Ambulatory 24-hour manometric and pH metric evidence of permanent impairment of clearance capacity in patients with esophageal atresia

Esophago-gastric junction findings on high resolution impedance manometry in children with esophageal atresia

OBJECTIVES

Using high resolution impedance manometry (HRIM), this study characterized the esophago-gastric junction (EGJ) dynamics in children with esophageal atresia (EA).

METHOD

Esophageal HRIM was performed in patients with EA aged less than 18 years. Objective motility patterns were analyzed, and EGJ data reported. Controls were pediatric patients without EA undergoing investigations for consideration of fundoplication surgery.

RESULTS

Seventy-five patients (M:F = 43:32, median age 1 year 3 months [3 months-17 years 4 months]) completed 133 HRIM studies. The majority (64/75, 85.3%) had EA with distal tracheo-esophageal fistula. Compared with controls, liquid swallows were poorer in patients with EA, as evident by significant differences in distension pressure emptying and bolus flow time (BFT). The integrated relaxation pressure for thin liquid swallows was significantly different between EA types, as well as when comparing patients with EA with and without previous esophageal dilatations. The BFT for solid swallows was significantly different when compared with EA types.

CONCLUSIONS

We have utilized HRIM in patients with EA to demonstrate abnormalities in their long-term EGJ function. These abnormalities correlate with poorer esophageal compliance and reduced esophageal peristalsis across the EGJ. Understanding the EGJ function in patients with EA will allow us to tailor long-term management to specific patients.

Predictors of enteral tube dependence in pediatric esophageal atresia

Children with esophageal atresia (EA) may require enteral tube feedings in infancy and a subset experience ongoing feeding difficulties and enteral tube dependence. Predictors of enteral tube dependence have never been systematically explored in this population. We hypothesized that enteral tube dependence is multifactorial in nature, with likely important contributions from anastomotic stricture. Cross-sectional clinical, feeding, and endoscopic data were extracted from a prospectively collected database of endoscopies performed in EA patients between August 2019 and August 2021 at an international referral center for EA management. Clinical factors known or hypothesized to contribute to esophageal dysphagia, oropharyngeal dysphagia, or other difficulties in meeting caloric needs were incorporated into regression models for statistical analysis. Significant predictors of enteral tube dependence were statistically identified. Three-hundred thirty children with EA were eligible for analysis. Ninety-seven were dependent on enteral tube feeds. Younger age, lower weight Z scores, long gap atresia, neurodevelopmental risk factor(s), significant cardiac disease, vocal fold movement impairment, and smaller esophageal anastomotic diameter were significantly associated with enteral tube dependence in univariate analyses; only weight Z scores, vocal fold movement impairment, and anastomotic diameter retained significance in a multivariable logistic regression model. In the current study, anastomotic stricture is the only potentially modifiable significant predictor of enteral tube dependence that is identified.

Management of Adults With Esophageal Atresia

Esophageal atresia (EA) with or without trachea-esophageal fistula is relatively common congenital malformation with most patients living into adulthood. As a result, care of the adult patient with EA is becoming more common. Although surgical repair has changed EA from a fatal to a livable condition, the residual effects of the anomaly may lead to a lifetime of complications. These include effects related to the underlying deformity such as atonicity of the esophageal segment, fistula recurrence, and esophageal cancer to complications of the surgery including anastomotic stricture, gastroesophageal reflux, and coping with an organ transposition. This review discusses the occurrence and management of these conditions in adulthood and the role of an effective transition from pediatric to adult care to optimize adult care treatment.

Pharmacogenomics fail to explain proton pump inhibitor refractory esophagitis in pediatric esophageal atresia

BACKGROUND

Esophagitis is prevalent in patients with esophageal dysmotility despite acid suppression, likely related to poor esophageal clearance. Esophageal atresia (EA) is a classic model of dysmotility where this observation holds true. In adult non-dysmotility populations, failure of esophagitis to respond to proton pump inhibitors (PPI) has been linked to variants in CYP2C19 that influence the activity of the encoded enzyme. It is unknown if CYP2C19 metabolizer phenotype contributes to PPI-refractory, non-allergic esophagitis in EA.

METHODS

We performed a cross-sectional study of 314 children with (N = 188) and without (N = 126) EA who were on PPI therapy at the time of endoscopy to evaluate for possible gastroesophageal reflux disease. Patients with eosinophilic esophagitis and/or fundoplication were excluded. Clinical and histology data were collected. Genomic DNA from biopsy samples was genotyped for polymorphisms in CYP2C19.

RESULTS

CYP2C19 metabolizer phenotypes were not associated with presence or severity of esophagitis (P = 0.994). In a multivariate logistic regression adjusted for potential confounders, EA was the strongest and only significant predictor of esophagitis (odds ratio 2.72, P = 0.023). Using negative binomial regression, we found that CYP2C19 phenotype was not a significant predictor of eosinophil count in children with PPI-refractory esophagitis.

CONCLUSIONS

Patients with EA are significantly more likely to experience PPI-refractory, non-allergic esophagitis than controls regardless of CYP2C19 metabolizer phenotype, suggesting that factors other than CYP2C19 genetics, including dysmotility, are the primary drivers of esophagitis in EA. CYP2C19 genotype failed to predict PPI-refractory, non-allergic esophagitis in both EA and non-EA children.

Characterization of Esophageal Motility in Children With Operated Esophageal Atresia Using High-resolution Impedance Manometry and Pressure Flow Analysis

OBJECTIVES

Esophageal dysmotility is common in patients with esophageal atresia (EA). High-resolution impedance manometry and pressure flow analysis (PFA) allow characterization of biomechanical events that drive bolus flow. The aims were to assess esophageal motility in children with EA, using PFA, and to test whether there is a correlation between PFA parameters and symptoms or endoscopic/histologic findings.

METHODS

High-resolution impedance manometry was performed in 16 children with EA (median age 11 years), compared with 13 patient controls (median age 14 years; P = NS vs patients). Wet swallows were analyzed using PFA. Medical charts were reviewed for symptoms and pathology results of the attendant esophagoscopy. Patients with EA were arbitrarily subgrouped according to their motility pattern: group A with presence of distal contraction in ≥50% of the swallows and group B with presence of distal contractions in <50% of the swallows.

RESULTS

Esophageal peristaltic motor patterns were abnormal in all patients with EA. Bolus transport was impaired as shown by the higher impedance ratio in EA than in controls (0.47 vs 0.22; P < 0.001). Impedance ratio was also higher in group B (n = 8) versus group A (n = 8) (P < 0.001). Symptoms of dysphagia were not correlated with the PFA measures. Contractile segment impedance, a marker of mucosal integrity, was significantly lower in the EA group.

CONCLUSIONS

Bolus transport was severely altered in patients with EA but was not predictive of symptoms. The presence of residual distal contractions is associated with a more efficient bolus propulsion.

Agreement between mothers', fathers', and children's' ratings on health-related quality of life in children born with esophageal atresia - a German cross-sectional study

BACKGROUND

Esophageal atresia (EA) is a rare congenital malformation, which is characterized by the discontinuity of the esophagus. We investigated the agreement between mothers', fathers', and children's' ratings on health-related quality of life (HRQOL) in children born with EA. We aimed to broaden the understanding of subjective experiences of HRQOL from different perspectives. We hypothesized that the agreement between mother and father ratings would be high, whereas the agreement between child and mother ratings as well as child and father ratings would show more substantial differences.

METHODS

We obtained data from 40 families (23 mother-father dyads of children aged 2-7 years and 17 mother-father-child triads of children and adolescents aged 8-18 years) with children born with EA, who were treated in two German hospitals. HRQOL was measured using the generic PedsQL™ questionnaires and the condition-specific EA-QOL© questionnaires. We calculated intraclass coefficients and performed one-way repeated measures ANOVAs to analyze differences for each domain as well as for the total scores.

RESULTS

Intraclass correlation coefficients (ICCs) indicated a strong agreement (≥.80) between mother and father reports of children's HRQOL for both generic and condition-specific measurements. The ICCs for the generic HRQOL for mother/father-child-dyads revealed only fair to good agreement, whereas ICCs for condition-specific HRQOL showed high agreement for mother-child and father-child-agreement. Analyses of Covariance revealed differences in mother/father-child agreement in the generic domain School, both parents reporting lower HRQOL scores than the children themselves. Fathers reported significantly higher scores in the condition-specific domain Social than their children.

CONCLUSIONS

Results showed that mothers' and fathers' reports corresponded to each other. Nonetheless, these reports might not be interchangeably used because mother-child and father-child agreement showed differences. Children might know the best on how they feel, and parent proxy-report is recommended when reasons such as young age, illness, or cognitive impairments do not allow to ask the child. But parent-report - no matter if reported by mother or father - should only be an additional source to broaden the view on the child's health status and well-being. The current study contributes to a better understanding of the complex family relationships involved when parenting a child born with EA.

Esophagitis in Pediatric Esophageal Atresia: Acid May Not Always Be the Issue

OBJECTIVE

Esophagitis is highly prevalent in patients with esophageal atresia (EA). Peptic esophagitis has long been assumed to be the primary cause of esophagitis in this population, and prolonged acid suppressive medication usage is common; such treatment is of unknown benefit and carries potential risk.

METHODS

To better understand the role of commonly used antireflux treatments in EA, we analyzed all patients with repaired EA who underwent endoscopy with biopsies at our institution between January 2016 and August 2018. Macroscopic erosive and histologic esophagitis on biopsy was graded per predefined criteria. Clinical characteristics including acid suppressive medication usage, type of EA and repair, presence of hiatal hernia, and history of fundoplication were reviewed.

RESULTS

There were 310 unique patients (33.5% long gap EA) who underwent 576 endoscopies with biopsies during the study period. Median age at endoscopy was 3.7 years (interquartile range 21-78 months). Erosive esophagitis was found in 8.7% of patients (6.1% of endoscopies); any degree of histologic eosinophilia (≥1 eosinophil/high power field [HPF]) was seen in 56.8% of patients (48.8% of endoscopies), with >15 eosinophils/HPF seen in 15.2% of patients (12.3% of endoscopies). Acid suppression was common; 86.9% of endoscopies were preceded by acid suppressive medication use. Fundoplication had been performed in 78 patients (25.2%). Proton pump inhibitor (PPI) and/or H2 receptor antagonist (H2RA) use were the only significant predictors of reduced odds for abnormal esophageal biopsy (P = 0.011 for PPI, P = 0.048 for H2RA, and P = 0.001 for PPI combined with H2RA therapy). However, change in intensity of acid suppressive therapy by either dosage or frequency was not significantly associated with change in macroscopic erosive or histologic esophagitis (P > 0.437 and P > 0.13, respectively). Presence or integrity of a fundoplication was not significantly associated with esophagitis (P = 0.236).

CONCLUSIONS

In EA patients, acid suppressive medication therapy is associated with reduced odds of abnormal esophageal biopsy, though histologic esophagitis is highly prevalent even with high rates of acid suppressive medication use. Esophagitis is likely multifactorial in EA patients, with peptic esophagitis as only one of multiple possible etiologies for esophageal inflammation. The clinical significance of histologic eosinophilia in this population warrants further investigation.

Gastroesophageal Reflux Disease and Aerodigestive Disorders

This relationship between gastroesophageal reflux and airway disorders is complex, possibly bidirectional, and not clearly defined. The tools used to investigate gastroesophageal reflux are mostly informative about involvement of gastroesophageal reflux within the gastrointestinal tract, although they are often utilized to study the relationship between gastroesophageal reflux and airway issues with are suspected to occur in relation to reflux. These modalities often lack specificity for reflux-related airway disorders. Co-incidence of gastroesophageal reflux and airway disorders does not necessarily infer causality. While much of our focus has been on managing acidity, controlling refluxate is an area that has not been traditionally aggressively pursued. Our management approach is based on some of the evidence presented, but also often from a lack of adequate study to provide further guidance.

Motility disorders in infants

Gastrointestinal motility disorders are common in the pediatric population and may affect the entire gastrointestinal tract and can vary from mild to severe conditions. They may clinically manifest as gastro-esophageal reflux symptoms, feeding difficulties and failure to thrive, constipation and diarrhea amongst others. This review first highlights the embryologic development of the gastrointestinal tract, after which the prenatal and neonatal development of gastrointestinal motility is discussed. Normal motility patterns as seen in (preterm) infants are described as a background for the discussion of the most common congenital and acquired motility disorders in infancy. This review specifically focuses on the role of preterm birth on the development of these disorders.

Dysmotility in Esophageal Atresia: Pathophysiology, Characterization, and Treatment

Esophageal dysmotility is almost universal after esophageal atresia (EA) repair and is mainly related to the developmental anomaly of the esophagus. Esophageal dysmotility is involved in the pathophysiology of numerous symptoms and comorbidities associated with EA such as gastroesophageal reflux disease, aspiration and respiratory complications, and symptoms of dysphagia and feeding disorders. High-resolution esophageal manometry (HREM) has facilitated the characterization of the dysmotility, but there is an incomplete correlation between symptoms and manometrical patterns. Impedance coupled to HREM should help to predict the clinical outcome and therefore personalize patient management. Nowadays, the management of esophageal dysmotility in patients with EA is essentially based on treatment of associated inflammation related to peptic or eosinophilic esophagitis.

Fluoroscopic balloon dilatation for anastomotic strictures in patients with esophageal atresia: A fifteen-year single centre UK experience

AIM OF THE STUDY

To assess the safety and effectiveness of fluoroscopic balloon dilatation (FBD) in children with esophageal anastomotic stricture after surgical repair of esophageal atresia.

METHODS

All patients undergoing surgery for esophageal atresia and requiring dilatation(s) during a consecutive 15-year period [April 2000-September 2014] were analyzed. Dilatations were performed as day case procedures under general anesthesia using a radial force generating balloon device (Boston Scientific Corporation) by surgeons. Outcomes assessed included - (1) the number of dilatations/patient, (2) effectiveness and (3) need for surgery and (4) complications.

RESULTS

One hundred thirty seven patients underwent 625 FBD sessions (median 3 dilations per patient; range 1-24 dilatations). Median age at 1st FBD was 0.74years (range 0.05-16.1years). Balloon catheter sizes ranged from 6mm to 20mm. FBD yielded excellent results in 99 patients (74%), while 17 cases (13%) had mild ongoing dysphagia/dysmotility. Ten patients (7%) required further dilatation(s) to control symptoms. No patient(s) required esophageal stenting. Five cases required G-tube feeds as a result of oral aversion behavior - all of these cases were complex/VACTERL patients. Only 1 minor radiological leak occurred after a dilatation session and this did not require surgical intervention. A single patient (long gap EA TEF) with severe neurological impairment having multiple dilatations and stricture resection ultimately required esophageal replacement. Anti-reflux surgery was performed in 36 patients (26%) for medical therapy resistant GER.

CONCLUSION

FBD for anastomotic stricture(s) following esophageal atresia repair achieved very good outcomes for the majority of EA TEF patients. The procedure can be accomplished safely as indicated by the low complication rate herein reported. Although some children may require more than one dilatation session prompt relief of symptoms can be achieved with a vigilant care program co-ordinated by a multidisciplinary specialist EA TEF team.

Motility, digestive and nutritional problems in Esophageal Atresia

Esophageal atresia (EA) with or without tracheoesophageal fistula (TEF) is a rare congenital malformation. Digestive and nutritional problems remain frequent in children with EA both in early infancy and at long-term follow-up. These patients are at major risk of presenting with gastroesophageal reflux and its complications, such as anastomotic strictures. Esophageal dysmotility is constant, and can have important consequences on feeding and nutritional status. Patients with EA need a systematic follow-up with a multidisciplinary team.

Long-term Complications of Congenital Esophageal Atresia, Single Institution Experience

OBJECTIVE

To evaluate general health condition of children operated for esophageal atresia, including complications from gastrointestinal tract and skeletal defects.

METHODS

Between 1990 and 2005, 77 patients were operated for esophageal atresia in the Polish Mothers Health Memorial Hospital. The study was based on retrospective analysis of medical case records of all children with esophageal atresia. All living patients (n=51) were invited for follow-up studies.

RESULTS

Pathological gastroesophageal reflux was found in 46.7% of children. Scoliosis was diagnosed in 20 patients. Chest deformations were observed in 43.3% children.

CONCLUSION

The absence of clinical symptoms does not exclude the presence of gastroesophageal reflux in children operated for esophageal atresia. Children operated for esophageal atresia should be followed up regularly by a multispecialistic medical team.

Insufficient Body Weight of Adults Born With Esophageal Atresia

OBJECTIVES

Impaired growth has been reported in children born with esophageal atresia (EA). Their nutritional fate at adulthood remains uncertain though. Our objectives were to determine the body mass index (BMI) of adult patients with EA followed up from 2009 to 2011 in the EA clinic of a university-affiliated hospital in Quebec (Canada), and investigate characteristics associated with underweight.

METHODS

The 40 adult patients with EA attending the clinic were invited to participate. Height and weight were measured and BMI calculated. Patients with BMI < 18.5 kg/m were deemed underweight. Patients' characteristics were obtained, including digestive symptoms and compensatory eating behaviors. Nonparametric tests were used to compare the proportion of underweight among patients with EA with that found in the Quebec population and the characteristics between patients with EA deemed underweight and those with BMI ≥ 18.5 kg/m.

RESULTS

The final sample included 16 women and 21 men, ages 18 to 44 years. Mean BMI was 21.3 ± 4.9 kg/m and 24.3% had BMI < 18.5 kg/m, which is higher than in the Quebec adult population (2.5%, P < 0.001). Compared with patients with EA having BMI ≥ 18.5 kg/m, underweight patients had more often experienced failure to thrive during their adolescence (55.6% vs 7.4%, P = 0.006), and reported severe postprandial fullness (62.5% vs 21.4%, P = 0.040), the need to eat slowly (87.5% vs 46.4%; P = 0.045), and severe difficulties to swallow dry solid foods (50.0% vs 14.3%, P = 0.054).

CONCLUSIONS

Insufficient body weight is prevalent in this sample of adult patients with EA and could result from digestive symptoms. Follow-up with a gastroenterologist and nutritional counseling should be considered for adult patients with EA.

Long-term esophageal and respiratory outcomes in children with esophageal atresia and tracheoesophageal fistula

OBJECTIVES

Few studies have evaluated the long-term complications and outcomes of esophageal atresia with or without tracheoesophageal fistula (EA/TEF) beyond childhood. The aim of our study was to characterize the esophageal and respiratory morbidity of EA/TEF through evaluation of clinical symptoms, diagnostic testing and therapeutic intervention at a tertiary care center.

METHODS

Patients with congenital EA/TEF evaluated from 2011 to 2014 were included. Demographic characteristics, type and mode of repair of EA/TEF, clinical symptoms, radiographic, endoscopic, bronchoscopic and medication use data were obtained.

RESULTS

A total of 43 patients were identified. The median age of this predominantly Caucasian population was 8 years (interquartile range: 3, 20). Twenty (62.5%) had type C (EA with distal TEF) abnormality. Twenty-one (48.8%) patients had heartburn, 19 (44.1%) had acid regurgitation, and 31 (72.1%) had dysphagia to solids. Barium swallow in 26 patients revealed strictures in 17 (65.4%), dysmotility in 20 (76.9%) and recurrent fistulas in four patients (15.4%). Thirty patients underwent upper endoscopy, of which 21 (70.0%) had a stricture, and six (20.0%) had recurrent fistula requiring surgical intervention. Eight (18.6%) patients underwent fundoplication. Pulmonary evaluation showed cough and choking in 31 (72.1%) patients and dyspnea and wheezing in 32 (53.4%) patients. Recurrent respiratory infections were reported in 19 (44.2%).

PATIENTS

Other findings included tracheomalacia in 86.7% and restrictive lung disease in 54.5% of patients.

CONCLUSION

There is a high burden of residual esophageal and pulmonary pathology in patients with EA/TEF. Ongoing follow-up is required to monitor both the clinical symptoms and treatment responses.

Quality of reporting of the literature on gastrointestinal reflux after repair of esophageal atresia-tracheoesophageal fistula

OBJECTIVES

There is variation in the management of postoperative gastroesophageal reflux (GER) in esophageal atresia-tracheoesophageal fistula (EA-TEF). Well-reported literature is important for clinical decision-making. We assessed the quality of reporting (QOR) of postoperative GER management in EA-TEF.

METHODS

A comprehensive search of MEDLINE, EMBASE, CINHAL, CENTRAL databases and gray literature was conducted. Included articles reported a primary diagnosis of EA-TEF, a secondary diagnosis of postoperative GER, and primary treatment of GER with antireflux medications. The QOR was assessed using the STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) checklist.

RESULTS

Retrieval of 2910 articles resulted in 48 relevant articles (N=2592 patients) with an overall quality percentage score of 48%-95% (median=65%). The best reported items were "participants" and "outcome data" (93.8% each), "generalisability" (91.7%) and "background/rationale" (89.6%). Less than 20% of studies provided detailed "main results"; less than 5% of studies reported adequately on "bias" or "funding." Sample size calculation and study limitations were included in 17 (35.4%) and 16 (33.3%) studies respectively. Follow-up time was inconsistently reported.

CONCLUSIONS

Although the overall QOR is moderate using STROBE, important areas are underreported. Inadequate methodological reporting may lead to inappropriate clinical decisions. Awareness of STROBE, emphasizing proper reporting is needed.

Health-related quality of life among children, young people and adults with esophageal atresia: a review of the literature and recommendations for future research

PURPOSE

Esophageal atresia (EA) is a rare congenital malformation requisite of surgical treatment. Survival rates have significantly increased in recent decades, but treated children are at risk of chronic morbidity. This study aims to review the literature on health-related quality of life (HRQOL) in patients with EA and describe the questionnaires used.

METHODS

A literature search was conducted in Pubmed, Cinahl and PsycINFO, from inception to January 2015. A meta-analysis of studies investigating HRQOL in patients with EA compared to healthy references was performed. The effect size was calculated as Cohen's d.

RESULTS

Twelve articles (published 1995-2014) describing HRQOL among children, young people and adults were identified. Only European studies were found, and these had variable sample sizes (8-128). Overall HRQOL was reported to be reduced in five of the seven studies that compared overall HRQOL with a healthy reference population. Impaired physical or general health was described in eight articles. In the meta-analysis, eight eligible studies provided 16 estimates of the effect of EA, six of which reached statistical significance for worse HRQOL (p < 0.05). Using Cohen's criteria, the pooled estimate of the effect of EA was small for overall and physical HRQOL, and <0.2 for the mental and social HRQOL components. Altogether, 15 different questionnaires were used, and none were condition specific for EA.

CONCLUSIONS

Different findings are reported; however, this study suggests that patients with EA may have a reduced HRQOL. Moreover, HRQOL is not adequately measured in this group. Additional research is required.

Dysphagia among adult patients who underwent surgery for esophageal atresia at birth

BACKGROUND

Clinical experiences of adults who underwent surgery for esophageal atresia at birth is limited. There is some evidence that suggests considerable long-term morbidity, partly because of dysphagia, which has been reported in up to 85% of adult patients who undergo surgery for esophageal atresia. The authors hypothesized that dysphagia in this population is caused by dysmotility and⁄or anatomical anomalies.

OBJECTIVE

To determine the motor and anatomical causes of dysphagia.

METHODS

A total of 41 adults, followed at the Esophageal Atresia Clinic at Hôpital Saint-Luc (Montreal, Quebec), were approached to particpate in the present prospective study. Evaluation was completed using upper endoscopy, manometry and barium swallow for the participants who consented. The medical charts of respondents were systematically reviewed from the neonatal period to 18 years of age to assess medical and surgical history.

RESULTS

All 41 patients followed at the clinic consented and were included in the study. Dysphagia was present in 73% of patients. Esophagogastroduodenoscopy was performed in 32 patients: hiatal hernia was present in 62% (n=20); esophageal diverticulum in 13% (n=4); macroscopic Barrett esophagus in 31% (n=10); and esophagitis in 19% (n=6). Histological esophagitis was present in 20% and intestinal metaplasia in 10%. There were no cases of dysplagia or adenocarcinoma. Esophageal manometry was performed on 56% of the patients (n=23). Manometry revealed hypomotility in 100% of patients and included an insufficient number of peristaltic waves in 96%, nonpropagating peristalsis in 78% and low-wave amplitude in 95%. Complete aperistalsis was present in 78%. The lower esophageal sphincter was abnormal in 12 (52%) patients, with incomplete relaxation the most common anomaly. Of the 41 patients, 29 (71%) consented to a barium swallow, which was abnormal in 13 (45%). The anomalies found were short esophageal dilation in 28%, delay in esophageal emptying in 14%, diverticula in 14% and stenosis in 7% of patients. There was more than one anomaly in 14% of patients.

CONCLUSION

Dysphagia was a highly prevalent symptom in adults who underwent surgery for esophageal atresia. The present study is the first to demonstrate that motor and anatomical abnormalities may be implicated in causes of dysphagia in this population. Furthermore, these anomalies may be demonstrated with simple investigations such as endoscopy, manometry and barium swallow.

Post-operative management of esophageal atresia-tracheoesophageal fistula and gastroesophageal reflux: a Canadian Association of Pediatric Surgeons annual meeting survey

BACKGROUND

Esophageal atresia (EA), with or without tracheoesophageal fistula (TEF), is commonly associated with gastroesophageal reflux (GER) after surgical repair. One risk factor for anastomotic stricture is post-operative GER. This survey assessed practice patterns among attendees at the Canadian Association of Pediatric Surgeons (CAPS) annual meeting with respect to management of GER post EA-TEF repair.

METHODS

A pre-piloted survey was handed out and collected at the 2012 CAPS annual meeting. Data were entered and coded, and descriptive statistics were calculated.

RESULTS

We distributed 70 surveys, and 57 (81.4%) surveys were returned. On average, the incidence of EA-TEF is 8-10 cases per institution, per year. Anti-reflux medication is started immediately post-operatively in 74% of patients at institution of feeds (11%), or if symptoms of reflux develop (14%). Proton pump inhibitors and H2-receptor antagonists are used in approximately equal proportion. Patients are typically kept on anti-reflux medication for 3-6 months (37%) or 6-12 months (35%).

CONCLUSIONS

Most CAPS attendees treat postoperative GER prophylactically. However, there is no consistency in management strategy regarding which anti-reflux agent to use or for how long. A multi-centered study is required to establish a standardized protocol for the post-operative management of EA-TEF to prevent reflux and its effect on anastomotic strictures.

Evaluation of gastroesophageal function and mechanisms underlying gastroesophageal reflux in infants and adults born with esophageal atresia

PURPOSE

To evaluate the mechanisms underlying gastroesophageal reflux (GER) following esophageal atresia (EA) repair and gastroesophageal function in infants and adults born with EA.

METHODS

Ten consecutive infants born with EA as well as 10 randomly selected adult EA patients were studied during their first postoperative follow-up visit and a purposely planned visit, respectively. A (13)C-octanoate breath test and esophageal pH-impedance-manometry study were performed. Mechanisms underlying GER and esophageal function were evaluated.

RESULTS

Transient lower esophageal sphincter relaxation (TLESR) was the most common mechanism underlying GER in infants and adults (66% and 62%, respectively). In 66% of all GER episodes, no clearing mechanism was initiated. On EFT, normal motility patterns were seen in six patients (four infants, two adults). One of these adults had normal motility overall (>80% of swallows). Most swallows (78.8%) were accompanied by abnormal motility patterns. Despite this observation, impedance showed normal bolus transit in 40.9% of swallows. Gastric emptying was delayed in 57.1% of infants and 22.2% of adults.

CONCLUSIONS

TLESR is the main mechanism underlying GER events in patients with EA. Most infants and adults have impaired motility, delayed bolus clearance, and delayed gastric emptying. However, normal motility patterns were seen in a minority of patients.

Esophageal atresia: gastroesophageal functional follow-up in 5-15 year old children

PURPOSE

Esophageal atresia (EA) is one of the most frequent congenital alimentary tract anomalies with a considerable morbidity throughout childhood. This study evaluates the gastroesophageal problems in 5-15 year old children with EA and aims to identify factors predisposing to esophagitis in EA.

MATERIAL AND METHODS

Fifty-nine patients primarily operated at Odense University Hospital, Denmark, during 1993-2005 were included in this follow-up study. The patients underwent the following examinations: Interview, upper endoscopy, endoscopic ultrasonography, high-resolution esophageal manometry (HREM), and pH- and multichannel intraluminal impedance (MII) measurements. Twenty-five patients with suspected gastro-esophageal reflux disease (GERD) underwent the same investigations and served as controls.

RESULTS

Median age was 10.2 years (7.1-13.3). Thirty-three (55.9%) presented with GERD symptoms, 41 (69.5%) with dysphagia, and 33 (55.9%) with respiratory symptoms. Twenty-nine (49.2%) had endoscopic esophagitis, and 26 (44.1%) histological esophagitis. Median reflux index (RI) was 8.3 (4.8-14.9). In 32 (55.2%) RI was above 7. Ten percent had eosinophilic inflammation. HREM showed dysmotility in the esophagus in all EA patients, 83.3% had no propagating swallows. No predictive factors predisposing the development of endoscopic esophagitis were identified.

CONCLUSIONS

Gastroesophageal problems in children born with EA are common. Routine follow-up with endoscopy and pH-metry in EA patients is warranted.

Characterization of esophageal motility following esophageal atresia repair using high-resolution esophageal manometry

BACKGROUND

Esophageal dysmotility, a considerable issue following esophageal atresia (EA) repair, has been reported but has not been precisely described and characterized. Using high-resolution esophageal manometry (HREM), we characterized the esophageal motility patterns in children with repaired EA and compared these patterns of dysmotility with symptomatology.

METHODS

HREM was performed as an outpatient procedure in patients with repaired EA. The tracings were analyzed using the software provided by the company and were then reviewed visually. Charts were reviewed for medical/surgical histories and symptoms were assessed by a standardized questionnaire.

RESULTS

Forty patients (25 boys, 15 girls) with a median age of 8 years (11 months-18 years) underwent an HREM. Thirty-five patients had type C EA and 5 had type A EA. Only 7 patients were asymptomatic at the time of the examination. HREM results were abnormal in all of the patients. Three different esophageal motility patterns were derived from HREM tracing analysis: aperistalsis (15 patients, 38%), pressurization (6 patients, 15%), and distal contractions (19 patients, 47%). Distal contractions pattern was found exclusively in type C EA. Dysphagia was encountered in the 3 groups. Gastroesophageal reflux disease-related symptoms predominated in the aperistalsis group.

CONCLUSIONS

HREM improves our understanding and allows precise characterization of esophageal dysmotility in patients who have undergone EA repair.

Esophageal atresia: long-term morbidities in adolescence and adulthood

Survival rates in esophageal atresia (EA) patients have reached 90%. In long-term follow-up studies the focus has shifted from purely surgical or gastrointestinal evaluation to a multidisciplinary approach. We evaluated the long-term morbidity in adolescent and adult EA patients and discussed mainly nonsurgical issues. Dysphagia is common and reported in up to 85% of patients. In young adults gastroesophageal reflux disease occurs frequently with development of Barrett esophagus in 6% reported in different series. It is difficult to estimate respiratory morbidity from the literature because many different definitions, questionnaires, and study designs have been used. However, many patients seem to suffer from respiratory problems even into adulthood. In conclusion, morbidity is not only restricted to surgical problems but many different domains are involved. These are all related and together determine to a large extent the quality of life of EA patients and also of their families. We assume that a multidisciplinary care approach seems best to address their special needs.

Esophageal dysmotility: characterization and pathophysiology

Esophageal dysmotility is a considerable long-term issue in patients born with esophageal atresia (EA). To better characterize it, the normal esophageal motility is briefly reviewed with emphasis on the specific defects in EA. Multiple studies attempted to describe the dysmotility seen in patients with operated EA using esophageal manometry. Recently, high-resolution manometry has improved our understanding of normal esophageal motility. Using this new technology, it is now possible to better characterize the esophageal motility of patients operated on for EA. Three different patterns are described and presented: aperistalsis, pressurization, and distal peristalsis. Up to now, it has not been possible to find a correlation between the dysmotility severity and the patient's symptomatology. Different pathophysiological hypotheses of esophageal dysmotility in that population are discussed. Developmental neuronal defects are certainly present from the beginning. Surgical trauma can also contribute to the dysmotility. Finally, defective esophageal acid clearance capacity is a cause of gastroesophageal reflux disease, but the resultant esophagitis can also impair the normal esophageal function. The evolution of esophageal dysmotility in patients with repaired EA is not known and further studies will be necessary to clarify it.

Follow-up of adult patients with repaired esophageal atresia: how, when, and for how long?

Esophageal atresia (EA) is the most common congenital anomaly of the esophagus. With the progress of surgical and anesthetic techniques, the survival is now more than 90% and the majority of children survives and eventually reaches adulthood. However, even if the continuity of the esophagus is anatomically replaced by the surgery, there are some new pieces of evidence that suggest considerable long-term morbidity. In this paper, we will illustrate how symptomatic gastroesophageal reflux, dysphagia, and esophageal motility disturbances, as well as columnar epithelial metaplasia, are common in adults with repaired EA. The ideal follow-up for adult patients born with EA has not been clearly defined, and routine endoscopic assessment has not been widely advocated. It is well known that the patient's symptoms have a poor correlation with histological findings. However, routine follow-up may be expensive and time consuming. With the growing number of children reaching adulthood, it is now essential to know and understand the natural history of this condition to improve the management of these patients.

Anti-reflux surgery for patients with esophageal atresia

Gastroesophageal reflux (GER) is almost constant in esophageal atresia and tracheoesophageal fistula (EA/TEF). These patients resist medical treatment and require antireflux surgery quite often. The present review examines why this happens, the long-term consequences of GER and the main indications and results of fundoplication in this particular group of patients. The esophagus of EA/TEF patients is malformed and has abnormal extrinsic and intrinsic innervation and, consequently, deficient sphincter function and dysmotility. These anomalies are permanent. Fifty percent of patients overall have GER, and one-fifth have Barrett's metaplasia. Close to 100%, GER of pure and long-gap cases require fundoplication. In the long run, these patients have 50-fold higher risk of carcinoma than the control population. GER in EA/TEF does not respond well to dietary, antacid, or prokinetic medication. Surgery is necessary in protracted anastomotic stenoses, in pure and long-gap cases, and when there is an associated duodenal atresia. It should be indicated as well in other symptomatic cases when conservative treatment fails. However, confection of a suitable wrap is anatomically difficult in this condition as shown by a failure rate of 30% that is also explained by the persistence for life of the conditions facilitating GER.

Current knowledge on esophageal atresia

Esophageal atresia (EA) with or without tracheoesophageal fistula (TEF) is the most common congenital anomaly of the esophagus. The improvement of survival observed over the previous two decades is multifactorial and largely attributable to advances in neonatal intensive care, neonatal anesthesia, ventilatory and nutritional support, antibiotics, early surgical intervention, surgical materials and techniques. Indeed, mortality is currently limited to those cases with coexisting severe life-threatening anomalies. The diagnosis of EA is most commonly made during the first 24 h of life but may occur either antenatally or may be delayed. The primary surgical correction for EA and TEF is the best option in the absence of severe malformations. There is no ideal replacement for the esophagus and the optimal surgical treatment for patients with long-gap EA is still controversial. The primary complications during the postoperative period are leak and stenosis of the anastomosis, gastro-esophageal reflux, esophageal dysmotility, fistula recurrence, respiratory disorders and deformities of the thoracic wall. Data regarding long-term outcomes and follow-ups are limited for patients following EA/TEF repair. The determination of the risk factors for the complicated evolution following EA/TEF repair may positively impact long-term prognoses. Much remains to be studied regarding this condition. This manuscript provides a literature review of the current knowledge regarding EA.

Current Controversies in the Surgical Treatment of Esophageal Atresia

Background and Aims:

Esophageal atresia (EA) with or without tracheo-esophageal fistula (TEF) is a rare condition that can be nowadays succesfully treated. The current interest therefore is focused on the management of the difficult cases, on thoracoscopic approach, and on some aspects of the long-term results.

Methods:

The current strategies for the difficult or impossible anastomoses in pure and long-gap EA, the introduction of thoracoscopic repair and the causes, mechanisms and management of post-operative gastro-esophageal reflux (GER) are reviewed.

Results:

Methods of esophageal elongation and multi-staged repair of pure and long-gap EA allow anastomosis but with functional results that are often poor. Esophageal replacement with colon or stomach achieves at least similar results and often requires less procedures. Thoracoscopic repair is a promising adjunct, but the difficulties for setting it as a gold-standard are pointed out. GER is a part of the disease and its surgical treatment, that is often required, is burdened by high failure rates.

Conclusions:

EA with or without TEF can be successfully treated in most cases, but a number of unsolved issues remain and the current approach to difficult cases will certainly evolve in the future.

Long-term results of esophageal atresia: Helsinki experience and review of literature

Esophageal atresia (EA) affects one in 2,840 newborns, and over half have associated anomalies that typically affect the midline. After EA repair in infancy, gastroesophageal reflux (GER) and esophageal dysmotility and respiratory problems are common. Significant esophageal morbidity associated with EA extends into adulthood. Surgical complications, increasing age, and impaired esophageal motility predict the development of epithelial metaplasia after repair of EA. To date, worldwide, six cases of esophageal cancer have been reported in young adults treated for EA. According to our data, the statistical risk for esophageal cancer is not higher than 500-fold that of the general population. However, the overall cancer incidence among adults with repaired EA does not differ from that of the general population. Adults with repaired EA have had significantly more respiratory symptoms and infections, as well as more asthma and allergies than does the general population. Nearly half the patients have bronchial hyperresponsiveness. Thoracotomy-induced rib fusion and gastroesophageal reflux-associated columnar epithelial metaplasia are the most significant risk factors for the restrictive ventilatory defect that occurs in over half the patients. Over half the patients with repaired EA are likely to develop scoliosis. Risk for scoliosis is 13-fold after repair of EA in relation to that of the general population. Nearly half of the patients have had vertebral anomalies predominating in the cervical spine, and of these, most were vertebral fusions. The natural history of spinal deformities seems, however, rather benign, with spinal surgery rarely indicated.

Evaluation of esophageal motility and reflux in children treated for esophageal atresia with the use of combined multichannel intraluminal impedance and pH monitoring

BACKGROUND

Gastroesophageal reflux (GER) and dysmotility are frequent in patients treated for esophageal atresia (EA). This aim of this study is to evaluate GER and dysmotility in young EA patients using pH-multichannel intraluminal impedance (pH-MII).

METHODS

Fifteen patients with a mean age of 7.5 years (group 1) have been studied and compared with 15 children without congenital malformation, submitted to pH-MII for suspected GER (group 2). These latter patients serve as a control group of healthy subjects. The following impedance reflux and motility parameters have been studied on 10 standardized swallows: number of reflux episodes, mean acid clearing time, median bolus clearing time, bolus presence time, total bolus transit time, segmental transit time, and total propagation velocity.

RESULTS

In the group of EA patients, mean acid clearing time and median bolus clearing time were pathological. In the control group, all reflux parameters were normal. Patients with EA had significantly longer median bolus presence time at each measuring site, median total bolus transit time, and median segmental transit time and slower total propagation velocity (P < .001).

CONCLUSIONS

pH-multichannel intraluminal impedance evaluates both GER and motility patterns. Our report studies impedance parameters of esophageal motility in healthy children and in EA patients using only pH-MII.

Anastomotic strictures following esophageal atresia repair: a 20-year experience with endoscopic balloon dilatation

OBJECTIVES

The aim of the study was to evaluate the safety, effectiveness, and long-term results of endoscopic balloon dilatation in children with anastomotic strictures following esophageal atresia (EA) repair.

PATIENTS AND METHODS

From January 1988 to January 2008, 59 patients were treated with balloon dilatation for anastomotic stricture following EA repair. Indication for dilatation was dysphagia of varying degree. Outcome parameters included the number of dilatations, response to dilatation, effectiveness, and complications. Response to dilatation was considered excellent when there was no need for any additional dilatation for recurrent dysphagia, satisfactory when up to 5 dilatations were required, and fair when >5 sessions were required. The treatment was considered effective when dysphagia was grade 0 or 1 for >12 months after the last dilatation session.

RESULTS

A total of 165 balloon dilatations were undertaken, with an average of 279 per patient (range 1-9). Age range at diagnosis was 1 to 36 months (mean 10.5). Response to dilatation was excellent in 21 cases (35.6%), satisfactory in 26 (44.1%), and fair in 12 (20.3%). The treatment was effective in 47 patients (79.7%) and ineffective in 12 (20.3%). The median follow-up period was 19.5 months. Four patients underwent surgery; in 1 patient a retrievable stent was placed. No perforation occurred.

CONCLUSIONS

Endoscopic balloon dilatation can be accomplished safely and effectively as a first-line therapy for the management of anastomotic strictures following EA repair.

Esophageal motility in children with suspected gastroesophageal reflux disease

BACKGROUND AND OBJECTIVES

Motility abnormalities in adults with gastroesophageal reflux disease (GERD) include nontransmitted contractions, reduced distal esophageal contraction amplitude, and simultaneous contractions. Information on esophageal body motility in children with GERD is scarce. Our aim was to study esophageal motility patterns in children with GERD, taking into account the presence of anatomical abnormalities and neurological impairment, the effect of age on esophageal motility in GERD, and the relation between esophageal manometry and GERD severity parameters (acid exposure and presence of esophagitis).

PATIENTS AND METHODS

Consecutive children referred for severe GER(D) symptoms underwent a barium swallow, upper endoscopy, pH monitoring, and stationary water-perfused esophageal manometry.

RESULTS

Mean lower esophageal sphincter (LES) pressure and velocity of propagation in the proximal and distal esophagus decreased with age in this group of children with GERD (all P < 0.01). Severely disturbed esophageal motility was found in children with previous esophageal atresia. Patients with psychomotor retardation had significantly lower occurrence of peristaltic waves (94% +/- 21% vs 79% +/- 38%; P = 0.001), distal propagation velocity (0.8 +/- 0.4 vs 0.6 +/- 0.5 cm/s; P = 0.05), and distal contraction duration (3.1 +/- 0.8 vs 3.4 +/- 1 seconds; P = 0.05). None of the manometric characteristics differed between patients with normal or abnormal esophageal pH monitoring or with or without erosive esophagitis.

CONCLUSIONS

LES pressure and esophageal velocity decreased with increasing age. Esophageal manometry is severely impaired in children with esophageal atresia and psychomotor retardation. No specific esophageal motor abnormalities related to the presence of endoscopic esophagitis or abnormal pH monitoring were found.

Intramural ganglion structures in esophageal atresia: a morphologic and immunohistochemical study

Introduction and Aim. Disorders of esophageal motility causing dysphagia and gastroesophageal reflux are frequent in survivors to esophageal atresia (EA) and distal tracheoesophageal fistula (TEF). The aim of the present study was to investigate the histologic and immunohistochemical features in both esophageal atretic segments to further understand the nature of the motor disorders observed in these patients. Material and Methods. Esophageal specimens from 12 newborns with EA/TEF and 5 newborns dead of unrelated causes were examined. The specimens were fixed in 5% buffered formalin, included in paraffin and cut in 5 micron sections that were stained with hematoxilin and eosin (H and E), and immunohistochemical stainings for Actin, S-100 protein, Neurofilament, Neuron-Specific-Enolase, Chromogranin A and Peripherin were evaluated under the microscope. Results. In controls, the distribution of the neural elements was rather homogenous at both levels of the esophagus. In contrast, the atretic segments showed quantitative and qualitative differences between them with sparser nervous tissue in the distal one in comparison with the proximal one and with controls. Conclusions. These results further support the assumption that histomorphological alterations of the muscular and nervous elements within the esophageal wall might contribute to esophageal dysmotility in patients surviving neonatal operations for EA/TEF.

Achievement of feeding milestones after primary repair of long-gap esophageal atresia

OBJECTIVES

To determine the pattern of feeding milestones following primary repair of long-gap esophageal atresia (EA).

METHOD

A questionnaire based upon well established feeding milestones was used. Children after long-gap EA repair, n=40, were compared from after primary repair to healthy children from birth, n=102.

RESULTS

The age when surveyed of the EA group and controls was different: 6.2+/-4.7 (mean+/-standard deviation) years, range 1.1-20.9, versus 2.5+/-2.4 years, range 0.0-12.1, p=0.00. The esophageal gap length in the EA group was 5.1+/-1.2 cm and age at repair was 5.5+/-5.0 months. There was no statistically significant difference between the atresia group and controls for feeding milestones; Self feeding finger foods approached significance. There was, however, greater variability in the timing of milestones in the atresia group compared to controls. Feeding milestones were negatively correlated with age at primary repair: drinking with a covered sippy cup, rho=-0.51, p=0.01 and self feeding finger foods, rho=-0.36, p=0.04 were statistically significant. Drinking from a cup correlated with gestational age, rho=0.38, p=0.04, and negatively correlated to esophageal gap length, rho=-0.45, p=0.01.

CONCLUSIONS

Despite delayed onset of feeding, major milestones after EA repair occurred in similar pattern to normal infants. An early referral for primary repair is beneficial for earlier acquisition of milestones for infants with long-gap EA.

Outcome of esophageal atresia beyond childhood

Survivors of esophageal atresia are reaching their adulthood in large numbers for the first time enabling assessment of true long-term outcome among this group of patients. This review summarizes the current knowledge on the subject focusing on late symptoms and complications, esophageal pathology and pulmonary function. Relationships between esophageal dysmotility, gastroesophageal reflux, esophagitis and epithelial metaplastic changes including esophageal cancer are outlined. In addition to pertinent literature, institutional experience, and follow-up of patients with esophageal atresia for more than 60 years is included.

Long-gap esophageal atresia treated by growth induction: the biological potential and early follow-up results

This study had two purposes. The first was to determine whether the growth procedure would allow true primary repairs of the most severe end of the esophageal atresia (EA) spectrum with the longest gaps (LG) and most rudimentary lower esophageal segments. The second goal was to provide the first short- to mid-term (3-12 years) follow-up data on the esophageal function and quality of life (QOL) data on the patients in this series. From our series of 60 LG-EA patients who underwent a growth procedure, 42 had the true primary esophageal repair completed 3 years ago. Among these, 18 had gaps over 6 cm, and for 6, only a rudimentary lower esophagus existed well below the diaphragm. No patient was turned down and all had primary repairs. These results suggest that even the most rudimentary segment has the potential to achieve normal size and that the full EA spectrum can have a primary repair. Our follow-up studies indicated that the esophageal function of these previously grown segments was very good. All contacted (40) were eating normally with only 3 receiving supplemental g-tube feeds because of other significant defects. We have actively treated significant reflux and 41/42 had fundoplication. By endoscopy (N = 15) no esophagitis was visible, but on biopsy, mild inflammation was found in 3. No conditions were found which would suggest that there would be a late deterioration or adverse consequences would arise. Based on these ongoing evaluations, the outlook seems very favorable for a good long-term QOL.

Adults with corrected oesophageal atresia: is oesophageal function associated with complaints and/or quality of life?

The aim of this study was to evaluate oesophageal function after correction of oesophageal atresia in adults, and to investigate the association between complaints, oesophageal function and quality of life (QoL). Twenty-five adults were included who participated in previous follow-up studies, during which complaints of dysphagia and gastro-oesophageal reflux (GOR), results of upper gastrointestinal endoscopy, oesophageal biopsies and QoL had been collected. Manometry was performed in 20 patients, 24 h pH-measurements were performed in 21 patients. pH-values (sample time 5 s) were calculated using criteria of Johnson and DeMeester. Associations were tested with ANOVA and chi (2)-tests. Ten patients (48%) reported complaints of dysphagia, seven (33%) of GOR. The amplitude of oesophageal contractions was low (<15 mmHg) in four patients (20%). pH-measurements showed pathological reflux in three patients (14%). Patients reporting dysphagia more often had disturbed motility (P = 0.011), and lower scores on the domains "general health perceptions" (SF-36) (P = 0.026), "standardised physical component" (SF-36) (P = 0.013), and "physical well-being" (GIQLI) (0.047). No other associations were found. This study shows a high percentage of oesophageal motility disturbances and a moderate percentage of GOR after correction of oesophageal atresia. Patients reporting dysphagia, whom more often had disturbed motility, seemed to be affected by these symptoms in their QoL.

Intrinsic esophageal innervation in esophageal atresia without fistula

Esophageal atresia and tracheo-esophageal fistula (EA + TEF) are often associated with malformations of neural crest origin. Esophageal innervation is also derived from the neural crest and it is abnormal in EA + TEF in which there is motor dysfunction. Our aim was to examine the intrinsic esophageal innervation in children with isolated EA in which different embryogenic mechanisms might be involved. Specimens from the proximal and distal esophageal segments of 6/35 patients who had esophageal replacement for isolated EA between 1965 and 2006 were suitable for the study. They were sectioned and immunostained with anti-neurofilament (NF) and anti-S-100 antibodies. The muscle and neural surfaces on each section were measured with the assistance of image processing software. The surface of the ganglia and the number of neurons per ganglion were determined at high power microscopy. The findings were compared with those of six autopsy specimens from newborns dead of other diseases by means of standard statistical tests and a significance threshold of P < 0.05. Unmatched age/size of babies in isolated EA and control groups precluded comparison of the relative surfaces occupied by neural elements. Patients with pure EA had denser fibrilar network and larger ganglia than controls. The number of neurons/ganglion were similar in both groups although the cells from EA patients were larger. The findings were similar at both esophageal levels studied. In spite of methodologic biases, it seems that intrinsic esophageal fibrilar network is denser and the intramural ganglia larger with larger cells in patients with pure EA than in controls on both esophageal ends of the organ. These neural anomalies are only in part reminiscent of those described in regular EA/TEF but may as well explain esophageal dysfunction in patients with repaired isolated EA.

Lack of distal esophageal contractions is a key determinant of gastroesophageal reflux disease after repair of esophageal atresia

BACKGROUND/PURPOSE

The objective of this study is to investigate the characteristics of esophageal motor activity responsible for the development of gastroesophageal reflux (GER) in patients with esophageal atresia (EA).

METHODS

The subjects consisted of 29 patients with EA (1 month to 19 years). Computerized esophageal manometry was conducted to investigate esophageal contractions at swallow. A topographic esophageal manometric analysis was conducted in each subject, providing 3-dimensional displays to reveal the pressure continuum representing esophageal contractions.

RESULTS

Significant contractions in the middle esophagus just below the anastomosis were absent in all subjects. Contractions in the distal esophagus were conspicuously absent in 17 subjects. Of these 17, 6 had already undergone fundoplication, and 9 had symptomatic GER requiring fundoplication subsequent to this study. The remaining 12 patients had contractions in the distal esophagus and did not require medical/surgical intervention. A lack of distal esophageal contractions was significantly correlated with the development of GER (P < .001). There was a significant difference in esophageal acid exposure between the 2 groups (median, 38% vs 4%, P < .001).

CONCLUSION

Lack of distal esophageal contractions indicating an impaired clearing capacity is considered a potential key determinant of GER in patients with EA.

Long-term outcome of laparoscopic Nissen-Rossetti fundoplication for neurologically impaired and normal children

BACKGROUND

This study aimed to assess the long-term effects of laparoscopic Nissen-Rossetti fundoplication (LNF) on clinical and pH evaluations of children with gastroesophageal reflux disease (GERD) according to neurologic status.

METHODS

The study examined 127 children (73 neurologically impaired and 54 neurologically normal with primary GERD) who consecutively underwent LNF from 1992 to 2003. The follow-up protocol included evaluations at 3, 15, and more than 36 months (long-term evaluation) postoperatively, which consisted of physical examination and 24-h pH monitoring. Recurrences were defined as abnormal pH-metry exhibited by symptomatic children.

RESULTS

The long-term follow-up period averaged 5.5 years. Of the 73 neurologically impaired children, 9 (12%) had GERD recurrences, which occurred during the evaluation period and required redo surgery in four cases, including two Bianchi procedures. In the neurologically normal group, one recurrence (2%) occurred 3 months after surgery. The long-term complications in this group included dyspepsia (n = 3), occasional dysphagia (n = 2), gas bloat syndrome (n = 1), and alimentary disorders (n = 2).

CONCLUSIONS

For children with primary GERD, LNF is a long-term efficient procedure. For the neurologically impaired children, the results were good, with more than 85% of the children symptom free after 5 years, although repeated evaluations are required to diagnose late recurrences related to evolving dysmotility disorders.

Midterm follow-up of esophageal anastomosis for esophageal atresia repair: long-gap versus non-long-gap

Current approaches to the repair of long-gap esophageal atresia (EA) favor esophageal anastomosis. This investigation provides a midterm follow-up of long-gap EA with a primary repair to determine whether this procedure affects symptom severity and whether symptom severity may predict worsening of dysmotility. Fifteen children at least 1-year post primary repair were divided into group 1 (long-gap) and group 2 (non-long-gap). The severity of their symptoms was graded using a questionnaire focused on their eating habits and gastroesophageal motor dysfunction symptoms. Esophageal transit time and gastric emptying were assessed by scintigraphy and used to grade esophagogastric dysmotility. At midterm follow-up the majority of patients in both groups were asymptomatic (66% in group 1 vs 77.7% in group 2; P > 0.05). Esophagogastric dysmotility grades for group 1 were more severe than for group 2 (median 2.5, range from 1 to 4 vs median 1, range from 1 to 2, respectively; P > 0.05). We found no relationship between the severity of the symptoms and the presence or severity of esophagogastric dysmotility. At midterm follow-up in patients with long-gap atresia that underwent primary repair, this study showed scintigraphic evidence of silent and serious esophagogastric dysmotility in symptom-free or minimally symptomatic children. It may therefore be unreliable to use symptoms in assessing the severity of esophagogastric dysmotility, since both groups showed similar clinical findings but different scintigraphic findings.

Prognosis of congenital tracheoesophageal fistula with esophageal atresia on the basis of gap length

Congenital tracheoesophageal fistula (TEF) with esophageal atresia (EA) is not an uncommon disease of newborns. Several classifications have been advocated for predicting the outcomes of these patients but all are physiological and concentrated on associated medical condition that influences survival. We emphasize a new classification on the basis of gap between two esophageal pouches to define the magnitude of surgical problems in the primary repair and correlate them with the outcomes in terms of anastomotic leak, esophageal stricture and mortality, keeping other prognostic factors constant. A total of 50 cases of congenital TEF with EA were included and all underwent primary esophageal anastomosis after the ligation of TEF. The gap between the two pouches was meticulously measured intraoperatively using a vernier caliper before the ligation of TEF, and patients were divided into four groups on the basis of gap length. Group A, where gap length was >3.5 cm (ultralong), group B where gap length was 2.1-3.5 cm (long gap), group C where gap length was >1 cm but not more than 2 cm (intermediate group) and group D, where the gap between two esophageal pouches was 1 cm or less (short gap). The incidence of anastomotic leak was 80, 50, 28, 10.5% and the incidence of esophageal stricture was 100, 75, 22.5, 19% after successful primary repair, respectively, in groups A, B, C and D. The mortality was highest in group A (80%) followed by group B (50%) and 22% in group C and least 15.6% in group D. The incidences of esophageal leak and mortality were found to be statistically significant. This classification which is based on easily measurable criteria provides a useful method to predict morbidity, long-term outcome and mortality of EA with TEF surgery.

The structural characteristics and expression of neuropeptides in the esophagus of patients with congenital esophageal atresia and tracheoesophageal fistula

PURPOSE

The aim of this study was to investigate the structural characteristics and the expression of a group of neuropeptides in the esophagus of patients with congenital esophageal atresia and tracheoesophageal fistula (EA-TEF), as well to elucidate the roles of these neuropeptides in the pathogenesis of postoperative incoordination of esophagus after successful surgical repair of EA-TEF.

METHODS

Twenty-four specimens from distal tracheoesophageal fistulas of patients with EA-TEF (EA-TEF group) and 10 esophageal specimens from neonates who died of nonesophageal diseases (control group) were studied. All of the specimens were subjected to routine pathologic study, ultrastructural observation, and immunohistochemical staining for neuron-specific enolase, substance P, vasoactive intestinal polypeptide, and nitric oxide synthase.

RESULTS

In the EA-TEF group, mitochondria were distributed along the membrane of smooth muscle cell, whereas mitochondria in the control group were distributed along the karyotheca of the smooth muscle cells. The ratio of granulated vesicles to clear vesicles in the varicosity of the intramuscular motor nerve ending of the EA-TEF group (0.520 +/- 0.137) was much higher than that in the control group (0.192 +/- 0.020, P < .05). The percentages of specimens shown to have positive expression of neuron-specific enolase and substance P in the EA-TEF group (20.8% and 12.5%, respectively) were significantly lower than those in the control group (90% and 80% respectively, P < .05). The percentages of specimens shown to have positive expression of vasoactive intestinal polypeptide and nitric oxide synthase in the EA-TEF group (83.3% and 75%, respectively) were significantly higher than that in the control group (30% and 10% respectively, P < .05).

CONCLUSION

Imbalance of neurotransmitters excretion in nerve vesicle, abnormal intrinsic dysplasia of nerve plexus and increased expression of certain neuropeptides were the main characteristics of esophagus with abnormal intrinsic innervation, which may be responsible for the postoperative esophageal dysfunction of EA-TEF.

The cumulative incidence of significant gastrooesophageal reflux in patients with oesophageal atresia with a distal fistula--a systematic clinical, pH-metric, and endoscopic follow-up study

BACKGROUND AND AIM

Gastrooesophageal reflux (GER) is common in patients with oesophageal atresia (OA). Complicated GER often manifests itself early after the primary repair (PR) and frequently requires antireflux surgery (ARS). How many patients will be later affected is unknown. We conducted an objective long-term follow-up for the cumulative incidence of OA-associated GER based on pH-metry and histology.

MATERIALS AND METHODS

Sixty-one consecutive patients with their native oesophagus, who underwent PR for OA with a distal fistula from 1989 to 2004, were included. These children were grouped according to the Spitz classification with 77% as type I, 20% as type II, and 3% as type III. Significant heart disease, tracheomalacia, or gastric outlet obstruction occurred in 18.0 %, 9.8%, and 17.3% respectively, and a wide gap between esophageal segments occurred in 13.1%. Endoscopy and pH-metry at 1 year were followed up by endoscopy and selective pH-metry at 3, 5, and 10 years. Gastrooesophageal reflux was considered significant (sGER) when a patient underwent ARS, endoscopic biopsies disclosed at least moderate oesophagitis, or when total or preprandial reflux index were greater than 10% or 5%, respectively, with or without long (>5 minutes) reflux periods). Significant GER was considered resolved if, without need for ARS or medication, pH-metry or biopsies returned to normal and the patient was symptomless for at least 3 years.

RESULTS

The incidence of sGER/(number of assessed patients) at 6 months, 1 year, 3 years, 5 years, and 10 years was 16.3% (61), 39.3% (61), 44.2% (52), 51.2 % (43), and 44.4% (27). Overall, 28/61 (45.9%) of patients had sGER, and 18/28 (64.3%) patients underwent ARS. In one patient, sGER resolved during the follow-up.

CONCLUSION

The number of children with sGER associated with OA more than doubled from 6 months to 1 year after PR. Thereafter, there is a progressive increase in the incidence of sGER with age up to 5 years. Spontaneous resolution of sGER is rare.

Young adult patients with a history of pediatric disease: impact on course of life and transition into adulthood

PURPOSE

To assess the course of life of young adults who grew up with a chronic or life-threatening disease, and to compare their course of life with that of peers from the general population. Optimal transition from pediatric to adult health care requires knowledge of the psychosocial history of patients grown up with a pediatric disease.

METHODS

A total of 508 young adults from the general Dutch population and 650 patients, aged 18-30 years, participated: 348 survivors of childhood cancer, 93 patients with anorectal malformations, 72 patients with Hirschsprung's disease, 61 patients with oesophageal atresia, 76 patients with end-stage renal disease. They completed the Course of Life Questionnaire, which retrospectively assesses the achievement of developmental milestones (autonomy, psychosexual and social development), and risk behavior (antisocial behavior, substance use and gambling).

RESULTS

The young adults grown up with a chronic or life-threatening disease proved to have achieved significantly fewer milestones, or at older age than their peers, in all course-of-life domains. The course of life of young adults grown up with esophageal atresia was not delayed compared with that of their peers, whereas that of survivors of childhood cancer and patients with end-stage renal disease was delayed most.

CONCLUSIONS

Health care providers should help to minimize the harm for children who grow up with a chronic or life-threatening disease by encouraging parents to stimulate social contacts and autonomy. Attention should especially be directed at children and adolescents growing up with childhood cancer or with end-stage renal disease.

Esophagitis and Barrett esophagus after correction of esophageal atresia

BACKGROUND

Gastroesophageal reflux is a frequent problem after esophageal atresia (EA) repair. Our aim was to determine the prevalence of esophagitis and Barrett esophagus more than 10 years after repair of EA.

METHODS

Ninety-two patients treated between 1973 and 1985 were included in this prospective study. A questionnaire was completed by 86 patients; esophagogastroscopy was performed in 49 patients.

RESULTS

Only 36 patients had no complaints at all. Thirty-one patients complained of difficulties swallowing solid food; 23 complained of heartburn. Esophagogastroscopy revealed grade 3 esophagitis in 2 patients and a macroscopic image of Barrett esophagus in 2. Histology showed esophagitis in 30 patients, gastric metaplasia in 3, and no intestinal metaplasia (Barrett esophagus).

CONCLUSIONS

For epidemiologic reasons, that is, the short interval of follow-up (10 years) and the low compliance of the study group, larger numbers are needed to decide if routine long-term endoscopic screening after repair of EA is necessary. For now, it cannot yet be recommended. The prevalence of symptoms of gastroesophageal reflux disease in this study group is higher than that in the general population, but we found no severe complications of gastroesophageal reflux in the pediatric age group.

The usefulness of videomanometry for studying pediatric esophageal motor disease

PURPOSE

Abnormalities in esophageal motor function underlie various symptoms in the pediatric population. Manometry remains an important tool for studying esophageal motor function, whereas its analyses have been conducted with considerable subjective interpretation. The usefulness of videomanometry with topographic analysis was examined in the current study.

METHODS

Videomanometry was conducted in 5 patients with primary gastroesophageal reflux disease (GERD), 4 with postoperative esophageal atresia (EA), 1 with congenital esophageal stenosis (CES), and 1 with diffuse esophageal spasms (DES). Digitized videofluoroscopic images were recorded synchronously with manometric digital data in a personal computer. Manometric analysis was conducted with a view of concurrent esophageal contour and bolus transit.

RESULTS

Primary GERD patients showed esophageal flow proceeding into the stomach during peristaltic contractions recorded manometrically, whereas patients with EA/CES frequently showed impaired esophageal transit during defective esophageal peristaltic contractions. A characteristic corkscrew appearance and esophageal flow in a to-and-fro fashion were seen with high-amplitude synchronous esophageal contractions in a DES patient. The topographic analysis showed distinctive images characteristic of each pathological condition.

CONCLUSIONS

Videomanometry is helpful in interpreting manometric data by analyzing concurrent fluoroscopic images. Topographic analyses provide characteristic images reflecting motor abnormalities in pediatric esophageal disease.

Does postoperative pH monitoring predict complicated gastroesophageal reflux in patients with esophageal atresia?

Gastroesophageal reflux (GER) is common after repair of esophageal atresia with a distal tracheoesophageal fistula (EATOF). In a retrospective study we assessed whether early 18-h pH monitoring can predict the development of EATOF-associated gastroesophageal reflux. During 1980-1997, 90 consecutive patients had primary repair for EATOF. Development of GER was classified as favorable if the patient developed no esophagitis or mild esophagitis and needed no antireflux medication, and as unfavorable if the patient developed moderate or secondary esophagitis or required an antireflux procedure. Patients who developed unfavorable GER outcome before pH monitoring or needed secondary reconstruction or those whose endoscopic follow-up data were insufficient were excluded. Eighteen-hour pH monitoring was considered pathologic if esophageal pH was <4 more than 10% of the recorded time or 5% of the recorded time minus 2 h after each meal, or if there were more than three preprandial reflux periods lasting longer than 5 min. A total of fifty patients were included into the study. pH monitoring was performed at the median age of 9.2 (range 2.5-95.0) months and classified as pathologic in 10 and normal in 40 patients. After a median follow-up of 59 (0.3-217.6) months, nine of 10 (90%) patients with pathologic pH monitoring and five of 40 (12.5%) patients with normal pH monitoring developed unfavorable outcomes ( p<.05). We conclude that early pH monitoring predicts the development of significant GER, but because 12.5% of patients with normal early pH monitoring also developed significant GER, early pH monitoring alone does not rule out the development of significant GER.