From
StayCurrentMD
Leak after Esophageal Atresia Repair / TEF Repair: Discussion of World Experts
With Dr. John Fokker · hosted by Dr. Todd Ponsky
Chapter 1 of 5 · Diagnosis & Workup
Contrast studies
Routine contrast studies and early feeding practices
Expert statements on this page
No expert statements were drawn from this page.
Host summaries · secondary, not cited in answers
Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
At Great Ormond Street, patients are fed about day 3 or 4 after TEF repair without routine contrast studies.
At Great Ormond Street, if there is a minor leak, it is of no consequence and will heal itself without need for contrast study.
At Great Ormond Street, patients do not have a chest tube left in place after TEF repair.
At Minnesota, routine contrast studies are not obtained for so-called easy type C cases.
At Minnesota, for difficult TEF cases, a contrast study is obtained at day 14 to check for reflux, which patients almost always have.
If there is clinical evidence of a leak (drainage in chest tube or small pneumothorax), conservative management is appropriate rather than immediate contrast study, with imaging delayed until clinical resolution.
The size of the pneumothorax determines management approach; a large or tension pneumothorax warrants contrast study to distinguish complete dehiscence from a manageable leak.
With a large or tension pneumothorax, exploration of the anastomosis may be warranted, and sometimes one stitch that has come loose can be repaired with insertion of one extra suture to resolve the situation.
Going back to explore very early after primary repair because of a significant leak can result in serious disasters, as the esophagus is often edematous and inflamed, potentially leading to loss of the esophagus.
Dehiscence usually occurs in the first 48 hours after repair.
If there is a leak that is being controlled with pneumothorax drainage via chest tube, the preferred approach is conservative management rather than early re-exploration, even though this may result in stricture formation.
Early re-exploration at 3-6 days postoperatively for a leak has resulted in disasters with loss of the esophagus.
If contrast study shows half the contrast going down and half going into the chest but the baby is stable, the appropriate management is to do nothing.
Indications for operative exploration are when the baby is very sick or when contrast study shows complete anastomotic disruption.
When exploring a complete disruption, if you find one stitch out that can be repaired, that is fortunate, but most of the time the anastomosis is a mess.
The worst outcome after performing an esophagostomy is that you will lose the esophagus in most cases.
With major anastomotic disruption, the main priority is to save the life of the patient, and the esophagus should be abandoned.
Major anastomotic disruption usually occurs due to tension or poor vascularization, and attempting re-anastomosis on day 2 or 3 will face the same problems and is unlikely to improve the outcome.
When performing esophagostomy after disruption in a sick baby with a long esophagus available, placement on the right side is preferred despite general preference for left-sided esophagostomy, because the surgeon is already operating on that side.
For a more stable baby, left-sided esophagostomy is preferred as it is easier to perform subsequent esophageal replacement into the left neck.
A complete esophageal disruption in a baby that is not sick is an unlikely scenario.
When performing esophagostomy, the distal esophagus should not simply be tied off because there is risk of recurrent fistula from the distal esophagus; instead, it should be taken low down and closed in 2 or 3 layers.
If a leak cannot be detected on esophagram but is present clinically, this does not change management since conservative observation is the approach regardless.
When taking down distal esophagus during esophagostomy, enough should be removed to separate it from the tracheal suture line to eliminate risk of re-fistulization.
For a type C repair with 2cm gap that went well but develops a medium leak with infection but cardiovascular stability, management options include draining with replogle tube in upper pouch and chest tube plus gastrostomy, versus conservative management with antibiotics and IV feeding.
For a stable patient with medium leak, if an anastomotic feeding tube is in place but no chest tube was initially placed, the appropriate management is to place a chest tube and observe on antibiotics, doing nothing further unless the baby becomes septic.
The concern with anastomotic leak is not the leak itself but whether it causes sepsis in the baby.
Leaving a chest drain at the time of initial repair allows for conservative management if a leak develops, avoiding the need for additional intervention.
In one case with persistent leak at two weeks post-repair, thoracoscopic repair with pleural flap coverage was performed successfully.
Leaving a drain at the time of the procedure is easy and allows conservative management of leaks without additional risky interventions.
Leaving a small chest tube as an insurance policy has no significant downside and allows everything to remain under control.
If the leak rate is less than 10%, then 90% of patients are drained unnecessarily when routine chest tubes are placed.
Chest drains can sit directly against the anastomosis and may cause a leak; the tube must be anchored a centimeter or two away from the anastomosis.
Chest drains often do not effectively drain anastomotic leaks; contained leaks can be present on contrast studies despite the presence of a drain.
Chest drains may cause pain, potentially increase leak rate, and often do not work, which are reasons not to leave them routinely.
If a drain is left and there is a leak that does not drain through it, an interventional radiologist can easily place a drain into the leaking area postoperatively.