Clinically Relevant Tracheomalacia after Repair of Esophageal Atresia: the Role of Minimal Intra-Operative Dissection and Timing for Aortopexy[1]

Abstract

Background: Tracheomalacia is associated with esophageal atresia (EA), but may go unnoticed from external splinting forces. Intra-operative dissection with fistula division releases external splinting, revealing tracheomalacia only post-operatively. Analysis of surgical technique may disclose an iatrogenic etiology. Methods: From 1995 - 2004, 44 neonates underwent surgery for EA. All patients underwent pre-, intra- and postoperative bronchoscopy. Operative and bronchoscopic notes were studied for malacia, and extensive dissection of the esophagus and fistula from the trachea. Results: Surgical mortality was 6.8 %. Pre-operative tracheomalacia was diagnosed in 3 patients, who eventually fared well. In 17 other patients, the pre-operative bronchoscopy was negative, but airway obstruction developed post-operatively. Tracheomalacia was documented at the site of the former fistula and surgical release maneuvers. Aortopexy was required in 5 instances, whereas 12 others with malacia were managed conservatively. Conclusions: Mediastinal connective tissue and the fistula may splint open the marginally diseased airway in patients with EA, the lack of which may disclose previously unknown tracheomalacia after repair. When aggressive release maneuvers have been required, early aortopexy may be preferred to ventilator dependency.

Tracheo-esophageal fistula repair - tracheomalacia - aortopexy

References

• 1 Choudhury S R, Ashcraft K W, Sharp R J. et al . Survival of patients with esophageal atresia: influence of birth weight, cardiac anomaly, and late respiratory complications.  J Pediatr Surg. 1999;  34 70-74
• 2 Usui N, Kamata S, Ishikawa S. et al . Anomalies of the tracheobronchial tree in patients with esophageal atresia.  J Pediatr Surg. 1996;  31 258-262
• 3 Carden K A, Boiselle P M, Waltz D A, Ernst A. Tracheomalacia and tracheobronchomalacia in children and adults: an in-depth review.  Chest. 2005;  127 984-1005
• 4 Little D C, Rescorla F J, Grosfeld J L. et al . Long-term analysis of children with esophageal atresia and tracheoesophageal fistula.  J Pediatr Surg. 2003;  38 852-856
• 5 Touloukian R J, Seashore J H. Thirty-five-year institutional experience with end-to-side repair for esophageal atresia.  Arch Surg. 2004;  139 371-374
• 6 Kovesi T, Rubin S. Long-term complications of congenital esophageal atresia and/or tracheoesophageal fistula.  Chest. 2004;  126 915-925
• 7 Delius R E, Wheatley M J, Coran A G. Etiology and management of respiratory complications after repair of esophageal atresia with tracheoesophageal fistula.  Surgery. 1992;  112 527-532
• 8 Spitz L. Esophageal atresia and tracheoesophageal fistula in children.  Curr Opin Pediatr. 1993;  5 347-352
• 9 Couriel J M, Hibbert M, Olinsky A. et al . Long term pulmonary consequences of esophageal atresia with tracheo-oesophageal fistula.  Acta Paediatr Scand. 1982;  71 973-978
• 10 Corbally M T, Spitz L, Kiely E. et al . Aortopexy for tracheomalacia in oesophageal anomalies.  Eur J Pediatr Surg. 1993;  3 264-266
• 11 Schwartz M A, Filler R M. Tracheal compression as a cause of apnea following repair of tracheoesophageal fistula: treatment by aortopexy.  J Pediatr Surg. 1980;  15 842-848
• 12 Filler R M, Messineo A, Vinograd I. Severe tracheomalacia associated with esophageal atresia: results of surgical treatment.  J Pediatr Surg. 1992;  27 1136-1141
• 13 Somppi E, Tammela O, Ruuska T. et al . Outcome of patients operated on for esophageal atresia: 30 years' experience.  J Pediatr Surg. 1998;  33 1341-1346
• 14 Rideout D T, Hayashi A H, Gillis D A. et al . The absence of clinically significant tracheomalacia in patients having esophageal atresia without tracheoesophageal fistula.  J Pediatr Surg. 1991;  26 1303-1305
• 15 Wailoo M P, Emery J L. The trachea in children with tracheoesophageal fistula.  Histopathology. 1979;  3 329-338
• 16 Blair G K, Cohen R, Filler R M. Treatment of tracheomalacia: eight years' experience.  J Pediatr Surg. 1986;  21 781-785
• 17 Engum S A, Grosfeld J L, West K W. et al . Analysis of morbidity and mortality in 227 cases of esophageal atresia and/or tracheoesophageal fistula over two decades.  Arch Surg. 1995;  130 502-508
• 18 Dodge-Khatami A, Tulevski I I, Hitchcock J F. et al . Vascular rings and pulmonary arterial Sling: from respiratory collapse to surgical cure, with emphasis on judicious imaging in the hi-tech era.  Cardiol Young. 2002;  12 96-104
• 19 Backer C L, Mavroudis C. Vascular rings and pulmonary artery sling. Mavroudis C, Backer CL Pediatric Cardiac Surgery. Philadelphia; Mosby 2003: 234-250

1 Presented at the 34th Annual Meeting of the German Society of Thoracic and Cardiovascular Surgery, Hamburg, Germany, February 13 - 16, 2005.