Etiologic factors in long-term respiratory function abnormalities following esophageal atresia repair

Proton pump inhibitors in esophageal atresia: A systematic review and meta-analysis

Gastroesophageal reflux disease (GERD) is frequent and prolonged in esophageal atresia (EA) pediatric patients requiring routine use of proton pump inhibitors (PPIs). However, there are still controversies on the prophylactic use of PPIs and the efficacy of PPIs on GERD and EA complications in this special condition. The aim of the study is to assess the prophylactic use of PPIs in pediatric patients with EA and its complications. We, therefore, performed a systematic review including all reports on the subject from 1980 to 2022. We conducted meta-analysis of the pooled proportion of PPI-and no PPI groups using random effect model, meta-regression, and estimate heterogeneity by heterogeneity index I2 . Thirty-eight reports on the topic met the criteria selection, representing a cumulative 6044 patients with EA. Prophylactic PPI prescription during the first year of life does not appear to prevent GERD persistence at follow-up and is not associated with a significantly reduced rate of antireflux surgical procedures (ARP). PPIs improve peptic esophagitis and induce remission of eosinophilic esophagitis at a rate of 50%. Their effect on other GERD outcomes is uncertain. Evidence suggests that PPIs do not prevent anastomotic stricture, Barrett's esophagus, or respiratory complications. PPI use in EA can improve peptic and eosinophilic esophagitis but is ineffective on the other EA complications. Side effects of PPIs in EA are almost unknown.

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.

Longitudinal Follow-up of Chronic Pulmonary Manifestations in Esophageal Atresia: A Clinical Algorithm and Review of the Literature

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.

Aspiration Risk and Respiratory Complications in Patients with Esophageal Atresia

Chronic, long-term respiratory morbidity (CRM) is common in patients with a history of repaired congenital esophageal atresia, typically associated with tracheoesophageal fistula (EA/TEF). EA/TEF patients are at high risk of having aspiration, and retrospective studies have associated CRM with both recurrent aspiration and atopy. However, studies evaluating the association between CRM in this population and either aspiration or atopy have reported conflicting results. Furthermore, CRM in this population may be due to other related conditions as well, such as tracheomalacia and/or recurrent infections. Aspiration is difficult to confirm, short of lung biopsy. Moreover, even within the largest evidence base assessing the association between CRM and aspiration, which has evaluated the potential relationship between gastroesophageal reflux and asthma, findings are contradictory. Studies attempting to relate CRM to prior aspiration events may inadequately estimate the frequency and severity of previous aspiration episodes. There is convincing evidence documenting that chronic, massive aspiration in patients with repaired EA/TEF is associated with the development of bronchiectasis. While chronic aspiration is likely associated with other CRM in patients with repaired EA/TEF, this does not appear to have been confirmed by the data currently available. Prospective studies that systematically evaluate aspiration risk and allergic disease in patients with repaired EA/TEF and document subsequent CRM will be needed to clarify the causes of CRM in this population. Given the prevalence of CRM, patients with repaired EA/TEF should ideally receive regular follow-up by multidisciplinary teams with expertise in this condition, throughout both childhood and adulthood.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

PATIENTS

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

CONCLUSION

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

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.

Impaired peripheral airway function in adults following repair of esophageal atresia

BACKGROUND

Esophageal atresia (EA) often leads to persistent symptoms and impaired respiratory function in adulthood. The role of peripheral airways in this impairment has not been previously investigated. Furthermore, asthma-like symptoms are common in these patients.

PURPOSE

The purpose of this study was to investigate pulmonary outcome, including possible peripheral airway dysfunction, perhaps missed by conventional pulmonary function tests and to see if the diagnosis asthma was accurate.

METHODS

Twenty eight patients operated for EA in Gothenburg 1968-1983 answered a questionnaire regarding respiratory symptoms and underwent pulmonary function tests. Peripheral airway function was measured by multiple breath washout.

RESULTS

22/28 (79%) patients had a history of respiratory symptoms. Abnormal peripheral airway function was found in 17 (61%) patients, while only 6 (21%) patients displayed values indicating central obstruction. Nine patients had restrictive disease. Airway hyperresponsiveness was frequent and associated with atopy and airway inflammation. However, respiratory symptoms or doctor-diagnosed asthma did not correlate with any specific lung function test abnormality.

CONCLUSION

Different lung function abnormalities are present in EA survivors, and peripheral airway disease is common. Classical asthma seems to be difficult to diagnose in this patient group. Given the high prevalence of respiratory morbidity, long-term follow-up of pulmonary function, including peripheral airway function, is warranted.

Current Controversies in the Surgical Treatment of Esophageal Atresia

Background and Aims:

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

Methods:

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

Results:

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

Conclusions:

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

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

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

Long-term respiratory symptoms following oesophageal atresia

Background

Oesophageal atresia (OA) is a congenital malformation that can lead to persistent respiratory symptoms in adulthood.

Aim

To describe the prevalence of respiratory symptoms in adulthood in a population-based study of patients with repaired OA and to compare this with the prevalence in the general population.

Methods

Of 80 patients operated for OA in Gothenburg in 1968–1983, 79 were located. The patients received a questionnaire on respiratory symptoms. Controls were 4979 gender- and age-matched subjects who answered the same questions.

Results

The questionnaire was answered by 73 of 79 (92%) patients. Physician-diagnosed asthma was reported by 30% in the OA group vs 10% in the control group (OR 4.1; 95% CI 2.4–6.8), and recurrent wheeze in 29% vs 5.5% (OR 6.9; 4.1–11.6). Also wheeze during the last year, asthma medication, a long-standing cough, cough with sputum production and chronic bronchitis were significantly more common among the patients with OA. In contrast, there was no significant difference regarding risk factors for asthma. The prevalence of respiratory symptoms did not appear to decrease with age.

Conclusion

A high prevalence of respiratory symptoms remains among adult patients with repaired OA. Many of the patients had an asthma diagnosis. However, asthma heredity or allergic rhinitis was not overrepresented.

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

The successful operative management of oesophageal atresia and tracheo-oesophageal atresia has been available for approximately 70 years. During this time neonatal intensive care has evolved, surgical techniques have improved and consequently near 100% survival for this condition may now be achieved. In keeping with promising results, the co-morbidities of the condition have gained increasing recognition. In this article, the clinical course from antenatal assessments, neonatal surgery and co-morbidities from infancy to adulthood are reviewed to provide a broad overview of the condition.

A prospective comparative evaluation of persistent respiratory morbidity in esophageal atresia and congenital diaphragmatic hernia survivors

PURPOSE

The aim of the study was to compare long-term respiratory morbidity in children after repair of esophageal atresia (EA) or congenital diaphragmatic hernia (CDH).

PATIENTS AND METHODS

Children were seen at 6, 12, and 24 months and 5 years within a prospective longitudinal follow-up program in a tertiary children's hospital. Respiratory morbidity and physical condition were evaluated at all moments. At age 5 years, pulmonary function and maximal exercise performance were tested.

RESULTS

In 3 of 23 atresia patients and 10 of 20 hernia patients, bronchopulmonary dysplasia was developed. Seventeen atresia and 11 hernia patients had recurrent respiratory tract infections mainly in the first years of life. At age 5, 25% of EA and CDH patients measured showed reduced forced expiratory volume in 1 second (z-score < -2). Both atresia and hernia patients showed impaired growth, with catch-up growth at 5 years in patients with EA but not in those with hernia. Maximal exercise performance was significantly below normal for both groups.

CONCLUSIONS

Esophageal atresia and CDH are associated with equal risk of long-term respiratory morbidity, growth impairment, and disturbed maximal exercise performance. Prospective follow-up of EA patients aimed at identifying respiratory problems other than tracheomalacia should be an integral part of interdisciplinary follow-up programs.

Esophageal atresia repair with thoracotomy: the Cincinnati contemporary experience

Esophageal atresia/tracheoesophageal fistula (EA/TEF) repair using an open muscle-sparing thoracotomy has been the standard approach used in our institution. Whereas perioperative mortality is now very uncommon, short- and long-term morbidity is very common in these patients. However, the complexity of the esophageal anatomy and significant comorbidities appear to be important contributors to significant complications in these patients. At least 30% of the EA/TEF patients required esophageal dilatations for anastomotic stricture; this increased to 50% for patients with pure EA. Gastroesophageal reflux requiring an antireflux procedure was performed 23% of the time for EA/TEF and 30% for EA patients. In addition, there were a few complications, such as winging of the scapula and scoliosis, that were attributed in part to the utilization of a nonmuscle-sparing thoracotomy. The standard muscle-sparing thoracotomy remains a very versatile and useful approach to repairing esophageal atresia, and it is the standard for repairing more complex anatomical variants. The self-reported long-term quality of life in these patients is very good, except for a few individuals with protracted feeding disorders and severe dysphagia.

Longitudinal follow-up of bronchial inflammation, respiratory symptoms, and pulmonary function in adolescents after repair of esophageal atresia with tracheoesophageal fistula

OBJECTIVE

To characterize symptoms, pulmonary function tests (PFT) and bronchial responsiveness (BR) in adolescents after repaired esophageal atresia with tracheoesophageal fistula and correlate these with endobronchial biopsy findings.

STUDY DESIGN

After a primary operation, 31 patients underwent endoscopies and bronchoscopies at the age of <3, 3 to 7, and >7 years. A questionnaire on respiratory and esophageal symptoms was sent to patients at a mean age of 13.7 years (range, 9.7-19.4). The questionnaire was completed by 27 of 31 patients (87%), and 25 of the 31 patients (81%) underwent clinical examination and pulmonary functioning tests. Endobronchial biopsies were analyzed for reticular basement membrane (RBM) thickness and inflammatory cells.

RESULTS

The prevalence of current respiratory and esophageal symptoms was 41% and 44%, respectively. "Doctor-diagnosed asthma" was present in 22% of patients. A restrictive and obstructive spirometric defect was observed in 32% and 30% of patients, respectively. Increased bronchial responsiveness, detected in 24% of patients, was weakly associated with current respiratory symptoms and low forced vital capacity. Mean exhaled nitric oxide was within predicted range. RBM thickness increased slightly with age, whereas inflammatory cell counts varied from normal to moderate, with intraindividual variation.

CONCLUSION

Inflammation of the airways in adolescents with a history of tracheoesophageal fistula, even in the presence of atopy, does not lead, in most cases, to the type of chronic inflammation and RBM changes seen in asthma.

Gastrointestinal motility disorders in adolescent patients: transitioning to adult care

A wide spectrum of gastrointestinal motility disorders present in childhood. Some are unique to children, especially congenital disorders including certain pseudo-obstruction disorders or those associated with anatomic developmental defects, whereas others are common adult disorders, such as achalasia, that rarely manifest in children. This article reviews the pediatric presentations and sequelae of childhood gastrointestinal motility disorders and then discusses long-term management issues for these children as they progress into adulthood. The goal is to optimize medical care and ensure the adequate nutritional status essential for neurocognitive and psychosocial development of the child. Multidisciplinary care from specialists, including gastroenterologists, psychologists, and pain specialists, is often required to optimize the lives of these patients.

Oesophageal atresia and tracheo-oesophageal fistula

Oesophageal atresia-tracheo-oesophageal fistula has featured in paediatric surgery since its beginnings. The first successful primary repair was in 1941. With overall survival now exceeding 90% in dedicated centres, the emphasis has changed to reducing morbidity and achieving improvements in the quality of life. An overview of current and emerging strategies in managing patients with this condition is presented. Advances in developmental biology and molecular genetics reflecting improved understanding of the pathogenesis are highlighted.

Long-term complications of congenital esophageal atresia and/or tracheoesophageal fistula

Congenital esophageal atresia (EA) and/or tracheoesophageal fistula (TEF) are common congenital anomalies. Respiratory and GI complications occur frequently, and may persist lifelong. Late complications of EA/TEF include tracheomalacia, a recurrence of the TEF, esophageal stricture, and gastroesophageal reflux. These complications may lead to a brassy or honking-type cough, dysphagia, recurrent pneumonia, obstructive and restrictive ventilatory defects, and airway hyperreactivity. Aspiration should be excluded in children and adults with a history of EA/TEF who present with respiratory symptoms and/or recurrent lower respiratory infections, to prevent chronic pulmonary disease.

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

Dysphagia and gastroesophageal reflux (GER) probably caused by structural disorganization of the esophagus occur frequently after repair of tracheoesophageal fistula (TEF), and the extent to which they may improve beyond childhood is not known. The aim of the present study is to assess by combined ambulatory 24-hour manometry and pH-metry the esophageal peristaltic activity and acid clearing capacity in adolescents and adults who had been operated on for TEF at birth. Twenty-two patients, aged 17.1 +/- 4.5 years (mean +/- SD), were examined with combined three-channel manometry and two-channel pH-metry followed by endoscopy and biopsy. Although they considered themselves healthy, on careful interrogation, 16 (72%) were found to have dysphagia, 13 (59%) had heartburn, 10 (45%) had foreign body impaction, and 7 (31%) had chronic respiratory tract disease. GER was detected in 12 (54%) patients (5 with histological esophagitis), 10 of whom had a pattern of prolonged nocturnal episodes with very slow clearance. All patients had diminished contractile activity with low-amplitude and short-duration waves that decreased from 0.53 +/- 0.35 waves per minute to 0.28 +/- 0.2 waves per minute during sleep. Propulsive activity was uniformly disorganized, with peristaltic sequences being few (less than 50% overall) and incomplete (above 80%). Finally, the acid-clearing capacity was nil; the proportions of ineffective sequences were above 90% for all periods considered, including sleep and mealtimes. The motor behavior of nonrefluxing and refluxing patients was identical despite the differences in esophageal acid exposure.(ABSTRACT TRUNCATED AT 250 WORDS)

Late pulmonary function following repair of tracheoesophageal fistula or esophageal atresia

Although tracheoesophageal fistula and esophageal atresia (TEF-EA) are surgically correctable, late respiratory complications have been reported. We administered a respiratory and gastrointestinal symptom questionnaire and performed standard pulmonary function tests (PF T's) and methacholine challenge testing on an unselected group of 25 subjects with TEF-EA who underwent surgery at our institution between 1963 and 1985. Results were compared to predicted normals, as well as 10 sibling controls. While the mean values of lung function test results for the TEF-EA group were within the normal range, they were significantly different from their siblings. Thirteen of the 25 TEF-EA group (52%), but none (0%) of the controls, had abnormal pulmonary function. This was classified as restrictive in 9 (36%), obstructive in 3 (12%), and mixed in 1. In addition, airway hyperreactivity [defined as a positive methacholine challenge (PC20 < or = 8 mg/mL)], was found in 6 of 18 TEF-EA subjects and 4 of the 9 controls who were evaluated. Comparison of TEF-EA subjects with normal and abnormal PFTs showed no difference in the incidence of tracheomalacia, esophageal strictures or dilatation, recurrent pneumonias, or gastroesophageal reflux. The respiratory symptom score in the subjects and controls was similar, and did not correlate with abnormal pulmonary function. The cause of the pulmonary function abnormalities remains unexplained.

Respiratory morbidity after repair of oesophageal atresia and tracheo-oesophageal fistula

Respiratory morbidity in 334 patients aged 1 to 37 years with repaired oesophageal atresia and tracheo-oesophageal fistula is reported. Just under half the patients were subsequently hospitalised with respiratory illness. Two thirds of admissions were before 5 years of age. Five percent were admitted on more than five occasions. Patients with gastro-oesophageal reflux and low birth weight were more likely to be admitted. Thirty one percent of patients had one or more episodes of pneumonia in the first five years of life and 5% after 15 years. The prevalence of annual bouts of bronchitis in these age groups was 74% and 41% respectively. The prevalence of wheeze was about 40% in all age groups. Patients with symptoms persisting after 15 years were more likely to have had lower respiratory tract illness in early childhood and a history of atopy. In the 12 months before review, weekly episodes of wheezing were present in one third under 5 years and 15% over 15 years. Thirty two percent of patients aged 5-10 years and 8% over 15 years missed two or more weeks of school or work in the previous year with respiratory illness.

Lung function abnormalities in repaired oesophageal atresia and tracheo-oesophageal fistula

BACKGROUND

Respiratory complications are common after neonatal repair of oesophageal atresia and tracheo-oesophageal fistula. The prevalence of lung function abnormalities and the relation between gastrointestinal complications and lung function has not been studied in a large number of patients.

METHODS

Lung volumes and flow-volume loops were measured in 155 patients without spinal curvature aged 6-37 years who had undergone surgery for oesophageal atresia and tracheo-oesophageal fistula.

RESULTS

Sixty four of the 155 patients had evidence of mild lower airways disease, with values for FEV1 more than two standardised scores below the predicted value in 39 (25%) and above 2 standardised scores for the residual volume (RV)/total lung capacity (TLC) ratio in 64 (41%). Restrictive lung disease (TLC more than 2 standardised scores below predicted) was present in 28 (18%). Severe lung function abnormalities were present in under 10% of the 155. Half the subjects had some evidence of extra-thoracic tracheal obstruction, with a high ratio of expiratory to inspiratory flow for peak flow in 76 (50%) and at 50% of vital capacity in 59 (38%). Patients with radiological gastro-oesophageal reflux in early childhood had more airways obstruction and smaller lung volumes. Patients with current gastrointestinal symptoms were similar in their lung function to symptom free patients.

CONCLUSIONS

Minor lung function abnormalities are common in patients after repair of oesophageal atresia. Early diagnosis and management of gastro-oesophageal reflux may help to minimise these lung function abnormalities.

The absence of clinically significant tracheomalacia in patients having esophageal atresia without tracheoesophageal fistula

The association of tracheomalacia (TM) with esophageal atresia (EA) has been well described. This study attempted to find a correlation between the severity of TM and the presence or absence of an associated tracheoesophageal fistula (TEF) in patients with EA. A review of all patients presenting at this institution with EA through the years 1970 to 1990 was carried out. Six patients with EA without fistula (type A) and 61 patients having EA with fistula (types B, C, D, and E) were analyzed. Five of the six type A patients required esophageal dilatations and antireflux procedures; none had clinically significant TM. Thirty-five of the 61 patients with fistula required esophageal dilatation, and 8 had an antireflux procedure; 11 (18%) required either long-tube tracheostomy or aortopexy for TM. This small study supports a recent hypothesis of different embryological events resulting in different types of esophageal and tracheal anomalies. When EA occurs without fistula, it appears that no significant alteration in tracheal development occurs.

Motor efficiency of the refluxing esophagus in basal conditions and after acid challenge

We have investigated manometrically and endoscopically 60 children with extended pH metering-documented gastroesophageal reflux (GER) and a control group of 14 children of comparable ages. In an attempt to simplify the evaluation of esophageal peristalsis, we measured the frequency of propulsive waves (in waves/hour) and their mean pressure (in mm Hg) in the body of the esophagus and multiplied both values to result in one single figure that reflected esophageal motor efficiency (EME) in some way. We performed the tests in basal conditions (EMEB) and after instillation of 5 mL of 0.1 N CIH into the esophageal lumen (EMECIH). In comparison with controls, refluxing children had a lower sphincter pressure (LESP) (14.9 +/- 8 v 11.8 +/- 6.9 mm Hg, P less than 0.05), an increased proportion of nonpropulsive waves (38.8 +/- 29.3% v 68 +/- 27%, P less than 0.001), and a significantly lower EMEB (896.6 +/- 777 v 375 +/- 306, P less than 0.001). These results suggest that both the sphincteric antireflux barrier and esophageal pump can be damaged in GER. There was a weak, but significant, correlation between EMEB and esophagitis grade (rs = -.25, P less than 0.05). Furthermore, esophageal motor response after CIH instillation may have some prognostic value because EMECIH was significantly higher in those of the 52 children followed-up for more than a year who responded to medical treatment (n = 16) than in those in whom medical treatment was a failure (n = 36) (981.2 +/- 617.4 v 460.5 +/- 452.3, P less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

Adults who survived repair of congenital oesophageal atresia and tracheo-oesophageal fistula

One hundred and twenty five adults who were born before 1969 with oesophageal atresia or tracheo-oesophageal fistula or both and were managed at the Royal Children's Hospital, Melbourne, were reviewed. Most enjoyed a normal life. Though over half had difficulties in swallowing and symptoms of gastro-oesophageal reflux, the symptoms occurred only occasionally and were regarded as inconsequential by most. One third of the patients had wheeze and a quarter had at least one episode of bronchitis a year, but these interfered little with daily activities. Overall, these results are encouraging for young patients with oesophageal atresia and their families.