Motility, digestive and nutritional problems in Esophageal Atresia

Breast Milk Feeding for Infants Who Required Major Surgery

OBJECTIVE

To identify barriers or facilitators that influenced mothers to provide mother's own milk (MOM) for 6 months to their infants who were hospitalized in the NICU after major surgery.

DESIGN

Descriptive qualitative.

SETTING

An 80-bed, Level 4 NICU of a regional pediatric hospital in the western United States.

PARTICIPANTS

Fourteen mothers who provided MOM for their infants who required surgery within 1 week of age.

METHODS

We conducted in-person interviews upon admission and discharge of the infant, phone interviews 1 and 2 weeks after discharge, and phone interviews monthly for 6 months or until discontinuance of the provision of MOM. We analyzed interviews using the Brooks thematic template analysis method.

RESULTS

Eleven infants received exclusive MOM at discharge, and nine infants remained on exclusive MOM at 6 months. We generated four principal themes from the participants' comments: Value of Breast Milk, Challenges of Providing MOM, Emotional Fluctuation, and Coping With Reality of Circumstances.

CONCLUSION

Internalizing the value of MOM, family support, and coping with barriers were key factors that influenced participants to provide MOM for at least 4 months. Findings of this study suggest that prenatal education with anticipatory guidance and lactation support in the NICU can help mothers achieve the goal of extended provision of MOM to infants with serious conditions that require surgery. Education and support may be especially helpful for young, first-time mothers.

Parents caring and sham-feeding their child born with Esophageal atresia at home while waiting for reconstructive surgery

PURPOSE

For children with Esophageal atresia who have to wait for reconstructive surgery, long hospital stay, delayed introduction of oral feeds and hampered oro-motor function has traditionally been draw-backs for this treatment as the patients have minimal training of oro-motor function while waiting for surgery. In this paper, we present the concept of sham-feed at home awaiting reconstructive surgery with the aim to obliviate these problems. The aim was to describe the characteristics of patients with Esophageal atresia waiting for reconstructive surgery sham-feeding at home by their parents and further describe adverse events that arose.

METHODS

The study is a retrospective descriptive single center study on all children with a delayed reconstruction of Esophageal atresia who was sham-fed by their parents at home before reconstructive surgery between January 2010 and January 2023 at the Karolinska University Hospital, Stockholm.

RESULTS

Nine patients where home waiting for reconstructive surgery for a median of 72 days. No adverse events were reported related to the sham-feed procedure at home. The children had reconstructive surgery at a median 120 days of age. Five of the children ate full meals orally day 8-27 after surgery. Two children ate fully before 1 year after surgery. Two children had surgery less than 1 year ago and were not eating fully orally at the time of data collection.

CONCLUSION

Sham-feeding at home by the parents was safe and feasible with the benefits of a prolonged time out of hospital awaiting reconstructive surgery.

Factors influencing outcomes of esophageal balloon dilatation for anastomosis site stenosis after esophageal atresia surgery

BACKGROUND

Esophageal balloon dilatation is an effective treatment for anastomotic strictures, but the factors affecting the outcome of dilatation remain unclear.

OBJECTIVE

To investigate the predictive factors of esophageal balloon dilatation outcome in children with anastomotic stricture after esophageal atresia repair.

MATERIALS AND METHODS

We retrospectively reviewed children with esophageal atresia who underwent esophageal balloon dilatation for postoperative strictures between August 2007 and February 2021. We investigated each child's age, weight and height; type of esophageal atresia surgery; shape, length and level of stricture; esophageal balloon dilatation balloon size; application of mitomycin; number of inflation sessions; and number of esophageal balloon dilatation sessions. The outcome of each esophageal balloon dilatation session was determined as improvement in stricture diameter between pre- and post-esophageal balloon dilatation esophagography. We used uni- and multivariate analyses with generalized estimating equations to evaluate outcome predictors.

RESULTS

Overall, 69 children (mean age, 2.3 years; 45 boys) underwent 227 esophageal balloon dilatations. In the univariate analysis, the positive effect of esophageal balloon dilatation decreased with increased age, weight, height, balloon size and number of esophageal balloon dilatation sessions. Additionally, the positive effect was decreased in cervical-level strictures and with the application of mitomycin during esophageal balloon dilatation. In the multivariate analysis, independent prognostic factors of the positive esophageal balloon dilatation effect were age (incidence rate ratio [IRR]: -0.01; 95% confidence interval [CI]: -0.01, -0.002), shape of stricture (IRR: -0.54; 95% CI: -0.91, -0.18) and number of esophageal balloon dilatation sessions (IRR, -0.10; 95% CI: -0.14, -0.18).

CONCLUSION

Repeated esophageal balloon dilatation, older age and eccentric stricture shape are associated with poor response to esophageal balloon dilatation in children with anastomotic strictures after esophageal atresia repair.

The Role of Pediatric Gastroenterologists in the Evaluation of Complex Aerodigestive Disorders

PURPOSE OF REVIEW

Children with aerodigestive disorders frequently have concerns regarding difficulty breathing, swallowing, and growing. In this review, we explored the role of pediatric gastroenterologists in the evaluation of complex aerodigestive disorders and the overall approach to these often-challenging patients.

RECENT FINDINGS

Pediatric gastroenterologists evaluate children with aerodigestive concerns ranging from dysphagia and gastroesophageal reflux to complex congenital abnormalities such as esophageal atresia. Diagnostic tools, such as multichannel intraluminal impedance-pH monitoring, are used for diagnosing gastroesophageal reflux and assessing the correlation with symptoms. Endoscopic evaluation, and in some complex cases, with therapeutic dilations may also be performed. Gastrointestinal dysmotility evaluation with manometry studies are also being increasingly utilized. Multidisciplinary aerodigestive programs can provide a coordinated approach to children with complex airway, pulmonary and gastrointestinal tract disorders. A pediatric gastroenterologist's expertise and specialized skills not only offer many diagnostic tools for these complicated medical cases but are also important in long term medical management.

The cause of dysphagia in patients with esophageal atresia: a systematic review and meta-analysis

PURPOSE

Dysphagia is the most common symptom in patients with esophageal atresia (EA) of all ages. There is no study addressing the direct relation between dysphagia and surgical results. Therefore, a systematic review was performed to define the relationship between surgical complications and dysphagia in patients with EA.

METHODS

The systematic review was drafted under PRISMA guidelines. Systematic literature search was performed for the period 2000 (Jan) to 2019 (Dec)-20 years-in the databases: MEDLINE, EMBASE, and PubMed. Statistical analysis was performed using Comprehensive Meta-Analysis Version 3.0 software.

RESULTS

Among 767 articles, 486 abstracts were screened for the inclusion criteria. The full-texts of 64 articles were assessed for eligibility. The sub-group analysis could be performed in 4 articles for anastomotic strictures. Heterogeneity was calculated by I² statistic as 18,487 and pooled odds ratio was measured under the fixed effect model (Q = 3.68; P = 0.298, I² = 18,487). There was no significant relationship with an odds ratio of 1.37 between anastomotic stricture (AS) and dysphagia (95% CI 0.631-2.973, p = 0.426). There was no publication bias for the data (Begg's test, p = 0.496; Egger's tests, p = 0.335).

CONCLUSION

This meta-analysis did not reveal a significant relationship between AS and dysphagia in children with EA. Since many other factors contribute to dysphagia, comprehensive variable information such as detailed standardized registry systems for rare diseases for pooling analysis is needed regarding other potential factors including surgical complications.

Utility of Functional Lumen Imaging Probe in Long-Term Follow-Up of Children with Esophageal Atresia: A Single-Center Retrospective Study

Long term follow-up of patients with esophageal atresia (EA) may be hampered by esophageal dysmotility, which affects quality of life and might lead to late complications. The endoluminal functional lumen imaging probe (EndoFlip™ Medtronic, Crospon Inc.) is an innovative diagnostic tool that assesses esophageal distensibility. Our aim was to report the use of EndoFlip™ in an EA follow-up, in order to describe distensibility patterns and to determine its possible role for functional evaluation of patients. We retrospectively collected data of EA patients, with a minimum follow-up of 9 years, who required endoscopic evaluation and underwent EndoFlip™. An adaptation of the Medtronic EF-322 protocol was applied and distensibility data were compared to those reported by Pandolfino et al. Nine patients (median age 13 years) were included in the study. The median minimum distensibility was 2.58 mm²/mmHg. Signs of peristalsis were observed in three patients. In one case, the esophagogastric junction (EGJ) after Toupet fundoplication showed low distensibility. EGJ distensibility values of 2.58 mm²/mmHg (median) confirmed both good esophagogastric continence and compliance. Esophagitis and absent peristalsis were found in one patient together with partial stenosis of the fundoplication, confirming the importance of surgical adaptation. Esophageal body distensibility was higher than that of the EGJ. Considering the presence of symptoms, the EndoFlip™ results seem to correlate better with the clinical picture. EndoFlip™ use was safe and feasible in children. It allowed for the measurement of esophageal distensibility and diameter and the acquisition of indirect information on motility with clinical implications. The routine use of EndoFlip™ could be part of EA follow-up, although considerable research is needed to correlate Endoflip™ system measurements to EA patient outcomes.

Growth assessments for children with recurrent tracheoesophageal fistulas

PURPOSE

To assess the growth status of children with recurrent tracheoesophageal fistula (rTEF), and determine the possible risk factors of growth retardation (GR).

METHODS

The medical records of 83 patients with rTEF who underwent surgical repair were retrospectively analyzed. The patients were retrospectively divided into two groups according to whether they had GR. The clinical variables were compared between the GR and non-GR groups. Univariate and multivariable logistic regression analysis were performed to identify the risk factors for GR.

RESULTS

Eighty-three children diagnosed with rTEF were included in this study. After a median follow-up of 31.4 (19.8, 48.7) months, GR occurred in 28 patients (33.7%). Among them, six patients with only weight for age Z score (WAZ) < -2SD, five patients with only height for age Z score (HAZ) < -2SD, and six patients with only BMI for age Z score (BAZ) < -2SD, while seven patients with both WAZ and HAZ < -2SD and four patients with both WAZ, HAZ and BAZ < -2SD. Multivariate logistic regression analysis showed that birth weight, anastomotic stricture and dysphagia after rTEF repair were independent risk factors with OR of 0.325 (0.119, 0.891), 4.396 (1.451, 13.324) and 5.341 (1.153, 24.752) for GR, respectively.

CONCLUSIONS

GR is a common complication after rTEF repair. Birth weight, anastomotic stricture and dysphagia after rTEF repair are independent risk factors affecting growth.

Eosinophilic Esophagitis in Esophageal Atresia: Is It Really a New Disease?

Eosinophilic esophagitis (EoE) is a chronic, immune-mediated esophageal disease. Symptoms are related to mucosal eosinophilic-predominant inflammation that leads to esophageal dysfunction. Recent data suggest that esophageal atresia (EA) patients may have an increased incidence of EoE compared to the general population. As EoE symptoms may be confused with EA-related symptoms, they may significantly worsen morbidity in this specific group of patients. We investigated specific characteristics of patients with AE and EoE compared to those with EoE only. We conducted an observational retrospective monocentric study including all patients diagnosed with EoE from 1 January 2010 to 31 December 2021. For each patient, demographic, clinical and histopathological data were collected and then compared between the two cohorts (EA-EoE vs. EoE only). During the study period, 62 patients were included: 17 children were in the follow-up because of EA (18.1% of 94 EA patients screened in that period), while the other 45 presented EoE only. The demographic and clinical features of EA-EoE patients demonstrate a lower prevalence of allergic subjects (23.5% vs. 80%, p < 0.05), a lower age of presentation (3.1 vs. 12.2 years, p < 0.05), non-specific symptoms and a higher resolution rate with PPI therapy (64.7% vs. 17.8%, p < 0.05) compared to EoE-only patients. Our data confirm that EA patients are at high risk for developing EoE. As symptoms may overlap with the EA spectrum, early recognition of EoE may prevent patients from receiving unnecessary invasive therapeutic interventions and from developing complications from untreated EoE.

Role of Esophageal High-Resolution Manometry in Pediatric Patients

PURPOSE

Dysphagia, vomiting and feeding difficulties are common symptoms, with which children present. Esophageal function testing with high resolution manometry can help in diagnosing and treating these patients. We aim to access the clinical utility of high-resolution manometry of esophagus in symptomatic pediatric patients.

METHODS

A retrospective chart review was done on all symptomatic patients who underwent esophageal high-resolution manometry between 2010 and 2019 at Sydney Children's Hospital, Australia. Manometry results were categorized based on Chicago classification. Demographic data, indication of procedure, manometric findings, and details of treatment changes were obtained and analyzed.

RESULTS

There were 62 patients with median age of 10 years (9 months-18 years). The main indication for the procedure was dysphagia (56%). Thirty-two percent of patients had a co-morbid condition, with esophageal atresia accounting for 16%. The majority (77%) of patients had abnormal manometry which included, ineffective esophageal motility in 45.2%. In esophageal atresia cohort, esophageal pressurization was seen in 50%, aperistalsis in 40% and 10% with prior fundoplication had esophago-gastric junction obstruction. Patients with esophago-gastric junction obstruction or achalasia were treated by either pneumatic dilation or Heller's myotomy. Patients with ineffective esophageal motility and rumination were treated with a trial of prokinetics/dietary texture modification and diaphragmatic breathing.

CONCLUSION

Esophageal high-resolution manometry has a role in the evaluation of symptomatic pediatric patients. The majority of our patients had abnormal results which led to change in treatments, with either medication, surgery and/or feeding modification with resultant improvement in symptoms.

Reliability and Validity of the Polish Version of the Esophageal-Atresia-Quality-of-Life Questionnaires to Assess Condition-Specific Quality of Life in Children and Adolescents Born with Esophageal Atresia

Aim: This study reports the reliability and validity of the Polish version of the Esophageal Atresia Quality of Life (EA-QOL) questionnaires, which were originally developed in Sweden and Germany. Methods: A total of 50 families of children (23 aged 2 to 7, and 27 aged 8 to 17) with EA/TEF (esophageal atresia/tracheoesophageal fistula) participated in the study. The development and validation of the Polish version of the EA-QOL involved forward-backward translation of the survey items following the guidelines for cross-cultural translation, cognitive debriefing and evaluation of psychometric properties, including assessment of internal and retest reliability, linguistic validity, content validity, known-group validity and convergent validity. The medical records of patients and standardized questionnaires were used to obtain clinical data. The level of significance was p < 0.05. Results: The Polish versions of the EA-QOL questionnaires demonstrated strong linguistic and content validity, are slightly discriminative for esophageal and respiratory problems, but do not show convergent validity with the PedsQL 4.0 generic core scales. In terms of reliability, the internal consistency of the subscale and total scale of Polish versions as measured by Cronbach’s alpha is good, and retest reliability is excellent. Conclusions: The Polish versions of the EA-QOL questionnaires meet most psychometric criteria that confirm the EA-QOL questionnaires’ reliability and validity. This study enables application of these questionnaires in future research among children with EA in Poland and participation in international multicenter studies focusing on advancing knowledge of condition-specific QOL in this population. Future cross-cultural research using larger sample sizes is still needed to better address the relationship between condition-specific and generic QOL, as well as the discriminative ability of the EA-QOL questionnaires.

Prevalence of acid gastroesophageal reflux disease in infants with esophageal atresia/tracheoesophageal fistula

BACKGROUND

Given the high prevalence and complication risks of acid gastroesophageal reflux (GERD) in the first months of life in infants with esophageal atresia, the ESPGHAN/NASPGHAN consensus statement recommends systematic treatment with proton pump inhibitors (PPIs) until the age of 1 year and checking for acid GERD thereafter. However, these recommendations have not been evaluated.

METHODS

This prospective study was conducted from 2007 to 2016. We evaluated the prevalence of acid GERD in 100 consecutive infants presenting with esophageal atresia/tracheoesophageal fistula after the age of 18 months when PPI treatment was stopped. The diagnosis of acid GERD was based on positive pH-metry and/or evidence of complications (e.g., peptic esophagitis, need for jejunal nutrition, or antireflux surgery). Those with acid GERD at a median age of 18 months received a control examination every year or adapted to their clinical situation.

RESULTS

The prevalence rates of acid GERD were 64.3% at 18 months and 22.8% at the last follow-up (median age 65 months).There is no risk factor for acid GERD identified.

CONCLUSIONS

This study shows a high prevalence of acid GERD in late infancy and supports the recommendation of systematic checking for acid GERD when treatment with PPI is stopped.

IMPACT

Acid gastroesophageal reflux disease (GERD) is a frequent complication of esophageal atresia in infants. The ESPGHAN/NASPGHAN consensus, which is based on expert opinion, recommends systematic treatment of children with PPI until the age of 1 year. The prevalence rates of acid GERD were 64.3% at 18 months and 22.8% at the last follow-up. This study shows a high prevalence of acid GERD in late infancy and supports the recommendation of systematic checking for acid GERD when treatment with PPI is stopped.

Neonatal anthropometry of malformed newborns: A large South American population-based study

BACKGROUND

Population-based anthropometric evaluation of malformed newborns is scarce.

OBJECTIVES

To evaluate malformed newborns' foetal growth using the ICD 10 malformations' classification.

METHODS

A study including 33,769 newborns (14,857 malformed and 18,912 nonmalformed), selected from 678,840 births from nine South American countries, period 2010-2018, was conducted. Prevalence of severe small and small for gestational age was calculated for malformed and nonmalformed newborns classified by preterm birth categories. Prevalence and relative risk (RR) with its 95% confidence interval (CI) were calculated. The associations between anthropometric phenotypes and congenital malformations were evaluated with generalized linear models.

RESULTS

Prevalence of preterm and term severe small and small for gestational age newborns was higher in malformed than that in nonmalformed neonates. For grouped ICD 10 malformations categories, the RR for severe small for gestational age was 2.88 (95% CI 2.51, 3.30) and 2.10 (95% CI 1.92, 2.30) for small for gestational age. For at-term and preterm malformed newborns, the RR for severe small for gestational age was 2.21 (95% CI 1.87, 2.61) and 3.21 (95% CI 2.52, 4.10), respectively; for small for gestational age, the RR was 2.31 (95% CI 2.11, 2.53) for at-term newborns and 2.58 (95% CI 2.16, 3.08) for preterm ones.

CONCLUSIONS

Prevalence and relative risk of severe small and small for gestational age vary according to the group of malformations and gestational age; they increase in congenital malformations of the nervous, respiratory and digestive systems, and in chromosomal abnormalities and are lower for malformations of eye, ear, face and neck and cleft lip and palate. Foetal growth considered together with malformed newborns' gestational age would allow for inferring different risks of morbidity and mortality.

Nutritional status at age 1 year in patients born with esophageal atresia: A population-based, prospective cohort study

OBJECTIVE

Despite recent progress in caring for patients born with esophageal atresia (EA), undernutrition and stunting remain common. Our study objective was to assess nutritional status in the first year after birth with EA and to identify factors associated with growth failure.

STUDY DESIGN

We conducted a population-based study of all infants born in France with EA between 2010 and 2016. Through the national EA register, we collected prenatal to 1 year follow-up data. We used body mass index and length-for-age ratio Z scores to define patients who were undernourished and stunted, respectively. Factors with P < 0.20 in univariate analyses were retained in a logistic regression model.

RESULTS

Among 1,154 patients born with EA, body mass index and length-for-age ratio Z scores at 1 year were available for about 61%. Among these, 15.2% were undernourished and 19% were stunted at the age of 1 year. There was no significant catch-up between ages 6 months and 1 year. Patients born preterm (41%), small for gestational age (17%), or with associated abnormalities (55%) were at higher risk of undernutrition and stunting at age 1 year (P < 0.05). Neither EA type nor surgical treatment was associated with growth failure.

CONCLUSION

Undernutrition and stunting are common during the first year after birth in patients born with EA. These outcomes are significantly influenced by early factors, regardless of EA type or surgical management. Identifying high-risk patient groups with EA (i.e., those born preterm, small for gestational age, and/or with associated abnormalities) may guide early nutritional support strategies.

Initial Esophageal Anastomosis Diameter Predicts Treatment Outcomes in Esophageal Atresia Patients With a High Risk for Stricture Development

Background and Aims: Children with esophageal atresia (EA) who undergo surgical repair are at risk for anastomotic stricture, which may need multiple dilations or surgical resection if the stricture proves refractory to endoscopic therapy. To date, no studies have assessed the predictive value of anastomotic diameter on long-term treatment outcomes. Our aim was to evaluate the relationship between anastomotic diameter in the early postoperative period and need for frequent dilations and stricture resection within 1 year of surgical repair. Methods: A retrospective chart review was performed of patients who had EA repair or stricture resection (SR). Medical records were reviewed to evaluate the diameter of the anastomosis at the first endoscopy after surgery, number and timing of dilations needed to treat the anastomotic stricture, and need for stricture resection. A generalized estimating equations (GEE) modeling with a logit link and binomial family was done to analyze the relationship between initial endoscopic anastomosis diameter and the outcome of needing a stricture resection. Median regression was implemented to estimate the association between number of dilations needed based on initial diameter. Results: A total of 121 patients (56 females) with a history of EA (64% long-gap EA) were identified who either underwent Foker repair at 46% or stricture resection with end-to-end esophageal anastomosis at 54%. The first endoscopy occurred a median of 22 days after surgery. Among all cases, a narrower anastomoses were more likely to need stricture resection with an OR of 12.9 (95% CI, 3.52, 47; p < 0.001) in patients with an initial diameter of <3 mm. The number of dilations that patients underwent also decreased as anastomotic diameter increased. This observation showed a significant difference when comparing all diameter categories when looking at all surgeries taken as a whole (p < 0.008). Conclusion: Initial anastomotic diameter as assessed via endoscopy performed after high-risk EA repair predicts which patients will require more esophageal dilations as well as the likelihood for stricture resection. This data may serve to stratify patients into different endoscopic treatment plans.

Care recommendations for the respiratory complications of esophageal atresia-tracheoesophageal fistula

Tracheoesophageal fistula (TEF) with esophageal atresia (EA) is a common congenital anomaly that is associated with significant respiratory morbidity throughout life. The objective of this document is to provide a framework for the diagnosis and management of the respiratory complications that are associated with the condition. As there are no randomized controlled studies on the subject, a group of experts used a modification of the Rand Appropriateness Method to describe the various aspects of the condition in terms of their relative importance, and to rate the available diagnostic methods and therapeutic interventions on the basis of their appropriateness and necessity. Specific recommendations were formulated and reported as Level A, B, and C based on whether they were based on "strong", "moderate" or "weak" agreement. The tracheomalacia that exists in the site of the fistula was considered the main abnormality that predisposes to all other respiratory complications due to airway collapse and impaired clearance of secretions. Aspiration due to impaired airway protection reflexes is the main underlying contributing mechanism. Flexible bronchoscopy is the main diagnostic modality, aided by imaging modalities, especially CT scans of the chest. Noninvasive positive airway pressure support, surgical techniques such as tracheopexy and rarely tracheostomy are required for the management of severe tracheomalacia. Regular long-term follow-up by a multidisciplinary team was considered imperative. Specific templates outlining the elements of the clinical respiratory evaluation according to the patients' age were also developed.

Dysphagia in Children with EA-TEF From the Perspective of Pediatric Surgeons in Clinical Settings

The current study was aimed to define clinical practice, knowledge and awareness, and best practice regarding dysphagia in children with esophageal atresia with/without tracheoesophageal fistula (EA-TEF) from the perspective of pediatric surgeons in Turkey. Pediatric surgeons practice EA repair were included. A survey related to clinical practice, knowledge and awareness, and best practice regarding dysphagia in EA-TEF was used. The survey was electronically sent to potential participants. Seventy-two pediatric surgeons with a mean professional experience of 14.73 ± 9.66 years (min = 1, max = 41) completed the survey. 19.4% (n = 14) had a standardized protocol for dysphagia screening and %51.4 (n = 37) provided swallowing rehabilitation to their patients. Most of the participants (80.6%) reported that they do not have an appropriate team approach for dysphagia management. The mean knowledge and awareness score was 11.04 ± 1.27 (min = 7, max = 12). The mean VAS score related to the need for standardized protocol in dysphagia management was 9.23 ± 1.44 (min = 3, max = 10). The mean VAS score related to the need for routine screening for dysphagia after surgery was 8.67 ± 2.17 (min = 1, max = 10). The mean score for the degree of the contribution of diagnosis and management of dysphagia to the surgical treatment in children operated for EA-TEF was 7.98 ± 2.08 (min = 3, max = 10). The participants mostly suggested the necessity of a standardized protocol in dysphagia and routine dysphagia screening in children with EA-TEF. Knowledge and awareness is found to be high among pediatric surgeons in Turkey. However, their clinical practice does not include a standardized protocol regarding dysphagia screening and management.

Oesophageal atresia: The growth gap

Poor growth is an under-recognised yet significant long-term sequelae of oesophageal atresia (OA) repair. Few studies have specifically explored the reasons for growth impairment in this complex cohort. The association between poor growth with younger age and fundoplication appears to have the strongest supportive evidence, highlighting the need for early involvement of a dietitian and speech pathologist, and consideration of optimal medical reflux management prior to referring for anti-reflux surgery. However, it remains difficult to reach conclusions regarding other factors which may negatively influence growth, due to conflicting findings, inconsistent definitions and lack of validated tool utilisation. While swallowing and feeding difficulties are particularly frequent in younger children, their relationship with growth remains unclear. It is possible that these morbidities impact on the diet of children with OA, but detailed analysis of dietary composition and quality, and its relationship with these complications and growth, has not yet been conducted. Another potential area of research in OA is the role of the microbiota in growth and nutrition. While the microbiota has been linked to growth impairment in other paediatric conditions, it is yet to be investigated in OA. Further research is needed to identify the most important contributory factors to poor growth, the role of the intestinal microbiota, and effective interventions to maximise growth and nutritional outcomes in this cohort.

Gastrointestinal Dysmotility and the Implications for Respiratory Disease

Purpose of the review

Gastroesophageal reflux disease (GERD) is frequently implicated as a cause for respiratory disease. However, there is growing evidence that upper gastrointestinal dysmotility may play a significantly larger role in genesis of respiratory symptoms and development of underlying pulmonary pathology. This paper will discuss the differential diagnosis for esophageal and gastric dysmotility in aerodigestive patients and will review the key diagnostic and therapeutic interventions for this dysmotility.

Recent findings

Previous studies have shown an association between GERD and pulmonary pathology in children with aerodigestive disorders. Recent publications have demonstrated the presence of esophageal and gastric dysfunction, using fluoroscopic and nuclear medicine studies, in aerodigestive patients who commonly present to pulmonary and otolaryngology clinics. High-resolution impedance manometry (HRIM) has revolutionized our understanding of esophageal dysmotility and its role in pathogenesis of aspiration and esophageal dysfunction and subsequent respiratory compromise.

Summary

Esophageal and gastric dysmotility have a profound effect on development of respiratory symptoms and pulmonary sequalae in aerodigestive patients. However, our understanding of the pathophysiology is in its infancy. Prospective studies in are needed to address key clinical questions such as: What degree of dysmotility initiates respiratory compromise? What diagnostic tests and therapeutic options best predict aerodigestive outcomes?

Anastomotic Strictures after Esophageal Atresia Repair: Incidence, Investigations, and Management, Including Treatment of Refractory and Recurrent Strictures

Improved surgical techniques, as well as preoperative and postoperative care, have dramatically changed survival of children with esophageal atresia (EA) over the last decades. Nowadays, we are increasingly seeing EA patients experiencing significant short- and long-term gastrointestinal morbidities. Anastomotic stricture (AS) is the most common complication following operative repair. An esophageal stricture is defined as an intrinsic luminal narrowing in a clinically symptomatic patient, but no symptoms are sensitive or specific enough to diagnose an AS. This review aims to provide a comprehensive view of AS in EA children. Given the lack of evidence-based data, we critically analyzed significant studies on children and adults, including comments on benign strictures with other etiologies. Despite there is no consensus about the goal of the luminal diameter based on the patient's age, esophageal contrast study, and/or endoscopy are recommended to assess the degree of the narrowing. A high variability in incidence of ASs is reported in literature, depending on different definitions of AS and on a great number of pre-, intra-, and postoperative risk factor influencing the anastomosis outcome. The presence of a long gap between the two esophageal ends, with consequent anastomotic tension, is determinant for stricture formation and its response to treatment. The cornerstone of treatment is endoscopic dilation, whose primary aims are to achieve symptom relief, allow age-appropriate capacity for oral feeding, and reduce the risk of pulmonary aspiration. No clear advantage of either balloon or bougie dilator has been demonstrated; therefore, the choice is based on operator experience and comfort with the equipment. Retrospective evidences suggest that selective dilatations (performed only in symptomatic patients) results in significantly less number of dilatation sessions than routine dilations (performed to prevent symptoms) with equal long-term outcomes. The response to dilation treatment is variable, and some patients may experience recurrent and refractory ASs. Adjunctive treatments have been used, including local injection of steroids, topical application of mitomycin C, and esophageal stenting, but long-term studies are needed to prove their efficacy and safety. Stricture resection or esophageal replacement with an interposition graft remains options for AS refractory to conservative treatments.

Update on Foregut Molecular Embryology and Role of Regenerative Medicine Therapies

Esophageal atresia (OA) represents one of the commonest and most severe developmental disorders of the foregut, the most proximal segment of the gastrointestinal (GI) tract (esophagus and stomach) in embryological terms. Of intrigue is the common origin from this foregut of two very diverse functional entities, the digestive and respiratory systems. OA appears to result from incomplete separation of the ventral and dorsal parts of the foregut during development, resulting in disruption of esophageal anatomy and frequent association with tracheo-oesophageal fistula. Not surprisingly, and likely inherent to OA, are associated abnormalities in components of the enteric neuromusculature and ultimately loss of esophageal functional integrity. An appreciation of such developmental processes and associated defects has not only enhanced our understanding of the etiopathogenesis underlying such devastating defects but also highlighted the potential of novel corrective therapies. There has been considerable progress in the identification and propagation of neural crest stem cells from the GI tract itself or derived from pluripotent cells. Such cells have been successfully transplanted into models of enteric neuropathy confirming their ability to functionally integrate and replenish missing or defective enteric nerves. Combinatorial approaches in tissue engineering hold significant promise for the generation of organ-specific scaffolds such as the esophagus with current initiatives directed toward their cellularization to facilitate optimal function. This chapter outlines the most current understanding of the molecular embryology underlying foregut development and OA, and also explores the promise of regenerative medicine.