Leak after Esophageal Atresia Repair / TEF Repair: Discussion of World Experts

Doctor Spitz, yeah, they don't, right. OK. We're feeding about 33 or 4 days. Ed Kylie feeds on day 2. if there is a minor leak, it is of no consequence. It will heal itself, and there's no need to do a contrast. OK, so Mark, maybe add to that no contrast study. I'm curious, uh, if people don't get any contrast studies other than, uh, Doctor Spitz. Now, is that pretty routine in the UK, Doctor Spitz? It's, it's routine at Great Ormond Street. I'm not sure about the rest of the country. I mean, not, not only do they not get a contrast, they don't leave a chest drain. No chest tube either. No chest tube. They just feed. Yeah, I, I, I bow to Doctor Spence. Yeah. OK, um, well, I'm curious, is anyone else, uh, on the faculty, on other than Doctor Spitz not get a contrast study? And please, John Fokker, it's For the, I assume we're talking about the so-called easy cases type C at Minnesota, we did not get a routine contrast study on them. It's a difficult case to get a contrast study at day 14 and check for reflux, which they almost always have. OK, uh, so does anyone, is anyone else here not get a contrast study? It sounds like the rest of the faculty do. And then audience, please go ahead and tell us your thoughts. It looks like almost. 74% get a day 7 contrast study. All right, day. 3, you see a pneumothorax. Do you, uh, do you get a contrast study on day 3? Do you wait a few more days? Do you, what do you do? I probably get a contrast study out of curiosity more than, and there's a leak. There's a leak. Leave it alone. So why'd you get the contrast study? Out of curiosity. OK, um, Steve. No, I mean, unless the, unless there's, I'm worried about a major disruption, but I mean if there's either clinical evidence of a leak either by drainage in the chest tube or a small pneumo, we just manage it conservatively instead of getting a contrast study on day 4 or 5. We just wait till clinically it looks like that's resolved and so we get a study later. Mark, can you put a poll up suspicion of leak, and then the question is, uh, contrast study. Observe or or explore contrast, observe or explore with suspicion of early leak. Uh, I'm just curious if anyone wants to make a comment on that before we move ahead. I'm just curious, uh, suspicion of leak postoperatively. Does anyone do anything different? Go ahead. I think it depends on, uh, on how big the pneumothorax is, you know, sometimes you get this big tension pneumothorax, and I think it's really important to know if you've got a complete dehiscence of the anastomosis or if it's a leak that you can. And treat conservatively. So I, I would be very liberal about getting a contrast study in that setting. OK, and so, Uh, I would, I would agree with Jack. It depends on how big the con the, the pneumothorax is. If it's a large pneumothorax, tension pneumothorax, we would actually explore the anastomosis, and sometimes there's one stitch that has come adrift and inserting ones uh, stitch, one extra suture, uh, resolve the whole situation. Can I, can I make a comment to that? Uh, Louis, I almost agree with everything you say about everything. But that's one area I think you got to be careful about. And that is I've seen some serious disasters of people going in very early after a primary repair because of a pretty good sized leak, big leak. Uh, and the esophagus often looks like Hamburg at that time, because it's edematous and inflamed, and it's turned out into a loss of the esophagus. So I think going back in may be appropriate with the dehiscence, uh, which I think usually occurs in the 1st 48 hours. But I think if it's a leak and you're controlling the pneumothorax and you've got a chest tube been draining, my inclination is to leave it alone. It will stricture down, but I'd rather leave it alone just because I've had this experience of seeing some patients where they going in at 3456 days, uh, ended up with a disaster. No, no, I agree with you, Arnie. I'm talking about a 1 or 2, a major, a major leak at that stage, that's usually, but don't you think that's a dehiscence at that time usually? Not, not always. There has been, uh, we've had a number of cases where there is just one suture put in that suture, and there is a completely benign course after that. So I think you've got to be good at the operation rather than an amateur. So if you get the, and then I want to, I want to hit on Witt's point. So we're going to talk about leak for a second, then we'll get to recurrent TF. If you, if you do a contrast study and let's say, let's take two situations. One, half the contrast goes down, half the contrast goes out into the chest, explore or wait, and the baby's stable. Do nothing, just do nothing. Would anyone explore in that situation? OK. This is now we're talking about you either the baby is very sick and you take the baby to the OR or you do a contrast study and it looks like a complete disruption. You go to the OR. Has anyone had experience with that? What do you find? What do you do? How do you manage? That's going to be a tough situation. Well, if you're lucky like, uh, Louis said and find one stitch out, that's great. I've never seen that. Uh, and most of the time it's a mess. And then you got to ask yourself, what are you going to do? Are you going to abandon the esophagus and do an esophagostomy and, and close the distal end and tack it up there, hope to come back another day. Uh, I don't think it's clear what you should do. I mean, the worst thing that happens is the minute you do an esophagostomy, as we said before, you're going to lose the esophagus. Uh, in most cases, I know Jack says they can salvage him, uh, but in most cases, you're going to lose the the esophagus. I think if you've got such a major at it from a if you have such a major disruption, your main priority is to save the life of the person, and I would abandon the esophagus. I would too. Yeah, OK, I agree. And then on top of that, there is a reason why there is a disruption, and most of the time it's tension or bad vascularization. And by redoing the anastomosis, I don't see how you can make it better than the first time. So now you have the tissue. I'm sorry, Holder. Um, I just want to say that that usually there's a major reason for the disruption, and the two major reasons for that would be tension or bad vascularization. And going back on day two or three, and trying to sell to rescue, that is a focus, meaning coming up against the same problems, tension and bad vascularization. So I doubt that you can make it very much better in a situation that is already terrible. OK, and I agree with that and I agree what Louis said. Save the patient. Patricio. We didn't mean to shut off your camera. Please turn your camera back on. We want to see you again. Um, let me ask you a question. You go in disruption, you decide you're going to abandon, or, well, before we say abandon, you're going to do an esophagostomy at this point. Um, would you do it on the right or the left? You have an entire right esophagus still there. Uh, it just fell apart, so you have a lot of length. Do you put it on the right side or the left side? So do you abandon the esophagus and put it on the left for a planned gastric pull-up, according to most of the audience, or do you put it on the right for eventual planned reastomosis of the esophagus and the neck? Um Well, I'll open it up to you first, Doctor Corn. Well, if we got a real sick baby, even though I don't like an esophagostomy on the right side, and I haven't had to deal with this catastrophe in many years now, I'd probably put it in that case on the right. If you had a more stable baby, which probably means then you don't have a, A total dehiscence, I try to put it on the left. I think it's easier to do the operation, the replacement into the left neck, as I said before, than on the right. So the baby's just to clarify, the baby's not sick. You got a whole long esophagus. You're going to abandon the esophagus. Yes, OK, OK. Well, any, any disagreement with Jack? I, well, I just, I've only had this once, but I can't imagine a complete esophageal disruption in a baby that's not sick. I mean, I, I just think that that scenario is probably not going to happen. OK. All right, um, so let's, let's move on. I would agree with Arnie. I would do the esophagostomy on the right hand side because you're there already. But I would caution against just merely closing off or tying off the distal esophagus because every now and again there is a recurrent fistula from the distal esophagus, and that is another dangerous situation. So I would take the distal esophagus low down and close it off in 2 or 3 layers. Yes, yes, we've had, we've seen that before. Um, so, uh, now we're going to get into it before we, uh, uh, there was a lot of questions in there. First of all, I want to hit on Witt's point. Uh, Witt says be careful. They've, they've had patients that they've done the, uh, esophagram on, and it looked like no leak, but the baby in fact did. So the question is how much can we trust the esophagram. Um, and then there were questions about if there is a leak. Then what? How long do you wait? Another week before, uh, uh, repeating your esophagram? Well, it, it all depends on the clinical status of the patient. If you don't, if there's a leak and you can't pick it up with an esophagram, who cares? You're not going to do anything anyhow. You're just going to watch the patient. So, I don't think that makes any difference. It gets back to Lewis's concept of not even bothering with getting a contrast study. The only time you're having to have to agonize is when the baby is super sick and you have an obvious leak. And that, and, and the thing Louis talks about, uh, what I've done is not take out a lot of the distal esophagus, and I don't know why, because maybe I'm having this hope that I can put it together again, but take enough of it down and separate it from the tracheal suture line. So there's real, no, no real risk of fistula re-fisulization. OK, Holger, you have a comment. Yeah, no, no, I have a question just to learn from you guys. Um, OK, it's a type C, um, 2 centimeters distance. Operation went fine. Uh, child, of course, has no gastrostomy, and then we have a medium leak, meaning that the child is sick, evidence of infection, but not cardiovascular and stable. Would you guys drain the leak, meaning a replica, uh, suction tube in the upper pouch, um. Uh, thoracic drain and then put in a gastrostomy, or would you just put it on antibiotics, um, IV feeding, and then uh wait conservatively. Question is, drain, draining it, uh, drying it out, saliva and everything else, or just leave it. Two questions, just to learn. Did you leave a reploal tube through the anastomosis or any other kind of tube into the stomach? Yeah, you did. If I can still, did you, did you leave a chest tube in initially? No, I never do. OK, so my situation would be, I don't have a chest tube in, and I do have a anastomotic, um, uh, feeding tube, and now there is a leak. I'd put a chest tube in. That's all you would do, yeah, and see how the baby does. I mean, the, the only thing you're worried about here is having the baby, baby hemodynamically stable and OK. The leak itself doesn't mean anything unless it's causing sepsis in the baby. So, if you put a chest tube in and put them on antibiotics, if they're not already on it, and the baby stabilizes, just leave it. Don't do anything. OK. Well, thanks. Yeah, I would agree. I mean, that's why we leave a drain in on the, in the case, and it's a rare occurrence, but that way if there is a leak, we have a drain in and, and we're covered and you don't have to do anything. And we've only, I've only had to, we've had one case, um, where, um, Where there was a leak post, uh, repair, and after two weeks, there was still a leak, and I went back in thoracoscopically, um, and repaired it and then put a pleural flap over it. Um, but I think if you have a drain in, then you have the ability to wait and be conservative, and there's not a big downside. Um, whereas opposed to if you don't have a drain, then people are more worried about getting a drain in safely and then not doing more damage. But Steve, aren't you too good of a surgeon to do that? Do what? To leave a drain in chest tube. Well, you know, again, it's, I don't think it has anything to do with being, I appreciate being a good, you're basically, you're doing damage control. It, it's easy to put a drain in at the time of the procedure and leave it there, and I'm not, and, and obviously Doctor Spitz has an incredible experience, and so I, I defer to him, but in my hands. It's very easy to put a drain in at the time of the procedure and to leave it in for 4 days till I get a study and prove to myself that there's not a leak, I think, is a small consequence to the worst case scenarios where you actually have a leak and you'd like to ride it out and now you've got to do some manipulation to allow you to do that. Can I ask the audience John Folker, uh, I'd like to comment. I, I agree with what I believe Steve is saying. Um, and it depends what your background is, but leaving a small tube in, uh, just, uh, you know, it's an insurance policy, and, you know, I don't have much experience or none with what you're talking about, but, but I always put a chest tube in, even in the simplest cases. It just allows everything to remain under control. And what's the downside? What has that got to do with being a good surgeon or a bad surgeon? It's got nothing to do with it. Jack, let me comment on that, Steve. I assume that Steve's leakage rate is less than 10%, so he drains 90% in vein. That's the only, you know, joke I'm trying to make. But Holder, Holger, according to Jack, what's the downside? Yeah, I agree with Jack. What's the downside of leaving a drain? The downside is that I think sometimes these drains sit right up against the anastomosis and may cause a leak. And absolutely, but you have to, you have to anchor it away. I mean that's old, old information that's in the literature. You have to anchor the tube a centimeter or two away from the anastomosis. The other problem is that in our experience of these drains actually don't drain the leak. Um, I saw this when I was training, and I see it now with my colleagues who still put drains in. Uh, we get routine contrast studies, and there's sometimes a leak that's contained, and it's not drained by the drain. So to me, it's, it's causing pain, it may increase your leak rate, and it doesn't even work most. Of the time. So that's why I don't leave drains. Dr. Spitz, I agree entirely with Jack. You leave a drain in, there's a leak, and it doesn't come out through the drain, and it's very easy for an interventional radiologist to put a drain into the leaking area which will drain post post leak. OK. Um,