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Section 6. Medical science
Eshkabilov Shukurali Davlatmuratovich, Tashkent Pediatric Medical Institute, Senior Researcher, the Department of Pediatric Surgery and Oncology, E-mail: shukur_s@mail.ru Ergashev Bakhtiyor Berdalievich, Republican training, medical and methodical center of neonatal surgery at the Republican perinatal center, Tashkent, Uzbekistan; PhD, Professor
Improvement of surgical treatment of esophageal atresia in newborns
Abstract: A comparative analysis of the results of surgical treatment of esophageal atresia (EA) with the use of advanced and traditional methods was performed. The case histories of 192 newborns whose primary esophageal anastomosis was performed from 2006 to 2015 were studied. Group 1 included 127 children operated by improved method since 2009; Group 2 consisted of 65 children operated by traditional method.
Keywords: esophageal atresia, complications, anastomotic leakage, treatment.
Esophageal atresia (EA) is one of the most common inborn defects of esophagus, the surgical correction of which is one of the most important problems of neonatal surgery and anesthesiology.
Despite the success achieved in the surgical correction of EA, there is a big number of post-operation complications in 40-60 % of operated patients [1, 38-40].
According to literature sources, anastomotic leakage is the most common complication and it occurs in 14-17 % [2, 44-46] to 32 % of cases [3, 26-28]. Factors leading to anastomotic leakage include: ischemia of oral and aboral ends of the esophagus, strong strain in the zone of anastomosis given the diastasis of over 3 cm., use of inappropriate stitch material and imperfect surgical technique [5, 508-511].
Also, in the majority ofworks, gastroesophageal reflux (GER) is one of the most common complications during post-operation period. According to E. Somppi, O. Tammela, T. Ruuska et al (1998), GER occurs in 78 %; according to D. Booss, H. Gigget (1998) in 42.8 %; L. Spitz (1999) in 54 %; D. Yu. Krivchenya, A. G. Dubrovin, A. D. Dudyrev (1994) recko n that GER occurs in all patients operated with regard to esophageal atresia [4, 13].
Thus, the problem of early post-operation complications shows a serious reason to search for new methods of treatment and makes it very necessary to improve the technique of surgical correction in the condition of esophageal atresia.
Goal of the research: improvement of the results of esophageal atresia treatment in newborns by way of improvement of the technique of surgical correction and reduction of post-operation complications.
Materials and methods
During the period from 2006 to 2015, 264 newborns with different forms of EA were admitted in the department of neonatal surgery of the Republican Perinatal Center. There were 165 (62.5 %) boys and 99 (37.5 %) girls. Full -term newborns accounted for 197 (75 %) and 67 (25 %) were born prematurely.
Among 264 children with different forms of EA, 192 (73 %) had initial esophagoplasty. All newborns with EA underwent the following at admission: esophageal intubation, Elephant test, contrast X-ray examination of the esophagus with water soluble contrast agent as well as ultrasound of internal organs, echocardiography and neurosonography. Combined defects and comorbidities were revealed in 31 % (83) of cases. Most often, EA was combined with GIT diseases (anorectal malformations and duodenal ileus) in 11.4 % of cases, heart diseases in 8.7 % of cases, urinary system defects in
4 % of cases and defects of other organs and systems in 4 % of cases. Also, the following comorbidities were detected: cerebral circulation disorder with intra-ventricular hemorrhage (IVH) in 11 cases (5 %), perforation of hollow organ of abdominal cavity in 1 case and inborn abdominal cavity tumor in 1 case.
This work presents a comparative analysis of the results of surgical treatment of 192 children with EA, who had initial esophagoplasty. For comparison and statistical processing of obtained data, the patients were divided into two groups depending on the way of operation. Group 1 (primary) included 127 (66 %) children with EA, who had esophageal anastomosis performed by a new method and Group 2 (control) consisted of 65 newborns, in whom, during esophagoplasty, one-row interrupted stitches or, more rarely, two-row Haigth stitches were used.
It is known that in the condition ofEA, after posterolateral thoracotomy in III or IV intercostal space and extrapleural access to mediastinum, tracheoesophageal fistula is secured, diastasis is defined and anastomosis is created. Most often, in the condition of EA in newborns, straight anastomosis with the use of one-row stitches is performed with atraumatic needle through all layers of esophagus. Ventricle is probed during the operation with a gastric tube the size of 6 Fr/Ch or 8 Fr/Ch. The operation finishes with a placement of drainage to the zone of inter-esophageal anastomosis.
The drawbacks of the traditional method of surgical treatment of EA are as follows: sufficient leak-tightness is not created, which can cause «leakage» of the content of the esophagus between interrupted stitches. In cases of gastric content discharge into the esophagus (gastroesophageal reflux), the latter can enter the mediastinum through the holes between anastomotic stitches and cause leakage and mediastinitis. Even in the vent of partial anastomotic leakage, there is risk of another complication — relapse (recanali-zation) of tracheoesophageal fistula, which requires a compulsory repeated operation.
Taking into account the above stated, the approach in esopha-geal atresia has changed since 2009. We use an advanced method of application of esophageal anastomosis and ventricle probing in newborns with EA. The purpose of this novelty is to create sufficient security of esophageal anastomosis, prevent gastroesophageal reflux during early post-operation period, thus improving the results of operative treatment of esophageal atresia in newborns. The method lies in the following: first, posteroletaral thoracotomy in III-IV intercostal space, extrapleural access to the esophagus, then mobilization of closed end of the esophagus, liquidation of tracheo-esophageal
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fistula and application of straight esophageal anastomosis with one-row uninterrupted stitches through all layers of the esophageal wall with atraumatic needle, vicryl 6/0 and vascular acceptance. The latter was performed as follows: after the promotion ofventricle probing, one-row uninterrupted stitch leaving both ends of the thread as traction suture, then, with the help of traction sutures, turn the esophagus 180° along own axis to apply one-row uninterrupted stich on the posterior wall of the esophagus. After the removal of traction sutures, the esophagus returns to normal anatomic position turning 180° along its axis. Also, when applying uninterrupted stitch, the needle should enter at the distance of 0.2 cm. from the edge of distal end of the esophagus, herewith, the esophagus partially enters the lumen of the oral end of the esophagus.
It is known that in EA, gastroesophageal reflux is often observed due to the disruption of angle of His. This may contribute to the penetration of gastric juice in the zone of anastomosis during early post-operation period and can lead to anastomotic leakage and/or other early post-operation complications. Hence, to prevent the penetration of gastric content in the zone of anastomosis, catheter Foley-6 Fr/Ch was used as gastric probing, which is placed into ventricle during operation, blown up and tightened. As a result, gastric cardia is sealed with a blown-up part of the catheter thus protecting the zone of anastomosis from the penetration of gastric content during early post-operation period. Consequently, it prevents the development of anastomotic leakage.
Results and discussion
During post-operation period, contrast X-ray of the esophagus was performed on 2-3 day to detect gastroesophageal reflux. Also, the control of the condition of anastomosis was conducted, if there was a suspicion of anastomotic leakage (in case of appearance of mucus-foam discharge in drainage) with water soluble X-ray contrast substance. The feeding of children with EA started on 4-5 day at small diastasis, and, at big diastasis, not earlier than on 7-8 day of the post-operation period. In case of absence of signs of leakage, the drainage was removed from posterior mediastinum on 6-7 day post operation. In case of anastomotic leakage, drainage from mediastinum and gastric probing were not removed until full healing of fistula. The period of healing of fistula was 32 ± 7.5 days.
The indicators of early post-operation period in the patients of primary and control groups are presented in Table 1.
Table 1. - Indicators of the early post-operation period in patients with EA
Indicators Primary group (n = 127) Control group (n = 65)
Gastro-esophageal reflux - 60 (92 %)
Leaking of anastomosis - 34 (52 %)
Anastomotic leakage and mediastinitis 4 (3 %) 15 (23 %)
As the table shows, among the patient in the primary group operated by the improved method, in the early post-operation period, gastro-esophageal reflux during contrast X-ray research was not revealed in a single case, and among children of the control group, gastro-esophageal reflux was detected in 60 (92 %) cases. This certifies about the fact that esophageal probing with the catheter Foley-6 Fr/Ch effectively prevents the penetration of gastric content in the zone of anastomosis.
Moreover, among the patients of the primary group, anastomotic leakage was observed only in 4 (3 %) children, which is almost 8 times less than in the application of anastomosis by traditional method. «Leaking» of mucus was not detected in this group, because uninterrupted stitches on the esophagus secured the tightness of anastomosis.
In the control group (n = 65), «leaking» of anastomosis in the early post-operation period was noted in 34 (52 %) patients, and anastomotic leakage — in 15 (23 %) patients. Although, most of these children showed for a long period of time own closing of the leakage, 6 (40 %) of them developed severe purulent-septic complications, which were one of the leading reasons of postoperation deaths.
The results of our observations allow concluding that the improved method of surgical correction significantly reduces the risk of post-operation anastomotic leakage and improves the results of operative treatment of esophageal atresia. This method is patented under № IAP 05092 and registered in the state register of inventions of the Republic of Uzbekistan.
References:
1. Erbolatov N. K. Esophageal atresia. Modern views on the problem//Pediatrics and children surgery. - 2008. - № 3. - P. 38-40.
2. Krasovskaya T. V., Kucherov Yu. I. and others. Complications of the operative treatment of esophageal atresia//Children surgery. -2001. - № 3. - P. 44-46.
3. Golovanov E. S., Malyshev M. G. Esophageal atresia in newborns in Arkhangelsk region//Ecology of the man. - 2003 - № 4. - P. 26-28.
4. Mokrushina O. G. Restoration of functions of esophagus after the application of esophageal anastomosis in newborns. Dissertation of the candidate of medical sciences. - Moscow, 2003. - P. 13.
5. Chittmittrapap S., Spitz L., Kielt E. M.//J. Pediatr. Surg. - 1990. - Vol. 25. - P. 508-511.
Yuldashev Sanjar Keldiyarovich, Republican specialized scientific-practice medical centre of obstetrics and gynecology, Uzbekistan, junior scientific employee
E-mail: yuldashev_s@inbox.ru
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