Search Results (36)

Background: Minimally invasive surgery (MIS) is increasingly adopted in pediatric surgical practice, yet it demands specific technical skills that require structured training. Simulation-based education offers a safe and effective environment for skill acquisition, especially in complex procedures such as thoracoscopic repair of esophageal atresia with tracheoesophageal fistula (EA-TEF). Objective: This study aimed to evaluate the effectiveness of a 3D-printed simulator for training pediatric surgeons in thoracoscopic EA-TEF repair, assessing improvements in operative time and technical performance. Methods: A high-fidelity, 3D-printed simulator replicating neonatal thoracic anatomy was developed. Six pediatric surgeons at different training levels performed eight simulation sessions, including fistula ligation and esophageal anastomosis. Operative time and technical skill were assessed using the Stanford Microsurgery and Resident Training (SMaRT) Scale. Results: All participants showed significant improvements. The average operative time decreased from 115.6 ± 3.51 to 90 ± 6.55 min for junior trainees and from 100.5 ± 3.55 to 77.5 ± 4.94 min for senior trainees. The mean SMaRT score increased from 23.8 ± 3.18 to 38.3 ± 3.93. These results demonstrate a clear learning curve and enhanced technical performance after repeated sessions. Conclusions: Such 3D-printed simulation models represent an effective tool for pediatric MIS training. Even within a short time frame, repeated practice significantly improves surgical proficiency, supporting their integration into pediatric surgical curricula as an ethical, safe, and efficient educational strategy. Full article

Background: The bone morphogenetic protein (BMP) signaling pathway is essential for lung development. BMP4, a key regulator, binds to type I (BMPR1) and type II (BMPR2) receptors to initiate downstream signaling. While the inactivation of Bmpr1a and Bmpr1b leads to tracheoesophageal fistulae, the role of BMPR2 mutations in lung epithelial development remains unclear. Methods: We generated induced pluripotent stem cells (iPSCs) from a patient carrying a BMPR2 mutation (c.631C>T), and gene-corrected isogenic controls were created using CRISPR/Cas9. These iPSCs were differentiated into lung progenitor cells and subsequently cultured to generate alveolar and airway organoids. The differentiation efficiency and epithelial lineage specification were assessed using immunofluorescence, flow cytometry, and qRT-PCR. Results: BMPR2-mutant iPSCs showed no impairment in forming a definitive or anterior foregut endoderm. However, a significant reduction in lung progenitor cell differentiation was observed. Further, while alveolar epithelial differentiation remained largely unaffected, airway organoids derived from BMPR2-mutant cells exhibited impaired goblet and ciliated cell development, with an increase in basal and club cell markers, indicating skewing toward undifferentiated airway cell populations. Conclusions: BMPR2 dysfunction selectively impairs late-stage lung progenitor specification and disrupts airway epithelial maturation, providing new insights into the developmental impacts of BMPR2 mutations. Full article

This case series presents four pediatric patients who developed tracheal complications after prolonged invasive mechanical ventilation. The first case involved an 11-year-old girl with severe hypoxic encephalopathy who developed extensive ulcerative granulation tissue obstructing 60% of the tracheal lumen. The second case was that of a 6-year-old boy with ACTA1-related nemaline myopathy who experienced recurrent tracheal obstruction due to granulomatous tissue formation. The third case involved a 9-year-old boy with hydroxyglutaric aciduria and a large plug obstructing his trachea. The last case involved a 19-year-old female with lissencephaly who developed a tracheoesophageal fistula. These cases highlight the importance of regular surveillance and early intervention in managing tracheal complications in pediatric patients with complex chronic conditions requiring long-term mechanical ventilation. The authors emphasize the need for specialized care and routine endoscopic examinations in order to prevent and address potentially life-threatening complications in this vulnerable patient population. Full article

Background: Esophageal atresia (EA) type A, characterized by the absence of a tracheoesophageal fistula and typically presenting with a long esophageal gap, usually requires staged repair. Methods: We report a rare case of a newborn with type A EA in which both the proximal and distal esophageal pouches were unexpectedly close and located in the cervical region. This anatomical variant allowed for a successful primary anastomosis through a cervical approach. Results: Initial imaging was misleading, and the true anatomy was clarified only through thoracoscopic exploration, underscoring the importance of intraoperative flexibility. Conclusions: To our knowledge, this is the first report of such a presentation in type A EA, with significant implications for diagnosis and surgical strategy. Full article

Background and Aims: Esophageal atresia (EA) and tracheoesophageal fistula (TEF) are rare but serious congenital anomalies requiring early surgical intervention. Over the past two decades, minimally invasive surgical (MIS) approaches—particularly thoracoscopic repair—have gained traction, aiming to reduce postoperative morbidity while maintaining surgical efficacy. Objective: This narrative review provides a comprehensive overview of the evolution and current status of MIS techniques for EA/TEF, assessing their clinical outcomes, technical challenges, and implications for patient care. Methods: A structured literature search was conducted to identify clinical studies, reviews, and reports on thoracoscopic, robotic-assisted, and endoscopic approaches to EA/TEF. Emerging adjuncts, including tissue engineering, botulinum toxin use, and magnet-assisted anastomosis, were also reviewed. Results: Thoracoscopic repair has demonstrated comparable anastomotic success rates to open surgery (approximately 85–95%) with significantly reduced rates of musculoskeletal complications, such as scoliosis and chest wall deformities (reported in less than 10% of cases, compared to up to 40% in open approaches). Robotic-assisted and endoscopic-assisted techniques have enabled improved visualization and precision in anatomically challenging cases, although their use remains limited to high-resource centers with specialized expertise. Common postoperative complications include anastomotic stricture (30–50%), gastroesophageal reflux disease (35–70%), and respiratory morbidity, necessitating long-term multidisciplinary follow-up. Recent innovations in simulation-based training and bioengineered adjuncts have facilitated safer MIS adoption in neonates. Conclusions: Minimally invasive techniques have improved the surgical management of EA/TEF, though challenges remain regarding technical complexity, training, and resource availability. Continued innovation and collaborative research are essential for advancing care and ensuring optimal outcomes for affected infants. Full article

Background/Objectives: Anastomotic leakage is one of the most frightening and potentially fatal complications after esophagectomy. The collaboration between the surgical team, interventional gastroenterologists, and radiologists has the potential to improve the hospital stay, as well as morbidity and mortality. The aim of this study is to present our experience and evaluate the results of the multimodal management of anastomotic leak following esophagectomy in our unit. Methods: This is a retrospective study analyzing a single referral center’s prospectively maintained database of all patients diagnosed with anastomotic leak between March 2019 and March 2025 using the definition of the Esophageal Complications Consensus Group. The treatment pathways and the patient outcomes are presented. The primary endpoint was 90-day mortality and in-hospital mortality. Results: A total of 241 esophageal resections were performed between March 2019 and March 2025. Lymphadenectomy of the mediastinum was performed in 88.4% of the patients. Cervical and intrathoracic anastomosis were performed in 143 (59.3%) and 98 (40.7%) cases, respectively. Twenty-nine patients (12%) with a mean age of 59.1 years developed anastomotic leak. Anastomotic leak occurred in 14.3% of intrathoracic anastomoses and 10.5% of cervical anastomoses. The median day of leak diagnosis was the sixth postoperative day. Leak management involved conservative strategies, wound exploration, endoscopic stent placement or vacuum therapy, drainage of effusions under radiologic guidance, and reoperation. The 90-day and in-hospital mortality rate was 3.4%. No cases of conduit necrosis or mediastinitis were reported. Endoscopic management was employed in 18 patients (62.1%) as a first- or second-line treatment, while reoperation was required in 6 patients (20.7%). The median interval from diagnosis to anastomosis healing was 21 days and the median duration of hospital stay 32 days. The management was successful in 27 patients (93.1%) except for 1 who developed tracheoesophageal fistula and 1 who died due to hemorrhagic complication of anticoagulant treatment. Conclusions: Anastomotic leak after esophagectomy is considered a complex, diversified, and morbid clinical entity. The evolving potential of multidisciplinary management encompassing surgical and interventional radiological and endoscopic treatment addresses the mortality rates and heralds a new era of minimizing morbidity. Full article

Background: The accurate measurement of the distances within the airways during bronchoscopy is necessary for diagnostic purposes; however, a reliable and simple device does not exist. Methods: The LJ system, consisting of a probe, a box with a display, an encoder, and a microcontroller, has been developed, and its prototype has been tested in vitro and validated in clinical practice in suitable procedures of interventional bronchoscopy. Results: In vitro, the device measurements showed a good correlation with the control performed with a digital caliper. Subsequently, ten patients were included in a pilot study evaluating this novel prototype of a measurement device. The device was used on four patients with tracheal stenosis indicated for Y-stent placement, four patients indicated for open surgery, and two cases of tracheoesophageal fistula. The measurements have been validated using computed tomography imaging or by direct inspection and measurement during open surgical procedures. Conclusions: The first experience and pilot study evaluating this novel instrument for distance measurements during interventional bronchology procedures showed that the LJ device can provide precise readings of the distance from the vocal cords, the lengths of tracheal stenoses, or the size of tumorous and other lesions. Its use might be widened to other endoscopic indications. Full article

Neonates with congenital conditions which require surgical management frequently experience respiratory distress. This review discusses the management of pulmonary complications and the respiratory support strategies for four conditions: oesophageal atresia-tracheoesophageal fistula (OA-TOF), congenital diaphragmatic hernia (CDH), congenital lung malformations (CLM), and anterior abdominal wall defects (AWD). Mechanical ventilation techniques which can reduce the risk of ventilator-induced lung injury (VILI) are discussed, as well as the use of non-invasive respiratory support modes. While advances in perioperative respiratory support have improved outcomes in infants with OA-TOF, managing respiratory distress in premature OA-TOF neonates remains a challenge. In CDH infants, a randomised trial has suggested that conventional ventilation may improve outcomes compared to high-frequency ventilation. Echocardiographic assessment is essential in the management of CDH infants with pulmonary hypertension. Lung-protective ventilation settings may lower the rate of postoperative complications in symptomatic CLM infants, but there remains debate regarding the choice of expectant versus surgical management in neonates with asymptomatic CLMs. Infants with AWDs can require ventilation due to pulmonary hypoplasia, but the effects of this on their long-term respiratory health are poorly understood. As surgical techniques continue to evolve and novel ventilation techniques become available, prospective multi-centre studies will be required to define the optimal respiratory support strategies for neonatal surgical conditions that affect lung function. Full article

Background: A tracheoesophageal fistula (TEF) represents a condition characterized by abnormal communication between the gastrointestinal tract and the airways. Although the current gold-standard treatment is surgery, pre-existing clinical conditions may represent contraindications. We therefore propose a bronchoscopic approach through rigid bronchoscopy without tracheostomy for total repair in patients suffering from benign tracheoesophageal fistulas. Methods: Fistula suture through rigid bronchoscopy with either absorbable (Vycryl 3.0, Ethicon, Inc.) or non-absorbable (Prolene, Ethicon US, LLC. 2022.) sutures was performed using a long needle holder as an alternative resolutive procedure to surgery. From 2015 to 2022, we retrospectively reviewed 10 consecutive patients affected by TEFs in our Endoscopic Unit at San Camillo-Forlanini Hospital (Rome, Italy) who underwent this bronchoscopic procedure. The coprimary outcomes were the proportion of fistulas successfully treated with the innovative treatment proposed and the rate of procedure-related complications. Results: The complete healing of the fistula was achieved in nine of the ten patients after 1 year. Follow-up with flexible bronchoscopy was scheduled and carried out at 1, 3, and 12 months following rigid bronchoscopy. Overall, seventeen endoscopic repair procedures were performed. Five of these patients required more than one endoscopic treatment to reach complete fistula closure. Fistula closure was not achieved post-procedure in one patient. No complications during procedures or in the follow-up period were reported. Conclusions: Despite the small cohort, our preliminary study has demonstrated that the endoscopic approach through rigid bronchoscopy, without tracheostomy, represents a safe and satisfactory alternative for patients affected by TEFs who are not suitable for surgery. Full article

Background: This paper presents the outcomes of employing the inferiorly based rotated sternocleidomastoid muscle flap in complex tracheal reconstruction/repair scenarios, focusing on the key objectives of ensuring stable airway, functional digestive tract and patient survival. Methods: A retrospective analysis was performed for patients treated at two medical centers (A.O. San Camillo Forlanini, Rome, and A.O.U. Careggi, Florence) from 2011 to 2023, in which the sternocleidomastoid muscle (SCM) flap, detached from the mastoid and basicranium, was rotated on the lower pivot directly onto the repair site and pedicled to the sternal origin to ensure the continuity of the airway. Average postoperative hospital stay, follow-up period and patient survival were analyzed. Follow-up assessments encompassed bronchoscopies and CT scans conducted at intervals of 15 and 28 days, and subsequently at 3 and 9 months. Results: A total of five patients were enrolled in this study. These cases included one patient with anterior tracheal wall lesions with abundant tissue loss, one patient with an anterior wall necrosis due to descending cervical mediastinitis and three patients with extra-long tracheoesophageal fistulas (TEFs) (greater than 4.5 cm or >30% of the total tracheal length). In the case of the direct repair of a TEF with a proximal tracheal stenosis, the sternocleidomastoid muscle was used to reconstruct the tissue deficit caused by extensive loss of substance in the left lateral side of the tracheal wall. In case of repair through exclusion of the TEF, the sternocleidomastoid muscle was interposed between the visceral sutures after exclusion of the TEF by an endomechanical device, in one case even substituting the membranous part of the tracheal wall. Our technique allows rotation on the sternal head of the sternocleidomastoid muscle with the lowest rotation radius, pedicled to the sternal origin, detached from the mastoid process and superior nuchal line, thus providing optimal vascularization from the superior thyroid artery/external carotid artery and accessory vasculature from the suprascapular artery. Patients exhibited uneventful postoperative recovery concerning airway and digestive patency. The mean postoperative hospitalization duration was 41 days. The follow-up assessments were negative for postoperative complications. Conclusions: The use of sternocleidomastoid muscle flap was proposed to ensure repair and protection of the suture margin or to constitute a portion, as a scaffold, of the wall by leveraging the muscle’s vascularization and thickness. This technique may be considered a leading component in managing complex situations in tracheal surgery. Full article

Aim: Esophageal atresia (EA) is the most common congenital esophageal malformation. Thoracoscopic repair is gaining popularity, but controversy persists regarding the ideal surgical approach for this challenging anomaly. This study’s aim is to analyze outcomes in terms of quality of life (QoL) of children undergoing thoracotomy and thoracoscopy for type III EA repair. Methods: Perinatal characteristics, malformations, surgical procedures, complications, gastrointestinal, and respiratory current symptoms were collected. QoL was investigated through Esophageal-Atresia-QoL (EAQoL) and Pediatric-QoL (PedsQL) 4.0 standardized and validated questionnaires. Statistical Mann–Whitney test with significance level p < 0.05 was carried out. Main results: A total of 32 patients undergoing type III EA primary repair answered the questionnaire, including 17 thoracotomy and 15 thoracoscopy. Median birth weight was not significantly different between two groups (median [2.385; 2.475], p = 0.3529) while gestational age showed statistically difference (median [36; 38], p = 0.0063). Thirty-five associated malformations (15 thoracotomy, 20 thoracoscopy) in 23 patients were observed. Postoperative complications occurred in nine patients in the thoracotomy group (one recurrent fistula, two leakages, six stenosis) and in six patients in the thoracoscopic group (two recurrent fistula, four stenosis). Analyzing EAQoL, we found statistically significant difference in physical health between the two groups (median [83; 96], p = 0.0119), while there was no difference in social relations, eating, and total score (median [100; 100], p = 0.3473) (median [91; 97], p = 0.5749) (median [91; 96], p = 0.1710). Investigating PedsQL, psychosocial health score (median [88; 98], p = 0.0069), and total score (median [91;99], p = 0.0043) were statically significant different between the groups, whereas there was no difference for physical health score (median [91; 100], p = 0.0706). Conclusions: Thoracoscopic EA repair is safe and feasible, allowing patient to have a better QoL in terms of physical and psychosocial health score. Full article

Background: Cervical esophageal reconstruction is vital to improve the quality of life in cancer surgery patients. Microsurgery is crucial in providing vascularized tissue for defect repair, particularly in secondary cases with a higher risk of failure due to larger defects and damage from previous surgery and radiotherapy. The purpose of this study was to describe the clinical characteristics of a series of patients who underwent secondary repair of esophageal defects and provide practical information for the management and treatment of such cases based on the authors’ experience and the literature review. Methods: We retrospectively reviewed the electronic medical records of the Plastic Surgery Clinic at the University of Trieste to identify cases of patients who underwent secondary esophageal microsurgical reconstructions following oncological surgery. Patient demographics, the etiology of esophageal defects, previous surgical history, and preoperative assessments were collected from medical records. Surgical techniques utilized for reconstruction, such as pedicled flaps or free tissue transfers, were documented along with intraoperative information. Postoperative outcomes, including complications, graft viability, and functional outcomes, were evaluated during follow-up. Results: We treated 13 cases of secondary esophageal reconstructions between 2011 and 2022. Most commonly, Antero-Lateral Thigh (ALT) flaps were used in 10 cases, while 2 cases employed a radial forearm flap (RFF), and 1 case employed a chimeric parascapular flap. No flap failures occurred during a median 50-month follow-up. One ALT flap patient experienced postop stricture but maintained swallowing ability. A single tracheoesophageal fistula occurred in an RFF patient with a history of radiotherapy and complete lymph node dissection. Conclusions: Cervical esophageal reconstruction significantly impacts patients’ quality of life by restoring oral feeding and phonation. When local flaps fall short, microsurgical reconstruction with intestinal flaps is valuable but is burdened by limitations. For challenging secondary cases, ALT or RFF flaps emerge as safer options due to their robust pedicles, yielding low complication rates and positive functional outcomes. Full article

Background: Congenital h-type tracheoesophageal fistula (H-TEF) without esophageal atresia (EA) represents about 4% of congenital esophageal anomalies. The diagnosis is challenging, and surgery is considered curative. The aim was to report a national survey on the diagnosis, management, and outcome of patients with congenital H-TEF. Methods: Following approval of the Italian Society of Pediatric Surgery, a survey was sent to all Pediatric Surgery Units to retrospectively collect H-TEF treated in the period 2010–2022. Descriptive analysis was performed, and results are given as prevalence, mean ± standard deviation (SD), or median and interquartile range (IQR). Results: The survey was sent to 65 units. Seventeen responded with one or more cases; 78 patients were diagnosed with H-TEF during the study period. Associated malformations were present in 43%, mostly cardiac (31%). The most frequent symptoms were cough (36%), bronchopneumonia (24%), and dysphagia (19%). H-TEF was detected by tracheobronchoscopy (90%), and/or upper GI (58%), and/or esophagoscopy (32%). The median age at diagnosis was 23 days (1 day–18 years). The most common approach was cervicotomy (76%), followed by thoracoscopy (14%) and thoracotomy (9%). The fistula underwent ligation and section of the fistula in 90% of the patients and clip closure and section in 9%. In one patient, the fistula was cauterized endoscopically. H-TEF preoperative cannulation was performed in 68% of cases, and a drain was placed in 26%. One month after surgery, 13% of the patients had mild persisting symptoms, mainly hypophonia. Recurrence occurred in 5%, and a second recurrence occurred in 1%. Conclusions: H-TEF prevalence was six cases/year, consistent with the expected rate of five cases/year in our country. The diagnosis was challenging, sometimes delayed, and, in most patients, required multiple examinations. Fistula ligation and section through cervicotomy were the most frequent treatment. Long-term outcomes are good, and recurrence is a rare event. Full article

Background: The aim of our multicenter retrospective study was to evaluate the long-term complications associated with primary and secondary tracheoesophageal puncture (TEP) in patients who underwent total laryngectomy (TL) for laryngeal cancer and were subsequently rehabilitated to phonatory function with tracheoesophageal speech (TES). Materials and Methods: To evaluate the long-term outcomes and complications of TEP, the following data were collected: mean time of prosthesis replacement, mean time of onset of complications, type of complications, and type of failure. Results: Complications occurred in 18 out of 46 patients (39.2%) with primary TEP and in 10 out of 30 patients (33.4%) with secondary TEP, out of a total of 76 enrolled patients. Common complications included prosthesis leakage, fistula leakage, granulation, and prosthesis extrusion. Prosthesis replacement due to fistula leakage or prosthesis extrusion was observed exclusively in the group of patients with primary TEP. Among the 28 patients (35.7%) who experienced complications, rehabilitation with TEP failed in 10 cases, primarily due to abandonment and spontaneous fistula closure. Conclusions: TEP, both primary and secondary, represents a valid option for vocal rehabilitation in patients undergoing TL. However, identifying prognostic factors that could influence the success of TEP would be beneficial to allow a targeted rehabilitation process. Full article

Background: Recurrent tracheoesophageal fistula (RTEF) is usually a consequence of leakage or other complications after esophageal atresia repair performed through right-sided access. This results in extensive intrapleural adhesions, and open redo surgery poses a challenge. Alternatively, endoscopic endotracheal fistula obliteration usually requires repetitive procedures, and its success rate varies significantly between centers. We present a novel approach to recurrent fistulas. The innovation is in reaching the fistula through the virgin field via left-sided three-port thoracoscopy instead of classical right-sided thoracotomy. Methods: This is a presentation of a new operative technique based on a retrospective case series of patients operated on at our department between 2016 and 2023. Results: Eight patients after esophageal atresia repair (six with RTEF and two with post-fistula tracheal diverticula) were successfully treated with left-sided thoracoscopy. There were no conversions. One patient required rethoracoscopy for chylothorax. Another one, after RTEF closure, underwent multiple endoscopic obliterations of subsequent tracheal diverticulum. No other major complications nor re-recurrences were noted. Conclusions: Left-sided thoracoscopy in redo esophageal atresia has the advantage of a “virgin” operative field and grants feasible access to the RTEF or tracheal diverticulum. We believe that this approach is worth further exploration because it combines minimal invasiveness with high effectiveness without all the consequences of a thoracotomy. Full article