title: Cervical repair of congenital tracheoesophageal fistula: Complications lurking!
abstract: OBJECTIVE
  Esophageal atresia (EA) and tracheoesophageal fistula (TEF) consist of a spectrum of rare congenital abnormalities. Although EA surgical treatment is well established, the outcome of EA with proximal fistula (type B and D EA) or isolated H-type fistula (type E EA) is poorly explored. These forms of EA shared a common surgical step: the need of a cervical approach to close the fistula. Therefore, the aim of present study is to evaluate postoperative outcomes of patients treated for Gross type B-D and E EA, on regards of their cervical surgery.
  
  
  METHODS
  A retrospective case series analysis of all patients affected by type B-D and E EA, and admitted to our tertiary care center between January 2003 and December 2014 was performed. All patients underwent preoperative flexible laryngo-tracheobronchoscopy (LTBS) as part of our standardized preoperative diagnostic assessment to define the diagnosis, evaluate preoperative vocal cord motility and to cannulate the fistula when required. Fistula closure was always performed through a right cervical access. Analysis of all cases and comparison between type B-D and E EA were performed. Mann-Whitney test, Chi-squared test and unpaired t test were used as appropriate; p<0.05 was considered significant.
  
  
  RESULTS
  During the study period, 180 EA newborns were treated. Proximal or isolated TEF was found in 18 patients (10%): 7 type B, 11 type E EA. Patients affected by type B and E EA/TEF frequently present associated major malformations (27%), and major cardiac abnormalities (44%). Major postoperative complications were: vocal cord paralysis (5 patients), bilateral in 2 infants requiring tracheostomy, cerebral ischemia (1 patient), and cardiac failure (1 patient).
  
  
  CONCLUSIONS
  Patients affected by type B and E EA have a high rate of associated abnormalities, and risk of possible sequelae. Postoperative complications are common, with possible transient vocal cord dismotility, but in some cases persistent paralysis may require tracheostomy. Therefore, both preoperative and postoperative LTBS is highly recommended to evaluate the presence of a proximal fistula, and vocal cord motility, even in asymptomatic patients, to rule out any possible intraoperative "surprise" and any vocal cord abnormality and to possibly define its pathogenesis (congenital vs. iatrogenic).
authors.affiliation: Neonatal Surgery Unit, Department of Medical and Surgical Neonatology, Bambino Gesù Children's Hospital, Rome, Italy. Electronic address: andrea.conforti@opbg.net.
authors.forename: Andrea
authors.initials: A
authors.lastname: Conforti
authors.affiliation: Neonatal Surgery Unit, Department of Medical and Surgical Neonatology, Bambino Gesù Children's Hospital, Rome, Italy.
authors.forename: Chiara
authors.initials: C
authors.lastname: Iacusso
authors.affiliation: Neonatal Surgery Unit, Department of Medical and Surgical Neonatology, Bambino Gesù Children's Hospital, Rome, Italy.
authors.forename: Laura
authors.initials: L
authors.lastname: Valfrè
authors.affiliation: Airway Surgery Unit, Department of Pediatric Surgery, Bambino Gesù Children's Hospital, Rome, Italy.
authors.forename: Marilena
authors.initials: M
authors.lastname: Trozzi
authors.affiliation: Airway Surgery Unit, Department of Pediatric Surgery, Bambino Gesù Children's Hospital, Rome, Italy.
authors.forename: Sergio
authors.initials: S
authors.lastname: Bottero
authors.affiliation: Neonatal Surgery Unit, Department of Medical and Surgical Neonatology, Bambino Gesù Children's Hospital, Rome, Italy.
authors.forename: Pietro
authors.initials: P
authors.lastname: Bagolan
mesh_terms: D001999:Bronchoscopy; D004933:Esophageal Atresia / Q000000981:diagnostic imaging / Q000601:surgery*; D005260:Female; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D007828:Laryngoscopy; D008297:Male; D009333:Neck / Q000601:surgery*; D011183:Postoperative Complications / Q000175:diagnosis / Q000453:epidemiology; D012189:Retrospective Studies; D014138:Tracheoesophageal Fistula / Q000000981:diagnostic imaging / Q000601:surgery*; D016896:Treatment Outcome
keywords: Esophageal atresia; Isolated tracheoesophageal fistula; TEF