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Ann Thorac Surg 1997;64:783-784
© 1997 The Society of Thoracic Surgeons
Doctor Tsai and her coauthors have presented a 20-year experience with a relatively small series of infants and children with esophageal atresia and tracheoesophageal fistula (EA/TEF). They have reported on 81 patients of whom 68 underwent definitive treatment of their anomaly. Their overall survival rates are excellent, with favorable cases (Waterston risk groups A and B) achieving a survival between 89% and 100%. Although the Waterston classification has been traditionally used to categorize infants with EA/TEF, the criteria are really out of date in the 1990s; the new classification reported by Spitz and associates [1] in 1991 is more appropriate today. The only criteria of importance in this new classification are weight of more or less than 1,500 g and the presence or absence of severe cardiac anomalies.
Although the survival rates in this series are comparable with those seen in other, current, large series, such as those reported by Spitz, Myers, and myself, the complication rates in this series are significantly higher. For instance, in a series of almost 600 patients at the University of Michigan, the leak rate is 10% (versus 19% in this series) and the stricture rate is 10% (versus 40% in this series). It is not clear to me why Tsai and coauthors have experienced such a high stricture rate; however, they do not mention any association between the strictures they encountered and the presence of gastroesophageal reflux (GER). In fact, in the Comment they state that the overall incidence of GER was only 13%. This is an extremely low incidence, because in most series GER is present in more than 50% of the patients. In addition, most surgeons dealing with this anomaly believe that the overwhelming majority of strictures are due to persistent GER. The incidence of TEF (10%) is similar to that seen in most other series. During the past 20 years, my colleagues and I have performed 225 repairs of EA/TEF and have experienced an incidence of recurrent TEF of 6%; however, during the past 10 years, we have not had any cases of recurrent TEF.
Finally, the management of long-gap EA remains difficult and controversial. In this series the use of esophageal replacement, specifically with colon, was fairly liberal, with 8 of 68 patients or 12% undergoing this procedure. This is a higher rate of esophageal replacement than done in most other series. I believe most long-gap EAs can eventually be brought together with a primary esophagoesophagostomy. At present, we prefer the gastric transposition to colon interposition, if replacement is necessary. At the Hospital for Sick Children in London, this is also the preferred approach.
Tsai and coauthors are to be commended for excellent survival rates in this series of infants with EA/TEF. Most likely further improvement in the survival of infants with this anomaly will have to await further improvement in the management of the severe associated cardiac anomalies.
Reference
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