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Ardenghi C, Vestri E, Costanzo S, Lanfranchi G, Vertemati M, Destro F, Pierucci UM, Calcaterra V, Pelizzo G. Congenital Esophageal Atresia Long-Term Follow-Up-The Pediatric Surgeon's Duty to Focus on Quality of Life. CHILDREN (BASEL, SWITZERLAND) 2022; 9:children9030331. [PMID: 35327704 PMCID: PMC8947008 DOI: 10.3390/children9030331] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 02/25/2022] [Accepted: 02/28/2022] [Indexed: 12/14/2022]
Abstract
Esophageal atresia (EA) is the most common congenital esophageal malformation. An improvement in survival led to a focus on functional outcomes and quality of life (QoL). We analyzed the long-term outcomes and QoL of patients submitted to surgery for EA. Perinatal characteristics, surgical procedures, gastrointestinal and respiratory current symptoms and QoL were investigated. Thirty-nine patients were included. Long Gap patients had a higher rate of prematurity and low birth weight. The prevalent surgical procedure was primary esophageal anastomosis, followed by gastric pull-up. Twenty-four patients had post-operative stenosis, while gastroesophageal reflux (GER) required fundoplication in eleven cases. Auxological parameters were lower in Long Gap patients. The lowest scores of QoL were in the Long Gap group, especially in younger patients, which was the group with the highest number of symptoms. In the long term, the QoL appeared to be more dependent on the type of esophageal atresia rather than on associated malformations. Surgical management of GER was indicated in all patients with Long Gap EA, supposedly due to the prevalence of gastric pull-up for this type of EA. The assessment of QoL is part of surgeon’s management and needs to be performed in each phase of a child’s development.
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Affiliation(s)
- Carlotta Ardenghi
- Pediatric Surgery Department, “Vittore Buzzi” Children’s Hospital, 20154 Milan, Italy; (C.A.); (E.V.); (S.C.); (G.L.); (F.D.); (U.M.P.)
| | - Elettra Vestri
- Pediatric Surgery Department, “Vittore Buzzi” Children’s Hospital, 20154 Milan, Italy; (C.A.); (E.V.); (S.C.); (G.L.); (F.D.); (U.M.P.)
| | - Sara Costanzo
- Pediatric Surgery Department, “Vittore Buzzi” Children’s Hospital, 20154 Milan, Italy; (C.A.); (E.V.); (S.C.); (G.L.); (F.D.); (U.M.P.)
| | - Giulia Lanfranchi
- Pediatric Surgery Department, “Vittore Buzzi” Children’s Hospital, 20154 Milan, Italy; (C.A.); (E.V.); (S.C.); (G.L.); (F.D.); (U.M.P.)
| | - Maurizio Vertemati
- CIMaINa (Interdisciplinary Centre for Nanostructured Materials and Interfaces), University of Milano, 20133 Milan, Italy;
| | - Francesca Destro
- Pediatric Surgery Department, “Vittore Buzzi” Children’s Hospital, 20154 Milan, Italy; (C.A.); (E.V.); (S.C.); (G.L.); (F.D.); (U.M.P.)
| | - Ugo Maria Pierucci
- Pediatric Surgery Department, “Vittore Buzzi” Children’s Hospital, 20154 Milan, Italy; (C.A.); (E.V.); (S.C.); (G.L.); (F.D.); (U.M.P.)
| | - Valeria Calcaterra
- Pediatric Department, Children’s Hospital “Vittore Buzzi”, 20154 Milan, Italy;
- Pediatrics and Adolescentology Unit, Department of Internal Medicine, University of Pavia, 27100 Pavia, Italy
| | - Gloria Pelizzo
- Pediatric Surgery Department, “Vittore Buzzi” Children’s Hospital, 20154 Milan, Italy; (C.A.); (E.V.); (S.C.); (G.L.); (F.D.); (U.M.P.)
- Department of Biomedical and Clinical Science “Luigi Sacco”, University of Milano, 20157 Milan, Italy
- Correspondence:
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Nucci DJ, Hurst KC, Monnet E. Retrospective comparison of short-term outcomes following thoracoscopy versus thoracotomy for surgical correction of persistent right aortic arch in dogs. J Am Vet Med Assoc 2018; 253:444-451. [DOI: 10.2460/javma.253.4.444] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Fragoso AC, Tovar JA. The multifactorial origin of respiratory morbidity in patients surviving neonatal repair of esophageal atresia. Front Pediatr 2014; 2:39. [PMID: 24829898 PMCID: PMC4017156 DOI: 10.3389/fped.2014.00039] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2014] [Accepted: 04/20/2014] [Indexed: 12/18/2022] Open
Abstract
Esophageal atresia with or without tracheoesophageal fistula (EA ± TEF) occurs in 1 out of every 3000 births. Current survival approaches 95%, and research is therefore focused on morbidity and health-related quality of life issues. Up to 50% of neonates with EA ± TEF have one or more additional malformations including those of the respiratory tract that occur in a relatively high proportion of them and particularly of those with vertebral, anal, cardiac, tracheoesophageal, renal, and limb association. Additionally, a significant proportion of survivors suffer abnormal pulmonary function and chronic respiratory tract disease. The present review summarizes the current knowledge about the nature of these symptoms in patients treated for EA ± TEF, and explores the hypothesis that disturbed development and maturation of the respiratory tract could contribute to their pathogenesis.
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Affiliation(s)
- Ana Catarina Fragoso
- INGEMM and Idipaz Research Laboratory, Department of Pediatric Surgery, Hospital Universitario La Paz , Madrid , Spain ; Department of Pediatrics, Universidad Autonoma de Madrid , Madrid , Spain ; Faculty of Medicine, University of Porto , Porto , Portugal
| | - Juan A Tovar
- INGEMM and Idipaz Research Laboratory, Department of Pediatric Surgery, Hospital Universitario La Paz , Madrid , Spain ; Department of Pediatrics, Universidad Autonoma de Madrid , Madrid , Spain
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van Wijk M, Knüppe F, Omari T, de Jong J, Benninga M. Evaluation of gastroesophageal function and mechanisms underlying gastroesophageal reflux in infants and adults born with esophageal atresia. J Pediatr Surg 2013; 48:2496-505. [PMID: 24314193 DOI: 10.1016/j.jpedsurg.2013.07.024] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2013] [Revised: 07/23/2013] [Accepted: 07/24/2013] [Indexed: 01/16/2023]
Abstract
PURPOSE To evaluate the mechanisms underlying gastroesophageal reflux (GER) following esophageal atresia (EA) repair and gastroesophageal function in infants and adults born with EA. METHODS Ten consecutive infants born with EA as well as 10 randomly selected adult EA patients were studied during their first postoperative follow-up visit and a purposely planned visit, respectively. A (13)C-octanoate breath test and esophageal pH-impedance-manometry study were performed. Mechanisms underlying GER and esophageal function were evaluated. RESULTS Transient lower esophageal sphincter relaxation (TLESR) was the most common mechanism underlying GER in infants and adults (66% and 62%, respectively). In 66% of all GER episodes, no clearing mechanism was initiated. On EFT, normal motility patterns were seen in six patients (four infants, two adults). One of these adults had normal motility overall (>80% of swallows). Most swallows (78.8%) were accompanied by abnormal motility patterns. Despite this observation, impedance showed normal bolus transit in 40.9% of swallows. Gastric emptying was delayed in 57.1% of infants and 22.2% of adults. CONCLUSIONS TLESR is the main mechanism underlying GER events in patients with EA. Most infants and adults have impaired motility, delayed bolus clearance, and delayed gastric emptying. However, normal motility patterns were seen in a minority of patients.
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Affiliation(s)
- Michiel van Wijk
- Department of Pediatric Gastroenterology and Nutrition, Emma Children's Hospital AMC, Academic Medical Center, Amsterdam, the Netherlands.
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Pedersen RN, Markøw S, Kruse-Andersen S, Qvist N, Hansen TP, Gerke O, Nielsen RG, Rasmussen L, Husby S. Esophageal atresia: gastroesophageal functional follow-up in 5-15 year old children. J Pediatr Surg 2013; 48:2487-95. [PMID: 24314192 DOI: 10.1016/j.jpedsurg.2013.07.019] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2013] [Revised: 06/13/2013] [Accepted: 07/12/2013] [Indexed: 02/06/2023]
Abstract
PURPOSE Esophageal atresia (EA) is one of the most frequent congenital alimentary tract anomalies with a considerable morbidity throughout childhood. This study evaluates the gastroesophageal problems in 5-15 year old children with EA and aims to identify factors predisposing to esophagitis in EA. MATERIAL AND METHODS Fifty-nine patients primarily operated at Odense University Hospital, Denmark, during 1993-2005 were included in this follow-up study. The patients underwent the following examinations: Interview, upper endoscopy, endoscopic ultrasonography, high-resolution esophageal manometry (HREM), and pH- and multichannel intraluminal impedance (MII) measurements. Twenty-five patients with suspected gastro-esophageal reflux disease (GERD) underwent the same investigations and served as controls. RESULTS Median age was 10.2 years (7.1-13.3). Thirty-three (55.9%) presented with GERD symptoms, 41 (69.5%) with dysphagia, and 33 (55.9%) with respiratory symptoms. Twenty-nine (49.2%) had endoscopic esophagitis, and 26 (44.1%) histological esophagitis. Median reflux index (RI) was 8.3 (4.8-14.9). In 32 (55.2%) RI was above 7. Ten percent had eosinophilic inflammation. HREM showed dysmotility in the esophagus in all EA patients, 83.3% had no propagating swallows. No predictive factors predisposing the development of endoscopic esophagitis were identified. CONCLUSIONS Gastroesophageal problems in children born with EA are common. Routine follow-up with endoscopy and pH-metry in EA patients is warranted.
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Affiliation(s)
- Rikke Neess Pedersen
- Hans Christian Andersen Children's Hospital, Odense University Hospital, Denmark.
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Khan KM, Krosch TC, Eickhoff JC, Sabati AA, Brudney J, Rivard AL, Foker JE. Achievement of feeding milestones after primary repair of long-gap esophageal atresia. Early Hum Dev 2009; 85:387-92. [PMID: 19188031 DOI: 10.1016/j.earlhumdev.2009.01.006] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2008] [Revised: 01/05/2009] [Accepted: 01/07/2009] [Indexed: 12/30/2022]
Abstract
OBJECTIVES To determine the pattern of feeding milestones following primary repair of long-gap esophageal atresia (EA). METHOD A questionnaire based upon well established feeding milestones was used. Children after long-gap EA repair, n=40, were compared from after primary repair to healthy children from birth, n=102. RESULTS The age when surveyed of the EA group and controls was different: 6.2+/-4.7 (mean+/-standard deviation) years, range 1.1-20.9, versus 2.5+/-2.4 years, range 0.0-12.1, p=0.00. The esophageal gap length in the EA group was 5.1+/-1.2 cm and age at repair was 5.5+/-5.0 months. There was no statistically significant difference between the atresia group and controls for feeding milestones; Self feeding finger foods approached significance. There was, however, greater variability in the timing of milestones in the atresia group compared to controls. Feeding milestones were negatively correlated with age at primary repair: drinking with a covered sippy cup, rho=-0.51, p=0.01 and self feeding finger foods, rho=-0.36, p=0.04 were statistically significant. Drinking from a cup correlated with gestational age, rho=0.38, p=0.04, and negatively correlated to esophageal gap length, rho=-0.45, p=0.01. CONCLUSIONS Despite delayed onset of feeding, major milestones after EA repair occurred in similar pattern to normal infants. An early referral for primary repair is beneficial for earlier acquisition of milestones for infants with long-gap EA.
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Affiliation(s)
- Khalid M Khan
- Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota, USA.
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Mortell AE, Azizkhan RG. Esophageal atresia repair with thoracotomy: the Cincinnati contemporary experience. Semin Pediatr Surg 2009; 18:12-9. [PMID: 19103416 DOI: 10.1053/j.sempedsurg.2008.10.003] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
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.
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Affiliation(s)
- Alan E Mortell
- Division of Pediatric and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio 45229, USA
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Deurloo JA, Klinkenberg EC, Ekkelkamp S, Heij HA, Aronson DC. Adults with corrected oesophageal atresia: is oesophageal function associated with complaints and/or quality of life? Pediatr Surg Int 2008; 24:537-41. [PMID: 18351366 PMCID: PMC2292794 DOI: 10.1007/s00383-008-2120-1] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/27/2008] [Indexed: 02/06/2023]
Abstract
The aim of this study was to evaluate oesophageal function after correction of oesophageal atresia in adults, and to investigate the association between complaints, oesophageal function and quality of life (QoL). Twenty-five adults were included who participated in previous follow-up studies, during which complaints of dysphagia and gastro-oesophageal reflux (GOR), results of upper gastrointestinal endoscopy, oesophageal biopsies and QoL had been collected. Manometry was performed in 20 patients, 24 h pH-measurements were performed in 21 patients. pH-values (sample time 5 s) were calculated using criteria of Johnson and DeMeester. Associations were tested with ANOVA and chi (2)-tests. Ten patients (48%) reported complaints of dysphagia, seven (33%) of GOR. The amplitude of oesophageal contractions was low (<15 mmHg) in four patients (20%). pH-measurements showed pathological reflux in three patients (14%). Patients reporting dysphagia more often had disturbed motility (P = 0.011), and lower scores on the domains "general health perceptions" (SF-36) (P = 0.026), "standardised physical component" (SF-36) (P = 0.013), and "physical well-being" (GIQLI) (0.047). No other associations were found. This study shows a high percentage of oesophageal motility disturbances and a moderate percentage of GOR after correction of oesophageal atresia. Patients reporting dysphagia, whom more often had disturbed motility, seemed to be affected by these symptoms in their QoL.
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Affiliation(s)
- J. A. Deurloo
- Pediatric Surgical Center of Amsterdam, Emma Children’s Hospital AMC and Vrije Universiteit Medical Center, P. O. Box 22660, 1100 DD Amsterdam, The Netherlands
| | - E. C. Klinkenberg
- Department of Gastroenterology, Vrije Universiteit Medical Center, P. O. Box 7057, 1007 MB Amsterdam, The Netherlands
| | - S. Ekkelkamp
- Pediatric Surgical Center of Amsterdam, Emma Children’s Hospital AMC and Vrije Universiteit Medical Center, P. O. Box 22660, 1100 DD Amsterdam, The Netherlands
| | - H. A. Heij
- Pediatric Surgical Center of Amsterdam, Emma Children’s Hospital AMC and Vrije Universiteit Medical Center, P. O. Box 22660, 1100 DD Amsterdam, The Netherlands
| | - D. C. Aronson
- Pediatric Surgical Center of Amsterdam, Emma Children’s Hospital AMC and Vrije Universiteit Medical Center, P. O. Box 22660, 1100 DD Amsterdam, The Netherlands
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Pederiva F, Burgos E, Francica I, Zuccarello B, Martinez L, Tovar JA. Intrinsic esophageal innervation in esophageal atresia without fistula. Pediatr Surg Int 2008; 24:95-100. [PMID: 17962964 DOI: 10.1007/s00383-007-2032-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Esophageal atresia and tracheo-esophageal fistula (EA + TEF) are often associated with malformations of neural crest origin. Esophageal innervation is also derived from the neural crest and it is abnormal in EA + TEF in which there is motor dysfunction. Our aim was to examine the intrinsic esophageal innervation in children with isolated EA in which different embryogenic mechanisms might be involved. Specimens from the proximal and distal esophageal segments of 6/35 patients who had esophageal replacement for isolated EA between 1965 and 2006 were suitable for the study. They were sectioned and immunostained with anti-neurofilament (NF) and anti-S-100 antibodies. The muscle and neural surfaces on each section were measured with the assistance of image processing software. The surface of the ganglia and the number of neurons per ganglion were determined at high power microscopy. The findings were compared with those of six autopsy specimens from newborns dead of other diseases by means of standard statistical tests and a significance threshold of P < 0.05. Unmatched age/size of babies in isolated EA and control groups precluded comparison of the relative surfaces occupied by neural elements. Patients with pure EA had denser fibrilar network and larger ganglia than controls. The number of neurons/ganglion were similar in both groups although the cells from EA patients were larger. The findings were similar at both esophageal levels studied. In spite of methodologic biases, it seems that intrinsic esophageal fibrilar network is denser and the intramural ganglia larger with larger cells in patients with pure EA than in controls on both esophageal ends of the organ. These neural anomalies are only in part reminiscent of those described in regular EA/TEF but may as well explain esophageal dysfunction in patients with repaired isolated EA.
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Affiliation(s)
- Federica Pederiva
- Department of Pediatric Surgery, Hospital Universitario La Paz, Paseo de la Castellana, 261, Madrid, Spain
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Kawahara H, Kubota A, Hasegawa T, Okuyama H, Ueno T, Watanabe T, Morishita Y, Saka R, Fukuzawa M. Lack of distal esophageal contractions is a key determinant of gastroesophageal reflux disease after repair of esophageal atresia. J Pediatr Surg 2007; 42:2017-21. [PMID: 18082699 DOI: 10.1016/j.jpedsurg.2007.08.023] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2007] [Accepted: 08/08/2007] [Indexed: 11/28/2022]
Abstract
BACKGROUND/PURPOSE The objective of this study is to investigate the characteristics of esophageal motor activity responsible for the development of gastroesophageal reflux (GER) in patients with esophageal atresia (EA). METHODS The subjects consisted of 29 patients with EA (1 month to 19 years). Computerized esophageal manometry was conducted to investigate esophageal contractions at swallow. A topographic esophageal manometric analysis was conducted in each subject, providing 3-dimensional displays to reveal the pressure continuum representing esophageal contractions. RESULTS Significant contractions in the middle esophagus just below the anastomosis were absent in all subjects. Contractions in the distal esophagus were conspicuously absent in 17 subjects. Of these 17, 6 had already undergone fundoplication, and 9 had symptomatic GER requiring fundoplication subsequent to this study. The remaining 12 patients had contractions in the distal esophagus and did not require medical/surgical intervention. A lack of distal esophageal contractions was significantly correlated with the development of GER (P < .001). There was a significant difference in esophageal acid exposure between the 2 groups (median, 38% vs 4%, P < .001). CONCLUSION Lack of distal esophageal contractions indicating an impaired clearing capacity is considered a potential key determinant of GER in patients with EA.
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Affiliation(s)
- Hisayoshi Kawahara
- Department of Pediatric Surgery, Osaka Medical Center and Research Institute for Maternal and Child Health, Osaka 594-1101, Japan.
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Affiliation(s)
- A Mortell
- Children's Research Centre, Our Lady's Hospital for Sick Children, Crumlin, Dublin 12, Ireland
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