ÖZOFAGUS ATREZİLİ YENİDOĞANLARDA ANESTEZİK RİSKLER, MORBİDİTE VE MORTALİTE

Giriş: Özofagus atrezisi (ÖA), özofagusun proksimal ve distal bölümlerinin  bağlantısının olmamasıdır ve 3000-4500 canlı doğumda bir görülür. Özofagus atrezisi ve trakeoözofageal fistül (TÖF), beslenme ve solunum sorunlarından dolayı ilk birkaç saatin içinde acilen tanı konulması gereken konjenital bir anomalidir. Bu defekt, oral sekresyon artışı ve beslenme anında aspirasyon ve regürjitasyona yol açar. TÖF’lü bebekte, ağlama ve öksürme anında, hava fistül yolu ile mideye geçer, sonuç olarak mide ve ince barsak genişler. ÖA’ da onarım ve postoperatif komplikasyonlarla mücadele etmek genellikle zordur. Amaç: Amacımız, özofagus atrezisinde perioperatif yaklaşım, ÖA onarımı sonrası erken gelişen sonuçlar, komplikasyonlarla ilişkili olabilecek faktörler ve mortaite oranlarını tanımlamayı amaçladık.           Gereç ve Yöntemler: Ocak 2010 - Ocak 2018 tarihleri arasında Zekai Tahir Burak Eğitim ve Araştırma Hastanesi’nde cerrahi onarım geçirmiş olan özofagus atrezili hastaları retrospektif olarak inceledik. Her grupta yüksek prematürite oranı (% 30), majör kardiyak (% 15) ve diğer cerrahi malformasyonlar (% 10) bulundu. Özefagus anastomoz cerrahisi uygulamada ortanca süre en fazla 70 günlük, en kısa 1  günlük bebekler şeklindeydi  (ortalama fark 59 gün,% 95 CI 48.1-70 gün, P = 0.01).           Bulgular: Uzun dönem özofagus atrezisi ameliyatı acil primer anastomoz (n = 10), gecikmiş primer anastomoz (n = 11), özofagus uzatma teknikleri (n = 12) ve primer özofageal replasman (n = 0) idi. Uzun süreli özofagus atrezisi, zor entübasyon insidansını artırmıyordu (OR 2.8,% 95 CI 0.6-22.1, P = 0.15), intraoperatif hipoksemi (OR 1.6,% 95 CI 0.6-4.5, P =0 .45) veya hipotansiyon (OR 0.9,% 95 CI 0.5-1.8, P = 0.98) tespit edildi. Cerrahi süre (180.2- 210.3 dakika, ortalama fark ([% 95 CI], 30 dk [5.5-50.4 dakika], P = 0.03) ve ameliyat sonrası mekanik ventilasyonda kalma süresi ortalama (180-250.8 saat, ortalama fark [95% CI] 91.8 [34.5-149.1 saat], P <0.01) uzun olmayan özefagus grubu için (tek seans) daha kısaydı. Genel hastane içi mortalite % 8'idi (ortalama % 7.2, uzun aşamalı operasyon için % 14 uzun veya  kısa süreli özefagus atrezisi için % 2.2, % 95 CI 0.4-14, P = 0.85).              Sonuç: Aşamalı cerrahi gerektiren uzatmalı özofagus atrezi olan bebeklerde ve normal özofagus atrezisi olan bebeklerde perioperatif komplikasyon insidansı benzerdir. Bununla birlikte, uzun süreli onarım için mevcut cerrahi yaklaşımlar daha uzun anestezik maruziyet, özofagus devamlılığını korumak için çoklu prosedürler gerektirir. Bu durum mortalite ve morbidite oranını artırır. ABSTRACT: Introduction: Esophageal atresia (OA) is the absence of connection between the proximal and distal parts of the esophagus and occurs every 3000-4500 live births. Esophageal atresia and tracheoesophageal fistula (TOF) is a congenital anomaly which should be diagnosed promptly within the first few hours due to feeding and respiratory problems. This defect leads to increased oral secretion and aspiration and regurgitation during feeding. In TOF infants, when crying and coughing, air passes through the fistula into the stomach, resulting in enlarged stomach and small intestine. It is often difficult to combat repair and postoperative complications in OA. The aim of this study was to define the perioperative approach in esophageal atresia, early outcomes after OA repair, factors that may be associated with complications and mortality rates.           Material and Methods: We retrospectively reviewed patients with esophageal atresia who underwent surgical repair in Zekai Tahir Burak Training and Research Hospital between January 2010 and January 2018. High prematurity rate (30%), major cardiac (15%) and other surgical malformations (10%) were found in each group. The median duration of esophageal anastomosis surgery was 70 days and shortest 1 day (mean difference 59 days, 95% CI 48.1-70 days, P = 0.01).           Results: Long-term esophageal atresia surgery was emergency primary anastomosis (n = 10), delayed primary anastomosis (n = 11), esophageal lengthening techniques (n = 12), and primary esophageal replacement (n = 0). Long-term esophageal atresia did not increase the incidence of difficult intubation (OR 2.8, 95% CI 0.6-22.1, P = 0.15), intraoperative hypoxemia (OR 1.6, 95% CI 0.6-4.5, P = 0.45) or hypotension (OR 0.9, 95% CI 0.5-1.8, P = 0.98). Surgical time (180.2 - 210.3 minutes, mean difference ([95% CI], 30 min [5.5-50.4 minutes], P = 0.03)) and the mean duration of postoperative mechanical ventilation (180-250.8 hours, mean difference [95% CI) 91.8 [34.5-149.1 h], P <0.01) was shorter for the non-long esophageal group (single session) Overall in-hospital mortality was 8% (average 7.2%, 14% for long-term operation, long or short-term esophageal atresia) 2.2%, 95% CI 0.4-14, P = 0.85).              Conclusion: The incidence of perioperative complications is similar in infants with prolonged esophageal atresia requiring gradual surgery and in infants with normal esophageal atresia. However, longer surgical approaches for long-term repair require multiple procedures to maintain esophageal continuity, with longer anesthetic exposure. This increases the mortality and morbidity rates.

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