49 - Determinants and Outcomes of Failed First Extubation After Primary Repair in Type C Esophageal Atresia: Results from a National Registry

Publication Number: 4048.49

Ankur Datta, Norton Children’s Hospital, Louisville, KY, United States; Karna Murthy, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States; Isabella Zaniletti, IZ Statistics LLC, Tampa, FL, United States; Loren Berman, Nemours Children's Hospital, wilmington, DE, United States; yigit Guner, UC Irvine, Irvine, CA, United States; Michael A.. Padula, Childrens Hospital of Philadelphia, Philadelphia, PA, United States; Theresa Grover, Children's Hospital Colorado, Aurora, CO, United States; Jennifer A. Rumpel, University of Arkansas for Medical Sciences College of Medicine, Little Rock, AR, United States; Philip T. Levy, Boston Children's Hospital, BROOKLINE, MA, United States; Shawn D. St. Peter, Children's Mercy Hospitals and Clinics, Kansas City, MO, United States; DonnaMaria E. Cortezzo, Connecticut Children's Medical Center, Hartford, CT, United States; Patricia Denning, Emory University School of Medicine, Atlanta, GA, United States; Kuan-Chi Lai, Children's Hospital Los Angeles, Los Angeles, CA, United States; Benjamin Zendejas, Boston Children's Hospital, Boston, MA, United States

Background: Infants with type C esophageal atresia and tracheoesophageal fistula (EA/TEF) are vulnerable to airway malacia, vocal fold movement impairment (VFMI), anastomotic complications, and extubation failure after esophageal anastomosis. Determinants of failed first extubation (FFE) in this population are not well defined.

Objective: To determine factors associated with FFE after esophageal anastomosis in infants with type C EA/TEF.

Design/Methods: Using the Children's Hospitals Neonatal Database (CHND), we performed a 5-year (2021-2025) retrospective cohort study of infants who underwent primary repair of type C EA/TEF. Infants with major comorbidities expected to preclude early extubation were excluded. The primary outcome was FFE, defined as reintubation within 7 days of first extubation attempt. Logistic regression was used to estimate unadjusted and independent associations between FFE and demographic characteristics, surgical factors, and comorbidities. Secondary outcomes included the correlation of FFE with mortality, length of stay, days of mechanical ventilation, and esophageal anastomotic leak.

Results: We identified 878 infants with type C EA/TEF that met inclusion criteria, of whom 243 (27.7%) had an FFE. In unadjusted analyses, lower gestational age (GA), small for gestational age (SGA, < 10th percentile), congenital heart disease (CHD), chromosomal anomaly, VFMI, and thoracotomy were associated with FFE, whereas greater birth weight, older age and preoperative intubation were protective. In multivariable analyses, GA, chromosomal anomaly, CHD and VFMI remained independently associated with FFE (Area Under the Curve = 0.74, Table 1). Secondarily, FFE was independently associated with greater inpatient mortality (adjusted odds ratio (aOR)=21.4; 95% CI = 6.7, 68), longer hospital stay (aOR=1.2; 95% CI = 1.1, 1.4), and prolonged mechanical ventilation (aOR =2.6; 95% CI = 2.2, 3.0), while anastomotic leak was not associated. Marked inter-center variation in FFE was observed (Figure 1), and postoperative day of extubation was unrelated to FFE (distribution in Figure 2).

Conclusion(s): In this large registry study of infants with type C EA/TEF, most predictors of FFE were non-modifiable (GA, chromosomal anomaly, CHD), except VFMI which is potentially preventable. Importantly, FFE and esophageal anastomotic leak were unrelated, and the timing of extubation did not influence outcomes. These findings suggest that infants should be extubated when clinically ready rather than maintaining prolonged ventilation to avoid FFE or perceived anastomotic risk.

Table 1. Multivariable Model for the Outcome of Failed Extubation


Figure 1. EA/TEF Extubation Outcomes Across CHNC Centers


Figure 2. Distribution of Extubation Timing by Outcomes