Evaluation of Azygos vein Preservation Necessary in Primary Repair of Trachea Esophageal Fistula in Patients with Esophageal Atresia

Document Type : Original Article


1 Department of Pediatric Surgery, School of Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran.

2 Department of General Surgery, School of Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran.


Introduction: Esophageal atresia is one of the most common congenital anomalies in neonates, and it can increase the incidence of complications and mortality, so it is essential to find a way to cure this disease more successfully. Therefore, the aim of this study was to evaluate the efficacy of maintaining the azygos vein in esophageal fistula in esophageal atresia patients.
Materials and Method: This study was performed on 40 neonates (20 patients in the preserved group and 20 patients in the ligation group). After recording the patient's demographic data, the complications of both surgical procedures, duration of surgery and hospital stay were recorded. Chi-square and t-tests were used to compare the data.
Results: In the present study, it was found that the maintenance of azygos vein in neonates with esophageal atresia can increase the duration of surgery (P <0.05), but it also reduces the hospitalization and ICU stay and, on the other hand, the incidence of various complications such as pneumonia and anastomosis leak decreased. (P <0.05)
Conclusion: Therefore, in neonates who are candidates for surgical treatment of esophageal atresia and who are admitted to the surgical department, this surgical method can be used instead of the classical


1-Mortell AE, Azizkhan RG. Esophageal atresia repair with thoracotomy: the Cincinnati contemporary experience. SeminPediatrSurg 2009; 18(1):12-19
2-Hiradfar M, Bazrafshan A, Judi M, Gharavi M, Shojaeian R. An 8-year experience of esophageal atresia repair in Sarvar children hospital (Mashhad-IRAN). J Neonat. 2011;3(1):20-.
3-Catalano P, Di Pace MR, Caruso AM, Salerno S, Cimador M, De Grazia E. A simple technique of oblique anastomosis can prevent stricture formation in primary repair of esophageal atresia. Journal of pediatric surgery. 2012 Sep 30;47(9):1767-71.
4-Melek M, Cobanoglu U. A New Technique in Primary Repair of Congenital Esophageal Atresia Preventing Anastomotic Stricture Formation and Describing the Opening Condition of Blind Pouch: Plus (“. Gastroenterology research and practice. 2011 May 17;2011.
5-Samadi M , Aslan Abadi Saeed A , Ghaffari  GH.  prevalence of congenital heart anomalies in patients with esophageal atresia and its effect on surgical prognosis of these patients. Tabriz University of Medical Sciences.2008;30(3):67-70.
6-Spitz L. Esophageal atresia: lessons I have learned in a 40-year experience. Journal of pediatric surgery. 2006 Oct 31;41(10):1635-40.
7-Upadhyaya VD, Gangopadhyaya AN, Gopal SC, Upadhyaya A, Sharma SP, Gupta DK, Kumar V, Pandey A. Is ligation of azygos vein necessary in primary repair of tracheoesophageal fistula with esophageal atresia?. European journal of pediatric surgery. 2007 Aug;17(04):236-40.
8-Patil RT, Prakash A. Strategies for optimizing surgical outcome in patients with esophageal atresia with tracheo-esophageal fistula. International Surgery Journal. 2017 Apr 22;4(5):1706-9.
9-Standring S, editor. Gray's Anatomy E-Book: The Anatomical Basis of Clinical Practice. Elsevier Health Sciences; 2015 Aug 7.
10-Rashid KA, Maletha M, Khan TR, Wakhlu A, Rawat J, Kureel SN. Esophageal anastomosis medial to preserved azygos vein in esophageal atresia with tracheoesophageal fistula: restoration of normal mediastinal anatomy. Journal of neonatal surgery. 2012 Oct;1(4).
11-Sharma S, Sinha SK, Rawat JD, Wakhlu A, Kureel SN, Tandon R. Azygos vein preservation in primary repair of esophageal atresia with tracheoesophageal fistula. Pediatric surgery international. 2007 Doi: 1;23(12):1215-8.
12-Waterston DJ, Carter RB, Aberdeen E. Oesophageal atresia: tracheo-oesophageal fistula: a study of survival in 218 infants. The Lancet. 1962 Apr 21;279(7234):819-22.
13-Kumar V, Abbas AK, Aster JC, eds. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Philadelphia: Elsevier Saunders; 2015.
14-Moore KL, Persaud TVN, Torchia MG. The Developing Human: Clinically Oriented Embryology. 10th ed. Philadelphia: Elsevier; 2016.
15-O'Rahilly R, Muller F. Chevalier Jackson lecture. Respiratory and alimentary relations in staged human embryos. New embryological data and congenital anomalies. Ann Otol Rhinol Laryngol. 1984 Sep-Oct. 93(5 Pt 1):421-9. [Medline].
16-Kluth D, Steding G, Seidl W. The embryology of foregut malformations. J Pediatr Surg. 1987 May. 22(5):389-93. [Medline].
17-Spilde TL, Bhatia AM, Marosky JK, et al. Fibroblast growth factor signaling in the developing tracheoesophageal fistula. J Pediatr Surg. 2003 Mar. 38(3):474-7. [Medline].
18-Crisera CA, Maldonado TS, Longaker MT, Gittes GK. Defective fibroblast growth factor signaling allows for nonbranching growth of the respiratory-derived fistula tract in esophageal atresia with tracheoesophageal fistula. J Pediatr Surg. 2000 Oct. 35(10):1421-5. [Medline].
19-Orford J, Manglick P, Cass DT, Tam PP. Mechanisms for the development of esophageal atresia. J Pediatr Surg. 2001 Jul. 36(7):985-94. [Medline].
20-Ashcraft KW, Holder TM. Pediatric Esophageal Surgery. Orlando, FL: Grune and Stratton; 1996.
21-Clark DC. Esophageal atresia and tracheoesophageal fistula. Am Fam Physician. 1999 Feb 15. 59(4):910-6, 919-20. [Medline].
22-Encinas JL, Luis AL, Avila LF, Martinez L, et al. Impact of preoperative diagnosis of congenital heart disease on the treatment of esophageal atresia. Pediatr Surg Int. 2006 Feb. 22(2):150-3. [Medline].
23-Jolley SG. A longitudinal study of children treated with the most common form of esophageal atresia and tracheoesophageal fistula. J Pediatr Surg. 2007 Sep. 42(9):1632-3; author reply 1633. [Medline].
24-Lopes MF, Botelho MF. Midterm follow-up of esophageal anastomosis for esophageal atresia repair: long-gap versus non-long-gap. Dis Esophagus. 2007. 20(5):428-35. [Medline].
25-Poenaru D, Laberge JM, Neilson IR, Guttman FM. A new prognostic classification for esophageal atresia. Surgery. 1993 Apr. 113(4):426-32. [Medline].
26-Spitz L, Kiely EM, Morecroft JA, Drake DP. Oesophageal atresia: at-risk groups for the 1990s. J Pediatr Surg. 1994 Jun. 29(6):723-5. [Medline].
27-Engum SA, Grosfeld JL, West KW, et al. Analysis of morbidity and mortality in 227 cases of esophageal atresia and/or tracheoesophageal fistula over two decades. Arch Surg. 1995 May. 130(5):502-8; discussion 508-9. [Medline].
28-Stringer MD, McKenna KM, Goldstein RB, et al. Prenatal diagnosis of esophageal atresia. J Pediatr Surg. 1995 Sep. 30(9):1258-63. [Medline].
29-Greenfield LJ, Mulholland M, Oldham KT. Surgery: Scientific Principles and Practice. 2nd ed. Philadelphia: Lippincott-Raven; 1997. 2011-6.
30-Shaw-Smith C. Oesophageal atresia, tracheo-oesophageal fistula, and the VACTERL association: review of genetics and epidemiology. J Med Genet. 2006 Jul. 43(7):545-54. [Medline][Full Text].
31-Diaz LK, Akpek EA, Dinavahi R, Andropoulos DB. Tracheoesophageal fistula and associated congenital heart disease: implications for anesthetic management and survival. Paediatr Anaesth. 2005 Oct. 15(10):862-9. [Medline].
32-FDA authorizes use of new device to treat esophageal birth defect in babies. US Food and Drug Administration. May 12, 2017. Available at https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm558241.htm.
33-van der Zee DC, Vieirra-Travassos D, Kramer WL, Tytgat SH. Thoracoscopic elongation of the esophagus in long gap esophageal atresia. J Pediatr Surg. 2007 Oct. 42(10):1785-8. [Medline].
34-Spitz L, Kiely E, Brereton RJ. Esophageal atresia: five year experience with 148 cases. J Pediatr Surg. 1987 Feb. 22(2):103-8. [Medline].
35-Spitz L. Esophageal atresia: past, present, and future. J Pediatr Surg. 1996 Jan. 31(1):19-25. [Medline].
36-Saxena AK, Ainoedhofer H, Höllwarth ME. Culture of ovine esophageal epithelial cells and in vitro esophagus tissue engineering. Tissue Eng Part C Methods. 2010 Feb. 16(1):109-14. [Medline].
37-Saxena AK. Tissue engineering and regenerative medicine research perspectives for pediatric surgery. Pediatr Surg Int. 2010 Jun. 26(6):557-73. [Medline].
38-Saxena AK. Congenital anomalies of soft tissues: birth defects depending on tissue engineering solutions and present advances in regenerative medicine. Tissue Eng Part B Rev. 2010 Oct. 16(5):455-66. [Medline].
39-Saxena AK, Ainoedhofer H, Höllwarth ME. Esophagus tissue engineering: in vitro generation of esophageal epithelial cell sheets and viability on scaffold. J Pediatr Surg. 2009 May. 44(5):896-901. [Medline].
40-Saxena AK, Baumgart H, Komann C, Ainoedhofer H, Soltysiak P, Kofler K, et al. Esophagus tissue engineering: in situ generation of rudimentary tubular vascularized esophageal conduit using the ovine model. J Pediatr Surg. 2010 May. 45(5):859-64. [Medline].
41-Dunn JC, Fonkalsrud EW, Atkinson JB. Simplifying the Waterston's stratification of infants with tracheoesophageal fistula. Am Surg. 1999 Oct. 65(10):908-10. [Medline].
42-Randolph JG, Newman KD, Anderson KD. Current results in repair of esophageal atresia with tracheoesophageal fistula using physiologic status as a guide to therapy. Ann Surg. 1989 May. 209(5):526-30; discussion 530-1. [Medline].
43-Konkin DE, O'hali WA, Webber EM, Blair GK. Outcomes in esophageal atresia and tracheoesophageal fistula. J Pediatr Surg. 2003 Dec. 38(12):1726-9. [Medline].
44-Way LW, ed. Current Surgical Diagnosis and Treatment. 10th ed. New York: Appleton & Lange; 1994.
45-McCollum MO, Rangel SJ, Blair GK, et al. Primary reversed gastric tube reconstruction in long gap esophageal atresia. J Pediatr Surg. 2003 Jun. 38(6):957-62. [Medline].
46-Skarsgard ED. Dynamic esophageal lengthening for long gap esophageal atresia: experience with two cases. J Pediatr Surg. 2004 Nov. 39(11):1712-4. [Medline].
47-Foker JE, Linden BC, Boyle EM, Marquardt C. Development of a true primary repair for the full spectrum of esophageal atresia. Ann Surg. 1997 Oct. 226(4):533-41; discussion 541-3. [Medline].
48-Foker JE, Kendall TC, Catton K, Khan KM. A flexible approach to achieve a true primary repair for all infants with esophagealatresia. Semin Pediatr Surg. 2005 Feb. 14(1):8-15. [Medline].
49-Allal H, Kalfa N, Lopez M, et al. Benefits of the thoracoscopic approach for short- or long-gap esophageal atresia. J Laparoendosc Adv Surg Tech A. 2005 Dec. 15(6):673-7. [Medline].
50-Bax KM, van Der Zee DC. Feasibility of thoracoscopic repair of esophageal atresia with distal fistula. J Pediatr Surg. 2002 Feb. 37(2):192-6. [Medline].
51-Holcomb GW 3rd, Rothenberg SS, Bax KM, et al. Thoracoscopic repair of esophageal atresia and tracheoesophageal fistula: a multi-institutional analysis. Ann Surg. 2005 Sep. 242(3):422-8; discussion 428-30. [Medline].
52-Rothenberg SS. Thoracoscopic repair of tracheoesophageal fistula in newborns. J Pediatr Surg. 2002 Jun. 37(6):869-72. [Medline].
53-Askarponr.Shahnam.Esophagcal Atresia:Our experience in a university Hospital,Amals of Pedintric surgery 2013
54-TOWNSEND COVRTNEY,ASBISTION TEXTBOOK Of surgery, 17 th Eclition Philadelphia,Saunders Elsevier 2004,P:2010-2014.
55-Toulonkian Rj,Reussessment of the end- to –side operation for esophageal atresin with chistre trochoaesophagcal fistnla:22 year experience with 68 cases, J  pediatric surgery 1992.
56-Lindahl H, 30 years follow – u[ of the original sulamau (end to side) operation for oesophagcal z kinderdir:1983.
57-Ein SHTheman TE.A comparison of  he results of primary repair of esophageal atresia with tracheoesophageal fistulas using end-to-side and end-to-end anastomoses. J Pediatr Surg. 1973 Oct;8(5):641-5.
58-Poenaru D1, Laberge JMNeilson IRNguyen LTGuttman FM.A more than 25-year experience with end-to-end versus end-to-side repair for esophageal atresia. J Pediatr Surg. 1991 Apr;26(4):472-6; discussion 476-7.
59-Pietsch JB, Stokes KB, Beardmore HE.Esophageal atresia with tracheoesophageal fistula: end-to-end versus end-to-side repair. J Pediatr Surg. 1978 Dec;13(6D):677-81.
60-Touloukian RJ1, Seashore JH.Thirty-five-year institutional experience with end-to-side repair for esophageal atresia. Arch Surg. 2004 Apr;139(4):371-4; discussion 374.
61-Pietsch JBStokes KBBeardmore HE.Esophageal atresia with tracheoesophageal fistula: end-to-end versus end-to-side repair. J Pediatr Surg. 1978 Dec;13(6D):677-81.
63-Fathi M1, Joudi M2, Morteza A3. Evaluating Necessity of Azygos Vein Ligation in Primary Repair of Esophageal Atresia. Indian J Surg. 2015 Dec;77(Suppl 2):543-5. doi: 10.1007/s12262-013-0917-1. Epub 2013 Apr 30.
64-Evans WNKogut KAcherman RJ. Preserving the azygos vein when repairing esophageal atresia and tracheoesophageal fistulaaccompanied by interrupted inferior vena cava. Pediatr Surg Int. 2014 Mar;30(3):345-7.
65-Zamboni P, Galeotti R, Menegatti E, et al. Chronic cerebrospinal venous insufficiency in patients with multiple sclerosis. J Neurol Neurosurg Psychiatry. 2009;80:392–399. doi: 10.1136/jnnp.2008.157164
66-Simka M, Latacz P, Ludyga T, et al. Prevalence of extracranial venous abnormalities: results from a sample of 586 multiple sclerosis patients. Funct Neurol. 2011;26:197–203. [PMC free article] [PubMed]
67-Kinottenbelt G, Skinner A, Seefelder C. Tracheo-oesophageal fistula (TOF) and oesophageal atresia (OA) Best Pract Res Clin Anaesthesiol. 2010;24:387–401. doi: 10.1016/j.bpa.2010.02.010. [PubMed] [Cross Ref]
68-Zivadinov R, Marr K, Cutter G, et al. Prevalence, sensitivity, and specificity of chronic cerebrospinal venous insufficiency in MS. Neurology. 2011;77:138–144. doi: 10.1212/WNL.0b013e318212a901. [PubMed] [Cross Ref]
69-Al-Omari MH, Rousan LA. Internal jugular vein morphology and hemodynamics in patients with multiple sclerosis. Int Angiol. 2010;29:115–120. [PubMed]
70-Simka M, Kostecki J, Zaniewski M, Majewski E, Hartel M. Extracranial Doppler sonographic criteria of chronic cerebrospinal venous insufficiency in the patients with multiple sclerosis. Int Angiol. 2010;29:109–114
71-Doepp F, Paul F, Valdueza JM, Schmierer K, Schreiber SJ. No cerebrocervical venous congestion in patients with multiple sclerosis. Ann Neurol. 2010;68:173–183. doi: 10.1002/ana.22182. [PubMed] [Cross Ref]
72-Baracchini C, Perini P, Calabrese M, Causin F, Rinaldi F, Gallo P. No evidence of chronic cerebrospinal venous insufficiency at multiple sclerosis onset. Ann Neurol. 2011;69:90–99. doi: 10.1002/ana.22228