Oesophageal atresia and tracheo-oesophageal fistula: current management strategies and complications

Successful management of oesophageal atresia in Cameroon, Sub-Saharan Africa

Background

Oesophageal atresia (EA) is the most common congenital anomaly of the oesophagus. Despite improvement of survival observed over the previous two decades in developed countries, the mortality remains very high and the management greatly challenging in resource-poor settings such as Cameroon. We report our experience of management of EA in this environment, with a successful outcome.

Materials and Methods

We prospectively assessed patients diagnosed with EA and operated in January 2019, at the University Hospital Centre of Yaounde. Records were reviewed for demographics, history and physical examinations, radiological findings, surgical procedures and outcomes. The study has received approval from the Institutional Ethics Committees.

Results

In total, six patients (three males and three females, sex ratio, 0.5; mean age at diagnosis, 3.6 days; range, 1-7 days) were assessed. A past history of polyhydramnios was found in one patient (16.7%). All patients were classified Waterston Group A at diagnosis, with Ladd-Swenson type III atresia. Early primary repair was performed in four patients (66.7%) and delayed primary repair in two patients (33.3%). Operative repair mainly involved resection of the fistula, suture of trachea and oesophagus end-to-end anastomosis, followed by interposition of vascularised pleural flap. Patients were followed up 24 months. With one late death, the survival rate was 83.3%.

Conclusion

Improvement has been achieved in the outcomes of neonatal surgery in Africa in the past two decades, but EA-related mortality remains relatively too high. Using simple techniques and available, reproducible equipment can improve survival in resource-poor settings.

Outcome of long gap esophageal atresia at 6 years: A prospective case control cohort study

BACKGROUND DATA

EA is the most frequent congenital esophageal malformation. Long gap EA remains a therapeutic challenge for pediatric surgeons. A case case-control prospective study from a multi-institutional national French data base was performed to assess the outcome, at age of 1 and 6 years, of long gap esophageal atresia (EA) compared with non-long gap EA/tracheo-esophageal fistula (TEF). The secondary aim was to assess whether initial treatment (delayed primary anastomosis of native esophagus vs. esophageal replacement) influenced mortality and morbidity at ages 1 and 6 years.

METHODS

A multicentric population-based prospective study was performed and included all patients who underwent EA surgery in France from January 1, 2008 to December 31, 2010. A comparative study was performed with non-long gap EA/TEF patients. Morbidity at birth, 1 year, and 6 years was assessed.

RESULTS

Thirty-one patients with long gap EA were compared with 62 non-long gap EA/TEF patients. At age 1 year, the long gap EA group had longer parenteral nutrition support and longer hospital stay and were significantly more likely to have complications both early post-operatively and before age 1 year compared with the non-long gap EA/TEF group. At 6 years, digestive complications were more frequent in long gap compared to non-long gap EA/TEF patients. Tracheomalacia was the only respiratory complication that differed between the groups. Spine deformation was less frequent in the long gap group. There were no differences between conservative and replacement groups at ages 1 and 6 years except feeding difficulties that were more common in the native esophagus group.

CONCLUSIONS

Long gap strongly influenced digestive morbidity at age 6 years.

Infant Perioperative Risk Factors and Adverse Brain Findings Following Long-Gap Esophageal Atresia Repair

Recent findings implicate brain vulnerability following long-gap esophageal atresia (LGEA) repair. We explored the relationship between easily quantifiable clinical measures and previously reported brain findings in a pilot cohort of infants following LGEA repair. MRI measures (number of qualitative brain findings; normalized brain and corpus callosum volumes) were previously reported in term-born and early-to-late premature infants (n = 13/group) <1 year following LGEA repair with the Foker process. The severity of underlying disease was classified by an (1) American Society of Anesthesiologist (ASA) physical status and (2) Pediatric Risk Assessment (PRAm) scores. Additional clinical end-point measures included: anesthesia exposure (number of events; cumulative minimal alveolar concentration (MAC) exposure in hours), length (in days) of postoperative intubated sedation, paralysis, antibiotic, steroid, and total parenteral nutrition (TPN) treatment. Associations between clinical end-point measures and brain MRI data were tested using Spearman rho and multivariable linear regression. Premature infants were more critically ill per ASA scores, which showed a positive association with the number of cranial MRI findings. Clinical end-point measures together significantly predicted the number of cranial MRI findings for both term-born and premature infant groups, but none of the individual clinical measures did on their own. Listed easily quantifiable clinical end-point measures could be used together as indirect markers in assessing the risk of brain abnormalities following LGEA repair.

Surgical Management of Acute Life-Threatening Events affecting Esophageal Atresia and/or Tracheoesophageal Fistula Patients

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.

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.

A Spectrum of Ultrasound and MR Imaging of Fetal Gastrointestinal Abnormalities: Part 1 Esophagus to Colon

Ultrasound (US) and magnetic resonance imaging (MRI) are two modalities for diagnosing fetal gastrointestinal (GI) anomalies. Ultrasound (US) is the modality of choice. MRI can be used as a complementary method. Despite its expanding utilization in central nervous system (CNS) fetal malformation, MRI has not yet been established for evaluation of fetal GI abnormalities. Therefore, more attention should be paid to the clinical implications of MRI investigations following screening by US.

From the Ground Up: Esophageal Atresia Types, Disease Severity Stratification and Survival Rates at a Single Institution

Esophageal atresia (EA), although a rare congenital anomaly, represents one of the most common gastrointestinal birth defects. There is a gap in our knowledge regarding the impact of perioperative critical care in infants born with EA. This study addresses EA types, disease severity stratification, and mortality in a retrospective cohort at a single institution. Institutional Review Board approved our retrospective cross-sectional study of term-born (n = 53) and premature infants (28–37 weeks of gestation; n = 31) that underwent primary surgical repair of EA at a single institution from 2009–2020. Demographic and clinical data were obtained from the electronic medical record, Powerchart (Cerner, London, UK). Patients were categorized by (i) sex, (ii) gestational age at birth, (iii) types of EA (in relation to respiratory tract anomalies), (iv) co-occurring congenital anomalies, (v) severity of disease (viz. American Society of Anesthesiologists (ASA) and Pediatric Risk Assessment (PRAm) scores), (vi) type of surgical repair for EA (primary anastomosis vs. Foker process), and (vii) survival rate classification using Spitz and Waterston scores. Data were presented as numerical sums and percentages. The frequency of anatomical types of EA in our cohort parallels that of the literature: 9.5% (8/84) type A, 9.5% (8/84) type B, 80% (67/84) type C, and 1% (1/84) type D. Long-gap EA accounts for 88% (7/8) type A, 75% (6/8) type B, and 13% (9/67) type C in the cohort studied. Our novel results show a nearly equal distribution of sex per each EA type, and gestational age (term-born vs. premature) by anatomical EA type. PRAm scoring showed a wider range of disease severity (3–9) than ASA scores (III and IV). The survival rate in our EA cohort dramatically increased in comparison to the literature in previous decades. This retrospective analysis at a single institution shows incidence of EA per sex and gestational status for anatomical types (EA type A-D) and by surgical approach (primary anastomosis vs. Foker process for short-gap vs. long-gap EA, respectively). Despite its wider range, PRAm score was not more useful in predicting disease severity in comparison to ASA score. Increased survival rates over the last decade suggest a potential need to assess unique operative and perioperative risks in this unique population of patients. Presented findings also represent a foundation for future clinical studies of outcomes in infants born with EA.

Evaluation of pulmonary complications and affecting factors in children for repaired esophageal atresia and tracheoesophageal fistula

INTRODUCTION

Recurrent pulmonary infections, wheezing and stridor due to swallowing dysfunction, esophageal dysmotility, gastroesophageal reflux, tracheomalacia and bronchomalacia are frequently seen complications after esophageal atresia and tracheo-esophageal fistula (EA-TEF) surgeries. This study aimed to investigate the frequency and causes of respiratory problems and to evaluate the factors that affect respiratory morbidity in patients who had undergone EA-TEF repair in a tertiary referral center.

METHODS

Preoperative and postoperative records of patients with EA, TEF + EA and isolated EA were examined retrospectively. Accompanied diseases and swallowing dysfunction symptoms were questioned. Bronchoalveolar lavage results were investigated if the patient had flexible bronchoscopy.

RESULTS

A total of 71 children with EA were included in the study, and seven patients who did not have follow-up after surgery were excluded. 46 of the 64 patients continue regular follow-up visits in our department. Male sex, primary EA repair in another center, EA type C, accompanying genetic anomalies, severe tracheomalacia, late per oral feeding (1 year after surgery), and severe GER were found to cause significantly higher incidence of coughing, recurrent wheezing, recurrent pneumonia, and bronchiectasis despite surgical and medical treatments (p = 0.048, p = 0.045, p = 0.009, p = 0.029, p = 0.025). CONCLUSİON: Even if anatomical anomalies are corrected by surgery in patients who underwent EA repair, precautions can be taken for GERD, laryngotracheomalacia, and swallowing dysfunction, and effective pulmonary rehabilitation can be initiated with early multidisciplinary approach before the development of respiratory tract symptoms.

Pulmonary Manifestations of Genetic Disorders in Children

Congenital bronchopulmonary malformations are relatively common and arise during various periods of morphogenesis. Although some are isolated or sporadic occurrences, others may result from single gene mutations or cytogenetic imbalances. Single gene mutations have been identified, which are etiologically related to primary pulmonary hypoplasia, lung segmentation defects as well as pulmonary vascular and lymphatic lesions. Functional defects in cystic fibrosis, primary ciliary dyskinesias, alpha-1-antitrypsin deficiency, and surfactant proteins caused by gene mutations may result in progressive pulmonary disease. This article provides an overview of pediatric pulmonary disease from a genetic perspective.

SIS/aligned fibre scaffold designed to meet layered oesophageal tissue complexity and properties

With donor organs not readily available, the need for a tissue-engineered oesophagus remains high, particularly for congenital childhood conditions such as atresia. Previous attempts have not been successful, and challenges remain. Small intestine submucosa (SIS) is an acellular matrix material with good biological properties; however, as is common with these types of materials, they demonstrate poor mechanical properties. In this work, electrospinning was performed to mechanically reinforce tubular SIS with polylactic-co-glycolic acid (PLGA) nanofibres. It was hypothesised that if attachment could be achieved between the two materials, then this would (i) improve the SIS mechanical properties, (ii) facilitate smooth muscle cell alignment to support directional growth of muscle cells and (iii) allow for the delivery of bioactive molecules (VEGF in this instance). Through a relatively simple multistage process, adhesion between the layers was achieved without chemically altering the SIS. It was also found that altering mandrel rotation speed affected the alignment of the PLGA nanofibres. SIS-PLGA scaffolds performed mechanically better than SIS alone; yield stress improvement was 200% and 400% along the longitudinal and circumferential directions, respectively. Smooth muscle cells cultured on the aligned fibres showed resultant unidirectional alignment. In vivo the SIS-PLGA scaffolds demonstrated limited foreign body reaction judged by the type and proportion of immune cells present and lack of fibrous encapsulation. The scaffolds remained intact at 4 weeks in vivo, and good cellular infiltration was observed. The incorporation of VEGF within SIS-PLGA scaffolds increased the blood vessel density of the surrounding tissues, highlighting the possible stimulation of endothelialisation by angiogenic factor delivery. Overall, the designed SIS-PLGA-VEGF hybrid scaffolds might be used as a potential matrix platform for oesophageal tissue engineering. In addition to this, achieving improved attachment between layers of acellular matrix materials and electrospun fibre layers offers the potential utility in other applications. STATEMENT OF SIGNIFICANCE: Because of its multi-layered nature and complex structure, the oesophagus tissue poses several challenges for successful clinical grafting. Therefore, it is promising to utilise tissue engineering strategies to mimic and form structural compartments for its recovery. In this context, we investigated the use of tubular small intestine submucosa (SIS) reinforced with polylactic-co-glycolic acid (PLGA) nanofibres by using electrospinning and also, amongst other parameters, the integrity of the bilayered structure created. This was carried out to facilitate smooth muscle cell alignment, support directional growth of muscle cells and allow the delivery of bioactive molecules (VEGF in this study). We evaluated this approach by using in vitro and in vivo models to determine the efficacy of this new system.

Oesophageal atresia

Oesophageal atresia (EA) is a congenital abnormality of the oesophagus that is caused by incomplete embryonic compartmentalization of the foregut. EA commonly occurs with a tracheo-oesophageal fistula (TEF). Associated birth defects or anomalies, such as VACTERL association, trisomy 18 or 21 and CHARGE syndrome, occur in the majority of patients born with EA. Although several studies have revealed signalling pathways and genes potentially involved in the development of EA, our understanding of the pathophysiology of EA lags behind the improvements in surgical and clinical care of patients born with this anomaly. EA is treated surgically to restore the oesophageal interruption and, if present, ligate and divide the TEF. Survival is now ~90% in those born with EA with severe associated anomalies and even higher in those born with EA alone. Despite these achievements, long-term gastrointestinal and respiratory complications and comorbidities in patients born with EA are common and lead to decreased quality of life. Oesophageal motility disorders are probably ubiquitous in patients after undergoing EA repair and often underlie these complications and comorbidities. The implementation of several new diagnostic and screening tools in clinical care, including high-resolution impedance manometry, pH-multichannel intraluminal impedance testing and disease-specific quality of life questionnaires now provide better insight into these problems and may contribute to better long-term outcomes in the future.

Strategies for improving early nutritional outcomes in children with oesophageal atresia and congenital diaphragmatic hernia

Post-natal growth in surgical lung conditions, such as congenital diaphragmatic hernia and oesophageal atresia with tracheo-oesophageal fistula, is often sub-optimal in the early years of life when lung growth is occurring. Whilst constitutional, behavioural and mechanical factors may contribute to poor feeding and weight gain, there is a common path of management with greater caloric supplementation that may change growth trajectories and potentially lead to better respiratory, anthropometric and cognitive outcomes. We provide simple, single page, feeding supplementation sheets in three age groups: 0-6months, 6-12months and 12-24months that have proven useful for enhancing weight gain in our patients.

Recurrent tracheoesophageal fistula in an adolescent without persistent symptoms: A case report

RATIONALE

Congenital esophageal atresia (EA) and tracheoesophageal fistula (TEF) ininfants have been treated well with surgery. Approximately 10% of children displayed recurrent fistula. In the present case, we reported recurrent TEF in an adolescent as a complication of EA/TEF in infancy.

PATIENT CONCERNS

An infant was diagnosed with gross type C congenital EA and TEF and subsequentlyunderwent repair in early infancy, with division of the TEF and primary esophageal anastomosis. Postoperative esophageal strictures developed and were relieved by bougienage of the esophagus partially. Then, the child had normal growth with mild symptoms, mainly choking when drinking water. At 11 years of age, the child developed fever and cough, and massive bronchiectasis in lobus inferior pulmonis sinister was found.

DIAGNOSIS

Recurrent tracheoesophageal fistula.

INTERVENTIONS

Division of the TEF and esophageal replacement with gastric tube was performed as treatment OUTCOMES:: The child recovered well.

LESSONS

Recurrent tracheoesophageal fistula aftercongenital EA and TEF could be diagnosed in adolescence. Massive bronchiectasis might develop without apparent symptoms.

Preoperative management of children with esophageal atresia: current perspectives

Esophageal atresia remains one of the most challenging congenital anomalies of the newborn. In recent years, because of the advances in prenatal diagnosis, neonatal critical care, and surgical procedures, overall outcomes have improved substantially, including for premature children. Nowadays, most of the research is focused on medium- and long-term morbidity, with particular reference to respiratory and gastroesophageal problems; the high frequency of late sequelae in esophageal atresia warrants regular and multidisciplinary checkups throughout adulthood. Surprisingly, there are few studies on the impact of prenatal diagnosis and there is continuing debate over the prenatal and preoperative management of these complex patients. In this review, we analyze the literature surrounding current knowledge on the management of newborns affected by esophageal atresia, focusing on prenatal management and preoperative assessment.

Does continuous positive airway pressure for extubation in congenital tracheoesophageal fistula increase the risk of anastomotic leak? A retrospective cohort study

AIM

Immediate post-operative care of tracheoesophageal fistula (TEF) and oesophageal atresia (EA) requires mechanical ventilation. Early extubation is preferred, but subsequent respiratory distress may warrant re-intubation. Continuous positive airway pressure (CPAP) is a well-established modality to prevent extubation failures in preterm infants. However, it is not favoured in TEF/EA, because of the theoretical risk of oesophageal anastomotic leak (AL). The aim of this study was to find out if post-extubation CPAP is associated with increased risk of AL.

METHODS

Retrospective cohort study (2007-2014).

RESULTS

Fifty-one infants underwent primary repair in the newborn period. Median age at surgery was 24 h (interquartile range: 12, 24). In the post-extubation period, 10 received CPAP, whereas 41 did not. The median post-operative day at the commencement of CPAP was 2.5 days (interquartile range: 1, 6 days). Zero out of 10 in the CPAP group and 4/41 in the 'no CPAP' group developed AL on routine post-operative contrast studies (P = 0.57). Zero out of 10 in the CPAP group and 1/41 in the 'no CPAP group' developed recurrence of TEF necessitating re-surgery (P = 1.00). The neonate with recurrent fistula also had coarctation of aorta and needed protracted hospitalisation of 6 months, mainly because of the recurrence of TEF.

CONCLUSION

The use of CPAP in the immediate post-extubation period after corrective surgery for TEF/EA appears to be safe and may not be associated with increased risk of AL or recurrence of the fistula. Information from other centres, surveys and large databases is needed to define the benefits and risks of use of CPAP in these infants.

Peri-operative management of neonates with oesophageal atresia and tracheo-oesophageal fistula

Oesphageal atresia is a relatively common congenital anomaly that requires urgent diagnosis, transfer to a neonatal surgical centre and management by a multidisciplinary team. Peri-operative management requires vigilant monitoring for the many possible associated morbidities. There are unique anaesthetic, airway and ventilatory considerations for this group of patients. Beyond the perinatal period, systematic neurodevelopmental follow-up is recommended to better understand the longer term outcomes for these children.

Neurodevelopmental outcomes of tracheoesophageal fistulas

PURPOSE

The purpose of this study was to perform a retrospective review of tracheoesophageal fistula (TEF) patients who followed up in a state-sponsored program to assess neurodevelopmental outcomes.

METHODS

Records were reviewed retrospectively of children who underwent TEF repair between August 2001 and June 2014. Children discharged from the neonatal intensive care unit were referred to the state-sponsored Developmental Tracking Infant Progress Statewide (TIPS) program. We reviewed TIPS assessments performed before age 24months and noted referral for early school intervention services. Poor outcomes were defined as scores of "failure" on the screening assessment or referral for enrollment in early intervention services by 24months. Children with TEF were compared with case-matched nonsyndromic children of similar gestational age and birth weight.

RESULTS

Seventy-eight children underwent TEF repair. Thirty-eight followed up with TIPS. Survival was 93.6%. Predictors of hospital survival were Waterston classification (p=0.001), birth weight (p=0.027), and ventilator days (p=0.013). LOS was the only significant predictor of referral for early intervention services (p=0.0092) in multivariate analysis. There was a borderline significant difference in referral rate between children with TEF and controls. 52.6% of TEF patients were referred, while 34.2% of controls were referred (p=0.071).

CONCLUSION

More than half of TEF patients experience neurodevelopmental delays requiring referral for early intervention (53%).

Common respiratory conditions of the newborn

KEY POINTS

Respiratory distress is a common presenting feature among newborn infants.Prompt investigation to ascertain the underlying diagnosis and appropriate subsequent management is important to improve outcomes.Many of the underlying causes of respiratory distress in a newborn are unique to this age group.A chest radiograph is crucial to assist in diagnosis of an underlying cause.

EDUCATIONAL AIMS

To inform readers of the common respiratory problems encountered in neonatology and the evidence-based management of these conditions.To enable readers to develop a framework for diagnosis of an infant with respiratory distress. The first hours and days of life are of crucial importance for the newborn infant as the infant adapts to the extra-uterine environment. The newborn infant is vulnerable to a range of respiratory diseases, many unique to this period of early life as the developing fluid-filled fetal lungs adapt to the extrauterine environment. The clinical signs of respiratory distress are important to recognise and further investigate, to identify the underlying cause. The epidemiology, diagnostic features and management of common neonatal respiratory conditions are covered in this review article aimed at all healthcare professionals who come into contact with newborn infants.

Oesophageal atresia and tracheo-oesophageal fistula in Western Australia: Prevalence and trends

AIM

A recent international study reported a higher prevalence of oesophageal atresia with or without tracheo-oesophageal fistula (OA±TOF) in Western Australia (WA). The aim of this study was to examine the prevalence and trends of OA and/or TOF in WA, determine the proportion of cases with associated anomalies and explore the impact of time of diagnosis.

METHODS

The study population comprised all infants born in WA, 1980-2009, and registered with OA and/or TOF on the WA Register of Developmental Anomalies (WARDA).

RESULTS

OA±TOF and TOF alone affect, on average, one in every 2927 births in WA, with a total prevalence of 3.00 and 0.42 per 10 000 births, respectively. The prevalence of OA±TOF increased by 2.0% per annum, with only cases with associated anomalies (64% of cases) demonstrating an increase. TOF rates were stable. Among OA±TOF infants, the proportion of live births, stillbirths and elective terminations of pregnancy for fetal anomaly (TOPFA) was 79%, 6% and 15%, respectively, whereas the majority (94%) of TOF only cases were live births. In 2000-2009, there was 30% fall in OA±TOF live births with 61 (58%) cases diagnosed in first week of life, 10 (9%) prenatally and 34 (32%) at post-mortem only.

CONCLUSIONS

A higher prevalence of OA±TOF in WA was observed with increase over time attributable to increase with associated anomalies. Consistent reporting, availability of prenatal diagnosis and ascertainment of cases following TOPFA or post-mortem examinations can significantly affect prevalence of OA and/or TOF.

Ground zero: not asthma at all

Upper airway obstruction is commonly misdiagnosed as asthma. We report on four children with recurrent respiratory symptoms who had been erroneously diagnosed as having asthma and who received anti-asthma medication for several years. The evaluation of spirometry tracing was neglected in all cases. Subglottic stenosis, tracheomalacia secondary to tracheo-esophageal fistula, double aortic arch, and vocal cord dysfunction were suspected by direct inspection of the flow-volume curves and eventually diagnosed. The value of clinical history and careful evaluation of spirometry tracing in children with persistent respiratory symptoms is critically discussed.

Predictive factors for complications in children with esophageal atresia and tracheoesophageal fistula

The objective of this study was to describe the incidence of complications in children with esophageal atresia (EA) with or without tracheoesophageal fistula (TEF) at a tertiary pediatric hospital and to identify predictive factors for their occurrence. A retrospective chart review of 110 patients born in or transferred to Sydney Children's Hospital with EA/TEF between January 1999 and December 2010 was done. Univariate and multivariate regression analyses were performed to identify predictive factors for the occurrence of complications in these children. From univariate analysis, early esophageal stricture formation was more likely in children with 'long-gap' EA (odds ratio [OR] = 16.32). Patients with early strictures were more likely to develop chest infections (OR = 3.33). Patients with severe tracheomalacia were more likely to experience 'cyanotic/dying' (OR = 180) and undergo aortopexy (OR = 549). Patients who had gastroesophageal reflux disease were significantly more likely to require fundoplication (OR = 10.83) and undergo aortopexy (OR = 6.417). From multivariate analysis, 'long-gap' EA was a significant predictive factor for late esophageal stricture formation (P = 0.007) and for gastrostomy insertion (P = 0.001). Reflux was a significant predictive factor for requiring fundoplication (P = 0.007) and gastrostomy (P = 0.002). Gastrostomy insertion (P = 0.000) was a significant predictive factor for undergoing fundoplication. Having a prior fundoplication (P = 0.001) was a significant predictive factor for undergoing a subsequent aortopexy. Predictive factors for the occurrence of complications post EA/TEF repair were identified in this large single centre pediatric study.

Non-operative advances: what has happened in the last 50 years in paediatric surgery?

Paediatric surgeons remain paediatric clinicians who have the unique skill set to treat children with surgical problems that may require operative intervention. Many of the advances in paediatric surgical care have occurred outside the operating theatre and have involved significant input from medical, nursing and allied health colleagues. The establishment of neonatal intensive care units, especially those focusing on the care of surgical infants, has greatly enhanced the survival rates and long-term outcomes of those infants with major congenital anomalies requiring surgical repair. Educational initiatives such as the advanced trauma life support and emergency management of severe burns courses have facilitated improved understanding and clinical care. Paediatric surgeons have led with the non-operative management of solid organ injury following blunt abdominal trauma. Nano-crystalline burn wound dressings have enabled a reduced frequency of painful dressing changes in addition to effective antimicrobial efficacy and enhanced burn wound healing. Burns care has evolved so that many children may now be treated almost exclusively in an ambulatory care setting or as day case-only patients, with novel technologies allowing accurate prediction of burn would outcome and planning of elective operative intervention to achieve burn wound closure.

Evaluation of decellularization protocols for production of tubular small intestine submucosa scaffolds for use in oesophageal tissue engineering

Small intestine submucosa (SIS) has emerged as one of a number of naturally derived extracellular matrix (ECM) biomaterials currently in clinical use. In addition to clinical applications, ECM materials form the basis for a variety of approaches within tissue engineering research. In our preliminary work it was found that SIS can be consistently and reliably made into tubular scaffolds which confer certain potential advantages. Given that decellularization protocols for SIS are applied to sheet-form SIS, it was hypothesized that a tubular-form SIS would behave differently to pre-existing protocols. In this work, tubular SIS was produced and decellularized by the conventional peracetic acid-agitation method, peracetic acid under perfusion along with two commonly used detergent-perfusion protocols. The aim of this was to produce a tubular SIS that was both adequately decellularized and possessing the mechanical properties which would make it a suitable scaffold for oesophageal tissue engineering, which was one of the goals of this work. Analysis was carried out via mechanical tensile testing, DNA quantification, scanning electron and light microscopy, and a metabolic assay, which was used to give an indication of the biocompatibility of each decellularization method. Both peracetic acid protocols were shown to be unsuitable methods with the agitation-protocol-produced SIS, which was poorly decellularized, and the perfusion protocol resulted in poor mechanical properties. Both detergent-based protocols produced well-decellularized SIS, with no adverse mechanical effects; however, one protocol emerged, SDS/Triton X-100, which proved superior in both respects. However, this SIS showed reduced metabolic activity, and this cytotoxic effect was attributed to residual reagents. Consequently, the use of SIS produced using the detergent SD as the decellularization agent was deemed to be the most suitable, although the elimination of the DNase enzyme would give further improvement.

A nationwide analysis of clinical outcomes among newborns with esophageal atresia and tracheoesophageal fistulas in the United States

BACKGROUND

The aim of this study was to examine national outcomes in newborn patients with esophageal atresia and tracheoesophageal fistula (EA/TEF) in the United Sates.

METHODS

Kids' Inpatient Database (KID) is designed to identify, track, and analyze national outcomes for hospitalized children in the United States. Inpatient admissions for pediatric patients with EA/TEF for kids' Inpatient Database years 2000, 2003, 2006, and 2009 were analyzed. Patient demographics, socioeconomic measures, disposition, survival and surgical procedures performed were analyzed using standard statistical methods.

RESULTS

A total of 4168 cases were identified with diagnosis of EA/TEF. The overall in-hospital mortality was 9%. Univariate analysis revealed lower survival in patients with associated acute respiratory distress syndrome, ventricular septal defect (VSD), birth weight (BW) < 1500 g, gestational age (GA), time of operation within 24 h of admission, coexisting renal anomaly, imperforate anus, African American race, and lowest economic status. Multivariate logistic regression identified BW < 1500 g (odds ratio [OR] = 4.5, P < 0.001), operation within 24 h (OR = 6.9, P < 0.001), GA <28 wk (OR = 2.2, P < 0.030), and presence of VSD (OR = 3.8, P < 0.001) as independent predictors of in-hospital mortality. Children's general hospital and children's unit in a general hospital were found to have a lower mortality rate compared with not identified as a children's hospital after excluding immediate transfers (P = 0.008).

CONCLUSIONS

BW < 1500 g, operation within 24 h, GA < 28 wk, and presence of VSD are the factors that predict higher mortality in EA/TEF population. Despite dealing with more complicated cases, children's general hospital and children's unit in a general hospital were able to achieve a lower mortality rate than not identified as a children's hospital.

Morbidity and mortality in patients with esophageal atresia

BACKGROUND

This study reports national estimates of population characteristics and outcomes for patients with esophageal atresia with or without tracheoesophageal fistula (EA/TEF) and evaluates the relationships between hospital volume and outcomes.

METHODS

Patients admitted within 30 days of life who had International Classification of Diseases, 9th Edition, Clinical Modification diagnosis and procedure codes relevant to EA/TEF during 1999-2012 were identified with the Pediatric Health Information System database. Baseline demographics, comorbidities, and postoperative outcomes, including predictors of in-hospital mortality, were examined up to 2 years after EA/TEF repair.

RESULTS

We identified 3,479 patients with EA/TEF treated at 43 children's hospitals; 37% were premature and 83.5% had ≥1 additional congenital anomaly, with cardiac anomalies (69.6%) being the most prevalent. Within 2 years of discharge, 54.7% were readmitted, 5.2% had a repeat TEF ligation, 11.4% had a repeat operation for their esophageal reconstruction, and 11.7% underwent fundoplication. In-hospital mortality was 5.4%. Independent predictors of mortality included lower birth weight, congenital heart disease, other congenital anomalies, and preoperative mechanical ventilation. There was no relationship between hospital volume and mortality or repeat TEF ligation.

CONCLUSION

This study describes population characteristics and outcomes, including predictors of in-hospital mortality, in EA/TEF patients treated at children's hospitals across the United States. Across these hospitals, rates of mortality or repeat TEF ligation were not dependent on hospital volume.

Retrospective cohort study of long-gap oesophageal atresia

AIM

Long-gap oesophageal atresia (LGOA) remains a rare variant of a relatively common congenital malformation. Objectives of this study were to review the short-term results including survival, length of stay and post-operative complications for infants with LGOA managed at a single centre in addition to their growth and neurodevelopmental assessment.

METHODS

Retrospective review of the case notes of all infants admitted with oesophageal atresia to our institution from January 2001 to May 2011. Infants with LGOA were selected based on pre-defined criteria. Demographic and clinical variables and details of follow-up visits including developmental assessments were extracted from their case notes.

RESULTS

Of 101 infants with oesophageal atresia, 15 fulfilled the criteria for LGOA. Overall survival was 80%. Median length of stay was 83 days. Additional congenital anomalies were present in nine (60%). A fall in weight centile during hospitalisation or outpatient follow-up signifying growth failure was seen in a majority with 11 of 13 patients showing this phenomenon. Follow-up at our institution ranged from 6 months to 9 years. Developmental assessments (Bayley-III) commenced in August 2006 were available in four patients (age 5-13 months) and were abnormal in all, with particular delay in the gross motor domain.

CONCLUSIONS

Infants with LGOA spend a long time in hospital. They remain at significant risk of growth failure during hospitalisation and following discharge. There appears to be a risk of developmental delay that warrants close monitoring.

Early developmental outcome following surgery for oesophageal atresia

AIM

To compare the developmental outcome of infants with oesophageal atresia with or without trachea-oesophageal fistula (OA/TOF) who underwent surgery in early infancy with healthy control infants in New South Wales, Australia.

METHODS

Infants diagnosed with OA/TOF requiring surgical intervention were enrolled prospectively between 1 August 2006 and the 31 December 2008. Healthy control infants were enrolled in the same time period. The children underwent a developmental assessment at 1 year of age (corrected) using the Bayley Scales of Infant and Toddler Development (Version III).

RESULTS

Of 34 infants with OA/TOF that were enrolled, 31 had developmental assessments. The majority (75%) were term infants (≥37 weeks gestation) with a mean birth weight of 2717 g. Fourteen infants (44%) had an associated birth defect and one infant with multiple associated anomalies subsequently died. Developmental assessments were also performed on 62 control infants matched for gestational age. Infants with OA/TOF had a mean score significantly lower on the expressive language subscale (P < 0.05) compared with the control infants.

CONCLUSIONS

This study found a lower than expected developmental score for infants following surgery for OA/TOF in the expressive language subscale compared with the healthy control infants. These findings support concerns over the potential impact of OA/TOF and its effects on development. Further studies, including continuing developmental review to determine whether these differences persist and their functional importance, should be performed.

Esophageal atresia with proximal tracheoesophageal fistula: a missed diagnosis

AIM OF THE STUDY

This retrospective study was performed to compare the relative incidence of esophageal atresia (EA) with proximal tracheoesophageal fistula (PTEF) at our institution with those reported in literature and to test the hypothesis that our higher relative incidence is caused by the routine use of tracheoscopy.

METHODS

A total of 204 children with EA were managed at our institution from 1981 to 2012. The type of EA and the diagnostic assessment were noted, and the relative incidence of PTEF was calculated. For patients managed from 1981 to 2003 (Group 1), the PTEF was diagnosed by contrast esophagogram or during surgical repair. For those born after 2004 (Group 2), the final diagnosis was made by routine rigid tracheoscopy performed preoperatively. The relative incidence of PTEF was compared between these two groups and with those reported in 15 selected published large series, encompassing 4197 patients with EA.

MAIN RESULTS

Of 204 patients with EA, 10 had PTEF, with a relative incidence of 4.9%, statistically higher than those reported in reference group (1.14%, P<0.001). The routine employ of tracheoscopy involved a higher relative incidence of PTEF (Group 2=11.11%, Group 1=3.14%, P=0.038). The age of diagnosis of PTEF was 2.8 days for children of Group 2 and 4.2 days for Group 1 (P=0.038).

CONCLUSION

The presence of the proximal TEF should be always ruled out before surgery. Routine employ of rigid tracheoscopy avoids delay of the diagnosis, improves diagnostic accuracy, and involves a higher relative incidence of proximal fistul. This procedure should be recommended in children undergoing EA repair.

Recurrent lower respiratory tract infections in children: a practical approach to diagnosis

Many children are affected by recurrent lower respiratory tract infections (LRTIs), but the majority of them do not suffer from serious lung or extrapulmonary disease. The challenge for clinicians is to distinguish the recurrent RTIs with self-limiting or minor problems from those with underlying disease. The aim of this review is to describe a practical approach to children with recurrent LRTIs that limits unnecessary, expensive and time-consuming investigations. The children can be divided into three groups on the basis of their personal and family history and clinical findings: 1) otherwise healthy children who do not need further investigations; 2) those with risk factors for respiratory infections for whom a wait-and-see approach can be recommended; and 3) those in whom further investigations are mandatory. However, regardless of the origin of the recurrent LRTIs, it is important to remember that prevention by means of vaccines against respiratory pathogens (i.e. type b Haemophilus influenzae, pertussis, pneumococcal and influenza vaccines) can play a key role.

Surgical correction of tracheo-oesophageal fistula and oesophageal atresia in infants with VACTERL association: a retrospective case-control study

INTRODUCTION

VACTERL is a rare, non-random association comprising at least three major component features defined by the acronym, and including Vertebral anomalies, Anorectal malformations, Cardiac defects, Tracheo-oEsophageal fistula with or without oesophageal atresia (TOF/OA), Renal abnormalities and Limb anomalies. The aim of this study was to compare the post-operative outcomes following surgical correction of TOF/OA in infants with VACTERL and isolated TOF/OA.

METHODS

A retrospective case-control study comparing infants with VACTERL (case group) versus infants with isolated TOF/OA (control group) that underwent surgical correction of TOF/OA at our centre between January 2006 and December 2011. Patient demographics, types of anomalies, operative techniques and post-operative outcomes were collected using inpatient and outpatient records.

RESULTS

We identified 30 consecutive infants with TOF/OA. Five infants had VACTERL (17 %) and 15 infants had isolated TOF/OA (50 %). There was no significant difference in the gestational age (P = 0.79), birth weight (P = 0.69) or operative repair (P = 0.14) between groups. Overall, surgical correction of TOF/OA led to satisfactory morbidity. Infants with VACTERL were not at higher risk of post-operative complications, such as oesophageal stricture (P = 0.17) or gastro-oesophageal reflux (P = 1.0), compared to infants with isolated TOF/OA.

CONCLUSIONS

VACTERL association does not increase the risk of post-operative complications following TOF/OA repair.

Early developmental outcomes following major noncardiac and cardiac surgery in term infants: a population-based study

OBJECTIVE

To ascertain developmental differences between term infants after major noncardiac surgery and cardiac surgery compared with healthy control infants in New South Wales, Australia.

STUDY DESIGN

This prospective population-based cohort study enrolled infants between August 1, 2006, and December 31, 2008, who required major noncardiac surgery within the first 90 days of life. Developmental outcomes were compared in these children, cohorts of term infants requiring cardiac surgery, and healthy controls. Infants were assessed at 1 year of age using the Bayley Scales of Infant and Toddler Development, Third Edition (BSID-III).

RESULTS

Of the 784 infants enrolled, 688 (90.2%) of infants alive at 1 year were assessed. Of these, 539 infants were term and were included in the present analysis. Compared with controls, the infants who underwent cardiac surgery had significantly lower (P < .001) mean scores in all 5 BSID-III subscales, and the infants who underwent noncardiac surgery had significantly lower (P < .05) mean scores in 4 of the 5 BSID-III subscales. The greatest difference was in the incidence of gross motor delay in both the cardiac surgery group (OR, 0.25; 95% CI, 0.16-0.41) and the noncardiac surgery group (OR, 0.41; 95% CI, 0.26-0.63).

CONCLUSION

This unique population-based prospective study compared the developmental outcomes of infants who underwent major noncardiac surgery and cardiac surgery. Major surgery in infants was found to be significantly associated with developmental delay at 1 year of age compared with control infants. These data have important implications for interventions and clinical review in the first year of life.

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.

A unique presentation of a standard type C esophageal atresia in a very low-birth-weight neonate

Neonates with esophageal atresia and tracheoesophageal fistula usually present with inability to swallow immediately after birth often associated with respiratory distress. This is an unusual presentation of a very low-birth-weight neonate with a type C tracheoesophageal fistula that was fed for the first 4 days of life through an unintentional tracheogastric tube without incident.

Pulmonary complications of gastrointestinal disorders

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.

Personalized genomic medicine: lessons from the exome

While genomic sequencing methods are powerful tools in the discovery of the genetic underpinnings of human disease, incidentally-revealed novel genomic risk factors may be equally important, both scientifically, and as relates to direct patient care. We performed whole-exome sequencing on a child with VACTERL association who suffered severe post-surgical neonatal pulmonary hypertension, and identified a potential novel genetic risk factor for this complication: a heterozygous mutation in CPSI. Newborn screening results from this patient's monozygotic twin provided evidence that this mutation, in combination with an environmental trigger (in this case, surgery), may have resulted in pulmonary artery hypertension due to inadequate nitric oxide production. Identification of this genetic risk factor allows for targeted medical preventative measures in this patient as well as relatives with the same mutation, and illustrates the power of incidental medical information unearthed by whole-exome sequencing.