Optimizing outcome of neonates with leaking esophageal anastomosis after repair of tracheo-esophageal fistula in limited resources setting. A cross-sectional study

The aim of this study is to outline the outcomes of different management strategies for major anastomotic leak (AL) after type C esophageal atresia (CEA) repair and to propose a management plan according to patient criteria in limited resources settings.Patients and Methods: We retrospectively reviewed patients who underwent primary repair for CEA in our institution from 2017 to 2020. Patients managed non-operatively by broad-spectrum antibiotics, chest tube drainage and parenteral nutrition were included in group A (GA), patients managed by rescue surgery in form of cervical esophagostomy and feeding gastrostomy were included in group B (GB).Results: 45 patients developed AL. Rescue surgery was done in 15 cases (33.3%), 80% of them (n=12) were within five to eight days after anastomosis, all of which were discharged later from hospital alive. In the remaining cases from GB, rescue surgery was attempted after eight days, all of which suffered mortality. The association between conservative management and mortality was statistically significant for preterm patients (n=7) (P=0.008), patients with Okamoto class II or more (n=11) (P=0.01), patients who needed assisted mechanical ventilation pre-operatively (n=4) (P=0.049) or post-operatively (n=13) (P<0.001).Conclusions: Watchful waiting to permit spontaneous closure of AL is considered high risk for mortality in premature neonates, cases with Okamoto class II or higher, moderate to severe pulmonary hypertension, patients in need of pre- or post-operative mechanical ventilation. Decision for termination of conservative management by rescue surgery is associated with better survival outcome when executed within eight days from initial repair.