M. Nguyen1, P. Delaplain1, C. Gayer1 1Children’s Hospital Los Angeles,Pediatric Surgery,Los Angeles, CA, USA
Introduction: Intraoperative chest tubes (IOCTs) can be placed at the time of esophageal atresia/tracheoesophageal fistula (EA/TEF) repair, in part to detect air and fluid leaks early. An IOCT may also prevent a second anesthesia if postoperative drainage is required. However, indwelling chest tubes come with risk, including pain, limited movement, and repeated imaging. As a result, IOCT placement is not standard and is somewhat controversial, with recent literature suggesting that it is unnecessary. We examined whether IOCT placement improved postoperative outcomes in a pediatric tertiary referral center. We hypothesized that the postoperative course of patients who received IOCTs would not differ from that of patients without IOCTs.
Methods: We performed a five-year retrospective review of all patients with EA/TEF. Data collection included patient demographics (birth weight, EA/TEF type, hospital length of stay (LOS)), comorbidities, operative details (approach, gap length, IOCT placement), postoperative management (chest X-rays, esophagrams, postoperative cehst tube (POCT) placement), and patient outcomes (mortality, indications for reoperation, and complications). Descriptive statistical analysis was performed using GraphPad Prism version 7. Comparison between groups was performed using t-test, chi-square, or Fischer's exact test for continuous and categorical variables respectively.
Results: Seventy-eight patients were included in the final analysis. Type C EA/TEF was most common (92%). Seventy patients underwent esophageal anastomosis; five type E patients did not require it, and three type C patients died prior to repair. No type A or E patients received IOCTs. Patients who received IOCTs had nearly two-times higher LOS (53.8±62.18 vs. 24±25.22, p=0.0195) and higher rate of reoperation for stricture (17 (34%) vs. 2 (7.1%), p=0.0083). The IOCT group also had increased incidence of POCT placement, however this was not significant. In a subgroup comparison, low birthweight (LBW) patients had increased incidence of pneumothorax (5 (17%) vs. 1 (2.2%), p=0.0229), more POCTs despite IOCTs (8 (28%) vs. 3 (12%), p=0.0416), and higher mortality (6 (20.7%) vs. 0, p=0.0026) versus normal birthweight (NBW) patients. There was no difference in rates of extra- versus intrapleural dissection between these groups.
Conclusion: EA/TEF patients who received IOCTs during repair had significantly increased hospital LOS and reoperation for stricture, suggesting that prophylactic IOCT placement is associated with worse postoperative course. Though LBW patients required more POCTs, this was despite IOCT placement, suggesting that prophylactic IOCTs are not beneficial even in this more fragile patient population.
