Clinical outcomes following implementation of a management bundle for esophageal atresia with distal tracheoesophageal fistula.
BACKGROUND/PURPOSE: This study evaluated compliance with a multi-institutional quality improvement management protocol for Type-C esophageal atresia with distal tracheoesophageal fistula (EA/TEF).
METHODS: Compliance and outcomes before and after implementation of a perioperative protocol bundle for infants undergoing Type-C EA/TEF repair were compared across 11 children's hospitals from 1/2016-1/2019. Bundle components included elimination of prosthetic material between tracheal and esophageal suture lines during repair, not leaving a transanastomotic tube at the conclusion of repair (NO-TUBE), obtaining an esophagram by postoperative-day-5, and discontinuing prophylactic antibiotics 24 h postoperatively.
RESULTS: One-hundred seventy patients were included, 40% pre-protocol and 60% post-protocol. Bundle compliance increased 2.5-fold pre- to post-protocol from 17.6% to 44.1% (p < 0.001). After stratifying by institutional compliance with all bundle components, 43.5% of patients were treated at low-compliance centers (80%). Rates of esophageal leak, anastomotic stricture, and time to full feeds did not differ between pre- and post-protocol cohorts, though there was an inverse correlation between NO-TUBE compliance and stricture rate over time (ρ = -0.75, p = 0.029).
CONCLUSIONS: Compliance with our multi-institutional management protocol increased 2.5-fold over the study period without compromising safety or time to feeds and does not support the use of transanastomotic tubes.
LEVEL OF EVIDENCE: Level II.
TYPE OF STUDY: Treatment Study.
Journal of pediatric surgery
Esophageal atresia; Quality improvement; Tracheoesophageal fistula
Bence, C. M., Rymeski, B., Gadepalli, S., Sato, T. T., Minneci, P. C., Downard, C., Hirschl, R. B., Amin, R. A., Burns, R., Cherney-Stafford, L., Courtney, C. M., Deans, K. J., Fallat, M. E., Fraser, J. D., Grabowski, J. E., Helmrath, M. A., Kabre, R. D., Kohler, J. E., Landman, M. P., Lawrence, A. E., Leys, C. M., Mak, G. Z., Port, E., Saito, J. M., Silverberg, J., Slidell, M. B., St Peter, S. D., Troutt, M., Walker, S., Wright, T., Lal, D. R., . Clinical outcomes following implementation of a management bundle for esophageal atresia with distal tracheoesophageal fistula. Journal of pediatric surgery 56, 47-54 (2021).