Ebook Surgical care of major newborn malformations: Part 2
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Ebook Surgical care of major newborn malformations: Part 2
CHAPTER 9ESOPHAGEAL ATRESIAFrederick Alexander, M.D.*Joseph M. Sanzari Children's Hospital, Hackensack, New JerseyINTRODUCTIONEsophageal atresia has r Ebook Surgical care of major newborn malformations: Part 2remained the defining challenge for several generations of pediatric surgeons. Coveted by pediatric surgical fellows and featured in the commercial hit movie “M*A*S*H”, these cases have epitomized a pediatric surgeon's ability to repair a catastrophic embryologic anomaly and restore normal life. Tod Ebook Surgical care of major newborn malformations: Part 2ay, thanks to the contributions of many brilliant pediatric surgeons, anesthesiologists, and neonatologists, children with esophageal atresia cannot oEbook Surgical care of major newborn malformations: Part 2
nly survive but thrive as they head into early childhood. As a result of this work, associated anomalies have now surpassed esophageal atresia as the CHAPTER 9ESOPHAGEAL ATRESIAFrederick Alexander, M.D.*Joseph M. Sanzari Children's Hospital, Hackensack, New JerseyINTRODUCTIONEsophageal atresia has r Ebook Surgical care of major newborn malformations: Part 2th the VACTERL syndrome. Hence, once the diagnosis is made it is critically important to perform a complete physical examination and obtain an echocardiogram as well as appropriate radiologic imaging to rule out associated Vertebral, Anal or Intestinal, Cardiac, Renal, and Limb/Lung anomalies. Addit Ebook Surgical care of major newborn malformations: Part 2ionally, genetic and neurologic screening should be done in every case. Moreover, since many infants are now diagnosed prenatally, it is often importaEbook Surgical care of major newborn malformations: Part 2
nt to consult with the maternal fetal medical specialist or fetal radiologist who may have pertinent information to share concerning associated anomalCHAPTER 9ESOPHAGEAL ATRESIAFrederick Alexander, M.D.*Joseph M. Sanzari Children's Hospital, Hackensack, New JerseyINTRODUCTIONEsophageal atresia has r Ebook Surgical care of major newborn malformations: Part 2 may be declining♦Address: Pediatric Surgical Associates, 30 West Century Road, Suite 235, Paramus, NJ 07652. E-mail: folexander@humed.com.190E Alexanderas the result of selective termination used in conjunction with prenatal screening. This is difficult to assess due to regional differences in pren Ebook Surgical care of major newborn malformations: Part 2atal management and referral patterns. This emphasizes the need for pediatric surgical involvement in fetal care programs to educate prospective parenEbook Surgical care of major newborn malformations: Part 2
ts and healthcare providers about treatment options, risks, benefits, and expected outcomes for esophageal atresia.HistoryThe history of esophageal atCHAPTER 9ESOPHAGEAL ATRESIAFrederick Alexander, M.D.*Joseph M. Sanzari Children's Hospital, Hackensack, New JerseyINTRODUCTIONEsophageal atresia has r Ebook Surgical care of major newborn malformations: Part 2atomy, gestational age, and associated anomalies; and surgical treatment has evolved through many iterations over the past six decades.Esophageal atresia was uniformly fatal until 1939 when Leven1 salvaged one patient using a three-staged repair including gastrostomy, extra-pleural division of an as Ebook Surgical care of major newborn malformations: Part 2sociated tracheoesophageal fistula, and cervical esophagostomy. Two years later, the first successful primary repair of esophageal atresia with fistulEbook Surgical care of major newborn malformations: Part 2
a was performed by Haight2 who very clearly described the technical innovations that would pave the way for future success, including meticulous mobilCHAPTER 9ESOPHAGEAL ATRESIAFrederick Alexander, M.D.*Joseph M. Sanzari Children's Hospital, Hackensack, New JerseyINTRODUCTIONEsophageal atresia has r Ebook Surgical care of major newborn malformations: Part 2iction and esophagram prior to feeding.Twenty years later, Waterston3 proposed a risk classification (Table 1) based upon a large series of patients with esophageal atresia and tracheoesophageal fistula that demonstrated greater than 90% survival in infants greater than 2000 g without congenital ano Ebook Surgical care of major newborn malformations: Part 2malies compared to less than 50% survival in premature infants with congenital anomalies, especially cardiac.At about the same time, Holder et al.4 reEbook Surgical care of major newborn malformations: Part 2
ported significantly improved survival in high-risk premature infants with esophageal atresia and tracheoesophageal fistula using a staged repair, incCHAPTER 9ESOPHAGEAL ATRESIAFrederick Alexander, M.D.*Joseph M. Sanzari Children's Hospital, Hackensack, New JerseyINTRODUCTIONEsophageal atresia has r Ebook Surgical care of major newborn malformations: Part 2eal fistula.Group A: Over 5.5 lb birth weight and well.Group B:1. Birth weight 4-5.5 lb and well.2. Higher birth weight, moderate pneumonia and congenital anomaly.Group C: 1. Birth weight under 4 lb.2. Higher birth weight and severe pneumonia and severe congenitalanomaly.Esophageal Atresia191delayed Ebook Surgical care of major newborn malformations: Part 2 primary anastomosis when the infant’s condition would safely permit. Using this strategy of repair, he achieved 66% survival in high-risk Waterston cEbook Surgical care of major newborn malformations: Part 2
infants. His strategy became the standard of care for high-risk infants with esophageal atresia and tracheoesophageal fistula and continues to be selCHAPTER 9ESOPHAGEAL ATRESIAFrederick Alexander, M.D.*Joseph M. Sanzari Children's Hospital, Hackensack, New JerseyINTRODUCTIONEsophageal atresia has r Ebook Surgical care of major newborn malformations: Part 2 atresia and tracheoesophageal fistula ranged between 30% and 70% depending upon associated risk factors, while survival of contemporaneous low-risk infants approached 100%.With improved technical support, surgical techniques, and perioperative care, surgeons began to have increasing success with pr Ebook Surgical care of major newborn malformations: Part 2imary repair in select high-risk infants. In 1972, Abrahamson and Shandling at the Hospital for Sick Children in Toronto6 reported equivalent survivalEbook Surgical care of major newborn malformations: Part 2
in groups of high-risk infants treated by primary versus staged repair. Although the study groups were not really comparable, the authors concluded tCHAPTER 9ESOPHAGEAL ATRESIAFrederick Alexander, M.D.*Joseph M. Sanzari Children's Hospital, Hackensack, New JerseyINTRODUCTIONEsophageal atresia has r Ebook Surgical care of major newborn malformations: Part 2er, Louhimo and Lindahl at the University of Helsinki7 reported similar findings and suggested a modification of the Waterston classification to exclude pneumonia and general condition from the criteria. Like the surgeons in Toronto, they reserved staged repair for infants who were desperately ill w Ebook Surgical care of major newborn malformations: Part 2ith severe respiratory problems or associated gross anomalies, any one of which were life-threatening. Using their modified risk classification, theyEbook Surgical care of major newborn malformations: Part 2
reported incrementally increased survival in all categories: 100% survival in group A patients, 95% survival in group B patients, and 57% survival in CHAPTER 9ESOPHAGEAL ATRESIAFrederick Alexander, M.D.*Joseph M. Sanzari Children's Hospital, Hackensack, New JerseyINTRODUCTIONEsophageal atresia has r Ebook Surgical care of major newborn malformations: Part 2l atresia would not survive even with a repaired esophagus, and esophageal atresia was no longer a limiting factor in the survival of infants with prematurity or associated congenital anomalies.One of the great unresolved technical challenges concerning esophageal atresia is long-gap atresia and so- Ebook Surgical care of major newborn malformations: Part 2called ultra-long-gap atresia, defined as a separation of greater than 6 cm between proximal and distal esophageal ends. Long-gap atresia may be foundEbook Surgical care of major newborn malformations: Part 2
in association with tracheoesophageal fistula, but most commonly occurs in the absence of fistula, sometimes referred to as “pure” esophageal atresiaCHAPTER 9ESOPHAGEAL ATRESIAFrederick Alexander, M.D.*Joseph M. Sanzari Children's Hospital, Hackensack, New JerseyINTRODUCTIONEsophageal atresia has r Ebook Surgical care of major newborn malformations: Part 2virtually all infants by placement of a gastrostomy tube for feeding along with intermittent nasopharyngeal suction to prevent aspiration pneumonia.Initial attempts at early primary repair of pure, long-gap atresia invariably failed. Attention soon turned to use of esophageal replacement procedures Ebook Surgical care of major newborn malformations: Part 2including the following: gastric pull-up, first performed at the Hospital for Sick Children in192F. AlexanderToronto in 1952 and later modified by spiEbook Surgical care of major newborn malformations: Part 2
tz;8 colon replacement, first reported by Dale and Sherman in 19559and subsequently advocated by Grosfeld,10 Hendren11 and others; and finally gastricCHAPTER 9ESOPHAGEAL ATRESIAFrederick Alexander, M.D.*Joseph M. Sanzari Children's Hospital, Hackensack, New JerseyINTRODUCTIONEsophageal atresia has r Ebook Surgical care of major newborn malformations: Part 2n used concurrently for nearly 50 years and continue to be selectively used by some surgeons with variable success. Each of these procedures has its advocates and each its complications including leak, stricture, gastroesophageal reflux, and dysphagia requiring surgical revision in as many as 50% of Ebook Surgical care of major newborn malformations: Part 2 all patients.1 ’In experienced hands, esophageal replacement may serve as an excellent substitute for the real thing, although even its staunchest adEbook Surgical care of major newborn malformations: Part 2
vocates have admitted that the patient’s own esophagus works best. Tn this regard, several early contributions set the stage for delayed primary repaiCHAPTER 9ESOPHAGEAL ATRESIAFrederick Alexander, M.D.*Joseph M. Sanzari Children's Hospital, Hackensack, New JerseyINTRODUCTIONEsophageal atresia has r Ebook Surgical care of major newborn malformations: Part 2 for elongating the proximal pouch using daily bougienage and delayed primary repair. Several years later, Livaditis17 reported the ingenious technique of circumferential esophagomyotomy of the proximal pouch. Using these techniques to construct a well-vascularized single layer anastomosis under ten Ebook Surgical care of major newborn malformations: Part 2sion, a number of surgeons demonstrated excellent results using delayed primary repair in the 1980s.18-20 Since then, the trend in North America has bEbook Surgical care of major newborn malformations: Part 2
een toward delayed primary repair for long-gap atresia, utilizing esophageal replacement only for failures or extremely complicated cases.ANATOMY ANDGọi ngay
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