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the level of the carina [28]. The gap between the esophageal pouches is usually greatest at this level, and either jejunal grafts or colonic interposition may be necessary to bridge this separation. Gastroesophageal reflux is also 10 times more commonly encountered in patients with a wide gap than in those without [28]. These patients may need an associated Nissen fundoplication to prevent reflux and its associated risk of aspiration. Severe reflux has been associated with a higher risk of recurrent anastomotic strictures. However, antireflux surgery is not as successful in patients with EATEF as it is in those patients with otherwise uncomplicated gastroesophageal reflux disease GERD [29].

Strictures are encountered in 18 to 40% of patients and are at the level of the anastomosis [27,28,30] (Fig. 2.9). They are often the sequelae of anastomotic leaks or reflux, as noted earlier. Although esophago-esophageal and esophagocolonic strictures were encountered with equal frequency, the latter led to surgical revision in most cases, while the former could be handled conservatively with dilatation(s) [27]. Leaks may be found in 17 to 21% of patients [27,28,30,31]. Recurrence of the fistula may occur in 5 to 12% of all patients [27,28,30].

Tension on the anastomosis was considered to be the primary cause and predictor of complications in patients undergoing EATEF repairs

Figure 2.9. Esophageal stricture following EATEF repair. Single frontal film of the thoracic esophagus in a child following previous primary repair of an esophageal atresia-tracheoesophageal fistula. A mild degree of stricture is noted at the site of the repair. Peristaltic contractions were interrupted at this level during fluoroscopic evaluation.

Figure 2.9. Esophageal stricture following EATEF repair. Single frontal film of the thoracic esophagus in a child following previous primary repair of an esophageal atresia-tracheoesophageal fistula. A mild degree of stricture is noted at the site of the repair. Peristaltic contractions were interrupted at this level during fluoroscopic evaluation.

[28]. However, the use of braided silk sutures was also noted to be a significant risk factor, especially for anastomotic leaks [30,31]. In critically ill children with pulmonary complications, emergency ligation of the fistula, without correction of the accompanying esophageal disorder, was considered to be preferable to gastrostomy alone [30].

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