Perioperative management of esophageal atresia/tracheoesophageal fistula: An analysis of data of 101 consecutive patients
This is a retrospective cohort analysis of electronic data in 101 neonates undergoing open and thoracoscopic surgical repair of esophageal atresia type C in one institution between 2007 and 2017. It looks at the perioperative courses of vital and metabolic parameters. Not surprisingly, the study found correction of TOF/OA is associated with periods of severe derangement of pH, pO2 and pCO2, BP and O2 saturation. The severities of metabolic disturbances did not differ between the different surgical approaches.
Intraoperative acidosis (pH<7.35) was found in 62 patients; severe acidosis (pH<7.20) in 33 patients, with four cases pH<7.0 (lowest value 6.83).
The median PaCO2 reached an upper level of 7.5kPa; in 13 cases above 10.0kPa, with a peak value of 25.8kPa.
The median PaO2 level reached an upper level of 16.9kPa, in 22 cases above 20.0kPa, with a peak value of 50.0kPa. These high levels fluctuated with lowest measured PaO2 levels of median 8.3kPa; the lowest PaO2 value was 4.7 kPa.
Hypoxemic events (peripheral sats<90%) were recorded for 75 of the 101 patients, which were severe (sats <80%) in 28 patients.
In total 22 patients had one or more hypertensive events and 14 patients had one or more hypotensive events. 44 patients received vasoactive drugs.
Take Home Message
Given the impressive number of cases, the study adds valuable information on demographics (cardiac, comorbidities, prematurity), surgical and anaesthetic data (times, use of flexible and rigid scopes, need for inotropes, post operative hospital and PICU stays) and complication rates (including mortality) to that already in the literature.
Independent of the surgical technique used, most patients in the study experienced periods of severe intraoperative acidosis, hypercapnia, hypocapnia, hyperoxia, hypoxemia, and hypertension. Vigilance and checking for metabolic changes at regular time intervals during the operation, preferably with arterial blood gas analysis, is recommended.
There still is no general consensus on a preferred surgical technique (open vs thoracoscopic). This study does not favour one against the other in terms of physiological derangement and it is likely that management is still decided in light of comorbidities, experience of the surgeon, distance between the two ends of the oesophagus, surgical and anesthesiologist preference and local hospital practice.
Reviewed by: G . Knottenbelt