Update course rewind: Management of esophageal leaks 2022

Hello everyone, I'm Cecilia Hijena from Cincinnati Children's Hospital. We are summarizing the talks of the update course in Pediatric surgery 2022. This talk is about management of esophageal leaks. The moderator for this talk was Dr. Mark Harman. And as speakers, we have doctors Miguel Gelfan, Jorge Godoy, and Mikele Ugasi. So, they started by presenting a case. Uh 10 month old female with a long gap esophageal atresia, status post laparoscopic gastrostomy tube, uh at birth, measurement of the esophageal ends just before surgery. An end to end esophageal anastomosis uh was done, a slight tension. Fifth day post stop, there was a right pneumothorax, esophageal contrast uh shows a large esophageal leak into the Plura, regular passage of distal esophageal, uh distal esophagus and stomach. Now, before I go further, for those in the room, I'm going to ask, if you just had a small contained leak after your esophageal repair, not coming out the chest tube, just contained, who would just watch that? They say that every small or moderate leak that it's contained, it can be managed by observation and there's no need for a new intervention. So, that leads us only consider a new intervention leaks that create huge pneumothorax are not well drained, or even if the patient is unstable. Okay, so let's see what Dr. Mikele Ugasi did with this patient. So, this thing was managed with chest drain, minus suction, necessary replog tube and you add botulin toxin. Yeah. Why? Because there's life. So, there was too much saliva for an endo back to work. So, what he did is he put an NG tube and blocked secretion of saliva. That can be used with Botox, as he did, or glycopyrolate. That it's a new medicine that it's available here in the US, that blocks the secretion of saliva. So, the leaks stop, I guess. Yeah. And you have an endoscopy after. Yes. Why? Uh because we want to see how was the the esophagus. So we we did endoscopy. You cannot look very well for upper side because there's a lot of fissures. So it's better to go back and put the wire through the gastrostomy. So we will retrograde endoscopy. Yeah, and then you do that. And it was great. Okay, so let's rephrase. With the treatment, the leak stopped and the esophagus was healed. But it healed with a stricture. So to manage that, they went on to do an endoscopy, but a normal endoscopy was not enough because they can't see anything because of the stricture. So, what they did is as this patient got a G tube first, they put a wire through the G tube to the esophagus and then dilated from there. That is called a retrograde endoscopy and it worked real well. So, now we are ready for the next case. Uh so, here we've got a 2-year-old who status post esophageal atresia repair at another hospital, a type 3C, uh high uh uh under diagnosed proximal TEF. So, we fixed the type C, but surprise, there's a proximal fistula. Surgeon decides to resect through the neck. Uh-oh. Six days after surgery, that's a problem. A leak, big leak coming out the neck. So it's coming out through the neck through the cervical incision. What do you do? Oof, really tough case. It seems like everyone agree that we can start treating these patients with a drain in his neck. But let's see if Dr. Miguel Gelfan has something else to do with this. This is the endoscopy. We did endoscopy, get the patient to the OR, get endoscopy. So, again, that's the fistula and you can see air coming out through the Okay. So, we decide to put an endoback. Endoback. This is an endoscopic vacuum closure. But how can we do this? Fortunately for us, we have Dr. Miguel Gelfan that will help us know when and how to use this. This is a paper described by Christopher Avel, he's a very very, very intelligent guy as work as well to how to do an end back so is in online, it's very easy to to make it. Actually, that's how it looks. It's a NG tube attached with a sponge and you can use a therma, a tag therma or something to protect that that that thing. But you just put it down through endoscopy and by radioscopy, just to see it just in in the side of the fistula and you can get suction. You can see it on in the soprogram that the leaks completely shut down immediately. And that you keep that for four, five days and that have a and then you review that, you know, again in the OR. And this is the the view five days after, completely closed. Okay, so let's repeat. This is an NG tube with the holes covered by a surgical sponge and that is covered by a perforated transparent adhesive. So we put that into the patient and connect it to suction. So, this is supposed to help the granulation tissue form by negative pressure and this will make the patient heal faster. And if you want to see more, you have a link in the description that takes you to a video where you can find how to do and when to use an endoback. And now it's time for the last case. It's a patient have done a type C with no problems. Newborn 7 days, 40 weeks, 3300 grams. They perform all thoracoscopic repair and at day three, they found a leak. And you can see the leak there. So Jorge said, I'm happy you said. Yes. Shouldn't be there. Exactly. So take it to the OR again. Interesting case, but why is surgery this time? Because in these cases, really I am happy for the suture without tension, I no understand because the the leak. Well, what Dr. Jorge Godoy explained us is that this was a pretty common surgery. No problems, no tension in the anastomosis and the leak was very big and not explained by anything. And though not everyone agree with this approach, he thought the surgery would be the most effective way to treat this patient. But let's see the results. First study. Three days after. Look, I went well. No stenosis. And repeat the study three weeks ago and look that no stenosis and this patient no require dilatation. So awesome, no more leaks and no strictures. What a great session. So now it's time to summarize. First, most of the esophageal leaks can be treated by observation or chest drain. Second, if there's an external leak, like in the neck, or a fistula that's not healing well, an endoback can be a great solution. Third, for some patients with deteriorated status or great leaks, anastomosis can be attempt. Fourth, after leak, a stricture is more common, so you have to follow the patient more thoroughly. I'm Cecilia Hijena from Cincinnati Children's Hospital and that was everything for today. And remember, we are sharing knowledge to improve child health around the globe.