal birth weight group88.8%); the incidence of other malformations was53.8%, and survival rate of group with other malformations was84%(vs no other malformations group95.3%); survival rate of group with pneumonia ahead of operation was80.4%(vs group without pneumonia ahead of operation97.9%); Ⅰ,Ⅲ A, Ⅲ B’s survival rates were94%,91%,90%respectively. Two V type cases died.2. Clinical data of21type Ⅲb esophageal atresia were analyzed retrospectively, and preoperative latency time and length of stay after operation have notable positive correlation.●Surgical treatment1. A total of71patients underwent surgical treatment.59patients were diagnosed and treated in our hospital, and survival rate was91.5%(54/59). Others were admitted to our hospital after operation by other medical centers, among which10were diagnosed as recurrent esophageal fistula.10were treated with esophageal reconstruction, while2were treated by closing the fistula, and all survived.2. For the long-gap esophageal atresia, the esophageal replacement surgery was performed, and survival rate was100%after operation. Three methods were included: gastric pull-up (GPU), colon interposition (CI), and pouch flap (PF)。Comparing these three groups, it is found that intubation length is less in CI group, thoracic drainage duration, gastric tube duration, intestinal feeding duration and length of stay were significantly higher in PF group, and the rate of reflux was higher in GPU group.●Nutrition support1. Twenty-two patients had EA type IIIA.8were excluded, among which5underwent esophageal replacement,1was LBW, and2died.4(29%) and10(71%) patients were identified as Nasointestinal feeding tube (NFT) and Control groups, respectively. There were no differences in gestational age, birth weight, associated anomalies, anastomotic leak, stenosis, TPN duration (20.8days vs18.4days). But postoperative direct bilirubin between two groups were significantly different.2. Using DSA technique in intestinal feeding tube placement is effective and shortens the operation time. The mean operative time was1.14hours, the success rate of100%, and the mean feeding time was2.63months.●Complications1.41of71(57.7%) cases after surgery had pneumonia and chest infections. Anastomotic leak was present in13cases (18.3%). Routine follow-up was carried out for those66survival cases after discharge, and time point was3months,6months and1year. The follow-up rate was92.4%(61/66). Each had good function of swallowing, no vomiting and weight gain for350-550g per month. In the long-term follow-up, complications concluded recurrent fistula (6), esophageal stricture (21, in which there were18cases with anastomotic stricture), esophageal diverticulum (3), gastroesophageal reflux (5), intestinal obstruction (1), recurrent pneumonia (1), and severe malnutrition (1). All of those were treated effectively.60.6%of patients (40/66) were followed with esophagography on a regular basis at our hospital.2.31cases diagnosed with esophageal stricture after surgery was treated by balloon dilatation. There were86times dilations in total,78of which were successful (90.7%). After3-6months follow-up, the treatment of26cases was effective (84%).These results suggested:1. The survival rate was lower than reported internationally. Significant difference existed among different terms of gender, gestational age, and birth weight, but did among different terms of associated malformations, certain preoperative complications(like pneumonia) and types. Therefore, it’s important to estimate in a comprehensive way. We believe that Montreal classification method is more in line with our actual situation when doing risk stratification.2. Once diagnosed as type Ⅲ b esophageal atresia, operation should be performed as early as possible, which can effectively shorten length of stay in hospital and ensure the survival rate.For long-gap esophageal atresia, the esophagus replacement surgery is recommended. CI has the minimal pulmonary influence, and GPU has gastroesophageal reflux more possibly. Nasointestinal feeding tube may lead to shorter TPN duration. Using DSA technique in intestinal feeding tube placement is effective and shortens the operation time with a high rate of success.3. There are a large number of short, medium and long-term complications. Complications associated with surgery affect prognosis badly, such as anastomotic leak, recurrent fistula. Hence patients should be coped with positively and followed up closely. Esophageal angiography is needed when necessary. Balloon dilation is an effective way to treat postoperative esophageal stenosis, and the application DSA technique can reduce the difficulty of the operation. |
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