APSA - Effect of transanastomotic feeding tubes on anastomotic strictures in patients with esophageal atresia and tracheoesophageal fistula- the Quebec experience - Kathryn LaRusso

A lot of excitement about this presentation. I'm not sure the refs are gonna have to say if uh Todd's giving you a little bit of a wink wink there is within the rules, but we'll see how it plays out. So let's see what else ABSA has in store for us. Doctor Catherine Lo Russo from the Montreal Children's Hospital at McGill University in Canada will come up next and discuss the effect of trans anastomotic feeding tubes on anastomotic strictures in patients with oesophageal atresia and tracheoesophageal fistula. And then we'll hear, hear from Doctor Miguel Guelfan from Chile um to tell us exactly how impactful this study has been on his practice. Hi. This study evaluates the effect of trans anastomotic feeding tubes on anastomotic strictures in patients with oesophageal resia and tracheoesophageal fistula. Risk factors for the development of post-operative stricture include anastomotic tension, long gap atresia, leak, gastroesophageal reflux, and more recently, trans anastomotic tubes have been implicated. Their use has increased since the 1980s, the rationale being a shorter time to feeds and a shorter duration of postoperative TPN. A recent study from the Midwest Pediatric Surgery Consortium, looking at 292 patients and only type C, found an increased rate of strictures in the transendastomatic tube group that was almost 2 times that of those without. Another study from the Children's Hospital of Pittsburgh, also looking um at EATEF, all types though, but the majority were type C, also found a significant difference between groups. Due to these recent studies implicating transasmodic feeding tubes as an independent risk factor for the development of postoperative strictures, Montreal Children's Hospital initiated a moratorium on their use until we evaluated our own outcomes. This study was expanded to include 2 other centers in our region. Our hypothesis was that was that transastomotic tubes increase the rate of postoperative strictures following EA and TEF repair. Our study population included all type C and type D patients at three university-affiliated hospitals in the province of Quebec in a 25-year period between 1993 and 2018. We included those that had primary repair within 6 months of birth and had at least 1 year follow-up. We excluded those with congenital esophageal stenosis with the roarresia, were operated on at another facility, or had made major cardiac surgery during the same mission, or if there was really insufficient data in the chart to evaluate the primary outcome. Our primary outcome was stricture, and which was defined as symptoms with imaging confirmation with either an upper GI or endoscopy at one year. Our secondary outcomes included time to first enteral feeding and duration of postoperative TPN. For a primary outcome of oesophageal stricture. Univariate and multivariate logistic regression were used to evaluate stricture in those with and without trans anastomotic feeding tubes. Adjustments were based on clinical knowledge and also current evidence. Wilcoxian rankum test was used to compare medians when the data was not normally distributed, and a P value of 0.05 was considered statistically significant. Within our study period, 371 EATEF patients. Uh, born of those 344 were type C or type D, and 2244 were included within the three groups. The majority were type C. And they were term infants. About 30% had stri strictures. And transassmotic tubes were used in 61% of patients. On univariate analysis, transcendasmotic tubes were associated with strictures, significantly. On a multivariate analysis, when we adjusted for gestational age, leak, long gap, anastomotic tension, and daily acid suppression, transastic tubes are almost 3 times higher odds of developing a stricture compared to those without. And secondary outcomes. We found that days in post-operative TPN were the same. Of note, all patients were on TPN in our study cohort. As expected, duration, um, number of excuse me, days to first interval feeding were shorter in the transasmotic feeding tube group than those without. In conclusion, we found that transastomotic feeding tubes are associated with an increased rate of postoperative strictures, decreased time to enteral feeding, but they do not confer a major benefit in the time on the number of days on postoperative TPN. We'd like to thank ABSA for allowing us to present our research and our colleagues in Quebec. Our emails are below and our Twitter accounts as well. Please feel free to contact us with any questions, and I'm happy to take any questions now, uh, within the group. Hey, um, thank you. First of all, thank you for this invitation for talk and, and Globalcast for an amazing new event. So thank you for that. And I can send you awesome paper from Doctor La Russo, uh, so you can stop the competition. We have a winner. This is a knockout, so we have the winner already. But uh saying about the paper, uh, uh, a long time ago, a surgeon told me not because we're using something or doing something for 30 years means it's a good thing to do. So this is a game, a, a, a change of the game, and absolutely, I agree with Dr. La Russo in terms of the results, but, uh, and, and definitely if a lot of people People are seeing that, uh, mainly young people, we need to stop using the transom the tube and start doing exactly what Doctor La Russo said to stop, uh, and reducing the stricture of the, our patients with esoattricia. But Doctor Aruza, I have some question about the paper. There's so many, any difference in your, in study about uh repair, MIS repair or open repair, and If there was any difference in the type of the transcend anastomotic tube or the time of using the transcanambotic tube in the study, there was a different difference in that, you'd have the chance to review that data. And the other thing that is not said in this paper is the risk of the replacement of the transatomic tube. Sometime in the middle of the night, some of the tube can get dislodged and for any reason, a nice nurse, very helpful, replaced the, the, eh eh tube without our consent. So that's another risk involved with the using of transramic tube in Solatricia, Doctor La Russo. Sorry, Doctor Larisa can you, can you unmute? OK. Sorry about that. So thanks so much for your questions, uh, and thanks again for inviting us to present our paper and talk further about this great topic. Um, it's very important. I think that, um, you highlighted a great number of things that are very important. Uh, number one, MIS, uh, techniques and whether or not that has any implication on stricture rates. In our data, we only had about 30 cases that were done thoroscopically, um, at about 244 patients. So unfortunately, our data really isn't too, is large enough. I would, the numbers are large enough to really, uh, say. Definitively whether or not um MIST techniques may implement like impact the rate of stricture rates. Um, I think right now given our data though, there's no difference what our follow-up analysis showed. Um, secondly, the types of tubes, we had like one standard type of tube that was used as a trans anastomotic feeding tube. Um, but you did highlight in the following point about the replacement tubes, and I think that's something that's really important to notice when you're reading papers about this topic, um, and in the future is that Oftentimes these kids fail PO at uh enteral feeding, and then they have to get either a follow-up feeding tube placed or the uh a similar tube gets replaced. And that data is still really difficult to analyze retrospectively. And I think going forward, we need to capture that data and have like more randomization, um, techniques involved in like who we're putting tubes into to really like highlight the data further to that I think we'll also continue, continue to show that these tubes potentially increase inflammation and acid, um. Exposure to anastomosis and increase restriction rate overall. Thank you very much. So, thank you so much. Great paper. Great discussion, Miguel. Um, lots of discussion in the comments of the live event page, so head on over there and, and answer those if you wouldn't mind.