Bronchoscopic Localization of Tracheoesophageal Fistula in Newborns with Esophageal Atresia: Intubate Above or Below the Fistula?

PURPOSE: In neonates with suspected type C esophageal atresia and tracheoesophageal fistula (EA/TEF) who require preoperative intubation, some texts advocate for attempted "deep" or distal-to-fistula intubation. However, this can lead to gastric distension and ventilatory compromise if a distal fistula is accidently intubated. This study examines the distribution of tracheoesophageal fistula locations in neonates with type C EA/TEF as determined by intraoperative bronchoscopy. METHODS: This was a single-center retrospective review of neonates with suspected type C EA/TEF who underwent primary repair with intraoperative bronchoscopy between 2010 and 2020. Data were collected on demographics and fistula location during bronchoscopic evaluation. Fistula location was categorized as amenable to blind deep intubation (>1.5 cm above carina) or not amenable to blind deep intubation intubation (≤1.5 cm above carina or carinal). RESULTS: Sixty-nine neonates underwent primary repair of Type C EA/TEF with intraoperative bronchoscopy during the study period. Three patients did not have documented fistula locations and were excluded (n = 66). In total, 49 (74 %) of patients were found to have fistulas located ≤1.5 cm from the carina that were not amenable to blind deep intubation. Only 17 patients (26 %) had fistulas >1.5 cm above carina potentially amenable to blind deep intubation. CONCLUSIONS: Most neonates with suspected type C esophageal atresia and tracheoesophageal fistula have distal tracheal and carinal fistulas that are not amenable to blind deep intubation. LEVEL OF EVIDENCE: Level III.

Surgical Treatment of Esophageal Anastomotic Stricture After Repair of Esophageal Atresia.

BACKGROUND: Anastomotic strictures (AS) after esophageal atresia (EA) repair are common. While most respond to endoscopic therapy, some become refractory and require surgical intervention, for which the outcomes are not well established. METHODS: All EA children with AS who were treated surgically at two institutions (2011-2022) were retrospectively reviewed. Surgical repair was performed for those with AS that were either refractory to endoscopic therapy or clinically symptomatic and undergoing surgery for another indication. Anastomotic leak, need for repeat stricture resection, and esophageal replacement were considered poor outcomes. RESULTS: 139 patients (median age: 12 months, range 1.5 months-20 years; median weight: 8.1 kg) underwent 148 anastomotic stricture repairs (100 refractory, 48 non-refractory) in the form of stricturoplasty (n = 43), segmental stricture resection with primary anastomosis (n = 96), or stricture resection with a delayed anastomosis after traction-induced lengthening (n = 9). With a median follow-up of 38 months, most children (92%) preserved their esophagus, and the majority (83%) of stricture repairs were free of poor outcomes. Only one anastomotic leak occurred in a non-refractory stricture. Of the refractory stricture repairs (n = 100), 10% developed a leak, 9% required repeat stricture resection, and 13% required esophageal replacement. On multivariable analysis, significant risk factors for any type of poor outcome included anastomotic leak, stricture length, hiatal hernia, and patient's weight. CONCLUSIONS: Surgery for refractory AS is associated with inherent yet low morbidity and high rates of esophageal preservation. Surgical repair of non-refractory symptomatic AS at the time of another thoracic operation is associated with excellent outcomes. LEVEL OF EVIDENCE: Level III.

Racial inequality in the trauma of women: A disproportionate decade.

BACKGROUND: Historically, women have been largely underrepresented in the body of medical research. Given the paucity of data regarding race and trauma in women, we aimed to evaluate the most common types of traumas incurred by women and analyze temporal racial differences. METHODS: A 10-year review (2007-2016) of the National Trauma Data Bank was conducted to identify common mechanisms of injuries among women. Trends of race, intent of injury, and firearm-related assaults were assessed using the Cochran-Armitage Trend test. Multivariable multinomial logistic regressions were utilized to examine the association between race and trauma subtypes. RESULTS: Of the 2,082,768 women identified as a trauma during this study period, the majority presented due to an unintentional intent (94.5%), whereas fewer presented secondary to an assault (4.4%) or self-inflicted injury (1.1%). While racioethnic minority women encompassed a small percentage of total traumas (19%), they accounted for roughly three fifths of assault-related traumas (p < 0.001). Though total assaults decreased by 20.8% during the study period, black and Hispanic women saw a disproportionately smaller decrease of 15.1% and 15.8%, respectively. On regression analysis, compared with white women, black women had more than four times the odds of being an assault-related trauma compared with unintentional trauma (odds ratio, 4.48; 95% confidence interval, 4.41-4.55). On subset analysis, firearm-related assault was 17.3 times more prevalent among black women (white, 0.3% vs. black: 5.2%; p < 0.001). In fact, history of alcohol abuse was found to be an effect modifier of the association of race/ethnicity and firearm-related trauma. CONCLUSION: Compelling data highlight a disproportionate trend in the assault-related trauma of minority women. Specifically, minority women, especially those with a history of alcohol abuse, were at increased risk of being involved in a firearm assault. Further studies are essential to help mitigate disparities and subsequently develop preventative services for this diverse population. LEVEL OF EVIDENCE: Epidemiological, Level III.