Use of Intercostal Muscle in Primary Repair of Esophageal Atresia with Tracheoesophageal Fistula Russ Zajtchuk, LTC, MC, Alan E. Seyfer, MAJ, MC, and Tracy E. Strevey, COL, MC, USA ABSTRACT Forty-one patients with esophageal atresia and distal tracheoesophageal fistula underwent primary repair. Results are compared among patients in whom an intercostal muscle graft was interposed between the trachea and esophagus and those without the graft. Patients with muscle interposition had lower morbidity and mortality and better long-term results.
T
he first attempt at primary repair of esophageal atresia with tracheoesophageal fistula was made by Shaw [4] more than 250 years following the first description of a case of esophageal atresia by William Durston in 1670 [I]. The child died 48 hours following operation from breakdown of the esophageal anastomosis and a recurrent fistula. In 194 1 Haight and Towsley [2]successfully ligated a tracheoesophageal fistula and performed an end-to-end anastomosisof the esophageal segments. Up to the present time, however, surgeons are still confronted with high morbidity and mortality rates. The lack of long-term evaluation and the difficulty in diagnosing recurrent fistulas create a false impression of good results. The purpose of this report is to present the clinical experience with 41 patients who had esophageal atresia and distal tracheoesophageal fistula. A comparison is made between two groups of patients, one with and one without interposed pedicled intercostal muscle grafts between the tracheal repair and the esophageal anastomosis.
Clinical Material and Results Forty-one patients with esophageal atresia and distal tracheoesophageal fistula were treated by primary repair between 1959 and 1972. Patients ranged in weight between 1.1 and 3.6 kg. The incidence of associated anomalies was 35%, the most common associated anomaly being patent ductus arteriosus. All operative procedures were done within four days of birth. Follow-up periods ranged between two and twelve years. Twenty-two patients had primary repair of the lesion without intercostal From the Department of Thoracic Surgery, Fitzsimons Army Medical Center, Denver, Colo. Accepted for publication Oct. 4, 1974. The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of the Army or the Department of Defense. Address reprint requests to Dr. Zajtchuk, Fitzsimons Army Medical Center, Denver, Colo. 80240.
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ZAJTCHUK, SEYFER, AND STREVEY muscle interposition. Eight of these patients died in the postoperative period. Five deaths were directly related to an esophageal leak or recurrent fistula. Of the 14 patients leaving the hospital, recurrent fistula was diagnosed and operated on in 2 and esophageal stricture in 2.Three patients had suspected recurrent fistula and 1 had partial tracheal obstruction. Nineteen patients had primary repair of the lesion with intercostal muscle interposition. There were 2 deaths in this group. At postmortem examination no recurrent fistulas were found. Of the 17 patients who recovered from the operation, 7 required dilations and only 1 required operative correction of esophageal stricture.
Comment In 1964, a survey of the members of the surgical section of the American Academy of Pediatrics [31 found that patients treated by primary repair had a much better survival rate than those who were treated by staged operative procedures. The same survey showed that the high mortality and morbidity associated with primary repair were related to the incidence of associated anomalies, the size and maturity of the patient, and anastomotic complications. It appears from analyses of our data that results can be improved by separating the tracheal suture line from the esophageal anastomosis by a pedicled intercostal muscle graft (Figure). The muscle should not be wrapped around the ESOPHAGUS
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T H E ANNALS OF THORACIC SURGERY
Intercostal muscle separates the tracheal suture lanefrom the esophageal anastomosis.
Repair of Esophageal Atresia esophagus but should lie only on the anterior portion of the suture line and against the tracheal closure. The occasional late complication of esophageal obstruction may occur secondary to calcification of the intercostal muscles. Inclusion of periosteum with the intercostal muscle grafts may be responsible for the calcification. An attempt should be made to strip some of the periosteum from the portion of the graft that is covering the esophageal anastomosis.
References Durston, W. A narrative of a monstrous birth in Plymouth, October 22nd, 1670; together with the anatomical observation taken thereupon by William Durston, Doctor in Physics, and communicated to Doctor Tim Clark. Philosoph Trans (London) 5:2096, 1670. 2. Haight, C., and Towsley, H. A. Congenital atresia of the esophagus with tracheoesophageal fistula with extrapleural ligation of fistula and end-to-end anastomosis of esophageal segments. Surg Gynecol Obstet 76:672, 1943. 3. Holder, T. M., Cloud, T. T., Lewis, E. J., Jr., and Philling, C. P., IV. Esophageal atresia and tracheoesophageal fistula. Pediatrics 34:542, 1964. 4. Shaw, R. Surgical correction of congenital atresia of the esophagus with tracheoesophageal fistula. J Thoruc Surg 9:2 13, 1939. 1.
Editor’s Note: This techniqueprobably should be used only in those patients in whom the distance between the proximal and distal segments is greater than 2.5 cm or in whom the anastomosis is performed under tension. The current mortality ratefor repair of esophageal atresia in robust infants (over 2.3 kg) in most major centers is 5%. The lower mortality rate reported by the authors cannot be used to justijj this operation.
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T
he first attempt at primary repair of esophageal atresia with tracheoesophageal fistula was made by Shaw [4] more than 250 years following the first description of a case of esophageal atresia by William Durston in 1670 [I]. The child died 48 hours following operation from breakdown of the esophageal anastomosis and a recurrent fistula. In 194 1 Haight and Towsley [2]successfully ligated a tracheoesophageal fistula and performed an end-to-end anastomosisof the esophageal segments. Up to the present time, however, surgeons are still confronted with high morbidity and mortality rates. The lack of long-term evaluation and the difficulty in diagnosing recurrent fistulas create a false impression of good results. The purpose of this report is to present the clinical experience with 41 patients who had esophageal atresia and distal tracheoesophageal fistula. A comparison is made between two groups of patients, one with and one without interposed pedicled intercostal muscle grafts between the tracheal repair and the esophageal anastomosis.
Clinical Material and Results Forty-one patients with esophageal atresia and distal tracheoesophageal fistula were treated by primary repair between 1959 and 1972. Patients ranged in weight between 1.1 and 3.6 kg. The incidence of associated anomalies was 35%, the most common associated anomaly being patent ductus arteriosus. All operative procedures were done within four days of birth. Follow-up periods ranged between two and twelve years. Twenty-two patients had primary repair of the lesion without intercostal From the Department of Thoracic Surgery, Fitzsimons Army Medical Center, Denver, Colo. Accepted for publication Oct. 4, 1974. The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of the Army or the Department of Defense. Address reprint requests to Dr. Zajtchuk, Fitzsimons Army Medical Center, Denver, Colo. 80240.
VOL. 19, NO. 3, MARCH, 1975
239
ZAJTCHUK, SEYFER, AND STREVEY muscle interposition. Eight of these patients died in the postoperative period. Five deaths were directly related to an esophageal leak or recurrent fistula. Of the 14 patients leaving the hospital, recurrent fistula was diagnosed and operated on in 2 and esophageal stricture in 2.Three patients had suspected recurrent fistula and 1 had partial tracheal obstruction. Nineteen patients had primary repair of the lesion with intercostal muscle interposition. There were 2 deaths in this group. At postmortem examination no recurrent fistulas were found. Of the 17 patients who recovered from the operation, 7 required dilations and only 1 required operative correction of esophageal stricture.
Comment In 1964, a survey of the members of the surgical section of the American Academy of Pediatrics [31 found that patients treated by primary repair had a much better survival rate than those who were treated by staged operative procedures. The same survey showed that the high mortality and morbidity associated with primary repair were related to the incidence of associated anomalies, the size and maturity of the patient, and anastomotic complications. It appears from analyses of our data that results can be improved by separating the tracheal suture line from the esophageal anastomosis by a pedicled intercostal muscle graft (Figure). The muscle should not be wrapped around the ESOPHAGUS
240
T H E ANNALS OF THORACIC SURGERY
Intercostal muscle separates the tracheal suture lanefrom the esophageal anastomosis.
Repair of Esophageal Atresia esophagus but should lie only on the anterior portion of the suture line and against the tracheal closure. The occasional late complication of esophageal obstruction may occur secondary to calcification of the intercostal muscles. Inclusion of periosteum with the intercostal muscle grafts may be responsible for the calcification. An attempt should be made to strip some of the periosteum from the portion of the graft that is covering the esophageal anastomosis.
References Durston, W. A narrative of a monstrous birth in Plymouth, October 22nd, 1670; together with the anatomical observation taken thereupon by William Durston, Doctor in Physics, and communicated to Doctor Tim Clark. Philosoph Trans (London) 5:2096, 1670. 2. Haight, C., and Towsley, H. A. Congenital atresia of the esophagus with tracheoesophageal fistula with extrapleural ligation of fistula and end-to-end anastomosis of esophageal segments. Surg Gynecol Obstet 76:672, 1943. 3. Holder, T. M., Cloud, T. T., Lewis, E. J., Jr., and Philling, C. P., IV. Esophageal atresia and tracheoesophageal fistula. Pediatrics 34:542, 1964. 4. Shaw, R. Surgical correction of congenital atresia of the esophagus with tracheoesophageal fistula. J Thoruc Surg 9:2 13, 1939. 1.
Editor’s Note: This techniqueprobably should be used only in those patients in whom the distance between the proximal and distal segments is greater than 2.5 cm or in whom the anastomosis is performed under tension. The current mortality ratefor repair of esophageal atresia in robust infants (over 2.3 kg) in most major centers is 5%. The lower mortality rate reported by the authors cannot be used to justijj this operation.
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