quiz esophageal anastomotic dehiscence post EA repair

[Ahmed Nabil]

First one with correct answer with justification win.

A two-kilogram male neonate with esophageal atresia and distal tracheoesophageal fistula underwent primary repair through a right thoracotomy at two days of age. Two days after repair the baby started having more respiratory distress and copious salivary output through the chest tube. The baby was otherwise physiologically well. A chest radiograph showed a large pneumothorax that did not resolve with stripping the chest tube or increasing the negative pressure on the tube. A contrast study shows full extravasation of contrast into the chest with no contrast going distally. During chest re-exploration the anastomosis has dehisced along 40% of its circumference. The most appropriate management for esophageal anastomotic dehiscence is

A washout and adequate pleural drainage.

B endoscopic placement of esophageal stent across anastomosis.

C creation of cervical esophagostomy.

D colon interposition.

E reconstruction with gastric transposition.

[Admin]

A washout and adequate pleural drainage

correct

In contemporary practice, most leaks after esophageal atresia repair are minor with an intact esophagus that will heal in almost all cases with nonoperative treatment. However, large esophageal anastomotic leaks can still occur. In the setting of a large volume leak due to an anastomotic disruption surgical reexploration may be required. The most common explanation for major anastomotic leaks is excessive tension on the anastomosis. In this particular case, the anastomosis is holding along the majority of the circumference. Washout of the thorax with wide drainage to assure complete drainage and re-expansion of the lung is the safest alternative.

Although there is some experience regarding the use of esophageal stents in patients with esophageal stenosis and esophageal leaks, these reports are in older patients and there have been no reports on the safety and effectiveness on the use of stents in this acute scenario. Revision of the anastomosis would create a situation where the anastomosis would be under more tension and in a contaminated field. When possible, saving the native esophagus is desirable. Gastric transposition or colon interposition would not be appropriate in this acute setting. Creation of a cervical esophagostomy will necessitate esophageal replacement and unlikely to be the correct treatment this early in his course.

[Abusnaina mohammed]

E

[Admin]

Think again my friend

[Farid Elallaghi]

B

[Admin]

Think again my dear

[Abusnaina mohammed]

В endoscopic placement of esophageal stent across anastomosis

[Admin]

Think again my dear

[Abusnaina mohammed]

A washout and adequate pleural drainage

[Admin]

A washout and adequate pleural drainage

correct

In contemporary practice, most leaks after esophageal atresia repair are minor with an intact esophagus that will heal in almost all cases with nonoperative treatment. However, large esophageal anastomotic leaks can still occur. In the setting of a large volume leak due to an anastomotic disruption surgical reexploration may be required. The most common explanation for major anastomotic leaks is excessive tension on the anastomosis. In this particular case, the anastomosis is holding along the majority of the circumference. Washout of the thorax with wide drainage to assure complete drainage and re-expansion of the lung is the safest alternative.

Although there is some experience regarding the use of esophageal stents in patients with esophageal stenosis and esophageal leaks, these reports are in older patients and there have been no reports on the safety and effectiveness on the use of stents in this acute scenario. Revision of the anastomosis would create a situation where the anastomosis would be under more tension and in a contaminated field. When possible, saving the native esophagus is desirable. Gastric transposition or colon interposition would not be appropriate in this acute setting. Creation of a cervical esophagostomy will necessitate esophageal replacement and unlikely to be the correct treatment this early in his course.