L. Michaud

Sténose anastomotique après traitement chirurgical de lˈatrésie de lˈœsophage : fréquence, facteurs de risque et efficacité des dilatations œsophagiennes

Resume La stenose anastomotique est la principale complication apres traitement de lˈatresie de lˈœsophage. Elle est habituellement traitee par dilatation mecanique par bougie ou par ballonnet. Buts de lˈetude. – Les buts de ce travail retrospectif etaient dˈetudier dans une population dˈenfants operes a la naissance dˈune atresie de lˈœsophage de type III ou IV : 1) la frequence et les facteurs associes a la survenue dˈune stenose anastomotique ; 2) lˈefficacite des dilatations œsophagiennes par bougie de Savary. Patients et methodes. – Les caracteristiques de 52 enfants operes sur une periode de cinq ans ont ete analysees. Le terme et le poids de naissance, la duree du maintien des drains mediastinaux et trans-anastomotiques, la tension lors de la realisation de lˈanastomose, la survenue de complications precoces (fistule et/ou mediastinite) et la presence d’un reflux gastro-œsophagien ont ete notes. Les parametres concernant le groupe dˈenfants ayant eu une stenose anastomotique ont ete compares a ceux du groupe dˈenfants indemnes de stenose. En cas de survenue dˈune stenose anastomotique, lˈâge de lˈenfant lors de la premiere dilatation, le nombre de seances de dilatation realisees et lˈefficacite des seances etaient notes. Resultats. – Vingt enfants (40 %) ont eu une stenose anastomotique. Le terme, le poids de naissance, la duree du maintien des drains trans-anastomotiques ou mediastinaux n’etaient pas associes a la survenue ulterieure dˈune stenose anastomotique. Lˈexistence dˈune tension lors de la realisation de lˈanastomose etait significativement liee a la survenue dˈune stenose ( p n = 1) ou severe ( n = 1). Conclusions. – La survenue dˈune stenose anastomotique apres traitement chirurgical de lˈatresie de l’œsophage est frequente, favorisee par la longueur du segment atresique conditionnant la tension lors de la suture. La realisation de dilatations œsophagiennes par bougie de Savary est une technique efficace, mais necessite habituellement plusieurs seances pour obtenir la disparition de la dysphagie.Anastomotic stricture is the most common complication following the surgical repair of esophageal atresia, and is usually treated by esophageal dilation. Objectives. – The aims of this study were to assess in an infant population operated on at birth for type III or IV esophageal atresia: 1) the frequency of esophageal stenosis following the repair of esophageal atresia, and associated factors; 2) the efficacy of esophageal dilation by the Savary-Gaillard bougie technique. Materials and methods. – The medical records of 52 children presenting with esophageal atresia over a 5-year period were retrospectively reviewed. Gestional age and birth weight, duration of mediastinal and transanastomotic drainage, and anastomotic complications including leakage, stricture, and the presence of gastroesophageal reflux were recorded and analysed. Patients presenting with anastomotic stricture were compared with a group of children without stricture. The number of esophageal dilations, their efficacy and the complication rate were analyzed. Results. – Anastomotic stricture developed in 20 (40%) of the 50 patients undergoing primary repair for esophageal atresia. The occurrence of anastomotic stricture was related to anastomotic tension during esophageal surgical repair (p < 0.03). Young children required esophageal dilation at a mean age of 142 days (24–930 days). Stricture resolution occurred after a mean of 3.2 dilations (1–15) over an average period of 7.9 months (range: 0–30 months). Dilation was successful in 90% of the 20 patients. Seven patients required only one dilation. Perforation of the esophagus occurred in one case, and this severe complication led to the death of the child. Esophageal dilation was unsuccessful in two patients, who presented prolonged severe dysphagia. Conclusion. – Anastomotic stricture following repair of esophageal atresia is connected with the length of the gap that has to be repaired, and tension during suture. Esophageal dilation by the Savary-Gaillard bougie technique is an effective method for treating esophageal stricture. Several dilations are usually needed before the disappearance of dysphagia.