Swallowing disorders after esophageal atresia evaluated with videomanometry

The characteristics of eating, drinking and oro-pharyngeal swallowing difficulties associated with repaired oesophageal atresia/tracheo-oesophageal fistula: a systematic review and meta-proportional analysis

INTRODUCTION

Eating, drinking and swallowing difficulties are commonly reported morbidities for individuals born with OA/TOF. This study aimed to determine the nature and prevalence of eating, drinking and oro-pharyngeal swallowing difficulties reported in this population.

METHOD

A systematic review and meta-proportional analysis were conducted (PROSPERO: CRD42020207263). MEDLINE, EMBASE, CINAHL, Pubmed, Scopus, Web of Science databases and grey literature were searched. Quantitative and qualitative data were extracted relating to swallow impairment, use of mealtime adaptations and eating and drinking-related quality of life. Quantitative data were summarised using narrative and meta-proportional analysis methods. Qualitative data were synthesised using a meta-aggregation approach. Where quantitative and qualitative data described the same phenomenon, a convergent segregated approach was used to synthesise data.

RESULTS

Sixty-five studies were included. Six oro-pharyngeal swallow characteristics were identified, and pooled prevalence calculated: aspiration (24%), laryngeal penetration (6%), oral stage dysfunction (11%), pharyngeal residue (13%), nasal regurgitation (7%), delayed swallow initiation (31%). Four patient-reported eating/drinking difficulties were identified, and pooled prevalence calculated: difficulty swallowing solids (45%), difficulty swallowing liquids (6%), odynophagia (30%), coughing when eating (38%). Three patient-reported mealtime adaptations were identified, and pooled prevalence calculated: need for water when eating (49%), eating slowly (37%), modifying textures (28%). Mixed methods synthesis of psychosocial impacts identified 34% of parents experienced mealtime anxiety and 25% report challenging mealtime behaviours reflected in five qualitative themes: fear and trauma associated with eating and drinking, isolation and a lack of support, being aware and grateful, support to cope and loss.

CONCLUSIONS

Eating and drinking difficulties are common in adults and children with repaired OA/TOF. Oro-pharyngeal swallowing difficulties may be more prevalent than previously reported. Eating, drinking and swallowing difficulties can impact on psychological well-being and quality of life, for the individual and parents/family members. Long-term, multi-disciplinary follow-up is warranted.

The Role of Oral Feeding Time and Sham Feeding on Oropharyngeal Swallowing Functions in Children with Esophageal Atresia

A retrospective study was performed to evaluate the role of oral feeding (OF) time and sham feeding (SF) on oral-pharyngeal swallowing functions in children with esophageal atresia (EA). Patients with EA were evaluated for age, sex, and types of atresia, time to start OF and surgical complications. Three to six weeks after full OF, videofluoroscopic swallowing evaluation (VFSE) was performed, and Penetration Aspiration Score (PAS, no aspiration = 1, penetration = 2-5, aspiration = 6-8), delay in swallowing reflex and residue after liquid and pudding consistency were noted. Patients were divided into three groups according to repair time; early primary repair (EPR, < 1 month of age), delayed primary repair (DPR, ≥ 1 month of age) and colonic interposition (CI). VFSE findings were compared between groups. In CI group, patients without aspiration in VFSE were encouraged to sham SF before CI. Patients with and without SF in CI group were also compared for oro-pharyngeal dysphagia (OPD). PAS scores were significantly higher in DPR (n = 13) group when compared to CI group (n = 12) in liquid swallowing (p = 0.032) and higher than EPR (n = 30) in pudding consistency (p = 0.03). Patients with CI showed significant OPD when compared to EPR (p = 0.017). Swallowing reflex delay was similar in both groups (p > 0.05). DPR group had significantly higher liquid residue at the level of vallecula (p = 0.028). The residue at other levels (oral, tongue base, pharyngeal wall and pyriform sinus) were similar in all groups in both liquid and pudding consistencies. There was no significant difference between sham-fed (n = 6) and not sham-fed (n = 6) infants in VFSE of OPD (p > 0.05). Patients with DPR without SF had significantly higher incidence of OPD and PAS scores when compared to EPR and CI. Although CI groups has the latest OF time, SF may improve oral motor abilities and cause better OF swallowing functions than patients with delayed repair.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

How to Care for Patients with EA-TEF: The Known and the Unknown

PURPOSE OF REVIEW

Guidelines were recently published highlighting why esophageal atresia (EA) patients are prone to complication risks, and the need for long-term follow-up. In this review, we will focus on how to investigate and treat potential complications, as well as the pros and cons of different investigative and treatment modalities, and what areas continue to need further research.

RECENT FINDINGS

EA patients are at high risk for gastroesophageal reflux and esophageal strictures, and the sequela that result. Extraintestinal manifestations of gastroesophageal reflux disease (GERD) can appear similar to other pathologic diagnoses commonly found in EA patients, such as congenital stricture, eosinophilic esophagitis, esophageal dysmotility, tracheomalacia, recurrent fistula, aspiration, etc. Therefore, it is important to have a standardized way to monitor for these issues. pH impedance allows for detection of nonacid reflux and the height of reflux, which are important in correlating symptoms with reflux episodes. A multidisciplinary approach is beneficial in evaluating and monitoring EA patients in the long term.

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.

Dysmotility in Esophageal Atresia: Pathophysiology, Characterization, and Treatment

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

ESPGHAN-NASPGHAN Guidelines for the Evaluation and Treatment of Gastrointestinal and Nutritional Complications in Children With Esophageal Atresia-Tracheoesophageal Fistula

BACKGROUND

Esophageal atresia (EA) is one of the most common congenital digestive anomalies. With improvements in surgical techniques and intensive care treatments, the focus of care of these patients has shifted from mortality to morbidity and quality-of-life issues. These children face gastrointestinal (GI) problems not only in early childhood but also through adolescence and adulthood. There is, however, currently a lack of a systematic approach to the care of these patients. The GI working group of International Network on Esophageal Atresia comprises members from ESPGHAN/NASPGHAN and was charged with the task of developing uniform evidence-based guidelines for the management of GI complications in children with EA.

METHODS

Thirty-six clinical questions addressing the diagnosis, treatment, and prognosis of the common GI complications in patients with EA were formulated. Questions on the diagnosis, and treatment of gastroesophageal reflux, management of "cyanotic spells," etiology, investigation and management of dysphagia, feeding difficulties, anastomotic strictures, congenital esophageal stenosis in EA patients were addressed. The importance of excluding eosinophilic esophagitis and associated GI anomalies in symptomatic patients with EA is discussed as is the quality of life of these patients and the importance of a systematic transition of care to adulthood. A systematic literature search was performed from inception to March 2014 using Embase, MEDLINE, the Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Clinical Trials, and PsychInfo databases. The approach of the Grading of Recommendations Assessment, Development and Evaluation was applied to evaluate outcomes. During 2 consensus meetings, all recommendations were discussed and finalized. The group members voted on each recommendation, using the nominal voting technique. Expert opinion was used where no randomized controlled trials were available to support the recommendation.

The evaluation of deglutition with videofluoroscopy after repair of esophageal atresia and/or tracheoesophageal fistula

AIM

A retrospective study was performed to evaluate the functional disorders of deglutition with videofluoroscopy (VFS), in children operated for esophageal atresia (EA) and/or tracheoesophageal fistula (TEF).

METHODS

Patients with the repair of EA-TEF were evaluated in respect to the type of malformation, operative procedure, postoperative complications, deglutitive and respiratory symptoms, and gastroesophageal reflux disease (GERD). The dysphagia score, VFS findings of oral, pharyngeal and esophageal phases, and penetration-aspiration scale (PAS) score were recorded in the evaluation of the deglutitive functions.

RESULTS

Thirty-two cases with a median age of 48months (2-120months), and male to female ratio of 14:18 were included in the study. Most of the cases had Gross type C anomaly (n=26, 81.3%), and the others were type A (n=3), D (n=2) and E (n=1). The incidence of associated anomalies was 71.8%. The patients underwent primary (n=26, 81.3%) or delayed (n=6, 18.7%) anastomosis. Postoperative complications including anastomotic stricture (n=12), leak (n=2) and recurrent fistula (n=2) were managed by dilatation, conservative approach and repair of the fistula, respectively. Recurrent pneumonia (n=13), cough with liquid intake (n=10) and food impaction (n=7) were recorded in the history. Management of GERD included medical (n=11) and surgical (n=7) treatment. The median dysphagia score was 3.5 (min: 0-max: 27). The oral phase of VFS was normal in most of the cases (n=29, 90.6%). Only three had mild or moderate impairment, and none had severe. The pharyngeal phase showed no impairment in 23 of the cases (71.8%), and severe impairment was observed only in 3 of all, for the parameters of hyolaryngeal elevation and airway closure. Opposite to the first two phases of the deglutition, the esophageal phase was normal in only 2 of the cases (6.3%). Among the other 30 cases with impairment, only two had mild, and the rest had moderate to severe problems. Esophageal backflow, motility and residue were the most severely impaired parameters of this phase. The PAS evaluation revealed no penetration and aspiration in 26 of the cases (81.3%), while 1 had penetration and five had aspiration.

CONCLUSION

The patients with repaired EA-TEF may reveal deglutitive and respiratory symptoms in follow-up, necessitating certain investigations. The deglutition is functionally evaluated with VFS. While the disorders of oral and pharyngeal phases are less frequent and prominent, the esophageal phase reveals disorders with higher incidence and severity.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Combined esophageal multichannel intraluminal impedance and pH monitoring after repair of esophageal atresia

OBJECTIVE

Gastroesophageal reflux disease and impaired esophageal motility is a frequent problem after repair of esophageal atresia (EA). Combined multichannel intraluminal impedance (MII) and pH measurement identifies acidic and weakly acidic esophageal bolus movements. Our aim was to evaluate gastroesophageal reflux and its association with gastrointestinal or extraintestinal symptoms using combined MII-pH measurement.

PATIENTS AND METHODS

In all, 24 patients (4 months-23 years; 17 male, 7 female) with repaired EA were included in this study. A single catheter with 6 impedance channels and 1 pH channel was used to perform the 24-hour MII-pH study. Symptoms were recorded during the study as events and with a standardized questionnaire. In a subgroup of patients, an impedance swallowing test evaluating liquid and viscous bolus movements was performed.

RESULTS

We detected a total of 911 episodes of retrograde bolus movement, 379 acidic and 532 weakly acidic bolus movements. In all, 201 symptom events were recorded. Of these events, 42% were associated with retrograde bolus movements. More symptom events were associated with weakly acidic reflux (26%) than with acid reflux episodes (16%). There was a poor correlation between symptoms and MII-pH study findings. In comparison with patients without esophageal surgery, EA patients showed significantly fewer complete swallows of liquid (42% vs 98%) and viscous material (18% vs 87%).

CONCLUSIONS

In patients with corrected EA, half of the reflux events could be detected only by MII. We also demonstrated that weakly acidic reflux can be responsible for the patients' symptoms. However, patients may have few or no symptoms despite poor esophageal function and extensive gastroesophageal reflux disease.

Esophageal atresia without distal tracheoesophageal fistula: high incidence of proximal fistula

BACKGROUND

This retrospective study was performed to test our suspicion that the incidence of esophageal atresia with proximal fistula in our institution is much higher than is generally reported.

METHODS

The charts of all patients with esophageal atresia and/or tracheoesophageal fistula admitted in the period 1982 to 2000 were analyzed. The type of atresia and/or tracheoesophageal fistula was noted, and the relative incidence was calculated and compared with the relative incidence in a cumulative series of 3492 patients taken from 9 published studies.

RESULTS

In the period under study, 123 patients with esophageal atresia and/or tracheoesophageal fistula were identified. The relative incidence of esophageal atresia without distal fistula was statistically not different (10.6% in the present series against 8.49% in the reference group). A statistically significant difference in the relative incidence of esophageal atresia with proximal fistula, however, was found: 5.69% in the present series against 1.05% in the reference group (P < .0001). Looking at the subgroup of patients without a distal fistula, more than half of the patients did have a proximal fistula.

CONCLUSIONS

The relative incidence of esophageal atresia with proximal fistula in this series of children with esophageal atresia and/or tracheoesophageal fistula is significantly higher than reported in the literature. This is on the account of the subgroup of patients without a distal fistula in which the incidence of a proximal fistula is more than 50%. Especially in this subgroup, the existence of a proximal fistula should be ruled out preoperatively.

Imaging of congenital anomalies of the gastrointestinal tract

The radiological imaging plays a vital role in the evaluation of patients with congenital anomalies of the gastrointestinal tract. The evaluation of these patients, most of which present early after birth, frequently requires the use of various imaging modalities for making the correct diagnosis and planning surgical correction. This article reviews the common congenital anomalies of the gastrointestinal tract including obstructive lesions, anomalies of rotation and fixation, anorectal anomalies, and intestinal duplications. The plain radiograph is often diagnostic in neonates with complete gastric of upper intestinal obstruction and further radiologic evaluation may be unnecessary. An upper gastrointestinal series should be performed in all patients with incomplete intestinal obstruction. Sonography is useful in the evaluation of many congenital anomalies affecting pediatric gastrointestinal tract especially hypertrophic pyloric stenosis, enteric duplication cysts, midgut malrotation, meconium ileus and meconium peritonitis. Moreover, CT and MRI has assumed a greater importance as these provide excellent anatomic details which may be necessary for correct diagnosis as well as treatment planning. This is particularly true in evaluation of congenital anomalies such as esophageal/enteric duplications, vascular rings and anorectal anomalies. It is important to be familiar with the role nad usefulness of the various imaging modalities so that these can be used judiciously to avoid unnecessary radiation exposure while minimizing the patient discomfort.

The usefulness of videomanometry for studying pediatric esophageal motor disease

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Gastric smooth muscle contractility changes in the esophageal atresia rat model: an in vitro study

PURPOSE

The aim of the study was to investigate the gastric smooth muscle reactivity in the Adriamycin-induced esophageal atresia (EA) rat model.

METHODS

The fetuses were divided into 3 groups. The control group was exposed to saline. The second group was comprised of fetuses that were exposed to Adriamycin but did not have EA (Adriamycin-no-EA group). The third group was comprised of fetuses that were exposed to Adriamycin and had EA (Adriamycin-EA group). Gastric fundus strips were studied in vitro for their contractile response to receptor activation in the 3 groups.

RESULTS

Contractile responses of gastric smooth muscle to carbachol and KCl were increased in the Adriamycin-EA group compared with the Adriamycin-no-EA group. Also serotonin-induced contractile response in the Adriamycin-EA group decreased compared with the Adriamycin-no-EA group. Relaxation of gastric smooth muscle strips to isoproterenol was comparably unaffected in the Adriamycin-EA and Adriamycin-no-EA groups. Likewise, no change in the response to agonist studies was observed between the control and Adriamycin-no-EA groups. The relaxant response to papaverine was not different in the 3 groups.

CONCLUSIONS

This study found changes of receptor-dependent and receptor-independent contraction of the gastric fundus smooth muscle in the fetuses with EA. Therefore, impaired contractile responses may be, at least in part, a contributing factor in the abnormal gastric motility seen in EA.

Impaired esophageal reactivity in adriamycin-induced rat esophageal atresia: an in vitro study

PURPOSE

The aim of this study was to investigate the reactivity of lower esophageal smooth muscle in the Adriamycin-induced esophageal atresia (EA) rat model.

METHODS

The fetuses were divided into 3 groups. The control group was exposed to saline. The second group comprised fetuses that were exposed to Adriamycin but in whom EA did not develop. The third group comprised of fetuses that were exposed to Adriamycin and EA was observed. The reactivity of distal esophageal strips was studied in organ chambers.

RESULTS

The tension was similar in all groups precontracted with carbachol for the study of relaxation to serotonin. Relaxation of lower esophageal strips to serotonin was comparably unaffected in the control and Adriamycin-no EA groups, whereas it was significantly inhibited in the EA group with decreased E(max) and pD(2) values. Contractile responses of esophageal smooth muscle to carbachol or 80 mmol/L KCl and relaxant responses to papaverine were similar in all groups. No change in agonist potency was observed among the groups.

CONCLUSIONS

Our study showed impairment of serotonin-receptor-mediated relaxation; but not of cholinoceptor-mediated contraction of the lower esophageal smooth muscle in the EA. Thus, impaired relaxant responses may be, at least in part, a contributing factor in the esophageal dismotility seen in EA.