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Historically, children afflicted with long gap esophageal atresia (LGEA) had few options, either esophageal replacement or a life of gastrostomy feeds. In 1997, John Foker from Minnesota revolutionized the treatment of LGEA. His new procedure focused on "traction-induced growth" when the proximal and distal esophageal segments were too far apart for primary repair. Foker's approach involved placement of pledgeted sutures on both esophageal pouches connected to an externalized traction system which could be serially tightened, allowing for tension-induced esophageal growth and a delayed primary repair. Despite its potential, the Foker process was received with criticism and disbelief, and to this day, controversy remains regarding its mechanism of action - esophageal growth versus stretch. Nonetheless, early adopters such as Rusty Jennings of Boston embraced Foker's central principle that " one's own esophagus is best " and was instrumental to the implementation and rise in popularity of the Foker process. The downstream effects of this emphasis on esophageal preservation would uncover the need for a focused yet multidisciplinary approach to the many challenges that EA children face beyond "just the esophagus", leading to the first Esophageal and Airway Treatment Center for children. Consequently, the development of new techniques for the multidimensional care of the LGEA child evolved such as the posterior tracheopexy for associated tracheomalacia, the supercharged jejunal interposition, as well as minimally invasive internalized esophageal traction systems. We recognize the work of Foker and Jennings as key catalysts of an era of esophageal preservation and multidisciplinary care of children with EA. [ABSTRACT FROM AUTHOR]

Anastomotic strictures (AS) after esophageal atresia (EA) repair are common. While most respond to endoscopic therapy, some become refractory and require surgical intervention, for which the outcomes are not well established. All EA children with AS who were treated surgically at two institutions (2011–2022) were retrospectively reviewed. Surgical repair was performed for those with AS that were either refractory to endoscopic therapy or clinically symptomatic and undergoing surgery for another indication. Anastomotic leak, need for repeat stricture resection, and esophageal replacement were considered poor outcomes. 139 patients (median age: 12 months, range 1.5 months–20 years; median weight: 8.1 kg) underwent 148 anastomotic stricture repairs (100 refractory, 48 non-refractory) in the form of stricturoplasty (n = 43), segmental stricture resection with primary anastomosis (n = 96), or stricture resection with a delayed anastomosis after traction-induced lengthening (n = 9). With a median follow-up of 38 months, most children (92%) preserved their esophagus, and the majority (83%) of stricture repairs were free of poor outcomes. Only one anastomotic leak occurred in a non-refractory stricture. Of the refractory stricture repairs (n = 100), 10% developed a leak, 9% required repeat stricture resection, and 13% required esophageal replacement. On multivariable analysis, significant risk factors for any type of poor outcome included anastomotic leak, stricture length, hiatal hernia, and patient's weight. Surgery for refractory AS is associated with inherent yet low morbidity and high rates of esophageal preservation. Surgical repair of non-refractory symptomatic AS at the time of another thoracic operation is associated with excellent outcomes. Level III. • Surgical treatment for refractory strictures can achieve a high rate of esophageal preservation; however, this carries an inherent but low risk of anastomotic leak, need for repeat stricture resection, or eventual esophageal replacement. • Children with co-existent refractory stricture and a hiatal hernia are at an increased risk of poor anastomotic outcomes. [ABSTRACT FROM AUTHOR]

• Indocyanine green is used to evaluate perfusion in a variety of surgical disciplines such as colorectal surgery, vascular surgery, and plastic surgery. • We defined qualitative features of indocyanine green fluorescence angiography of esophageal anastomoses in children, and created an anastomotic scorecard that indicates risk of a poor outcome. Indocyanine green (ICG) is commonly used to assess perfusion, but quality defining features are lacking. We sought to establish qualitative features of esophageal ICG perfusion assessments, and develop an esophageal anastomotic scorecard to risk-stratify anastomotic outcomes. Single institution, retrospective analysis of children with an intraoperative ICG perfusion assessment of an esophageal anastomosis. Qualitative perfusion features were defined and a perfusion score developed. Associations between perfusion and clinical features with poor anastomotic outcomes (PAO, leak or refractory stricture) were evaluated with logistic and time-to-event analyses. Combining significant features, we developed and tested an esophageal anastomotic scorecard to stratify PAO risk. From 2019 to 2021, 53 children (median age 7.4 months) underwent 55 esophageal anastomoses. Median (IQR) follow-up was 14 (10–19.9) months; mean (SD) perfusion score was 13.2 (3.4). Fifteen (27.3%) anastomoses experienced a PAO and had significantly lower mean perfusion scores (11.3 (3.3) vs 14.0 (3.2), p = 0.007). Unique ICG perfusion features, severe tension, and primary or rescue traction-induced esophageal lengthening [Foker] procedures were significantly associated with PAO on both logistic and Cox regression. The scorecard (range 0–7) included any Foker (+2), severe tension (+1), no arborization on either segment (+1), suture line hypoperfusion >twice expected width (+2), and segmental or global areas of hypoperfusion (+1). A scorecard cut-off >3 yielded a sensitivity of 73% and specificity of 93% (AUC 0.878 [95%CI 0.777 to 0.978]) in identifying a PAO. A scoring system comprised of qualitative ICG perfusion features, tissue quality, and anastomotic tension can help risk-stratify esophageal anastomotic outcomes accurately. Diagnostic - II [Display omitted] [ABSTRACT FROM AUTHOR]

Left-sided repair for long gap esophageal atresia (LGEA) has been described for patients with a large leftward upper pouch, no thoracic tracheoesophageal fistula (TEF) nor tracheobronchomalacia (TBM), or as salvage plan after prior failed right-sided repair. We describe our experience with left-sided MIS traction induced growth process. We retrospectively reviewed patients who underwent Foker process for LGEA at two institutions between December 2016 and November 2021. Patient characteristics, surgical techniques, and outcomes were reviewed. 71 patients underwent Foker process. Of 34 MIS cases, 28 patients (82%) underwent left-sided repair (median gap length 5 cm) at median age 4 months with median 3 (range 2–8) operations and median 13.5 (IQR 11–21) days on traction until esophageal anastomosis. 9 patients (32%) underwent completely MIS approach, whereas 5 patients (18%) converted to open at first operation and 14 patients (50%) converted to open later in the traction process. Traction was internal in 68%, external in 11%, and combination in 21%. Median follow-up was 15.4 (IQR 7.5–31.7) months after anastomosis. 14% had anastomotic leak managed with antibiotics and/or esophageal vacuum therapy. Median number of esophageal dilations was 3.5 (range 0–13). 18% required stricture resection. 39% underwent Nissen fundoplication. None have needed esophageal replacement. For multiple reasons including the tendency of both esophageal pouches to have a leftward bias, less tracheal compression by upper pouch, and clean field of surgery for reoperative cases, we now more commonly use left-sided approach for MIS LGEA repair compared to right side, regardless of left aortic arch. Level IV Treatment Study. [ABSTRACT FROM AUTHOR]

The use of magnets for the treatment of long gap esophageal atresia or "magnamosis" is associated with increased incidence of anastomotic strictures; however, little has been reported on other complications that may provide insight into refining selection criteria for appropriate use. A single institution, retrospective review identified three cases referred for treatment after attempted magnamosis with significant complications. Their presentation, imaging, management, and outcomes were reviewed. All three patients had prior cervical or thoracic surgery to close a tracheoesophageal fistula prior to magnamosis, creating scar tissue that can prevent magnet induced esophageal movement, leading to either magnets not attracting enough or erosion into surrounding structures. Two patients had a reported four centimeter esophageal gap prior to attempted magnamosis, both failing to achieve esophageal anastomosis, suggesting that these gaps were either measured on tension with variability in gap measurement technique, or that the esophageal segments were fixed in position from scar tissue and unable to elongate. One patient had severe tracheobronchomalacia requiring tracheostomy, with improvement in his airway after eventual tracheobronchopexies, highlighting that magnamosis does not address comorbidities often associated with this patient population. We propose the following inclusion criteria and considerations for magnamosis: an esophageal gap truly less than four centimeters off tension with standardized measurement across centers, cautious use with a history of prior thoracic or cervical esophageal surgery, no associated tracheobronchomalacia or great vessel anomaly that would benefit from concurrent repair, and ideally to be used in centers equipped to manage potential complications. Level IV treatment study. • What is currently known about this topic? There are no detailed reports of significant complications following magnamosis for esophageal atresia beyond anastomotic strictures. • What new information is contained in this article? We propose the following inclusion criteria and considerations for magnamosis: an esophageal gap truly less than four centimeters off tension with standardized measurement, cautious use with a history of prior esophageal surgery, no associated tracheobronchomalacia or great vessel anomaly that would benefit from concurrent repair, and ideally to be used in centers equipped to manage potential complications. [ABSTRACT FROM AUTHOR]

• What is currently known about this topic? • Anti-reflux procedures are associated with a high failure rate in children with esophageal atresia. • What new information is contained in this article? • In complex EA patients (e.g. long-gap, prior ARP, hiatal hernia, esophageal stricture), ARP fail in about a third of cases. In these complex EA patients, a Nissen fundoplication performed via laparotomy seems to provide the lowest risk of ARP failure, while partial fundoplications or those performed with a minimally invasive approach have a greater risk of failure. Anti-reflux procedures (ARP) in esophageal atresia (EA) patients can be challenging and prone to failure. These challenges become more evident with increasing complexity of EA. We sought to determine predictors of ARP failure in complex EA patients. Single-institution retrospective review of complex EA patients (e.g. long-gap EA, esophageal strictures, hiatal hernia, and reoperative ARP) who underwent an ARP from 2002 to 2019. ARP failure was defined as hiatal hernia recurrence, wrap migration/loosening, or need for reoperation. Predictors of failure were evaluated using univariate and multivariable time-to-event analysis. 121 patients underwent 140 ARP at a median age of 13.5 months (IQR 7, 26.5). Nissen fundoplication (89%) was the most common ARP. Mesh (bovine pericardium) reinforcement was used in 41% of the patients. Median follow-up was 3.2 years (IQR 0.9, 5.8); 44 instances of ARP failure occurred (31%), though only 20 (14%) required reoperation. Median time to failure was 8.7 months (IQR 3.2, 25). Though fewer mesh-reinforced ARP failed (21% with vs 39% without, p = 0.02), on multivariable analysis only partial fundoplication (aHR 2.22 [95% CI 1.01–4.78]) and minimally invasive repair (aHR 2.57 [95% CI 1.12–6.01]) were significant predictors of ARP failure. In our practice of complex EA patients, where ARP fail in nearly one third of cases, a Nissen fundoplication performed via laparotomy provided the lowest risk of ARP failure. [ABSTRACT FROM AUTHOR]

Esophageal growth using the Foker process (FP) for long-gap esophageal atresia (LGEA) has evolved over time. Contemporary LGEA patients treated from 2014–2020 were compared to historical controls (2005 to <2014). 102 contemporary LGEA patients (type A 50%, B 18%, C 32%; 36% prior anastomotic attempt; 20 with esophagostomy) underwent either primary repair (n=23), jejunal interposition (JI; n = 14), or Foker process (FP; n = 65; 49 primary [p], 16 rescue [r]). The contemporary p-FP cohort experienced significantly fewer leaks on traction (4% vs 22%), bone fractures (2% vs 22%), anastomotic leak (12% vs 37%), and Foker failure (FP→JI; 0% vs 15%), when compared to historical p-FP patients (n = 27), all p ≤ 0.01. Patients who underwent a completely (n = 11) or partially (n = 11) minimally invasive FP experienced fewer median days paralyzed (0 vs 8 vs 17) and intubated (9 vs 15 vs 25) compared to open FP patients, respectively (all p ≤ 0.03), with equivalent leak rates (18% vs 9% vs 26%, p = 0.47). At one-year post-FP, most patients (62%) are predominantly orally fed. With continued experience and technical refinements, the Foker process has evolved with improved outcomes, less morbidity and maximal esophageal preservation. [ABSTRACT FROM AUTHOR]

The jejunal interposition is our preferred esophageal replacement route when the native esophagus cannot be reconstructed. We report the evolution of our approach and outcomes. The study was a single-center retrospective review of children undergoing jejunal interposition for esophageal replacement. Outcomes were compared between historical (2010–2015) and contemporary cohorts (2016–2019). Fifty-five patients, 58% male, median age 4 years (interquartile range 2.4–8.3), with history of esophageal atresia (87%), caustic (9%) or peptic (4%) injury, underwent a jejunal interposition (historical cohort n = 14; contemporary cohort n = 41). Duration of intubation (11 vs 6 days; P =.01), intensive care unit (22 vs 13 days; P =.03), and hospital stay (50 vs 27 days; P =.004) were shorter in the contemporary cohort. Anastomotic leaks (7% vs 5%; P =.78), anastomotic stricture resection (7% vs 10%; P =.74), and need for reoperation (57% vs 46%; P =.48) were similar between cohorts. Most reoperations were elective conduit revisions. Microvascular augmentation, used in 70% of cases, was associated with 0% anastomotic leaks vs 18% without augmentation; P =.007. With median follow-up of 1.9 years (interquartile range 1.1, 3.8), 78% of patients are predominantly orally fed. Those with preoperative oral intake were more likely to achieve consistent postoperative oral intake (87.5% vs 64%; P =.04). We have made continuous improvements in our management of patients undergoing a jejunal interposition. Of these, microvascular augmentation was associated with no anastomotic leaks. Despite its complexity and potential need for conduit revision, the jejunal interposition remains our preferred esophageal replacement, given its excellent long-term functional outcomes in these complex children who have often undergone multiple procedures before the jejunal interposition. [ABSTRACT FROM AUTHOR]

• Esophageal negative vacuum therapy (EVAC) is used to treat esophageal perforation. • Prophylactic EVAC use to prevent complications at esophageal anastomoses is unexplored. • Prophylactic EVAC did not improve outcomes in this pediatric case control study. Background: Esophageal anastomoses are at risk for leak or stricture. Negative pressure vacuum-assisted closure (VAC) therapy is used to treat leak. We hypothesized that a prophylactic VAC (pEVAC) at the time of new anastomosis may lead to fewer leaks and strictures. Methods: Single center retrospective case-control study of patients undergoing high-risk esophageal anastomoses between July 2015 and January 2019. Outcomes of leak and long-term anastomotic failure (refractory stricture requiring surgery) were compared between groups. Results: Sixteen patients had a pEVAC placed during LGEA repair (N = 10) or stricture resection (N = 6). Of pEVAC cases, 3 (N = 1 Foker, N = 2 stricture resections) experienced leak (18.8%). In comparison, leak occurred in 9/41 (22%) Foker patients and in 1/20 (5%) stricture resections without pEVAC, all p > 0.05. Long-term anastomotic failure was more common in the pEVAC cohort versus controls (56.3% versus 11.5%, p < 0.001). Conclusions: Prophylactic EVAC placement does not appear to reduce leak and is associated with significantly greater odds of long-term anastomotic failure. Further device refinement could improve its potential role in prophylaxis of high-risk anastomoses, but future research is needed to better understand optimal patient selection, device design, and duration of pEVAC therapy. [ABSTRACT FROM AUTHOR]

: We describe a left-sided approach for long gap esophageal atresia (LGEA) repair in patients who have a large leftward upper pouch and no significant tracheomalacia, or as a salvage strategy after prior failed right-sided repairs. : Retrospective review of patients who underwent repair via traction induced growth (Foker procedure [FP]) from 2014 to 2019 was performed. Surgical technique and post-operative outcomes were evaluated. : Of 47 LGEA patients, 18 (38%) were approached via the left side – 94% had a left aortic arch, and 22% had prior attempts at a right-sided anastomosis. More left-sided patients underwent minimally invasive repair (39% vs 7%, p = 0.007) and internal traction (50% vs 10%, p = 0.002) compared to right-sided patients. On multivariate analysis, internal traction was associated with a decreased length of paralysis (p <0.01); length of intubation and hospital stay were similar between groups. Anastomotic leak (17% vs 20%, p = 0.80) and stricture resection (6% vs 24%, p = 0.12) rates were similar. No left-sided FP patient required additional surgery for tracheomalacia, while six right-sided patients required intervention. : Left-sided FP can be considered for LGEA patients with a large leftward upper pouch or as a salvage pathway after a failed right chest approach, with similar outcomes to the right-sided approach. [ABSTRACT FROM AUTHOR]

The descending thoracic aorta typically crosses posterior to the left mainstem bronchus (LMSB). We sought to evaluate patient factors that may lead one to consider a posterolateral descending thoracic aortopexy (PLDA) in addition to a posterior tracheopexy (PT) in the surgical treatment of symptomatic tracheobronchomalacia (TBM) that involves the LMSB. Retrospective review of patients who underwent PT with or without PLDA between 2012 and 2017. Severity and extent of TBM were assessed using dynamic tracheobronchoscopy. Aortic positioning compared to the anterior border of the spine (ABS) at the level of the left mainstem bronchus was identified on computed tomography (CT). Factors associated with performing a PLDA were evaluated with logistic regression. Of 188 patients who underwent a PT, 70 (37%) also had a PLDA performed. On multivariate analysis, > 50% LMSB compression on bronchoscopy (OR 8.06, p < 0.001), > 50% of the aortic diameter anterior to the ABS (OR 2.06, p = 0.05), and more recent year of surgery (OR 1.61, p = 0.003) were associated with performing a PLDA. When performing a PT, a PLDA should be considered for patients who have > 50% LMSB compression on dynamic bronchoscopy, and in those with a descending thoracic aorta located > 50% anterior to the ABS. III Retrospective comparative study. [ABSTRACT FROM AUTHOR]

Congenital esophageal stenosis (CES) is an inborn condition of the esophagus that can be refractory to endoscopic dilation. Surgical intervention is not curative, with patients experiencing frequent ongoing need for therapy for anastomotic stricture postoperatively. We hypothesized that novel methods of endoscopic CES management including endoscopic incisional therapy (EIT) would lead to less surgical intervention. We retrospectively reviewed the medical records of all patients with CES treated by our tertiary care center who had at least one endoscopy between July 2007 and July 2019. Statistical comparison of cohorts who underwent advanced endoscopic therapy involving EIT versus traditional endoscopic therapy with balloon dilation was performed. Primary outcome measure was need for surgical intervention. Thirty-six patients with CES met inclusion criteria. Thirty-four ever had at least one endoscopic intervention such as balloon dilation, steroid injection, stenting, and/or endoscopic incisional therapy (EIT) at their CES. Esophageal vacuum assisted closure (EVAC) was used for treatment or prevention of esophageal leak. Odds of surgical intervention were significantly lower in the group who received therapeutic endoscopy with EIT (odds ratio (OR) 0.1; p = 0.007). Clinical feeding outcomes were similar in the endoscopic and surgical management groups. Odds of complications after therapeutic endoscopies involving EIT were significantly greater than those without EIT (odds ratio 6.39; 95% confidence interval (2.34, 17.44); p < 0.001), though our rates of esophageal leak significantly decreased over time as our use of EVAC increased (Spearman's ρ = − 0.884; p = 0.004). Complementary endoscopic techniques such as EIT broaden the toolbox of the treating physician and may allow for avoidance of surgery in CES. Level III. [ABSTRACT FROM AUTHOR]

Tracheobronchial compression (TBC) from great vessel anomalies (GVA) can contribute to tracheobronchomalacia (TBM) symptoms. The frequency, impact on symptoms and optimal management of GVA in these patients, with or without a history of esophageal atresia (EA), are still unclear. Patients who underwent surgery for TBM/ TBC between 2001 and 2017 were reviewed. Demographics, type of GVA, and operative interventions were collected. The frequency and treatment modalities of GVA between EA and non-EA patients were compared. Overall, 209 patients met criteria; 120 (57.4%) patients had at least one GVA, including double aortic arches (n = 4, 1.9%), right aortic arches (n = 14, 6.7%), aberrant right subclavian arteries (n = 15, 7.2%), and innominate artery compression (n = 71, 34.0%). Non-EA patients were more likely to have surgery later in life (29.5 months versus 16 months, p = 0.0002), double aortic arch (p = 0.0174), right aortic arch (p < 0.0001), and undergo vascular reconstruction concurrently with their airway procedure (25% vs 8.4%, p = 0.002). Vessel reconstruction was performed in 25 patients; six required cardiac bypass. The frequency of GVA in patients with symptomatic airway collapse is substantial. Multidisciplinary evaluation is imperative for operative planning as many require complex reconstruction and collaboration with cardiac surgery, particularly patients without a history of EA. Level III. [ABSTRACT FROM AUTHOR]

Posterior descending aortopexy can relieve posterior intrusion of the left mainstem bronchus that may limit the effectiveness of posterior tracheobronchopexy. We review outcomes of patients undergoing both descending aortopexy and posterior tracheopexy for severe tracheobronchomalacia with posterior intrusion and left mainstem compression to determine if there were resolution of clinical symptoms and bronchoscopic evidence of improvement in airway collapse. All patients who underwent both descending aortopexy and posterior tracheopexy from October 2012 to October 2016 were retrospectively reviewed. Clinical symptoms, tracheomalacia scores based on standardized dynamic airway evaluation by anatomical region, and persistent airway intrusion requiring reoperation were collected. Data were analyzed by Wald and Wilcoxon signed-rank tests. Thirty-two patients underwent descending aortopexy and posterior tracheopexy at median age of 18 months (interquartile range 6-40 months). Median follow-up was 3 months (interquartile range 1-7 months). There were statistically significant improvements in clinical symptoms postoperatively, including cough, noisy breathing, prolonged and recurrent respiratory infections, ventilator dependence, blue spells, and brief resolved unexplained events (all P < 0.001), as well as exercise intolerance (P = 0.033), transient respiratory distress requiring positive pressure (P = 0.003), and oxygen dependence (P = 0.007). Total tracheomalacia scores improved significantly (P < 0.001), with significant segmental improvements in the middle (P = 0.003) and lower (P < 0.001) trachea, and right (P = 0.011) and left (P < 0.001) mainstem bronchi. Two patients (6%) had persistent airway intrusion requiring reoperation with anterior aortopexy or tracheopexy. Descending aortopexy and posterior tracheopexy are effective in treating severe tracheobronchomalacia and left mainstem intrusion with significant improvements in clinical symptoms and degree of airway collapse on bronchoscopy. [ABSTRACT FROM AUTHOR]

Introduction Gastro-jejunostomy tubes (GJT) are commonly used for enteral nutrition in patients with gastric feeding intolerance, gastroesophageal reflux, and those at high risk of aspiration. Complications are generally minor, however highly morbid complications exist, specifically in younger and smaller infants. Case presentation A 12 month old male with a history of long gap esophageal atresia presented for management of refractory esophageal stricture and intolerance of enteral feeds. To improve his nutritional status and enteral tolerance, he underwent conversion of his gastrostomy tube to a GJT with fluoroscopic guidance. Eight days later, a computed tomography scan of the chest obtained for preoperative planning incidentally noted a splenic abscess containing the tip of the GJT. The patient was taken to the operating room where diagnostic laparoscopy revealed a small bowel perforation at the ligament of Treitz (LOT), with the tip of the GJT embedded within the spleen. The tube was removed, the abscess was debrided, and the small bowel repaired. He completed a post-operative course of intravenous antibiotics and recovered without further complications. Conclusion While complications from GJTs are well described, this case uniquely highlights the risk of intestinal perforation from GJT, with a delayed and subtle presentation. We suggest that patients, specifically those under 12 months of age and weighing under 10 kg, be monitored closely for complications post-operatively, and the use of modified GJTs with jejunal limbs employing smaller/thinner feeding tubes that are placed well beyond LOT be strongly considered. [ABSTRACT FROM AUTHOR]

Purpose In severe tracheomalacia, aortopexy addresses anterior vascular compression, but does not directly address posterior membranous tracheal intrusion. We review patient outcomes of posterior tracheopexy for tracheomalacia with posterior intrusion to determine if there were resolution of clinical symptoms and bronchoscopic evidence of improvement in airway collapse. Methods All patients who underwent posterior tracheopexy from October 2012 to March 2016 were retrospectively reviewed. Clinical symptoms, tracheomalacia scores based on standardized dynamic airway evaluation by anatomical region, and persistent airway intrusion were collected. Data were analyzed by Wald and Wilcoxon signed-ranks tests. Results 98 patients (51% male) underwent posterior tracheopexy at a median age of 15 months (IQR 6–33 months). Median follow-up was 5 months (range 0.25–36 months). There were statistically significant improvements in clinical symptoms postoperatively, including cough, noisy breathing, prolonged and recurrent respiratory infections, transient respiratory distress requiring positive pressure, oxygen dependence, blue spells, and apparent life-threatening events ( p < 0.001), as well as ventilator dependence ( p = 0.04). Tracheomalacia scores on bronchoscopy improved significantly in all regions of the trachea and bronchi ( p < 0.001). 9.2% had persistent airway intrusion requiring reoperation, usually with aortopexy. Conclusions Posterior tracheopexy is effective in treating severe tracheomalacia with significant improvements in clinical symptoms and degree of airway collapse on bronchoscopy. Level of evidence Level III, treatment study. [ABSTRACT FROM AUTHOR]

Purpose Recurrent trachea-esophageal fistula (recTEF) is a frequent (5%–10%) complication of congenital TEF (conTEF) and esophageal atresia (EA) repair. In addition, postoperative acquired TEF (acqTEF) can occur in addition to or even in the absence of prior conTEF in the setting of esophageal anastomotic complications. Reliable repair often proves difficult by endoluminal or standard surgical techniques. We present the results of an approach that reliably identifies the TEF and facilitates airway closure as well as repair of associated tracheal and esophageal problems. Methods Retrospective review of 66 consecutive patients 2009–2016 (55 referrals and 11 local) who underwent repair via reoperative thoracotomy or cervicotomy for recTEF and acqTEF (IRB P00004344). Our surgical approach used complete separation of the airway and esophagus, which reliably revealed the TEF (without need for cannulation) and freed the tissues for primary closure of the trachea and frequently resection of the tracheal diverticulum. For associated esophageal strictures, stricturoplasty or resection was performed. Separation of the suture lines by rotational pexy of the both esophagus and the trachea, and/or tissue interposition were used to further inhibit re-recurrence. For associated severe tracheomalacia, posterior tracheopexy to the anterior spinal ligament was utilized. Results The TEFs were recurrent (77%), acquired from esophageal leaks (26%), in addition to persistent or missed H-type (6%). Seven patients in this series had multiple TEFs of more than one category. Of the acqTEF cases, 6 were esophagobronchial, 10 esophagopulmonic, 2 esophagotracheal (initial pure EA cases), and 2 from a gastric conduit to the trachea. Upon referral, 18 patients had failed endoluminal treatments; and open operations for recTEF had failed in 18 patients. Significant pulmonary symptoms were present in all. During repairs, 58% were found to have a large tracheal diverticulum, and 51% had posterior tracheopexy for significant tracheomalacia. For larger esophageal defects, 32% were treated by stricturoplasty and 37% by segmental resection. Rotational pexy of the trachea and/or esophagus was utilized in 62% of cases to achieve optimal suture line separation. Review with a mean follow-up of 35 months identified no recurrences, and resolution of pulmonary symptoms in all. Stricture treatment required postoperative dilations in 30, and esophageal replacement in 6 for long strictures. There was one death. Conclusion This retrospective review of 66 patients with postoperative recurrent and acquired TEF following esophageal atresia repair is the largest such series to date and provides a new categorization for postoperative TEF that helps clarify the diagnostic and therapeutic challenges for management. [ABSTRACT FROM AUTHOR]

Purpose Tracheobronchomalacia (TBM) is associated with esophageal atresia, tracheoesophageal fistulas, and congenital heart disease. TBM results in chronic cough, poor mucous clearance, and recurrent pneumonias. Apparent life-threatening events or recurrent pneumonias may require surgery. TBM is commonly treated with an aortopexy, which indirectly elevates trachea’s anterior wall. However, malformed tracheal cartilage and posterior tracheal membrane intrusion may limit its effectiveness. This study describes patient outcomes undergoing direct tracheobronchopexy for TBM. Methods The records of patients that underwent direct tracheobronchopexy at our institution from January 2011 to April 2014 were retrospectively reviewed. Primary outcomes included TBM recurrence and resolution of the primary symptoms. Data were analyzed by McNemar’s test for matched binary pairs and logistic regression modeling to account for the endoscopic presence of luminal narrowing over multiple time points per patient. Results Twenty patients were identified. Preoperative evaluation guided the type of tracheobronchopexy. 30% had isolated anterior and 50% isolated posterior tracheobronchopexies, while 20% had both. Follow-up was 5 months (range, 0.5–38). No patients had postoperative ALTEs, and pneumonias were significantly decreased (p = 0.0005). Fewer patients had tracheobronchial collapse at postoperative endoscopic exam in these anatomical regions: middle trachea (p = 0.01), lower trachea (p < 0.001), and right bronchus (p = 0.04). Conclusion The use of direct tracheobronchopexy resulted in ALTE resolution and reduction of recurrent pneumonias in our patients. TBM was also reduced in the middle and lower trachea and right mainstem bronchus. Given the heterogeneity of our population, further studies are needed to ascertain longer-term outcomes and a grading scale for TBM severity. [ABSTRACT FROM AUTHOR]

Purpose The Foker process (FP) uses tension-induced growth for primary esophageal reconstruction in patients with long gap esophageal atresia (LGEA). It has been less well described in LGEA patients who have undergone prior esophageal reconstruction attempts. Methods All cases of LGEA treated at our institution from January 2005 to April 2014 were retrospectively reviewed. Patients who initially had esophageal surgery elsewhere were considered secondary FP cases. Demographics, esophageal evaluations, and complications were collected. Median time to esophageal anastomosis and full oral nutrition was estimated using the Kaplan–Meier method. Multivariate Cox-proportional hazards regression identified potential risk factors. Results Fifty-two patients were identified, including 27 primary versus 25 secondary FP patients. Median time to anastomosis was 14 days for primary and 35 days for secondary cases (p < 0.001). Secondary cases (p = 0.013) and number of thoracotomies (p < 0.001) were identified as significant predictors for achieving anastomosis and the development of a leak. Predictors of progression to full oral feeding were primary FP cases (O.R. = 17.0, 95% CI: 2.8–102, p < 0.001) and patients with longer follow-up (O.R. = 1.06/month, 95% CI: 1.01–1.11, p = 0.005). Conclusions The FP has been successful in repairing infants with primary LGEA, but the secondary LGEA patients proved to be more challenging to achieve a primary esophageal anastomosis. Early referral to a multidisciplinary esophageal center and a flexible approach to establish continuity in secondary patients is recommended. Given their complexity, larger studies are needed to evaluate long-term outcomes and discern optimal strategies for reconstruction. [ABSTRACT FROM AUTHOR]

Background We investigated whether removable stents, such as self-expandable plastic stents (SEPSs) and fully covered self-expandable metal stents (FCSEMSs) could provide an alternative treatment for recalcitrant strictures and esophageal perforations after esophageal atresia (EA) repair. Objective The primary aim of our study was to evaluate technical feasibility. Secondary aims were to evaluate safety and procedural success. Design Retrospective study. Setting Tertiary-care referral center. Patients A total of 24 children with EA. Interventions Retrospective review of all children with EA who underwent dilation and esophageal stent placement from January 2010 to February 2013 at our institution. Main Outcome Measurements Healing of perforation and stricture resolution at 30 and 90 days. Results A total of 41 stents (SEPSs 14, FCSEMSs 27) were placed in 24 patients with EA during the study period, including 14 who had developed esophageal leaks. Procedural success of esophageal stent placement in the treatment of refractory strictures was 39% at 30 days and 26% at 90 days. The success rate was 80% for closure of esophageal perforations with stent therapy after dilation and 25% for perforations associated with surgical repair. Adverse events of stent placement included migration (21% of SEPSs and 7% of FCSEMSs), granulation tissue (37% of FCSEMSs), and deep ulcerations (22% of FCSEMSs). Limitations Retrospective study with small sample size. Conclusion SEPSs and FCSEMSs can be placed successfully in small infants and children with a history of EA repair. The stents appear to be safe and beneficial in closing esophageal perforations, especially post-dilation. However, a high stricture recurrence rate after stent removal may limit their usefulness in treating recalcitrant esophageal anastomotic strictures. [ABSTRACT FROM AUTHOR]

Abstract: Purpose: The Children's Oncology Group (COG) renal tumor study (AREN03B2) requires real-time central review of radiology, pathology, and the surgical procedure to determine appropriate risk-based therapy. The purpose of this study was to determine the inter-rater reliability of the surgical reviews. Methods: Of the first 3200 enrolled AREN03B2 patients, a sample of 100 enriched for blood vessel involvement, spill, rupture, and lymph node involvement was selected for analysis. The surgical assessment was then performed independently by two blinded surgical reviewers and compared to the original assessment, which had been completed by another of the committee surgeons. Variables assessed included surgeon-determined local tumor stage, overall disease stage, type of renal procedure performed, presence of tumor rupture, occurrence of intraoperative tumor spill, blood vessel involvement, presence of peritoneal implants, and interpretation of residual disease. Inter-rater reliability was measured using the Fleiss' Kappa statistic two-sided hypothesis tests (Kappa, p-value). Results: Local tumor stage correlated in all 3 reviews except in one case (Kappa=0.9775, p<0.001). Similarly, overall disease stage had excellent correlation (0.9422, p<0.001). There was strong correlation for type of renal procedure (0.8357, p<0.001), presence of tumor rupture (0.6858, p<0.001), intraoperative tumor spill (0.6493, p<0.001), and blood vessel involvement (0.6470, p<0.001). Variables that had lower correlation were determination of the presence of peritoneal implants (0.2753, p<0.001) and interpretation of residual disease status (0.5310, p<0.001). Conclusion: The inter-rater reliability of the surgical review is high based on the great consistency in the 3 independent review results. This analysis provides validation and establishes precedent for real-time central surgical review to determine treatment assignment in a risk-based stratagem for multimodal cancer therapy. [Copyright &y& Elsevier]

Abstract: Purpose: The purpose of this study was to determine the outcomes among three different surgical approaches for performing an aortopexy to treat severe tracheomalacia (STM). Methods: A retrospective review was performed for all patients who underwent an aortopexy by pediatric surgeons at a single institution during 1997–2012. Data collected included details of the operative approaches and clinical results. The data were analyzed using Chi-square and Fisher exact test. Results: Forty-one patients underwent an aortopexy. The operation was chosen by the surgeon and not randomized. Exposure was by partial sternotomy (PS) (20), open thoracotomy (12), or thoracoscopic approach (7). Only the PS approach was done by a single team. All groups showed improvement in work of breathing, prevention of severe respiratory distress, and acute life threatening events. These effects were more dramatic for the PS group, especially regarding oxygen and/or ventilator dependence and the ability to undergo tracheostomy decannulation. Among the sixteen patients with failure-to-thrive before successful aortopexy by any technique, ten demonstrated significant improvement in their growth (p=0.025). The recurrence rate for the thoracoscopic approach was 38%, and there were no recurrences in the partial sternotomy and the thoracotomy groups, 38% vs 0% vs 0%, p=0.005. Simultaneous bronchoscopy was utilized more commonly in the PS group compared to the thoracotomy and thoracoscopic group, 95% vs 62% vs 38%. Conclusions: In this series, the partial sternotomy technique had the most reliable resolution of symptoms and no recurrence requiring reoperation. The PS approach to STM has the technical advantages of an improved exposure with equal access to the vessels over the right and left mainstem bronchi, as well as the trachea and a more specific elevation of the arteries, including suspension of the pulmonary arteries and trachea itself when desirable. Simultaneous bronchoscopy during aortopexy and an experienced team also likely contribute to improved outcomes. The variations in populations, follow-up, and use of continuous intraoperative bronchoscopy, however, make firm conclusions difficult. [Copyright &y& Elsevier]

Abstract: Purpose: Initial Children''s Oncology Group (COG) management for Wilms'' tumor (WT) consists of primary nephroureterectomy with lymph node sampling. While this provides accurate staging to define further treatment, it may result in intraoperative spill (IOS), which is associated with higher recurrence rates and therefore requires more intensive therapy. The purpose of this study is to determine current rates and identify factors which may predispose a patient to IOS. Methods: The study population was drawn from the AREN03B2 renal tumor banking and classification study of the Children''s Oncology Group. All children with a first time occurrence of a renal mass were eligible for the study. At the time of enrollment and prior to risk stratification, the institution is required to submit operative notes, pathology specimens, a chest computed tomography scan (CT), and a contrast-enhanced CT or magnetic resonance imaging (MRI) of the abdomen and pelvis for central imaging review. These data are then used to determine an initial risk classification and therapeutic protocol eligibility. Patients who had a unilateral nephroureterectomy for favorable histology WT underwent further review to assure data accuracy and to clarify details regarding the spill. Analyses were performed using chi square and logistic regression. Odd ratios (OR) are shown with 95% confidence intervals. Results: There were 1,131 primary nephrectomies for unilateral WT with an IOS rate of 9.7% with an additional 1.8% having possible tumor spill during renal vein or IVC tumor thrombectomy. IOS correlated with diameter (>12cm, p<0.0001) and laterality (right, p=0.0414). Simple logistic regression indicated that IOS increased 2.7% [p=0.0240, OR 1.027 (1.004, 1.052)] with each 1 cm increase in diameter (3 – 21cm) and 4.7% [p=0.0147 OR 1.047 (1.009, 1.086)] with each 100 g increase in weight (80 – 1800 g). Multiple logistic regression indicated that laterality [right p=0.048, OR 1.46 (1.004, 2.110)] and weight (p=0.03, OR 1.039 (1.003, 1.075) were predictive of IOS when diameter was included as a continuous variable. Diameter as a binary variable was highly prognostic of IOS (p=0.0002), while laterality and weight were not significant. Conclusions: Intraoperative tumor spill occurs in about one out of every ten cases of primary nephroureterectomies for WT. Right-sided and larger tumors are at higher risk of IOS. [Copyright &y& Elsevier]

Wilms tumor is the most common renal malignancy that occurs in childhood. The remarkable evolution of treatment for this malignancy has served as a paradigm for multimodal cancer treatment. A rich database has accrued over time from well-controlled clinical trials. Translational research has directly affected patient care by allowing risk-based therapy. This article will summarize advances in our knowledge of the biology of Wilms tumor and describe the impact on clinical treatment of Wilms tumor. [ABSTRACT FROM AUTHOR]

Abstract: Purpose: The purpose of this study was to evaluate whether initial diagnostic technique influenced the ability to identify anaplastic histology, to determine the time interval to diagnosis of anaplasia, and to delineate the incidence of discordant pathology in bilateral Wilms'' tumor. We hypothesized that delay in diagnosis of anaplasia could affect time to appropriate surgery and intensive multimodality therapy. Methods: One hundred eight-nine children were enrolled in the fourth National Wilms'' Tumor Study with synchronous bilateral tumors, 27 of whom were eventually shown to have anaplastic histology. Initial diagnostic technique, time interval to diagnosis of anaplasia, and the incidence of discordant pathology were determined. Results: Anaplasia was identified in 0 of 7 tumors by core needle biopsy, 3 of 9 tumors by open wedge biopsy, and in 7 of 9 cases by partial or complete nephrectomy. The mean duration of first chemotherapy regimen (DD or EE) was 20, 39, and 36 weeks, respectively, before anaplasia was identified at second surgery. Discordant pathology between bilateral tumors was identified on final tissue diagnosis in 20 patients. Only 4 patients had anaplastic tumors in both kidneys. Conclusions: Core needle biopsy did not identify anaplasia in 7 of 7 children. Open biopsy or partial/complete nephrectomy identified anaplasia at initial diagnostic procedure in 10 of 18 children. Twenty of 24 patients at final tissue diagnosis had discordant pathology between the 2 kidneys. Earlier interval incisional biopsy or resection may identify anaplastic histology and limit the duration of chemotherapy targeted to favorable histology for children with bilateral Wilms'' tumor and anaplasia. [Copyright &y& Elsevier]

Abstract: Background/Purpose: Computed tomography (CT) of the chest with its increased sensitivity frequently identifies lesions not visible on chest radiograph. Treatment of such lesions is controversial. A recent review suggests that patients with Wilms'' tumor with pulmonary lesions detected only by CT, who were treated with dactinomycin and vincristine, have an inferior outcome compared with those who also received pulmonary radiation therapy (RT) and doxorubicin. It is important to determine if these small lesions seen only on CT represent metastatic disease and whether patients with these lesions require RT and/or doxorubicin for optimal outcome. Methods: Patients with Wilms'' tumor with lung metastasis, registered on National Wilms'' Tumor Study 5, were reviewed, and those with CT-only lesions who had a radiology and surgical checklist submitted were identified. The treatment regimens of these patients and the histological findings of the pulmonary lesions are presented. We analyzed the pathological findings by whether the patients had single or multiple lesions. Results: Of 2498 patients registered on National Wilms'' Tumor Study 5, 252 had pulmonary metastases. Of these patients, 129 (5.2%) had CT-only lesions (<1 cm). Forty-two of these patients (20 boys and 22 girls) underwent lung biopsy at the discretion of the attending physicians. The local tumor stages in these patients were stage I (7%), II (34%), and III (59%). The treatment stages in these patients were stage I (n = 3, 2 drugs), II (n = 3, 2 drugs), III (n = 12, 3 drugs); and IV (n = 24, 3 drugs + RT). There were 16 patients with isolated lung lesions and 26 with multiple lesions, average size 5.8 ± 0.5 mm. Of 16 isolated lesions, 13 patients (82%) and 69% (18/26) with multiple lesions had tumor on biopsy. Of the 24 who received RT, 8 had a negative biopsy and, thus, may not have needed the RT. Five of 6 treated with just 2 drugs may have been undertreated. Nine of 12 treated with 3 drugs had tumor on biopsy. Conclusions: Computed tomography–only pulmonary lesions are not invariably tumor, demonstrating the need for histopathological confirmation. Biopsy remains critical until radiographic techniques allow differentiation between benign and malignant lesions to optimally direct therapy. [Copyright &y& Elsevier]

Abstract: Purpose: We reviewed the long-term local tumor control in patients with bilateral Wilm''s tumor (BWT) who received no definitive surgical therapy to one kidney after complete radiographic resolution after initial chemotherapy. Methods: National Wilm''s Tumor Study 4 (NWTS-4) enrolled 3335 patients (pts) during the period August 1986 to August 1994. There were 188 pts with BWT or 5.6% of the total enrolled. The treatment records and imaging reports were reviewed to ascertain those children who had documented tumors without definitive surgical therapy after initial treatment. Patients who did not have renal surgery because of progression of tumor were excluded from this study. Results: Eleven children had no definitive surgical treatment of renal lesions in one kidney (right, 6; left, 5) after initial treatment with chemotherapy and/or radiation therapy. The pretreatment size of the lesions were less than 3 cm (4 pts), 3 to 6 cm (5 pts), more than 6 cm (1 pt), and unknown (1 pt). Prechemotherapy biopsy was performed in 6 of 11 patients. Lesions were less than 3 cm (1 pt), 3 to 6 cm (3 pts), more than 6 cm (1 pt), and unknown (1 pt). Four biopsy specimens showed favorable Wilm''s histologic findings. One lesion (4 cm) showed an intralobar nephrogenic rest, another lesion of unknown size was read as favorable histologic findings vs perilobar nephrogenic rest. Biopsy was not performed on 5 lesions (4 pts, <1 cm; 1 pt, 3cm). Only 2 children in this study received radiation treatment. One child received 1050 cGy whole abdominal radiation, and 1 child received 1060 cGy to the left flank postnephrectomy. Radiation therapy was not given to any patient because of failure of the tumor to respond to chemotherapy. Five patients received treatment regimen EE-4A, dactinomycin, and vincristine. The duration of therapy ranged from 24 to 102 weeks for an average of 55.6 weeks. Three patients received treatment regimen DD-4A, dactinomycin, vincristine, and doxorubicin for 28, 52, and 52 weeks, respectively. Three patients received 2 separate regimens of chemotherapy. One child was treated with dactinomycin, vincristine, and cyclophosphamide for 60 weeks and then received regimen EE-4A for 24 weeks. Another patient received regimen EE-4A for 16 weeks and then regimen DD4-A for 36 weeks. One child received regimen EE-4-A for 12 weeks and then regimen DD4A for 40 weeks. Management of the contralateral kidney was complete nephrectomy in all 11 patients. There were no local relapses in the renal tumor bed. All patients were alive at a median follow-up of 9 years (range, 9 months to 15 years). Conclusion: Children with synchronous BWT or Wilm''s tumor and contralateral nephrogenic rests that have radiographic resolution, after initial treatment, have a low risk for local relapse. These children should be followed by serial imaging. [Copyright &y& Elsevier]

Background: A recurrent tracheo-esophageal fistula can complicate esophageal atresia and tracheo-esophageal fistula (TEF) repair in children. Therapeutic approaches and the rate of recurrence vary widely. Most reports are limited by small cohorts and short-term follow-up, and rates of re-recurrence are substantial, making it difficult to select the treatment of choice. We aimed to review our experience with the treatment of recurrent TEF using posterior tracheopexy, focusing on operative risks and long-term outcomes.Study Design: We conducted a retrospective review of patients with esophageal atresia TEF with recurrent TEF treated at 2 institutions from 2011 to 2020. We approach recurrent TEFs surgically. Once the TEF is divided and repaired, the membranous trachea is sutured to the anterior longitudinal ligament of the spine (posterior tracheopexy) and the esophagus is rotated into the right chest (rotational esophagoplasty), separating the suture lines widely. To detect re-recurrence, patients undergo endoscopic surveillance during follow-up.Results: Sixty-two patients with a recurrent TEF were surgically treated (posterior tracheopexy/rotational esophagoplasty) at a median age of 14 months. All had significant respiratory symptoms. On referral, 24 had earlier failed endoscopic and/or surgical attempts at repair. Twenty-nine required a concomitant esophageal anastomotic stricturoplasty or stricture resection. Postoperative morbidity included 3 esophageal leaks, and 1 transient vocal cord dysfunction. We have identified no recurrences, with a median follow-up of 2.5 years, and all symptoms have resolved.Conclusions: The surgical treatment of recurrent TEFs that incorporates a posterior tracheopexy and rotational esophagoplasty is highly effective for preventing re-recurrence with low perioperative morbidity. [ABSTRACT FROM AUTHOR]

Background: Anastomotic stricture is a common complication after esophageal atresia (EA) repair. Patients with a recalcitrant stricture may require surgical intervention. The technique of reanastomosis after stricture resection can affect patient outcomes.Study Design: Patients with EA who underwent anastomotic stricture resection, from July 2010 to February 2017, were reviewed. After stricture resection, patients who had slide esophagoplasty performed were compared with those having conventional end-to-end anastomosis.Results: Fifty patients underwent stricture repair surgery by slide esophagoplasty (n = 12) or end-to-end (n = 38) anastomosis technique at a median age of 14 months (interquartile range [IQR] 6 to 23 months). Significantly fewer patients required dilation therapy after slide esophagoplasty: 6 of 12 (50%) compared with 32 of 38 (84%) in the end-to-end group (p = 0.02). The number of dilation sessions was significantly lower in the slide group vs the end-to-end (p = 0.004) group, with a risk ratio confirming the approximately half the number of dilations for the slide approach (risk ratio 0.57, 95% CI 0.38 to 0.86). Steroid injection was combined with dilation in 3 of 12 (25%) vs 22 of 38 (58%) in the slide and end-to-end groups, respectively (p = 0.10). Stent placement was used in none of slide cases vs 8 of 38 (21%) in the end-to-end group (p = 0.17). Stricture incision was performed in 1 of 12 (8%) in the slide group and 11 of 38 (29%) in the end-to-end group (p = 0.25). There were leak complications in fewer patients after slide esophagoplasty compared with end-to-end anastomosis: 1 of 12 (8%) vs 8 of 38 (21%) (p = 0.43).Conclusions: Slide esophagoplasty may be a useful technique of anastomotic configuration for selected patients with recalcitrant esophageal stricture, offering more favorable outcomes compared with end-to-end anastomosis. [ABSTRACT FROM AUTHOR]

Background: The early outcomes of using jejunal interpositions to establish esophageal continuity in patients who have had a failed repair of esophageal atresia (EA) were determined.Study Design: This was a retrospective review of all patients treated at our institution with a jejunal interposition after a failed EA repair from 2010 to 2015. Demographics, anatomy encountered, operative techniques, requirement for microvascular support, and length of stay were analyzed. Outcomes measures included conduit survival, as well as feeding status at last follow-up.Results: Ten patients were reviewed. Median age at time of interposition operation was 48 months (range 8 to 276 months) and median weight was 14.2 kg (range 7.2 to 49.7 kg). Preoperative anatomy, operative techniques, and outcomes are presented. Four patients had microvascular "supercharging" for a long jejunal graft. Median follow-up was 1.5 years (range 0.5 to 5 years) with no long-term loss of graft or deaths. Six patients are eating by mouth completely, 1 by mouth primarily with supplemental night-time feeds, 1 is transitioning from tube to oral feeds, and 2 with functional grafts are fed mostly enterally due to severe oral aversion in 1 and aspiration in 1.Conclusions: Jejunal interpositions have been used for the past 5 years to establish esophageal continuity after a failed EA repair. All jejunal conduits survived and were joined to the upper esophageal segment. For shorter gaps with a longer upper esophageal pouch, a thoracic esophageal anastomosis was possible without additional vascular support. For longer interpositions into the neck, upper conduit survival might benefit from additional vascular anastomoses (ie, supercharging). To provide adequate space in the mediastinum, the first rib can be removed, as well as a portion of the manubrium to enlarge the pathway into the neck. [ABSTRACT FROM AUTHOR]

Purpose: Long-term follow-up studies sometimes rely on retrospective identification of the cohort to be followed. Few such studies have been conducted, however, that rely on very old source records, perhaps because of concern that identification and location of a cohort based on very old records would not be feasible. Methods: The Hanford Thyroid Disease Study (HTDS), conducted in the 1990s, identified 5199 cohort members using Washington state birth records from 1940–1946. The limited information contained therein was used to trace cohort members to the present day, nearly 50 years later. Results: We found the best strategy to locate individuals efficiently is to use a combination of methods and resources in a phased approach, beginning with readily available and easy-to-use sources of information before employing more time-intensive strategies that are costly and rely on information that is difficult to obtain. Motor vehicle licensing records and directories were the most useful individual sources of information. Using this approach, the HTDS successfully located 94% of the 5199 cohort members identified. Conclusions: It is feasible to successfully trace and locate a very high proportion of individuals identified from very old records that contain little information. [Copyright &y& Elsevier]