04029695

January 08, 2024, 21:27

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The fundamental goal of EA repair is to restore esophageal continuity and ultimately allow for nutritional autonomy by mouth. Thoracoscopic repair of EA is one of the most challenging advanced pediatric endoscopic procedures, but the vast majority of senior pediatric surgeons are capable of performing this surgery satisfactorily via thoracotomy. In general terms, thoracotomy is more invasive than thoracoscopy and thoracoscopy is more invasive than endoscopy. But we do not think that ‘open approaches are extremely invasive and there are many postoperative complications’. A significant proportion of children develop musculoskeletal deformities after thoracotomy, but most of them are subclinical. An axillary muscle-sparing technique significantly decreases the incidence of these deformities. Other complications (leakage, dehiscence, stenosis...) are not directly related to the surgical approach, but with the type of esophageal atresia, the patient's characteristics and technical details. Although the patient comes from a county hospital, the delay in diagnosis is conspicuous, presenting the classic clinical signs (drooling of saliva, dyspnea, and vomiting immediately after feeding) and even having prenatally detected polyhydramnios. ‘Angiography’ is used to image anatomical and structural details of the vascular system by detecting contrast injected into a blood vessel. Authors describe a contrast in upper pouch or esophagogram (not angiography), as they show in Figure 1. Esophagogram can be useful to establish size and location of the proximal pouch but its systematic implementation is not indicated because it may cause serious complications as aspiration. A less dangerous alternative is to insufflate air through the probe at the time of the X-ray. Authors placed a tube in the proximal esophageal pouch during physical examination, but not a ‘gastric tube’ (as the tube did not reach the stomach). The classification used by the authors is the one described by Robert E. Gross, one of great pioneers of Pediatric Surgery. Since it is his last name, it should be written in capital letters: EA Gross type C. ‘To avoid the complications associated with open surgery, the baby’s parents signed the written informed consent and authorized the surgeons to perform the thoracoscopic esophageal magnetic compression anastomosis.’ Here, it would be better to remove ‘to avoid the complications associated with open surgery’, since a laparotomy (open surgery) has been performed to access the stomach. It would be nice to add a photo of the patient's unnecessary abdominal scar to verify the cosmetic result mentioned by the authors. Authors should provide the code of approval of their hospital's ethics committee. We do not agree that the procedure described by the authors is a less invasive procedure. The case of type C esophageal atresia presented by the authors is the ideal case for surgery, since it is a full-term newborn with a good weight (3500g), without severe cardiopathy or other associated anomalies (and if he has them, they should have been described) and with both pouches close to each other. We believe that the ideal procedure, in this particular case, would have been to close the tracheoesophageal fistula and perform an end-to-end esophageal anastomosis. An unnecessary laparotomy would have been avoided in this patient. It would be interesting to know the anesthetic time and duration of this surgical procedure. Did the authors modify the patient's position for the laparotomy? Where the pouches overlapping or did the authors fix both pouches between them with sutures? Figure 3C: is it the proximal or the distal magnet? Another point of controversy that could be discussed is the preservation or not of the azygos vein. And if not preserved, which is better to ligate or to coagulate it? The authors made 3 ligatures (2 in the azygos vein and one in the fistula) and two purse strings (one in each esophageal pouch). This added to: the laparotomy, the measurement with the lower esophagus probes, the placement of the magnets, the progression of the transanastomotic probe through the magnets, the measurement of the ideal site for the placement of the silk stitch over the probe and its proper positioning, the closure of the stomach and the laparotomy.... Is all this easier, faster and with better results than a termino-terminal esophageal anastomosis (it generally does not require more than 10 stitches)? Skilled surgeons in thoracoscopic repair of esophageal atresia take less than 1 hour to perform the procedure in this favorable type of case. How long was the patient intubated and relaxed? Days of NICU admission? Days of hospital admission? Why didn't they administer enteral nutrition through the transanastomotic tube? To prevent a stomach leak of the gastrostomy? This patient could have avoided 23 days of parenteral nutrition. After a non-complicated procedure of tracheoesophageal fistula closure and an end-to-end esophageal anastomosis, the esophagogram is routinely performed on the 5-7th postoperative day and can start transoral feeding. In addition, the patient has previous received enteral nutrition through the transanastomotic catheter. Authors show a minor leak on the postoperative day 15th. Did they perform any other studies before? How many days with chest tube? How was the drainage through it? Figures 4B and C show an image of atelectasis and pachypleuritis in the right hemithorax, suggesting that the leak previously had a higher debit than shown. Figure B also shows effusion in the right costophrenic sinus. Therefore, we do not agree with authors’ statement: ‘Although the postoperative X-ray also found a minor leakage, the contrast agent did not enter the pleural cavity’. Authors used a transpleural approach, so the mediastinum and pleura were connected. Although the information in the abstract is congruent with the content of the manuscript, they do not mention the leakage, which is a very important detail. They say: ‘No leakage existed when the transoral feeding started’. In fact, if you don't read the whole case, you get the impression that there was never any leakage. Anastomotic leakage is a serious and widely reported complication in esophageal atresia, but it has rarely been reported in magnamosis. It is important to report complications. Do you think that the leak may be related to an area where the esophageal tissue did not coapt with each other because the purse string suture is interposed? In the case described by the authors, since they did not use the transanastomotic tube to nourish the patient, they could have avoided its placement and the opening of the proximal esophagus. In this way they would have avoided the first purse string suture. In addition, having two magnets of different diameters and the proximal magnet being larger in diameter than the distal esophagus, the probability of displacement into the gastric chamber is minimal. Therefore, they could have also avoided the stopper with the silk attached to the probe. To avoid the interposition of the distal purse string suture favoring leakage, the tracheoesophageal fistula can be sectioned between two ligatures and the magnet placed to create an end-to-side anastomosis. The authors removed the magnets on postoperative day 23, but do not explain how they removed them. The image of the control esophagogram is suboptimal because the esophagus is faintly stained. An essential fact that is not described is the evolution of the patient in the short, medium and long term. The most frequent complication after magnamosis is recalcitrant stenosis and this occurs at a later stage. Another aspect to consider is the increased exposure to ionizing radiations with magnamosis since both positioning and removal of magnets are usually completed under pulsed fluoroscopy. In this case, direct viewing by thoracoscopy may have reduced radiation dose, although the authors do not mention this data. We recognize that the use of magnets holds specific indications in surgical practice. Our experience includes 9 cases where magnamosis was employed, yielding diverse outcomes. Consequently, we emphasize the need for meticulous selection when considering its application. Although thoracoscopic repair of esophageal atresia is one of the most challenging advanced pediatric endoscopic procedures, nowadays there are many possibilities for learning and training. Procedures are described and documented step by step. Technical skills can be acquired through simulation. Although this technique is likely to expand when robotic surgery miniaturizes. In conclusion, we believe it is important to individualize each case. And even if a procedure is feasible, it does not mean that it is the best and least invasive option that can be offered to a patient.

First, thank you very much for your professional comments on the article published in World Journal of Gastrointestinal Surgery. Second, we read your comments with great interest. You are welcome to format your valuable comments into a Letter to the Editor and submit it online to World Journal of Gastrointestinal Surgery at https://www.f6publishing.com. There are no restrictions on the number of words, figures (color, B/W) or authors for a Letter to the Editor. In addition, the article processing charge will be exempted for this Letter to the Editor. As with all articles published by the Baishideng Publishing Group, the Letter to the Editor will be published online after completing peer review. The guidelines for a Letter to the Editor can be found at: https://www.wjgnet.com/bpg/GerInfo/219. Finally, we look forward to receiving your high-quality Letter to the Editor, which will promote academic communication and lead the development of this discipline.

Replied on January 23, 2024, 15:10

Thank you for your careful reading and pertinent suggestions. We have contacted the editors to correct the figure legend of Figure 3C and the written format of “Gross”. Actually, the ideal repair for EA type Gross C is an end-to-end suturing anastomosis. However, based on our previous researches, it has been proven that the magnetic anastomosis has many advantages over the manual anastomosis. In our past practice, we repaired EA type Gross C with suturing anastomosis. In this report, it was an exploration in the repair of EA type Gross C, and our practical experience was that it was easier to perform than suturing. The anesthetic time was about 3 hours, and a lot of time was wasted in maintaining the oxygen saturation. Therefore, the exact duration of procedure could not be recorded. Intraoperatively, a slight position change was made during performing gastrostomy; the pouches were not fixed with sutures. The azygos vein was ligated and dissected, because it might affect the operation and also possible be compressed by the magnets. These problems would be avoided after the dissection of the azygos vein. Ligation may be more reliable than coagulation. Individual case could not prove that this method is faster or more effective than manual end-to-end anastomosis. You mentioned that manual anastomosis requires skillful techniques, this has also been proved by many literatures that laparoscopic anastomosis is an advanced technique which requires a long learning curve. However, the magnetic anastomosis requires less skill than the manual anastomosis. The reason for not feeding through the gastric tube immediately in the postoperative period was that the tube was passed through the cardia, which might cause reflux, so the feeding was delayed. Regarding the leakage, we also speculate that it related to a large purse-string suture, which may lead to incomplete compression of the anastomotic tissue by the magnets. The silk stopper was attached to avoid the displacement of the magnets, and this also allowed the transoral removal of the magnets by pulling the tube The patient was only discharged from the hospital at the time of writing the manuscript, and there were no mid- or long-term follow-up results. However, in our telephone follow-up at the end of December, the family told us that the child was fine and they would follow up with the hospital after the Chinese New Year.