SAVE THE CHILDS ESOPHAGUS - MANAGEMENT OF MAJOR DISRUPTION AFTER REPAIR OF ESOPHAGEAL ATRESIA

Purpose: Given the bias that the native esophagus is the best conduit between the oropharynx and the stomach, the authors report a ''conserv ative'' approach to massive esophageal leak, which may be considered ' 'radical'' by others. Major disruption of the anastomosis after primar y repair of esophageal atresia is a recognized and feared complication . Historically, management has been the performance of cervical esopha gostomy and gastrostomy. The aim of this report is to describe the aut hors' approach to this difficult and serious complication. Methods: A 15-year retrospective analysis was performed of all patients having es ophageal atresia. Data collection focused on the management of ail pat ients with clinically significant esophageal disruption. Radiographica lly detected (clinically asymptomatic) leaks were managed by continuat ion of drainage by thoracostomy tubes already in place and are not inc luded. Reoperative thoracotomies were performed, which included primar y repair (2), placement of pleural patch alone (2), pleural patch with intercostal muscle flap buttress (2), and operative debridement and d rainage alone (1). Results: It was noted that seven patients had clini cally significant esophageal disruption requiring reoperation, with ci rcumferential disruptions ranging from 15% to 85%. Presentation includ ed persistent pleural collection (4) and pneumothorax (3). Both patien ts who underwent primary repair had no evidence of leakage on follow-u p esophagograms, neither did one with a pleural patch alone and one wi th an intercostal muscle flap. Five of the seven patients were tolerat ing oral feedings at the time of follow-up (range, 6 months to 8 years ). One of the two others (both currently inpatients), has a recurrent leak associated with mediastinitis, and the other (who had primary rep air) has a presumed neurological impairment of eating. Conclusion: Cli nically significant disruption of primary esophageal repair should not warrant a cervical esophagostomy and placement of a gastrostomy tube, thus precluding eventual use of the native esophagus. The authors hav e shown that management by reoperation with primary repair, intercosta l muscle flap with or without pleural patch, and/or drainage allows th e patient to maintain the native esophagus and yields a generally good outcome after a prolonged healing time. Copyright (C) 1996 by W.B. Sa unders Company