A standardised investigative strategy prior to revisional oesophageal surgery in children: High incidence of unexpected findings

Background/PurposeRevisional oesophageal reconstructive surgery carries uncommon and unusual risks related to previous surgery. To provide maximum anatomical detail and facilitate successful outcome, we report a standardised pre-operative investigative strategy for all such patients.MethodsProspective 8-month cohort study following the introduction of this strategy. All patients underwent high resolution thoracic contrast CT scan and micro-laryngo-bronchoscopy by a paediatric ENT surgeon in addition to upper gastrointestinal contrast study, oesophagoscopy, and echocardiogram.ResultsSeven children (median age 5.6 months [range 2.2-60]) completed the pathway. Four were referred with recurrence of a previously divided tracheo-oesophageal fistula (3 congenital, 1 acquired) and 3 (all with oesophagostomy) for oesophageal replacement for congenital isolated oesophageal atresia (OA, n = 1) and failed repair of OA with distal TOF with wide gap (n = 2). Overall, unanticipated findings were demonstrated in 6/7 children and comprised severe tracheomalacia and right main bronchus stenosis requiring aortopexy (n = 1), vocal cord palsy (n = 2), extensive mediastinal rotation (n = 1), proximal tracheal diverticulum (n = 1), severe subglottic stenosis requiring airway reconstruction (n = 1), proximal tracheal diverticulum (n = 1), right sided aortic arch (n = 1) and left sided aortic arch (previously reported to be right sided, n = 1).ConclusionsThis standardised approach for this complex group of patients reveals a high incidence of unexpected anatomical and functional anomalies with significant surgical and possible medico-legal implications. We recommend these investigations during the pre-operative work-up prior to all revisional oesophageal surgery.