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Davis SE, Davis C, Patel N, Kubba H, Clement WA. Long-term Airway Outcomes and Interventions in Children With Oesophageal Atresia With Tracheoesophageal Fistula: A 20-year Single Centre Observational Study. J Pediatr Surg 2024; 59:1066-1071. [PMID: 38429129 DOI: 10.1016/j.jpedsurg.2024.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 01/10/2024] [Accepted: 02/06/2024] [Indexed: 03/03/2024]
Abstract
BACKGROUND Airway anomalies, symptoms and interventions are commonly reported in children with oesophageal atresia with tracheoesophageal fistula (OA/TOF). The purpose of this study was to assess the incidence of these airway pathologies and those requiring interventions in the long-term. METHODS A retrospective case note review of all patients admitted to the Neonatal Unit at the Royal Hospital for Children, Glasgow between January 2000 and December 2015 diagnosed with OA/TOF. Included patients had a minimum of 5 years follow-up. RESULTS 121 patients were identified. 118 proceeded to OA/TOF repair. 115 patients had long-term follow-up data. Ninety-five (83%) children had one or more airway symptom recorded. Thirty-six (31%) neonates underwent airway endoscopy at the time of their initial OA/TOF repair. Forty-six (40%) children underwent airway endoscopy at a later date due to airway symptoms. Airway pathologies identified included airway malacia, thirty-two (28%), subglottic stenosis, eleven (10%), tracheal pouch, twenty-five (22%), laryngeal cleft, seven (6%) and recurrent fistula, five (4%). Airway interventions included endoscopic division of tracheal pouch, ten (9%), tracheostomy, seven (6%), aortopexy, six (5%), repair of recurrent fistula, five (4%), endoscopic repair of laryngeal cleft, three (3%) and four (3%) required open airway reconstruction for subglottic stenosis. One child (1%) remains tracheostomy dependent. CONCLUSIONS Long-term airway pathologies are common in children with OA/TOF. Many of these are remediable with surgical intervention. Clinicians should be cognisant of this and refer to Airway Services appropriately.
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Affiliation(s)
- Sandra E Davis
- Department of Paediatric Surgery, Royal Hospital for Children, Glasgow, United Kingdom.
| | - Carl Davis
- Department of Paediatric Surgery, Royal Hospital for Children, Glasgow, United Kingdom
| | - Neil Patel
- Department of Neonatology, Royal Hospital for Children, Glasgow, United Kingdom
| | - Haytham Kubba
- Department of Paediatric Otolaryngology Head and Neck Surgery, Royal Hospital for Children, Glasgow, United Kingdom
| | - W Andrew Clement
- Department of Paediatric Otolaryngology Head and Neck Surgery, Royal Hospital for Children, Glasgow, United Kingdom
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Surgical Management of Acute Life-Threatening Events affecting Esophageal Atresia and/or Tracheoesophageal Fistula Patients. J Pediatr Surg 2023; 58:803-809. [PMID: 36797107 DOI: 10.1016/j.jpedsurg.2023.01.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 01/05/2023] [Indexed: 01/19/2023]
Abstract
BACKGROUND Following surgical correction, many patients with esophageal atresia with or without tracheoesophageal fistula (EA/TEF) present to the emergency department (ED) with acute airway complications. We sought to determine the incidence and risk factors for severe acute life-threatening events (ALTEs) in pediatric patients with repaired congenital EA/TEF and the outcomes of operative interventions. METHODS A retrospective cohort chart review was performed on patients with EA/TEF with surgical repair and follow-up at a single centre from 2000 to 2018. Primary outcomes included 5-year ED visits and/or hospitalizations for ALTEs. Demographic, operative, and outcome data were collected. Chi-square tests and univariate analyses were performed. RESULTS In total, 266 EA/TEF patients met inclusion criteria. Of these, 59 (22.2%) had experienced ALTEs. Patients with low birth weight, low gestational age, documented tracheomalacia, and clinically significant esophageal strictures were more likely to experience ALTEs (p < 0.05). ALTEs occurred prior to 1 year of age in 76.3% (45/59) of patients with a median age at presentation of 8 months (range 0-51 months). Recurrence of ALTEs after esophageal dilatation was 45.5% (10/22), mostly due to stricture recurrence. Patients experiencing ALTEs received anti-reflux procedures (8/59, 13.6%), airway pexy procedures (7/59, 11.9%), or both (5/59, 8.5%) within a median age of 6 months of life. The resolution and recurrence of ALTEs after operative interventions are described. CONCLUSION Significant respiratory morbidity is common among patients with EA/TEF. Understanding the multifactorial etiology and operative management of ALTEs have an important role in their resolution. TYPE OF STUDY Original Research, Clinical Research. LEVEL OF EVIDENCE Level III Retrospective Comparative Study.
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Londahl M, Irace AL, Kawai K, Dombrowski ND, Jennings R, Rahbar R. Prevalence of Laryngeal Cleft in Pediatric Patients With Esophageal Atresia. JAMA Otolaryngol Head Neck Surg 2019; 144:164-168. [PMID: 29270628 DOI: 10.1001/jamaoto.2017.2682] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Esophageal atresia (EA), with or without tracheoesophageal fistula (TEF), and laryngeal cleft are rare congenital anomalies that often occur together. Previous reports have established a link between EA/TEF and laryngeal cleft, but there have been no large case series to further characterize this relationship. Objectives To assess the prevalence of laryngeal cleft among patients with EA/TEF, identify associations between types of laryngeal cleft and EA/TEF, and identify factors associated with the timing of diagnosis for both conditions. Design, Setting, and Participants Retrospective analysis of 270 patients. The Esophageal Atresia database was used to identify patients seen at the Esophageal and Airway Treatment (EAT) Center at Boston Children's Hospital, Boston, Massachusetts, a tertiary referral hospital, from August 1, 2009, to August 1, 2016. Patients were included if they were younger than 18 years at the time they were diagnosed with EA, TEF, or both and had undergone a procedure or examination by a surgeon from the EAT Center. Patients with acquired airway or esophageal problems were excluded. Main Outcomes and Measures Data regarding patient demographics, primary diagnoses, dates of diagnosis, comorbidities, and airway/esophageal surgical interventions were collected and analyzed. Association between type of EA/TEF and laryngeal cleft type was evaluated. Secondary outcomes were age at diagnosis between patients who resided in Massachusetts and those who resided outside the state. Results Of 270 patients diagnosed with EA/TEF during the 7-year period, 138 (51.1%) were male, and the median age at diagnosis of EA/TEF was 1.0 years (IQR, 0.4-2.0) and at diagnosis of laryngeal cleft was 1.1 years (interquartile range [IQR], 0.6-2.8). Laryngeal cleft was diagnosed in 53 of the 270 patients (19.6%) (95% CI, 14.9%-24.4%). No apparent difference was found in the distribution of types of laryngeal cleft by type of EA/TEF. Among patients with EA/TEF type A or B, 9 patients (56%) had a type I cleft, 6 (38%) had a type II cleft, and 1 (6%) had a type III cleft. Among those with EA/TEF type C or D, 20 (57%) had a type I cleft, 11 (31%) had a type II cleft, and 3 (9%) had a type III cleft. Out-of-state patients were more likely to be diagnosed with EA/TEF at an older age than in-state patients (mean difference, 1.5 years; 95% CI, 0-2.9 years). Conclusions and Relevance Pediatric patients with EA/TEF have a much greater prevalence of laryngeal cleft than the general population. Multidisciplinary esophageal and airway programs serve as an ideal clinical setting for management of EA/TEF.
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Affiliation(s)
- Monica Londahl
- Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital, Boston, Massachusetts
| | - Alexandria L Irace
- Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital, Boston, Massachusetts
| | - Kosuke Kawai
- Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital, Boston, Massachusetts.,Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts
| | - Natasha D Dombrowski
- Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital, Boston, Massachusetts
| | - Russell Jennings
- Department of Surgery, Boston Children's Hospital, Boston, Massachusetts.,Department of Surgery, Harvard Medical School, Boston, Massachusetts
| | - Reza Rahbar
- Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital, Boston, Massachusetts.,Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts
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Mirra V, Maglione M, Di Micco LL, Montella S, Santamaria F. Longitudinal Follow-up of Chronic Pulmonary Manifestations in Esophageal Atresia: A Clinical Algorithm and Review of the Literature. Pediatr Neonatol 2017; 58:8-15. [PMID: 27328637 DOI: 10.1016/j.pedneo.2016.03.005] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Revised: 12/26/2015] [Accepted: 03/30/2016] [Indexed: 01/17/2023] Open
Abstract
In the past decades improved surgical techniques and better neonatal supportive care have resulted in reduced mortality of patients with esophageal atresia (EA), with or without tracheoesophageal fistula, and in increased prevalence of long-term complications, especially respiratory manifestations. This integrative review describes the techniques currently used in the pediatric clinical practice for assessing EA-related respiratory disease. We also present a novel algorithm for the evaluation and surveillance of lung disease in EA. A total of 2813 articles were identified, of which 1451 duplicates were removed, and 1330 were excluded based on review of titles and abstracts. A total of 32 articles were assessed for eligibility. Six reviews were excluded, and 26 original studies were assessed. Lower respiratory tract infection seems frequent, especially in the first years of life. Chronic asthma, productive cough, and recurrent bronchitis are the most common respiratory complaints. Restrictive lung disease is generally reported to prevail over the obstructive or mixed patterns, and, overall, bronchial hyperresponsiveness can affect up to 78% of patients. At lung imaging, few studies detected bronchiectasis and irregular cross-sectional shape of the trachea, whereas diffuse bronchial thickening, consolidations, and pleural abnormalities were the main chest X-ray findings. Airway endoscopy is seldom included in the available studies, with tracheomalacia and tracheobronchial inflammation being described in a variable proportion of cases. A complete diagnostic approach to long-term respiratory complications after EA is mandatory. In the presence of moderate-to-severe airway disease, patients should undergo regular tertiary care follow-up with functional assessment and advanced chest imaging.
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Affiliation(s)
- Virginia Mirra
- Department of Translational Medical Sciences, Federico II University, Naples, Italy
| | - Marco Maglione
- Department of Translational Medical Sciences, Federico II University, Naples, Italy
| | - Laida L Di Micco
- Department of Translational Medical Sciences, Federico II University, Naples, Italy
| | - Silvia Montella
- Department of Translational Medical Sciences, Federico II University, Naples, Italy
| | - Francesca Santamaria
- Department of Translational Medical Sciences, Federico II University, Naples, Italy.
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ESPGHAN-NASPGHAN Guidelines for the Evaluation and Treatment of Gastrointestinal and Nutritional Complications in Children With Esophageal Atresia-Tracheoesophageal Fistula. J Pediatr Gastroenterol Nutr 2016; 63:550-570. [PMID: 27579697 DOI: 10.1097/mpg.0000000000001401] [Citation(s) in RCA: 214] [Impact Index Per Article: 26.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Esophageal atresia (EA) is one of the most common congenital digestive anomalies. With improvements in surgical techniques and intensive care treatments, the focus of care of these patients has shifted from mortality to morbidity and quality-of-life issues. These children face gastrointestinal (GI) problems not only in early childhood but also through adolescence and adulthood. There is, however, currently a lack of a systematic approach to the care of these patients. The GI working group of International Network on Esophageal Atresia comprises members from ESPGHAN/NASPGHAN and was charged with the task of developing uniform evidence-based guidelines for the management of GI complications in children with EA. METHODS Thirty-six clinical questions addressing the diagnosis, treatment, and prognosis of the common GI complications in patients with EA were formulated. Questions on the diagnosis, and treatment of gastroesophageal reflux, management of "cyanotic spells," etiology, investigation and management of dysphagia, feeding difficulties, anastomotic strictures, congenital esophageal stenosis in EA patients were addressed. The importance of excluding eosinophilic esophagitis and associated GI anomalies in symptomatic patients with EA is discussed as is the quality of life of these patients and the importance of a systematic transition of care to adulthood. A systematic literature search was performed from inception to March 2014 using Embase, MEDLINE, the Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Clinical Trials, and PsychInfo databases. The approach of the Grading of Recommendations Assessment, Development and Evaluation was applied to evaluate outcomes. During 2 consensus meetings, all recommendations were discussed and finalized. The group members voted on each recommendation, using the nominal voting technique. Expert opinion was used where no randomized controlled trials were available to support the recommendation.
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Hseu A, Recko T, Jennings R, Nuss R. Upper Airway Anomalies in Congenital Tracheoesophageal Fistula and Esophageal Atresia Patients. Ann Otol Rhinol Laryngol 2015; 124:808-13. [DOI: 10.1177/0003489415586844] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective: To examine the prevalence of upper airway anomalies in patients diagnosed with congenital tracheoesophageal fistula and esophageal atresia (TEF/EA). Methods: A retrospective review was conducted of all TEF/EA patients seen at a tertiary pediatric hospital between January 2008 and December 2013. Inclusion criteria included evaluation by the otolaryngology service. Exclusion criteria included age >18 years, acquired TEF/EA, subsequent rule out of TEF/EA, and otolaryngology evaluation for reasons not pertaining to the airway. Data collected and analyzed included demographics, comorbidities, presenting symptoms, surgical interventions, laryngoscopic and bronchoscopic examinations, and subsequent medical and surgical management. Results: Four hundred and thirty patients were diagnosed with TEF/EA at our institution. In all, 32.3%, or 139 children, were included in the analysis; 56.1% (n = 78) male, 43.9% (n = 61) female. Of the analyzed patients, 4.3% (n = 6) were diagnosed with laryngomalacia. Eighteen patients (12.9%) were diagnosed with subglottic stenosis. Thirty (21.6%) had vocal fold paresis or immobility. Laryngeal cleft was diagnosed in 25.9% (n = 36). Tracheomalacia was the most common airway finding, diagnosed in 37.4% (n = 52) patients. Conclusion: Patients diagnosed with congenital TEF/EA have a high rate of secondary upper airway anomalies. Consideration should be given to perform a complete airway evaluation in all of these patients.
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Affiliation(s)
- Anne Hseu
- Department of Otolaryngology and Communication Enhancement, Boston Children’s Hospital, Boston, Massachusetts, USA
| | - Thomas Recko
- Department of Otolaryngology and Communication Enhancement, Boston Children’s Hospital, Boston, Massachusetts, USA
| | - Russell Jennings
- Department of Pediatric Surgery, Boston Children’s Hospital, Boston, Massachusetts, USA
| | - Roger Nuss
- Department of Otolaryngology and Communication Enhancement, Boston Children’s Hospital, Boston, Massachusetts, USA
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Kay-Rivest E, Baird R, Laberge JM, Puligandla PS. Evaluation of aortopexy in the management of severe tracheomalacia after esophageal atresia repair. Dis Esophagus 2015; 28:234-9. [PMID: 24446971 DOI: 10.1111/dote.12179] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Severe tracheomalacia (TM) is a difficult problem in esophageal atresia (EA) patients. We reviewed our experience with aortopexy and other interventions for severe TM in this population. With review ethics board approval, a retrospective review of TM in postoperative EA patients was conducted (1989-2010). Demographics, perinatal, and surgical information regarding EA repair was collected. TM infants were analyzed for symptomatology, clinical severity, investigations, interventions, and outcomes. Data are presented as proportions or median(range). One hundred and thirty-two EA patients were reviewed. Most had type C atresia (87.3%), and 18 patients (13.6%) died. Twenty-five patients (18.9%) had TM of whom five (20%) died. Median symptom onset was 18 days (0-729) after EA repair, with stridor (64%) or retractions/distress (44%) being most frequent. Four and two patients had airway obstruction or cardiorespiratory arrest, respectively. Median time from symptom onset to investigations was 11 days; these were most commonly rigid bronchoscopy (56%) and fluoroscopy (36%). Ten patients (40%) had severe TM on bronchoscopy. Six underwent aortopexy, one fundoplication, and three were treated medically. Length of hospital stay (LOS) post-aortopexy was 13 days (5-60), and ventilation time was 2 days (0-9). LOS was 60.5 (1-69) days postdiagnosis in non-aortopexy patients. Readmission rates for respiratory issues were significantly less in the aortopexy (median 0 vs. 5; P = 0.048) group over 2-year follow up after discharge. Complications of aortopexy included transfusion (1) and temporary diaphragmatic paresis (1), and one mortality secondary to severe congenital cardiac anomalies. Our experience suggests that aortopexy is safe and effective for the treatment of severe TM. It is associated with reduced LOS compared with other treatment strategies and few complications or long-term sequelae.
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Affiliation(s)
- E Kay-Rivest
- The Montreal Children's Hospital, Montreal, Quebec, Canada
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Koivusalo AI, Pakarinen MP, Rintala RJ. Modern outcomes of oesophageal atresia: single centre experience over the last twenty years. J Pediatr Surg 2013; 48:297-303. [PMID: 23414855 DOI: 10.1016/j.jpedsurg.2012.11.007] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2012] [Accepted: 11/12/2012] [Indexed: 12/24/2022]
Abstract
AIM OF THE STUDY The aim of this study was assessment of the contemporary outcomes of oesophageal atresia (OA) in a national paediatric surgical centre. PATIENTS AND METHODS A review of the hospital records of all patients who underwent repair of oesophageal atresia (OA) in our institute between 1991 and 2011 was performed. RESULTS The study included 130 consecutive infants with OA: types A (n=4, 3%), B (n=2, 2%), C (n=110, 85%), D (n=5, 4%), and E (n=9, 7%). Median follow-up was 8.8 (range 0.1-21) years. Twenty-nine (22%) infants had cardiac and 76 (58%) other anomalies, and seventeen (13%) had a long-gap OA. The final repair was primary (n =113, 87%) or delayed (n=3) end-to-end anastomosis, oesophageal replacement (n=8) (6%) with gastric tube (n=4) or with jejunum interposition (n=4), and closure of the trachea-oesophageal fistula (Type E, n=9). Oesophageal continuity was achieved in all patients. Overall mortality was 3/130 (2%) and caused by gastric perforation (n=1), prolonged apnoeic spell (n =1), and food asphyxiation (n=1). Oral feeds were achieved in 121 (94%) children. Eight (6%) children remain dependent on feeding ostomy. Long-gap OA was a major predictor of post-repair complications. CONCLUSION The modern outcome for infants with OA is characterized by an extremely low hospital mortality and satisfactory oesophageal function, enabling full oral feeds in the vast majority of children.
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Affiliation(s)
- Antti I Koivusalo
- Section of Paediatric Surgery, Children's Hospital University of Helsinki, Finland.
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Abstract
Most of the children operated for esophageal atresia will survive the neonatal period. However, medium-term and late complications are frequent in this population. Gastroesophageal reflux disease is observed in 26 to 75% of the cases and can be responsible for peptic esophagitis, anastomotic stenosis, and Barrett esophagus, which is a risk factor for adenocarcinoma of the esophagus. Dysphagia is frequently observed, sometimes several years after the surgery, affecting up to 45% of children at the age of 5 years. Growth retardation is present in nearly one-third of children at the age of 5 years. Ear, nose, and throat and respiratory complications are also very frequent but tend to improve with time. Tracheomalacia is found in 75% of these children at birth, sometimes responsible for severe complications (malaise, bradycardia). Respiratory symptoms are dominated by chronic cough, wheezing, and infections reported in 29% of the children by the age of 5 years. Restrictive, obstructive syndromes and bronchial hyperactivity can be observed, but usually remain moderate. All these complications can influence the patient's quality of life, which is moderately impaired compared to healthy controls. The high frequency of late sequelae in esophageal atresia justifies regular and multidisciplinary follow-up through adulthood.
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Abstract
The pulmonary involvement concurrent with gastrointestinal (GI) diseases is often clinically subtle. Radiological manifestations might lag behind the respiratory compromise, and only such specialized testing as high resolution computed tomography (HRCT), permeability studies with labelled proteins, or comprehensive pulmonary function tests (PFTs) may be sensitive enough to detect the evolving pathophysiology. Increasing recognition of specific entities, such as immune-mediated alveolitis, will allow implementation of therapies that can significantly improve a patient's prognosis.
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Koivusalo AI, Pakarinen MP, Wikström A, Rintala RJ. Assessment and treatment of gastroesophageal reflux in healthy infants with apneic episodes: a retrospective analysis of 87 consecutive patients. Clin Pediatr (Phila) 2011; 50:1096-102. [PMID: 21997146 DOI: 10.1177/0009922811410872] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
This retrospective study sought to assess whether gastroesophageal reflux (GER) is associated with recurrent infant apneic episodes (AEs) and whether its treatment prevents AEs. Symptoms, diagnostic measures, and treatment of GER in 87 infants admitted for AEs were recorded. The effect of GER on recurrent AEs and survival were assessed. Esophageal pH monitoring was done to 58/87 (67%) patients, of whom 53/58 (91%) had a pathological finding; 48 patients had treatment for GER (medical 43%/49%; surgical 5%/6%) with continuing AEs during hospitalization (25%/29% patients) as the main indication. Follow-up (65 patients) disclosed recurrent AEs in 12 (18%) patients (no treatment 4/21, medical 8/39, surgical 0/5, P = NS). All 87 patients survived. Recurrent AEs after discharge was predicted by AEs during hospitalization but not by pathological GER. AEs observed during hospitalization predicted postdischarge AE recurrence. Of GER treatment modalities, only surgery prevented recurrent AEs.
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Zhao R, Li K, Shen C, Zheng S. The outcome of conservative treatment for anastomotic leakage after surgical repair of esophageal atresia. J Pediatr Surg 2011; 46:2274-8. [PMID: 22152864 DOI: 10.1016/j.jpedsurg.2011.09.011] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2011] [Accepted: 09/03/2011] [Indexed: 12/14/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate the clinical outcome of conservative management of anastomotic leakage (AL) after surgical repair for esophageal atresia. METHODS Data from 85 neonates with esophageal atresia who underwent surgical correction were retrospectively analyzed. Conservative treatment had been adopted for AL. The incidence and severity of postoperative AL as well as its effects were analyzed. RESULTS Among the 85 neonates, postoperative AL occurred in 21 (25%) cases, with major leaks in 15 cases and minor leaks in 6. The stricture index of the 21 neonates with AL (0.615 ± 0.032) was significantly different (P = .008) from that of the 64 neonates without leakage (0.509 ± 0.018). The overall incidence of gastroesophageal reflux (GER) was 36%. Esophageal dysmotility and clinically significant tracheomalacia were observed in 69 and 7 infants, respectively, of the 80 surviving patients. The incidence of GER, dysmotility, and tracheomalacia in patients with or without AL was similar. The severity of GER in patients with different numbers of sessions of dilation was significantly different (P = .0015). CONCLUSIONS Postoperative esophageal AL is effectively treatable by conservative methods in most neonates. The occurrence of AL may aggravate the severity of esophageal stricture but does not affect the incidence of GER, esophageal dysmotility, and tracheomalacia.
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Affiliation(s)
- Rui Zhao
- Department of Pediatric Surgery, Children's Hospital of Fudan University, Shanghai, People's Republic of China
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Shah AR, Lazar EL, Atlas AB. Tracheal diverticula after tracheoesophageal fistula repair: case series and review of the literature. J Pediatr Surg 2009; 44:2107-11. [PMID: 19944217 DOI: 10.1016/j.jpedsurg.2009.04.036] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2008] [Revised: 04/28/2009] [Accepted: 04/28/2009] [Indexed: 11/30/2022]
Abstract
BACKGROUND Tracheoesophageal fistula (TEF) is the most common congenital tracheal abnormality, frequently associated with esophageal atresia. Respiratory symptoms are associated with all types of TEF, even after surgical repair of the fistula. Gastroesophageal reflux (GER) with aspiration of gastric contents, structural instability of the airways (tracheomalacia), abnormal respiratory epithelium, abnormal esophageal motility, recurrent TEF, and esophageal stenosis contribute to postsurgical complications. METHODS We review 7 patients between 4 and 14 years of age with a history of TEF repair and persistent or worsening respiratory symptoms despite conventional airway clearance techniques and treatment of GER. RESULTS Bronchoscopic evaluation in all 7 patients revealed tracheomalacia and a diverticulum on the posterior wall of the trachea at the fistula repair site. CONCLUSION We hypothesize that the diverticula impaired airway clearance and contributed to persistent respiratory symptoms. Possible mechanisms for the diverticulum contributing to poor airway clearance include facilitating the pooling of secretions and acting as a "barrier" to the lower airway clearance mechanism. The diagnosis of a diverticulum should be considered early in patients with persistent respiratory symptoms after management of GER and tracheomalacia. Early obliteration of tracheal diverticula might improve respiratory status in some patients.
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Affiliation(s)
- Ashish R Shah
- Respiratory Center For Children, Goryeb Children's Hospital, Atlantic Health, Morristown, NJ 07962, USA.
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Gottrand F, Sfeir R, Coopman S, Deschildre A, Michaud L. Atrésie de l’œsophage : devenir des enfants opérés. Arch Pediatr 2008; 15:1837-42. [DOI: 10.1016/j.arcped.2008.09.027] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2008] [Revised: 09/25/2008] [Accepted: 09/29/2008] [Indexed: 01/24/2023]
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Ein SH, Brindle M. The best 10 clinical articles for the last 50 years from the Division of General Surgery, Hospital for Sick Children, Toronto, Ontario, Canada. J Pediatr Surg 2008; 43:734-9. [PMID: 18405724 DOI: 10.1016/j.jpedsurg.2007.11.035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2007] [Revised: 11/23/2007] [Accepted: 11/27/2007] [Indexed: 11/20/2022]
Abstract
PURPOSE The aim of the review was to present the best 10 clinical articles for the last 50 years (1956-2006) from the Division of General Surgery, Hospital for Sick Children (HSC), Toronto, Canada. These articles were judged by the major change (impact) in clinical practice of pediatric general surgery after their publication. METHODS All clinical articles from 1956 to 2006 inclusively written by members of the division (while working at HSC) were evaluated. The 2 authors of this article (retired honorary staff surgeon and recently trained chief surgical resident/fellow) separately rated the articles. Each lead author (if possible) was asked to comment on "the significance of their paper, then and now." If the lead author was unavailable, 1 of the 2 authors of this article commented on the articles. RESULTS The best 10 clinical articles selected involved spleen trauma, necrotizing enterocolitis, esophageal replacement, Hirschsprung's disease, tracheal compression, fecal incontinence, gastroesophageal reflux, diaphragmatic hernia, and ruptured appendix. There were 8 staff members and 5 surgical residents/fellows who were lead authors, along with 10 staff from other divisions, departments, and/or hospitals. CONCLUSION The conservative management of splenic trauma was judged the best article from this Division that made the largest clinical impact for the last 50 years.
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Affiliation(s)
- Sigmund H Ein
- Division of General Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada.
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Koivusalo A, Pakarinen MP, Rintala RJ. 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. J Pediatr Surg 2007; 42:370-4. [PMID: 17270551 DOI: 10.1016/j.jpedsurg.2006.10.010] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
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.
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Affiliation(s)
- Antti Koivusalo
- Hospital for Children and Adolescents, University of Helsinki, PO BOX 281, 00029, Helsinki, Finland.
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