title: A standardised investigative strategy prior to revisional oesophageal surgery in children: High incidence of unexpected findings.
abstract: OBJECTIVE
  Revisional oesophageal reconstructive surgery carries uncommon and unusual risks related to previous surgery. To provide maximum anatomical detail and facilitate successful outcome, we report a standardised pre-operative investigative strategy for all such patients.
  
  
  METHODS
  Prospective 8-month cohort study following the introduction of this strategy. All patients underwent high resolution thoracic contrast CT scan and micro-laryngo-bronchoscopy by a paediatric ENT surgeon in addition to upper gastrointestinal contrast study, oesophagoscopy, and echocardiogram.
  
  
  RESULTS
  Seven children (median age 5.6 months [range 2.2-60]) completed the pathway. Four were referred with recurrence of a previously divided tracheo-oesophageal fistula (3 congenital, 1 acquired) and 3 (all with oesophagostomy) for oesophageal replacement for congenital isolated oesophageal atresia (OA, n=1) and failed repair of OA with distal TOF with wide gap (n=2). Overall, unanticipated findings were demonstrated in 6/7 children and comprised severe tracheomalacia and right main bronchus stenosis requiring aortopexy (n=1), vocal cord palsy (n=2), extensive mediastinal rotation (n=1), proximal tracheal diverticulum (n=1), severe subglottic stenosis requiring airway reconstruction (n=1), proximal tracheal diverticulum (n=1), right sided aortic arch (n=1) and left sided aortic arch (previously reported to be right sided, n=1).
  
  
  CONCLUSIONS
  This standardised approach for this complex group of patients reveals a high incidence of unexpected anatomical and functional anomalies with significant surgical and possible medico-legal implications. We recommend these investigations during the pre-operative work-up prior to all revisional oesophageal surgery.
authors.affiliation: Surgery Unit, UCL Institute of Child Health, London, UK; Department of General Surgery, Great Ormond Street Hospital NHS Foundation Trust, London, UK. Electronic address: nigel.hall@ucl.ac.uk.
authors.forename: Nigel J
authors.initials: NJ
authors.lastname: Hall
authors.forename: Michelle
authors.initials: M
authors.lastname: Wyatt
authors.forename: Joe I
authors.initials: JI
authors.lastname: Curry
authors.forename: Edward M
authors.initials: EM
authors.lastname: Kiely
mesh_terms: D000015:Abnormalities, Multiple / Q000601:surgery; D001999:Bronchoscopy; D002675:Child, Preschool; D003287:Contrast Media; D019091:Critical Pathways; D004452:Echocardiography; D004933:Esophageal Atresia / Q000601:surgery; D004944:Esophagoplasty / Q000379:methods*; D004946:Esophagostomy; D006801:Humans; D015994:Incidence; D033162:Incidental Findings; D007223:Infant; D007431:Intraoperative Complications / Q000517:prevention & control; D007828:Laryngoscopy; D007829:Laryngostenosis / Q000601:surgery; D011183:Postoperative Complications / Q000601:surgery*; D011300:Preoperative Care / Q000379:methods / Q000592:standards*; D011446:Prospective Studies; D012086:Reoperation; D014057:Tomography, X-Ray Computed; D014138:Tracheoesophageal Fistula / Q000601:surgery; D055090:Tracheomalacia / Q000601:surgery; D014826:Vocal Cord Paralysis / Q000175:diagnosis / Q000209:etiology
chemical_list: D003287:Contrast Media
keywords: Airway reconstruction; Oesophageal atresia; Oesophageal replacement; Revisional surgery; Tracheomalacia