In select patients with type C esophageal atresia, primary anastomosis is not appropriate and a staged approach is required. We aim to summarize our experience in the management of type C EA using a staged approach.

A retrospective chart-review of patients with type C EA admitted to Beijing Children's Hospital between July 2020 to October 2023 were conducted. Those diagnosed with type C EA who were not amendable to primary anastomosis were included for analysis. Clinical information was recorded, and follow- up was performed.

Seven (five boys) patients with type C EA who received staged repair were included in the study. Initial surgeries included thoracotomy and thoracoscopy. 71% (5/7) patient had complications after the initial surgery, including pyopneumothorax, pneumonia, recurrent tracheoesophageal fistula (rTEF), and anastomotic leak. Esophageal elongation techniques were applied in 3 patients. All delayed anastomosis were performed thoracoscopically, except for in one case where spontaneous fistulization occurred and no anastomosis were necessary. Complications after delayed anastomosis included recurrent esophageal pulmonary fistula (rEPF) in 50% (3/6), anastomotic leak in 33% (2/6), and esophageal stricture in all (6/6) patients. After a median follow-up of 14 months (range: 2-24), all patients were in generally good condition.

Primary operations should be kept simple and minimal in patients diagnosed with type C EA who are not appropriate for primary anastomosis. Internal traction is an effective method that allows for subsequent anastomosis. Intraoperative indocyanine green fluorescence can aid in fistula determination and anastomosis.

Elective ventilation and paralysis have been shown to decrease the anastomosis-related complications following primary repair of esophageal atresia (EA). Repeated endotracheal tube (ETT) block and replacement can increase these complications. We evaluated the results of our strategy of electively changing the ETT just before shifting the patient to the postoperative ward for elective ventilation.

A retrospective study was conducted using the case records of patients from July 2015 to February 2024 including all the patients of EA with tracheoesophageal fistula who underwent primary repair with end-to-end esophageal anastomosis. The patients were divided into two groups Group A: ETT was changed and Group B: ETT was not changed immediately before shifting. The groups were compared for anastomotic leak and ETT tube block in the first 48 h.

Ninety-one patients were included in the study, 36 in Group A and 55 in Group B. Elective replacement of ETT decreased the tube block rates in the first 48 h following surgery (P = 0.032). Tension in the anastomosis was associated with a higher leak rate. The leak was present in 58.3% and 3.6% in cases with and without tension in the anastomosis (P = 0.001). Overall, the anastomotic leak was similar in both groups. In the subgroup of patients with anastomosis under tension, the rate of anastomotic leak was higher in patients with ETT block (P = 0.028).

Elective replacement of EET decreases the tube block rates and anastomotic leak rates in cases with anastomosis under tension.

Long-gap esophageal atresia (LGEA) is still a challenge for pediatric surgery. No consensus exists as to what constitutes a long gap, and few studies have investigated the maximum gap length safely repairable by primary anastomosis. Based on surgical outcomes at a single institution, we aimed to determine the gap length in LGEA with a high risk of complications.

The medical records of 51, consecutive patients with esophageal atresia (EA) with primary repair in the early neonatal period between 2001 and 2021 were retrospectively reviewed. Three, major complications were found in the surgical outcomes: (1) anastomotic leakage, (2) esophageal stricture requiring dilatation, and (3) GERD requiring fundoplication. The predictive power of the postsurgical complications was assessed using receiver operating characteristic analysis, and the area under the curve (AUC) and the cutoff value with a specificity of > 90% were calculated.

Sixteen patients (31.4%) experienced a complication. The AUC of gap length was0.90 (p < 0.001), and the gap length cutoff value was ≥ 2.0 cm for predicting any complication (sensitivity: 62.5%, specificity: 91.4%).

A gap length ≥ 2.0 cm was considered as defining LGEA and was associated with an extremely high complication rate after primary repair.

In neonates with suspected type C esophageal atresia and tracheoesophageal fistula (EA/TEF) who require preoperative intubation, some texts advocate for attempted "deep" or distal-to-fistula intubation. However, this can lead to gastric distension and ventilatory compromise if a distal fistula is accidently intubated. This study examines the distribution of tracheoesophageal fistula locations in neonates with type C EA/TEF as determined by intraoperative bronchoscopy.

This was a single-center retrospective review of neonates with suspected type C EA/TEF who underwent primary repair with intraoperative bronchoscopy between 2010 and 2020. Data were collected on demographics and fistula location during bronchoscopic evaluation. Fistula location was categorized as amenable to blind deep intubation (>1.5 cm above carina) or not amenable to blind deep intubation intubation (≤1.5 cm above carina or carinal).

Sixty-nine neonates underwent primary repair of Type C EA/TEF with intraoperative bronchoscopy during the study period. Three patients did not have documented fistula locations and were excluded (n = 66). In total, 49 (74 %) of patients were found to have fistulas located ≤1.5 cm from the carina that were not amenable to blind deep intubation. Only 17 patients (26 %) had fistulas >1.5 cm above carina potentially amenable to blind deep intubation.

Most neonates with suspected type C esophageal atresia and tracheoesophageal fistula have distal tracheal and carinal fistulas that are not amenable to blind deep intubation.

Level III.

 Management of long gap esophageal atresia (LGOA) is controversial. This study aims at comparing the management of LGOA between two high-volume centers.

 We included patients with LGOA (type A and B) between 2008 and 2022. Demographics, surgical methods, and outcomes were collected and compared.

 The study population involved 28 patients in center A and 24 patients in center B. A surgical approach was thoracoscopic in center A, only for one patient was open for final procedure. In center B, 3 patients were treated only thoracoscopically, 2 converted to open, and 19 as open surgery. In center A primary esophageal anastomosis concerned 1 case, two-staged esophageal lengthening using external traction 1 patient, and 26 were treated with the multistaged internal traction technique. In 24 patients a full anastomosis was achieved: in 23 patients only the internal traction technique was used, while 1 patient required open Collis-Nissen procedure as final management. In center B primary anastomosis was performed in 7 patients, delayed esophageal anastomosis in 8 patients, esophageal lengthening using external traction in 1 case, and 9 infants required esophageal replacement with gastric tube. Analyzed postoperative complications included: early mortality, 2/28 due to accompanied malformations (center A) and 0/24 (center B); anastomotic leakage, 4/26 (center A) treated conservatively-all patients had a contrast study-and 0/24 (center B), 1 case of pleural effusion, but no routine contrast study; recurrent strictures, 13/26 (center A) and 7/15 (center B); and need for fundoplication, 5/26 (center A) and 2/15 (center B). Age at esophageal continuity was as a median of 31 days in center A and 110 days in center B. Median time between initial procedure and esophageal anastomosis was 11 days in center A and 92 days in center B.

 Thoracoscopic internal traction technique reduces time to achieve esophageal continuity and the need for esophageal substitution while maintaining a similar early complication rate.

The operative management of patients born with long-gap esophageal atresia (LGEA) remains a major challenge for most pediatric surgeons, due to the rarity and complex nature of this malformation. In LGEA, the distance between the proximal and distal esophageal end is too wide, making a primary anastomosis often impossible. Still, every effort should be made to preserve the native esophagus as no other conduit can replace its function in transporting food from the oral cavity to the stomach satisfactorily. In 1981, Puri et al. observed that in newborns with LGEA spontaneous growth and hypertrophy of the two segments occur at a rate faster than overall somatic growth in the absence of any form of mechanical stretching, traction or bouginage. They further noted that maximal natural growth arises in the first 8-12 weeks of life, stimulated by the swallowing reflex and reflux of gastric contents into the lower esophageal pouch. Since then, creation of an initial gastrostomy and continuous suction of the upper esophageal pouch followed by delayed primary anastomosis at approximately 3 months of age has been widely accepted as the preferred treatment option in most LGEA cases, generally providing good functional results. The current article offers a comprehensive update on the various aspects and challenges of this technique including initial preoperative management and subsequent gap assessment, while also discussing potential postoperative complications and long-term outcome.

Esophageal atresia (EA) with or without tracheoesophageal fistula (TEF) is a congenital anomaly that can cause frequent digestive and nutritional problems, even after repair. The most common complication is anastomotic stricture, for which reoperation or balloon dilatation is performed. This study aimed to evaluate the postoperative complications of EA and the role of endoscopic balloon dilatation (EBD) in cases of anastomotic stricture.

We retrospectively analyzed patients diagnosed with EA with or without TEF between January 2000 and February 2021. Patients' baseline characteristics, associated anomalies, and postoperative complications were reviewed.

Among 26 patients, 14 (53.8%) were male, 12 (46.2%) had coexisting anomalies, and the median follow-up was 6.1 years (range, 1.2-15.7 years). In univariate analysis, prematurity, low birth weight, and long-gap EA were associated with postoperative complications in 12 (46.2%) patients. Among the 10 (38.5%) patients with anastomotic stricture, nine (90.0%) required EBD. Regarding the first EBD, it was performed at a median of 3.3 months (range, 1.2-7.6 months) post-repair, while the average patient weight was 4.6 kg. The mean diameter ranged from 3.3 to 9.1 mm without major complications. In univariate analysis, long-gap EA alone was significantly associated with EBD.

Approximately half of the patients experienced complications after EA repair. In particular, patients with a long-gap EA had a significantly increased risk of complications, such as anastomotic strictures. EBD can be safely used, even in infants.

 To assess the risk factors for anastomotic stricture (AS) in end-to-end anastomosis (EEA) in patients with esophageal atresia (EA).

 With ethical consent, hospital records of 341 EA patients from 1980 to 2020 were reviewed. Patients with less than 3 months survival (n = 30) with Gross type E EA (n = 24) and with primary reconstruction (n = 21) were excluded. Outcome measures were revisional surgery for anastomotic stricture (RSAS) and number of dilatations required for anastomotic patency without RSAS. The factors that were tested for risk of RSAS or dilatations were distal tracheoesophageal fistula (TEF) at the carina in C-type EA (congenital TEF [CTEF]), type A/B EA, antireflux surgery (ARS), anastomotic leakage, recurrent TEF, and Spitz group and congenital heart disease.

 A total of 266 patients, Gross type A (n = 17), B (n = 3), C (n = 237), or D (n = 9) underwent EEA (early n = 240, delayed n = 26). Early anastomotic breakdown required secondary reconstruction in five patients. Of the remaining 261 patients, 17 (6.1%) had RSAS, whereas 244 patients with intact end to end required a median of five (interquartile range: 2-8) dilatations for anastomotic patency. Main risk factors for RSAS or (> 8) dilatations were CTEF, type A/B, ARS, and anastomotic leakage that increased the risk of RSAS or dilatations from 4.6- to 11-fold.

 The risk of severe AS is associated with long-gap EA, significant gastroesophageal reflux, and anastomotic leakage.

VACTERL is a complicated syndrome with an unknown etiology where many studies have failed to identify the cause. In esophageal atresia (EA) roughly 10%-23% also have concurrent anomalies that align with VACTERL disorder. The aim of this study is to investigate if there is a difference regarding localization of the tracheoesophageal fistula between patients with VACTERL and non-VACTERL patients.

Retrospective chart review of newborn operated for esophageal atresia between 2006 and 2016 at our Institution was performed. Children with a C-type fistula according to Gross and reliable preoperative tracheoesophageal fistula to carina distance measurement at rigid tracheoscopy were included in the study.

A total of 90 patients were included in the study. Fifteen of those were diagnosed with VACTERL. Before and after adjusting for weight and gestational week patients with VACTERL had significantly shorter carina to fistula distance at perioperative rigid tracheoscopy (p = <0.001 nonadjusted, p = 0.016 adjusted).

Patients with VACTERL born with EA type C had shorter carina to fistula distance as shown at perioperative rigid tracheoscopy. The significantly shorter distance may not only present surgical difficulties but may also suggest a structural or molecular difference in the development of the esophageal atresia between the two groups.

III.