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.
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.
Conflicts of interest
There are no conflicts of interest.
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