Transanastomotic tubes not linked to anastomotic stricture after esophageal atresia repair

1. Transanastomotic tube placement did not result in different rates of anastomotic stricture in infants undergoing esophageal atresia repair.

2. Moderate-to-severe surgeon-assessed anastomotic tension was independently associated with increased odds of anastomotic stricture.

Evidence Rating Level: 1 (Excellent)

Study Rundown: Anastomotic stricture is a common complication following repair of type C esophageal atresia with distal tracheoesophageal fistula. Transanastomotic tubes have historically been utilized to facilitate postoperative enteral feeding and potentially support anastomotic healing. However, prior retrospective studies linked tube placement to increased stricture risk. This multicenter, randomized controlled trial evaluated whether transanastomotic tube placement was associated with anastomotic stricture among infants undergoing primary repair of type C esophageal atresia with distal tracheoesophageal fistula. Infants were randomized to repair with or without transanastomotic tube placement. The primary outcome was anastomotic stricture requiring endoscopic dilation within 12 months. The study found no difference in stricture rates between the no-tube and tube groups. Rates of postoperative leak, infection, reoperation, readmission, and most feeding outcomes were also similar. However, feeding was initiated earlier in the tube group. Multivariate analysis revealed that transanastomotic tube placement was not independently associated with stricture, whereas moderate-to-severe surgeon-assessed anastomotic tension was indeed associated with greater odds of stricture. In summary, transanastomotic tubes may not be an independent driver of stricture formation, perhaps instead simply coinciding with higher-risk anastomoses. Strengths of the study included its prospective multicenter randomized design, standardized prospective data collection, and inclusion of 10 pediatric centers. Limitations included the lack of blinding, variation in postoperative feeding management between institutions, and insufficient power to detect small differences in secondary outcomes or evaluate high-risk subgroups such as infants with severe anastomotic tension.

Click to read the study in Annals of Surgery

Relevant Reading: Effect of transanastomotic feeding tubes on anastomotic strictures in patients with esophageal atresia and tracheoesophageal fistula: The Quebec experience

In-Depth [randomized controlled trial]: This trial enrolled infants undergoing primary repair of type C esophageal atresia with distal tracheoesophageal fistula at 10 children’s hospitals between 2017 and 2025. Patients were randomized to repair with a transanastomotic tube or without a tube. Of 142 randomized patients, 74 were assigned to the no-tube group and 68 to the tube group, with one patient subsequently withdrawn from the tube group. The primary outcome was anastomotic stricture requiring endoscopic dilation within 12 months of surgery. Stricture occurred in 47.3% of patients in the no-tube group and 50.4% of patients in the tube group (P = .45). The groups also had similar rates of anastomotic leak (20.3% vs. 19.9%, P = .90), unplanned return to the operating room (37.8% vs. 38.3%, P = .91), and unplanned readmission (53.5% vs. 50.7%, P = .49). Feeding was initiated earlier among patients receiving a transanastomotic tube (P = .021), although time to full feeds did not differ significantly (16 days vs. 14 days, P = .49). On multivariate analysis, transanastomotic tube placement was not independently associated with stricture (OR 1.18; 95% CI, 0.58-2.45; P = .64). In contrast, moderate-to-severe surgeon-assessed anastomotic tension was associated with increased odds of stricture (OR 2.45; 95% CI, 1.11-5.40; P = .026). Among patients who developed a stricture, the mean time to first dilation was 106.2 days, and patients required a mean of 3.6 dilations. These findings suggested that anastomotic tension may be more important than transanastomotic tube placement in determining subsequent stricture risk.

Image: PD

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