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Esophageal atresia: comparison between survivors and mortality cases who underwent surgery over a 2-year period in two referral hospitals, Tehran, Iran

Peyvasteh, Mehrana; Askarpour, Shahnama; Sarmast, Mohammad Hosseina; Javaherizadeh, Hazhirb; Mehrabi, Valiollahc; Ahmadi, Javadc; Kalantari, Mehdic

Annals of Pediatric Surgery: April 2012 - Volume 8 - Issue 2 - p 42–44
doi: 10.1097/01.XPS.0000412346.91254.0e
ORIGINAL ARTICLES
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Introduction and aim The aim of this study was to compare the type of suture, technique of suture, and technique of anastomosis between survivors and mortality cases.

Patients and methods This study was conducted in Bahrami Hospital and Children’s Medical Center on cases with esophageal atresia who underwent surgery for esophageal atresia and/or tracheoesophageal fistula repair. The places of study were Bahrami Hospital and Children’s Medical Center, two referral centers for pediatric surgery in Tehran. The duration of the study was 2 years, starting from April 1999. Survivors and mortality cases were compared with regard to sex, type of surgery, suture material, and technique of anastomosis. Gross classification was used for typing of anomaly. All data were analyzed again using SPSS ver. 13.0 and Epi-info ver. 6.04d (CDC, WHO). The χ2-test was used for comparison.

Results In this study, 21 (male=9, female=12) mortality cases and 53 (male=29, female=24) survivors were included. Among them, 18 (85.7%) mortality cases and 51 (96.2%) survivors had type C atresia (P=0.23). Thoracotomy and repair of atresia was performed in 10 (47.6%) mortality cases and 51 (96.2%) survivors. Gastrostomy and tracheoesophageal fistula repair was performed in eight (38.1%) mortality cases. Gastrostomy and cervical esophagostomy was performed in three (14.7%) mortality cases and two (3.8%) survivors. Anastomotic leak was noted in eight mortality cases and 10 survivors who underwent thoracotomy and atresia repair (P=0.0005). End-to-end anastomosis was performed for nine mortality cases and 45 survivors (P=0.7). Extrapleural thoracotomy was performed in nine mortality cases and 45 survivors (P=0.7). Single-layer anastomosis was performed in eight mortality cases and 36 survivors (P=0.82). There were no significant differences between survivors and mortality cases with regard to sex and type of atresia (P=0.23). Thoracotomy and atresia repair was more frequently performed in survivors than in mortality cases (P=0.000004). Anastomotic leakage was significantly higher in mortality cases compared with survivors (P=0.0005).

Conclusion Anastomosis leakage was associated with higher mortality. The rate of thoracotomy and atresia repair surgery is higher in survivors compared with mortality cases.

aDepartment of Surgery, Imam Khomeini Hospital

bArvand International Division, Ahvaz Jundishapur University of Medical Sciences, Ahvaz

cChildren’s Medical Center, Tehran University of Medical Sciences, Tehran, Iran

Correspondence to Shahnam Askarpour, Department of Surgery, Imam Khomeini Hospital, Ahvaz Jundishapur University of Medical Sciences, Ahvaz 6193672166, Iran Tel/fax: +98 611 221 6504; e-mail: shahnam_askarpour@yahoo.com

Received October 9, 2011

Accepted January 26, 2012

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Introduction and aim

Esophageal atresia (EA) and tracheoesophageal fistula (TEF) are congenital malformations that occur in ∼1 : 2500–3500 live-born infants 1,2. The survival of infants born with this anomaly has markedly improved since Cameron Haight’s first report of successful surgical correction in 1941 3. In our previous study, between April 1999 and March 2000, we compared cases with esophageal stricture with cases without stricture 4. After 5 years, we decided to compare mortality cases and survivors in the same period. The aim of this study was to compare the type of suture, technique of suture, and technique of anastomosis between survivors and mortality cases.

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Patients and methods

The data for this study were collected from Bahrami Hospital and Children’s Medical Center in children operated upon for EA from April 1999 to March 2000. The patients who died had not been included in the previous study. All cases had undergone surgery. Clinical and/or radiological findings were used to diagnose anastomotic leakage. Patients who survived were placed in the survivor group, and patients who died were placed in the mortality group. Gross classification was used for classification of anomaly 5. Data were analyzed using SPSS ver. 13.0 (SPSS Inc., Chicago, Illinois, USA) and Epi-info ver. 6.04d (CDC, WHO). The χ2-test was used for analysis.

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Results

During the study period, 74 cases underwent surgery. Of these cases, 38 (51.4%) were boys and 36 (48.6%) were girls. Of the 74 cases, 21 (28.4%) cases died and 53 survived. Two cases underwent gastrostomy, esophagostomy, and colon interposition. Fifty-one cases underwent thoracotomy and atresia repair. Of the 74 cases, type C atresia was noted in 69 (93.2%) cases, and type A atresia was noted in five (6.8%) cases.

As shown in Table 1, most of the survivors were born at 36–38 weeks and mortality occurred at 34, 35, and 38 weeks of gestation. There was no significant difference between mortality cases and survivors with regard to age.

Table 1

Table 1

As shown in Table 2, there were no significant differences between survivors and mortality cases for sex and type of atresia. Thoracotomy and atresia repair was more commonly used in survivors than in mortality cases (P=0.000004). As shown in Table 3, anastomotic leakage was significantly higher in mortality cases compared with survivors (P=0.0005).

Table 2

Table 2

Table 3

Table 3

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Discussion

In the current study, we found that anastomotic leakage was significantly higher in mortality cases. Overall, we found anastomotic leak in 18 (29.5%) of 61 cases who had undergone thoracotomy and repair of atresia. Anastomotic leaks occurred in 15–20 patients 6. Seo and colleagues retrospectively reviewed 97 cases with confirmed TEF and EA in South Korea. Of the 97 cases, 81 underwent surgery. Anastomotic leakage was noted in nine (12%) cases who underwent surgery 7. The incidence of anastomotic leakage was about six to seven in other studies 8–10. In contrast, Orford et al.11 found a higher incidence of anastomotic leak. They did not evaluate anastomosis leak as a possible factor in predicting mortality. In the study by Orford and colleagues, the rate of primary repair leak declined from 24 to 17% over the 20-year study period. In the study by Tsai et al.12, anastomotic leakage was present in 12 of 62 patients who had undergone anastomosis. Tönz and colleagues studied 104 cases from 1973 to 1999 in three time periods. They reported 5, 7, and 8% anastomotic leaks in their study for the first, second, and third time periods, respectively 9. In the study by Engum et al.13, conducted on 227 cases of EA and/or TEF, anastomotic leakage was present in 16%. In survivors, the rate of anastmotic leakage in our study was similar to that of other studies.

Survival rate increased from 70 to 78% in the study by Orford et al.11. Tönz and colleagues reported mortality rates of 33, 14, and 14% at different periods of the study. In our study, the overall mortality rate was 28.37%. This mortality rate was higher than that at Kyushu University. In 14 cases, between 1990 and 1999, operative mortality was 0% and overall mortality was 7%. Between 2000 and 2006, operative and overall mortality was 0 in 14 cases 14. In the study by Engum et al.13, on 227 cases of EA and/or TEF, the survival rate was 95%. In the study by Tsai et al. 12, operative mortality was 12%. In our study, the rate of mortality (28.4%) was similar to that of the first period of the study by Tönz et al. 9. The mortality rate in our study was higher than that in the studies by Tsai et al.12 and Engum et al.13. In the study by Seo et al.7, the mortality rates were 39% (1990–1999) and 23% (2000–2007). Most of these studies were carried out in countries with a higher level of equipment and experience. Therefore, it is expected that their mortality rate would be lower than that in our country.

As mentioned in most studies, anastomotic leakage remains one of the most important causes of postoperative morbidity and mortality 15,16. In our study, anastomotic leakage was significantly higher in mortality cases than in survivors. This finding was similar to that of other studies 15,16. Several factors have been proposed to be implicated in the etiology of anastomosis leakage, such as silk suture material 17, tension at the anastomosis site 18, end-to-end anastomosis 19, and interference with the blood supply of anastomosis because of vigorous dissection of distal esophagus 20.

In our study, there were no significant differences between survivors and mortality cases with regard to the type of suture, technique of anastomosis, and type of anastomosis, because only a few cases underwent anastomosis with silk suture, end-to-side anastomosis, or two-layer anastomosis. There was evidence that silk sutural material may be implicated in the etiology of anastomosis leakage 17.

In our study, there was no significant difference between survivors and mortality cases with regard to the type of thoracotomy. In our study, intrapleural thoracotomy was performed in only a few patients. Thus, a conclusive decision cannot be made on the side effects of intrapleural or extrapleural thoracotomy. In another study by Shahnam et al., there was no significant difference between extrapleural and intrapleural thoracotomy for leakage and mortality rate 21. However, we used the extrapleural approach for most cases, because this method is more advantageous than the transpleural approach for patients 22.

Gastrostomy and cervical esophagectomy was used for three (14.3%) mortality cases and two (3.8%) survivors. Technically, this method was used for cases with long-gap EA 22. In the study by Orford et al., the rate of gastrostomy decreased from 35% (1970s) to 5% (1990s) 11. In our study, the rate of gastrostomy was similar to that of the study by Orford et al. conducted in the 1990s 10.

Gap length may increase the possibility of anastomotic leak 23. Unfortunately, we had no access to gap length in our study.

In conclusion, in our study, the mortality rate was higher than that in other studies. This may be a result of problems with nurseries, technique of surgery, associated anomalies, or infections after surgery. Anastomotic leakage was significantly higher in mortality cases. The rate of thoracotomy and atresia repair surgery is higher in survivors compared with mortality cases.

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Limitation

In this study, we have limited access to reliable data for gap length. Limited amount of data for resolution of anastomotic leakage is another limitation. In addition, duration of follow-up is another limitation.

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Acknowledgements

Conflicts of interest

There are no conflicts of interest.

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