the management options for an anastomotic leak ( al ) vary from conservative management to reoperation .
a major al may require esophageal diversion that leads to discarding of the native esophagus . to retain the native esophagus , a redo anastomosis with or without vascularized flaps or a conservative approach with adequate nutritional supplementation have all been described in the literature , however , the reported success of conservative treatment is quite variable .
there is no controversy regarding the conservative management of minor leaks , but the management strategies for major anastomotic disruptions are still not standardized .
gastroesophageal reflux is associated with a significant number in patients of ea and is one of the factors preventing the closure of al leading to failure of conservative treatment .
we performed transgastric feeding jejunostomy ( fj ) with decompressing gastrostomy in patients of ea with anastomotic dehiscence and studied its effect on healing .
from january 2006 to october 2012 , 20 consecutive neonates with major al , fulfilling the inclusion criteria , were prospectively studied .
all the leaks were identified in the chest tubes and these patients were managed with a decompressing gastrostomy and transgastric fj .
transgastric fj was used for enteral nutrition , and none of the patients received total parenteral nutrition ( tpn ) . in our study ,
a major leak was defined as the presence of either more than 20% of the total nasogastric feeds draining out through the intercostal drain or < 20% of total nasogastric feeds with chest complications ( pneumothorax , persistent collection , and lung collapse ) , increase in ventilatory parameters and worsening general condition of the neonate .
patients with a major leak who developed pneumothorax or persistent collections were considered for insertion of a second intercostal chest drain ( icd ) .
the patients with high icd output draining more than 20% of the feeds and those with continuing chest complications underwent gastrostomy and fj and formed the subjects of this report [ figure 1 ] .
the patients with a minor leak and those who improved with a second icd were excluded from the study . algorithm for management of major anastomotic leak
a transgastric fj was done by selecting an area in the body of the stomach as is done for gastrostomy .
a hole was created within a purse string suture through which a malecot 's catheter of suitable size and a 6 fr infant feeding tube were introduced .
the malecot 's catheter was kept inside the stomach while the feeding tube was guided across the duodenum into the jejunum .
the purse string was tightened , and the stomach was fixed to the abdominal wall in a watertight manner at the exit of the tubes .
a gastrostomy tube was used for decompression while the jejunostomy was used for feeding purpose .
the objectives of the study were to analyze the effect of fj and gastrostomy in terms of decrease in the chest tube output , improvement of lung complications , change in parameters of ventilation , and subsequent anastomotic healing .
over a period of 6 years , 20 patients with major anastomotic dehiscence were analyzed .
the birth weight of patients ranged from 1.6 to 3.3 kg ( mean-2.2 kg ) .
all patients underwent primary end to end anastomosis of the esophagus ( vicryl 5 - 0 ) with ligation of fistula and 15 patients required mobilization of the lower pouch also .
as per the management protocol , after primary repair , the patients were nursed in head up position , and the feeds were started by transanastomotic feeding tube on 2 postoperative day in all the patients , except two who had associated jejunal and rectal atresia .
al was clinically noted in all these patients from 3 to 5 postoperative day with chest tube showing evidence of saliva .
all the patients of al were managed conservatively , and the feeding was continued through the nasogastric tube .
the contents of the leak were saliva mixed with feeds , and the amount was more than 20% of nasogastric feeds in all the patients .
the first chest drain was effective in 75% of the patients , whereas a second icd was required in the remaining 25% ( 5/20 ) for persistent pneumothorax or collection . on an average , the patients underwent gastrostomy and fj on the 12 postoperative day ( range 8 - 15 days ) after an adequate trial of conservative management .
after fj and gastrostomy , the condition of lungs improved gradually in 53% of patients ( 8/15 ) with single chest tube over next 8 - 10 days who could then be extubated .
the rest of the patients required prolonged ventilation due to persistent high chest tube output , and associated heart and gastrointestinal diseases .
there was a gradual reduction in chest tube output and improvement in the condition of chest in these patients also . on an average
, the postoperative ventilation was required for 25 days ( 14 - 51 days ) .
enteral nutrition could be started through the jejunostomy in two - thirds ( 14/20 ) of the patients on the 2 postoperative day .
esophagogram demonstrated healing of the anastomosis and leak free patency after an average of 1.5 months ( range 1 - 3 months ) when oral feeds could be instituted .
of these six , two developed jejuno - cutaneous fistulas as a complication of jejunal intubation , two necrotizing enterocolitis and one each had associated jejunal and rectal atresia .
remaining two patients had severe associated congenital heart anomalies . in the follow - up , gastroesophageal reflux was noted in seven patients , and six of them had a resolution of the reflux over next 2 years .
four patients developed stricture , out of which two were amenable to multiple dilatations , but the other two required resection of the strictured segment and end to end anastomosis .
one had a rare complication of pseudo - diverticulum that required excision [ figure 2 ] .
the overall incidence of al age after surgical repair of ea is around 15 - 17% but major leakage is approximately 3.5% .
the main factors held responsible for anastomotic dehiscence are the use of certain suture materials such as silk , devascularization secondary to extensive dissection , excess tension on the sutures , small and friable lower segment , technically poor suturing techniques , and inaccurate mucosal apposition .
current management of als depends on the clinical condition of the patient and the extent of leak .
labeled involvement of more than one - fourth circumference of the esophagus as a major leak .
chavin et al . reported 11 cases of als , seven of which were considered 
in contrast to the above - mentioned studies , we defined the of degree of al as major or minor based not only on chest tube output but also the presence or absence of pneumothorax , chest collection , and lung collapse .
major leaks usually occur in early postoperative period ( < 48 h ) and may require additional procedures such as rethoracotomy or esophageal diversion to tide over the situation .
however , minor leaks detected on the  routine  contrast study on 5 - 7 day postoperatively usually heal spontaneously , with or without strictures .
when anastomotic dehiscence occurs , the choice between surgical and conservative management can be difficult .
initially , a conservative approach was advised as long as the lungs were maintained in an expanded state although this required careful and prolonged monitoring .
inability to prevent lung complications and deliver adequate enteral nutrition via nasogastric route necessitated surgical intervention .
in addition , tpn is required for these patients , which has its own short and long - term complications and availability may be an issue in developing countries .
however , many a times , the decision to abandon the  wait - and - see  approach and reoperate is both complex and crucial .
some authors advice early thoracotomy and reanastamosis , with good results . in most cases , the recently operated friable tissue is further jeopardized by being constantly in contact with salivary and possibly gastric juices from the leak .
another approach to manage major als involves a cervical esophagostomy and gastrostomy followed by gastric , colonic , or jejunal interposition at an appropriate time , like a staged procedure .
apart from abandoning the native esophagus , consequences of interposition grafts such as poor motility , severe gastric reflux and the tenuous nature of the blood supply especially in jejunal grafts make these less than ideal .
primary gastric pull up in patients with als has also been described but is not feasible , most of the times , due to sepsis , and poor general condition .
use of anticholinergic medications , to reduce the drain output , during the conservative approach has also been described recently .
none of the above - mentioned approaches have turned out to be ideal and free of complications . with this background
, we describe an innovative addition in the form of an fj with gastrostomy , which is feasible in an acute setting without rendering the native esophagus unusable in future .
our results even though not very encouraging show significant improvement in a subset of patients who did not require esophageal replacement after major al .
first , it is less time consuming and requires less anesthesia time in the friable , septic cohort of patients with major al .
furthermore , gastrostomy drainage in the early period helps in decreasing the reflux which is an aggravating factor for al .
third ; an ability to institute early enteral feedings is a major advantage which could be done in the majority of our patients .
this improved the overall well - being , avoided complications of parenteral nutrition and provided breast milk during this crucial period .
nonavailability of silastic tubes which are more suitable for jejunostomy forced us to use simple nasogastric tubes although these are likely to become hard with the passage of time .
many complications such as accidental dislodgment of the tube , bowel perforation with peritonitis , and a jejunocolic fistula formation have been described in the literature and were noted in our patients as well . in the initial part of the study ,
the decision for doing fj was delayed as it was based on lung condition and chest tube output .
there was a tendency to continue conservative management in the presence of good lung condition even with persistent chest tube drainage . in the later part of study ,
the patients underwent the procedure at an earlier stage as a result of the experience gained and showed better outcomes .
we do not claim that this procedure is an ideal way of managing major anastomotic dehiscence but can be considered in a septic cohort of patients who would otherwise end up with an esophageal replacement .
it can also be considered at centers , which can not provide long - term tpn . although many of our patients required secondary procedures to normalize the esophageal tube , yet they had the benefit of native esophagus .
the mainstay of treatment of most esophageal al after tracheoesophageal fistula repair includes adequate chest drainage , treatment of infection , observation , and maintenance of proper nutrition .
protocolized treatment can lead to better results , avoiding the therapeutic dilemmas , and delay in interventional decisions .
gastrostomy and fj are feasible in this crucial period and may help in salvaging the native esophagus .
 aims : to investigate the role of feeding jejunostomy ( fj ) in patients of esophageal atresia with anastomotic leak ( al ) to decrease the degree of gastroesophageal reflux ( ger ) and its effect on anastomotic healing.materials and methods : twenty neonates , with major al and severe ger after primary repair were managed with decompressing gastrostomy and transgastric fj and analyzed prospectively.results:male to female ratio was 1.7:1 . 
 mean birth weight was 2.2 kg . 
 anastomotic gap ranged from 0 to 4 cm . 
 the amount of leak was more than 20% of nasogastric feeds . 
 gastrostomy and fj was done on an average of the 12th postoperative day , after observing the general condition , chest tube output , lung expansion , and ventilatory requirement . 
 there was a drastic reduction in chest tube output and lung expanded in all patients . 
 average hospital stay was 36 days ( 8 - 80 days ) . 
 sixty percentage patients were discharged successfully on fj . 
 esophagogram demonstrated healing and leak free patency after an average of 1.5 months . 
 ger was noted in seven patients , four developed stricture , and one had pseudodiverticulum in follow-up.conclusion:decompressing gastrostomy and fj can be an alternative to managing major als . 
 it helps in healing of anastomotic dehiscence and in preserving the native esophagus . 
INTRODUCTION
MATERIALS AND METHODS
RESULTS
DISCUSSION
CONCLUSION
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