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Yasuda JL, Kamran A, Servin Rojas M, Hayes C, Staffa SJ, Ngo PD, Chang D, Hamilton TE, Demehri F, Mohammed S, Zendejas B, Manfredi MA. Surveillance Endoscopy in Pediatric Esophageal Atresia: Toward an Evidence-Based Algorithm. J Am Coll Surg 2024; 238:831-843. [PMID: 38078620 DOI: 10.1097/xcs.0000000000000923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/18/2024]
Abstract
BACKGROUND Individuals with esophageal atresia (EA) have lifelong increased risk for mucosal and structural pathology of the esophagus. The use of surveillance endoscopy to detect clinically meaningful pathology has been underexplored in pediatric EA. We hypothesized that surveillance endoscopy in pediatric EA has high clinical yield, even in the absence of symptoms. STUDY DESIGN The medical records of all patients with EA who underwent at least 1 surveillance endoscopy between March 2004 and March 2023 at an international EA referral center were retrospectively reviewed. The primary outcomes were endoscopic identification of pathology leading to an escalation in medical, endoscopic, or surgical management. Logistic regression analysis examined predictors of actionable findings. Nelson-Aalen analysis estimated optimal endoscopic surveillance intervals. RESULTS Five hundred forty-six children with EA underwent 1,473 surveillance endoscopies spanning 3,687 person-years of follow-up time. A total of 770 endoscopies (52.2%) in 394 unique patients (72.2%) had actionable pathology. Esophagitis leading to escalation of therapy was the most frequently encountered finding (484 endoscopies, 32.9%), with most esophagitis attributed to acid reflux. Barrett's esophagus (intestinal metaplasia) was identified in 7 unique patients (1.3%) at a median age of 11.3 years. No dysplastic lesions were identified. Actionable findings leading to surgical intervention were found in 55 children (30 refractory reflux and 25 tracheoesophageal fistulas). Significant predictors of actionable pathology included increasing age, long gap atresia, and hiatal hernia. Symptoms were not predictive of actionable findings, except dysphagia, which was associated with stricture. Nelson-Aalen analysis predicted occurrence of an actionable finding every 5 years. CONCLUSIONS Surveillance endoscopy uncovers high rates of actionable pathology even in asymptomatic children with EA. Based on the findings of the current study, a pediatric EA surveillance endoscopy algorithm is proposed.
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Affiliation(s)
- Jessica L Yasuda
- From the Division of Gastroenterology, Hepatology and Nutrition (Yasuda, Ngo, Chang, Manfredi), Boston, MA
| | - Ali Kamran
- From the Division of Gastroenterology, Hepatology and Nutrition (Yasuda, Ngo, Chang, Manfredi), Boston, MA
| | - Maximiliano Servin Rojas
- From the Division of Gastroenterology, Hepatology and Nutrition (Yasuda, Ngo, Chang, Manfredi), Boston, MA
| | - Cameron Hayes
- From the Division of Gastroenterology, Hepatology and Nutrition (Yasuda, Ngo, Chang, Manfredi), Boston, MA
| | - Steven J Staffa
- From the Division of Gastroenterology, Hepatology and Nutrition (Yasuda, Ngo, Chang, Manfredi), Boston, MA
| | - Peter D Ngo
- From the Division of Gastroenterology, Hepatology and Nutrition (Yasuda, Ngo, Chang, Manfredi), Boston, MA
| | - Denis Chang
- From the Division of Gastroenterology, Hepatology and Nutrition (Yasuda, Ngo, Chang, Manfredi), Boston, MA
| | - Thomas E Hamilton
- From the Division of Gastroenterology, Hepatology and Nutrition (Yasuda, Ngo, Chang, Manfredi), Boston, MA
| | - Farokh Demehri
- From the Division of Gastroenterology, Hepatology and Nutrition (Yasuda, Ngo, Chang, Manfredi), Boston, MA
| | - Somala Mohammed
- From the Division of Gastroenterology, Hepatology and Nutrition (Yasuda, Ngo, Chang, Manfredi), Boston, MA
| | - Benjamin Zendejas
- From the Division of Gastroenterology, Hepatology and Nutrition (Yasuda, Ngo, Chang, Manfredi), Boston, MA
| | - Michael A Manfredi
- From the Division of Gastroenterology, Hepatology and Nutrition (Yasuda, Ngo, Chang, Manfredi), Boston, MA
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Dimitrov G, Aumar M, Duhamel A, Wanneveich M, Gottrand F. Proton pump inhibitors in esophageal atresia: A systematic review and meta-analysis. J Pediatr Gastroenterol Nutr 2024; 78:457-470. [PMID: 38262739 DOI: 10.1002/jpn3.12115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 12/09/2023] [Accepted: 12/18/2023] [Indexed: 01/25/2024]
Abstract
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.
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Affiliation(s)
- Georges Dimitrov
- Unit of Pediatric Surgery, Unit of Pediatrics, Competence Centre for Rare Esophageal Diseases, University Hospital Center of Orléans, Orléans, France
| | - Madeleine Aumar
- Reference Centre for Rare Esophageal Diseases, University of Lille, CHU Lille, Lille, France
| | - Alain Duhamel
- Biostatistics Unit, University Hospital of Lille, Lille, France
| | | | - Frédéric Gottrand
- Reference Centre for Rare Esophageal Diseases, University of Lille, CHU Lille, Lille, France
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Hamilton-Hall MN, Jungbauer D, Finck C, Middlesworth W, Zendejas B, Alaish SM, Griggs CL, Russell RT, Shieh HF, Scholz S, Kunisaki SM, Feng C, Danko ME, DeFazio JR, Smithers CJ, Zamora IJ, Knod JL. Esophageal Surveillance Practices in Esophageal Atresia Patients: A Survey by the Eastern Pediatric Surgery Network. J Pediatr Surg 2023; 58:1213-1218. [PMID: 36931942 DOI: 10.1016/j.jpedsurg.2023.02.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 02/10/2023] [Indexed: 02/24/2023]
Abstract
INTRODUCTION Endoscopic surveillance guidelines for patients with repaired esophageal atresia (EA) rely primarily on expert opinion. Prior to embarking on a prospective EA surveillance registry, we sought to understand EA surveillance practices within the Eastern Pediatric Surgery Network (EPSN). METHODS An anonymous, 23-question Qualtrics survey was emailed to 181 physicians (surgeons and gastroenterologists) at 19 member institutions. Likert scale questions gauged agreement with international EA surveillance guideline-derived statements. Multiple-choice questions assessed individual and institutional practices. RESULTS The response rate was 77%. Most respondents (80%) strongly agree or agree that EA surveillance endoscopy should follow a set schedule, while only 36% claimed to perform routine upper GI endoscopy regardless of symptoms. Many institutions (77%) have an aerodigestive clinic, even if some lack a multi-disciplinary EA team. Most physicians (72%) expressed strong interest in helping develop evidence-based guidelines. CONCLUSIONS Our survey reveals physician agreement with current guidelines but weak adherence. Surveillance methods vary greatly, underscoring the lack of evidence-based data to guide EA care. Aerodigestive clinics may help implement surveillance schedules. Respondents support evidence-based protocols, which bodes well for care standardization. Results will inform the first multi-institutional EA databases in the United States (US), which will be essential for evidence-based care. LEVEL OF EVIDENCE This is a prognosis study with level 4 evidence.
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Affiliation(s)
- Malcolm N Hamilton-Hall
- MD/MPH Dual-Degree Program, University of Connecticut School of Medicine, UConn John Dempsey Hospital, 100 Hospital Drive, Farmington, CT, 06030, United States
| | - Dana Jungbauer
- Division of Research Operations and Development, Connecticut Children's Medical Center, 282 Washington Street, Hartford, CT, 06106, United States
| | - Christine Finck
- Division of Pediatric Surgery, Connecticut Children's Medical Center, 282 Washington Street, Hartford, CT, 06106, United States
| | - William Middlesworth
- Division of Pediatric Surgery, Columbia Irving Medical Center, 622 W 168th St, New York, NY, 10032, United States; Department of Pediatric Surgery, Monroe Carell Jr. Children's Hospital at Vanderbilt, 2200 Children's Way, Nashville, TN, 37232, United States
| | - Benjamin Zendejas
- Department of Surgery, Boston Children's Hospital, 300 Longwood Ave, Boston, MA, 02115, United States
| | - Samuel M Alaish
- Department of Surgery, Johns Hopkins University School of Medicine, 733 N Broadway, Baltimore, MD, 21205, United States
| | - Cornelia L Griggs
- Division of Pediatric Surgery, Massachusetts General Hospital, 55 Fruit St, Boston, MA, 02114, USA; Harvard Medical School, 25 Shattuck St, Boston, MA, 02115, United States
| | - Robert T Russell
- Division of Pediatric Surgery, Children's of Alabama, 1600 7th Avenue South, Birmingham, AL, 35233, United States
| | - Hester F Shieh
- Division of Pediatric Surgery, Johns Hopkins All Children's Hospital, 501 6th Ave S, St. Petersburg, FL, 33701, United States
| | - Stefan Scholz
- Division of Pediatric General and Thoracic Surgery, UPMC Children's Hospital of Pittsburgh, One Children's Hospital Drive, 4401 Penn Ave, Pittsburgh, PA, 15224, United States
| | - Shaun M Kunisaki
- Department of Surgery, Johns Hopkins University School of Medicine, 733 N Broadway, Baltimore, MD, 21205, United States
| | - Christina Feng
- Division of Pediatric Colorectal & Pelvic Reconstruction, Children's National Hospital, 111 Michigan Ave NW, Washington, DC, 20010, United States
| | - Melissa E Danko
- Department of Pediatric Surgery, Monroe Carell Jr. Children's Hospital at Vanderbilt, 2200 Children's Way, Nashville, TN, 37232, United States
| | - Jennifer R DeFazio
- Division of Pediatric Surgery, NewYork-Presbyterian Morgan Stanley Children's Hospital, 3959 Broadway, New York, NY, 10032, United States
| | - Charles J Smithers
- Division of Pediatric Surgery, Johns Hopkins All Children's Hospital, 501 6th Ave S, St. Petersburg, FL, 33701, United States
| | - Irving J Zamora
- Division of Pediatric Colorectal & Pelvic Reconstruction, Children's National Hospital, 111 Michigan Ave NW, Washington, DC, 20010, United States
| | - J Leslie Knod
- Division of Pediatric Surgery, Connecticut Children's Medical Center, 282 Washington Street, Hartford, CT, 06106, United States.
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Kaul I, Chiou EH. The Role of Pediatric Gastroenterologists in the Evaluation of Complex Aerodigestive Disorders. Curr Gastroenterol Rep 2022; 24:211-221. [PMID: 36401684 DOI: 10.1007/s11894-022-00855-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/11/2022] [Indexed: 06/16/2023]
Abstract
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.
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Affiliation(s)
- Isha Kaul
- Division of Pediatric Gastroenterology, Hepatology & Nutrition, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, 6701 Fannin St., Houston, TX, 77030, USA
| | - Eric H Chiou
- Division of Pediatric Gastroenterology, Hepatology & Nutrition, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, 6701 Fannin St., Houston, TX, 77030, USA.
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Lerner DG, Mencin A, Novak I, Huang C, Ng K, Lirio RA, Khlevner J, Utterson EC, Harris BR, Pitman RT, Mir S, Gugig R, Walsh CM, Fishman D. Advances in Pediatric Diagnostic Endoscopy: A State-of-the-Art Review. JPGN REPORTS 2022; 3:e224. [PMID: 37168622 PMCID: PMC10158303 DOI: 10.1097/pg9.0000000000000224] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 04/20/2022] [Indexed: 05/13/2023]
Abstract
Pediatric endoscopy has revolutionized the way we diagnose and treat gastrointestinal disorders in children. Technological advances in computer processing and imaging continue to affect endoscopic equipment and advance diagnostic tools for pediatric endoscopy. Although commonly used by adult gastroenterologists, modalities, such as endomicroscopy, image-enhanced endoscopy, and impedance planimetry, are not routinely used in pediatric gastroenterology. This state-of-the-art review describes advances in diagnostic modalities, including image-enhanced endoscopy, confocal laser endomicroscopy, optical coherence tomography, endo functional luminal imaging probes, wireless motility/pH capsule, wireless colon capsule endoscopy, endoscopic ultrasound, and discusses the basic principles of each technology, including adult indications and pediatric applications, safety cost, and training data.
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Affiliation(s)
- Diana G. Lerner
- From the Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, Medical College of Wisconsin, Milwaukee, WI
| | - Ali Mencin
- Division of Pediatric Gastroenterology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY
| | - Inna Novak
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, Children’s Hospital at Montefiore, Bronx, NY
| | - Clifton Huang
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, Cook Children’s Medical Center, Fort Worth, TX
| | - Kenneth Ng
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Richard A. Lirio
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, UMASS Memorial Children’s Medical Center/UMASS Medical School, Worcester, MA
| | - Julie Khlevner
- Division of Pediatric Gastroenterology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY
| | - Elizabeth C. Utterson
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, Washington University School of Medicine, St. Louis Children’s Hospital, St. Louis, MO
| | - Brendan R. Harris
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, Washington University School of Medicine, St. Louis Children’s Hospital, St. Louis, MO
| | - Ryan T. Pitman
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, Washington University School of Medicine, St. Louis Children’s Hospital, St. Louis, MO
| | - Sabina Mir
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, UNC School of Medicine, Chapel Hill, NC
| | - Roberto Gugig
- Lucile Packard Children’s Hospital at Stanford, Palo Alto, CA
| | - Catharine M. Walsh
- Department of Paediatrics and the Wilson Centre, Division of Gastroenterology, Hepatology and Nutrition and the Research and Learning Institutes, Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Doug Fishman
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, Baylor College of Medicine, Houston, TX
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Donoso F, Beckman A, Malinovschi A, Engstrand Lilja H. Predictors of histopathological esophagitis in infants and adolescents with esophageal atresia within a national follow-up programme. PLoS One 2022; 17:e0266995. [PMID: 35427378 PMCID: PMC9012387 DOI: 10.1371/journal.pone.0266995] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 03/25/2022] [Indexed: 11/18/2022] Open
Abstract
PURPOSE Esophageal atresia (EA) is a congenital anomaly of the foregut. Although the survival has improved over the years there is a significant gastrointestinal morbidity affecting physical function and health-related quality of life. The aims of the study were to identify and evaluate predictors of histopathological esophagitis in infants and adolescents with EA. METHODS Single centre, cross-sectional study including one and 15-year-old patients operated for EA that participated in the national follow-up programme between 2012 and 2020 according to a pre-established protocol including upper endoscopy with oesophageal biopsies and 24h-pH-test. Data was collected from patients' medical records and pH-analysis software. Regression models were used to identify predictors of histopathological oesophagitis. Possible predictors were abnormal reflux index, endoscopic esophagitis, hiatal hernia, symptoms of gastroesophageal reflux (GER) and age. RESULTS 65 patients were included, 47 children and 18 adolescents. All children were treated with PPI during their first year of life. Symptoms of GER were reported by 13 (31.7%) of the infant's caregivers, 34 of the children (72.3%) had abnormal reflux index and 32 (68.1%) had histopathological esophagitis. The corresponding numbers for adolescents were 8 (50%), 15 (83.3%) and 10 (55.6%). We found no significant associations between histopathological esophagitis and endoscopic esophagitis, symptoms of GER, hiatus hernia or age group. Abnormal reflux index was an independent predictor of histopathological esophagitis. Seven patients with normal reflux index had histopathological esophagitis, all grade I. CONCLUSIONS We found a high prevalence of histopathological esophagitis despite PPI treatment in accordance with recommendations. No significant difference between the two age groups was seen. Abnormal reflux index was an independent predictor of histopathological esophagitis. However, we cannot recommend the use of pH-metry as a substitute for esophageal biopsies; future studies are needed to elucidate if esophageal biopsies might be postponed in infants with normal reflux index.
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Affiliation(s)
- Felipe Donoso
- Department of Women’s and Children’s Health, Uppsala University, Uppsala, Sweden
- Section of Pediatric Surgery, Uppsala University Children’s Hospital, Uppsala, Sweden
| | - Anna Beckman
- Department of Medical Sciences, Clinical Physiology, Uppsala University, Uppsala, Sweden
| | - Andrei Malinovschi
- Department of Medical Sciences, Clinical Physiology, Uppsala University, Uppsala, Sweden
| | - Helene Engstrand Lilja
- Department of Women’s and Children’s Health, Uppsala University, Uppsala, Sweden
- Section of Pediatric Surgery, Uppsala University Children’s Hospital, Uppsala, Sweden
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van Lennep M, Chung E, Jiwane A, Saoji R, Gorter RR, Benninga MA, Krishnan U, van Wijk MP. Fundoplication in children with esophageal atresia: preoperative workup and outcome. Dis Esophagus 2022; 35:6535694. [PMID: 35211748 PMCID: PMC9562824 DOI: 10.1093/dote/doac006] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 01/18/2022] [Indexed: 12/11/2022]
Abstract
Up to 45% of esophageal atresia (EA) patients undergo fundoplication during childhood. Their esophageal dysmotility may predispose to worse fundoplication outcomes compared with patients without EA. We therefore compared fundoplication outcomes and symptoms pre- and post-fundoplication in EA patients with matched patients without EA. A retrospective review of patients with- and without EA who underwent a fundoplication was performed between 2006 and 2017. Therapeutic success was defined as complete sustained resolution of symptoms that were the reason to perform fundoplication. Fundoplication indications of 39 EA patients (49% male; median age 1.1 [0.1-17.0] yrs) and 39 non-EA patients (46% male; median age 1.3 [0.3-17.0] yrs) included respiratory symptoms, brief resolved unexplained events, typical symptoms of gastroesophageal reflux disease, recurrent strictures and respiratory problems. Post-fundoplication, therapeutic success was achieved in 5 (13%) EA patients versus 29 (74%) non-EA patients (P<0.001). Despite therapeutic success, all 5 (13%) EA patients developed postoperative sustained symptoms/complications versus 12 (31%) non-EA patients. Eleven (28%) EA patients versus 3 (8%) non-EA patients did not achieve any therapeutic success (P=0.036). Remaining patients achieved partial therapeutic success. EA patients suffered significantly more often from postoperative sustained dysphagia (41% vs. 13%; P=0.039), gagging (33% vs. 23%; P<0.001) and bloating (40% vs. 17%; P=0.022). Fundoplication outcomes in EA patients are poor and EA patients are more susceptible to post-fundoplication sustained symptoms and complications compared with patients without EA. The decision to perform fundoplication in EA patients with proven gastroesophageal reflux disease needs to be made with caution after thorough multidisciplinary evaluation.
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Affiliation(s)
- Marinde van Lennep
- Department of Pediatric Gastroenterology and Nutrition, Emma Children’s Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Eric Chung
- Department of Paediatric Gastroenterology, Sydney Children’s Hospital, Sydney, New South Wales, Australia
| | - Ashish Jiwane
- Department of Paediatric Surgery, Sydney Children’s Hospital, Sydney, New South Wales, Australia
| | - Rajendra Saoji
- Children’s Surgical and Endoscopy Center, Midas Heights, Nagpur, India
| | - Ramon R Gorter
- Department of Pediatric Surgery, Emma Children’s Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Marc A Benninga
- Department of Pediatric Gastroenterology and Nutrition, Emma Children’s Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Michiel P van Wijk
- Address correspondence to: Michiel P. van Wijk, MD, PhD, Meibergdreef 9 (room H7-221), 1105 AZ Amsterdam.
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ten Kate CA, de Klein A, de Graaf BM, Doukas M, Koivusalo A, Pakarinen MP, van der Helm R, Brands T, IJsselstijn H, van Bever Y, Wijnen RM, Spaander MC, Brosens E. Intrinsic Cellular Susceptibility to Barrett's Esophagus in Adults Born with Esophageal Atresia. Cancers (Basel) 2022; 14:cancers14030513. [PMID: 35158780 PMCID: PMC8833471 DOI: 10.3390/cancers14030513] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2021] [Revised: 01/01/2022] [Accepted: 01/10/2022] [Indexed: 11/25/2022] Open
Abstract
Simple Summary We investigated the increased prevalence of Barrett’s esophagus in adults with esophageal atresia. A higher polygenic risk score and disturbances in inflammatory, stress response and oncological pathways upon acid exposure suggest a genetic susceptibility and increased induction of inflammatory processes. Although further research is required to explore this hypothesis, this could be a first-step into selecting patients that are more at risk to develop Barrett’s esophagus and/or esophageal carcinoma. Currently, an endoscopic screening and surveillance program is in practice in our institution for patients born with esophageal atresia, to early detect (pre)malignant lesions. Since recurrent endoscopies can be a burden for the patient, selecting patients by for example genetic susceptibility would allow to only include those at risk in future practice. Abstract The prevalence of Barrett’s esophagus (BE) in adults born with esophageal atresia (EA) is four times higher than in the general population and presents at a younger age (34 vs. 60 years). This is (partly) a consequence of chronic gastroesophageal reflux. Given the overlap between genes and pathways involved in foregut and BE development, we hypothesized that EA patients have an intrinsic predisposition to develop BE. Transcriptomes of Esophageal biopsies of EA patients with BE (n = 19, EA/BE); EA patients without BE (n = 44, EA-only) and BE patients without EA (n = 10, BE-only) were compared by RNA expression profiling. Subsequently, we simulated a reflux episode by exposing fibroblasts of 3 EA patients and 3 controls to acidic conditions. Transcriptome responses were compared to the differential expressed transcripts in the biopsies. Predisposing single nucleotide polymorphisms, associated with BE, were slightly increased in EA/BE versus BE-only patients. RNA expression profiling and pathway enrichment analysis revealed differences in retinoic acid metabolism and downstream signaling pathways and inflammatory, stress response and oncological processes. There was a similar effect on retinoic acid signaling and immune response in EA patients upon acid exposure. These results indicate that epithelial tissue homeostasis in EA patients is more prone to acidic disturbances.
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Affiliation(s)
- Chantal A. ten Kate
- Department of Pediatric Surgery and Intensive Care Children, Erasmus MC-Sophia Children’s Hospital, 3000 CA Rotterdam, The Netherlands; (C.A.t.K.); (H.I.); (R.M.H.W.)
- Department of Gastroenterology and Hepatology, Erasmus MC Cancer Institute, 3000 CA Rotterdam, The Netherlands;
- Department of Clinical Genetics, Erasmus MC Sophia Children’s Hospital, 3000 CA Rotterdam, The Netherlands; (A.d.K.); (B.M.d.G.); (R.v.d.H.); (T.B.); (Y.v.B.)
| | - Annelies de Klein
- Department of Clinical Genetics, Erasmus MC Sophia Children’s Hospital, 3000 CA Rotterdam, The Netherlands; (A.d.K.); (B.M.d.G.); (R.v.d.H.); (T.B.); (Y.v.B.)
| | - Bianca M. de Graaf
- Department of Clinical Genetics, Erasmus MC Sophia Children’s Hospital, 3000 CA Rotterdam, The Netherlands; (A.d.K.); (B.M.d.G.); (R.v.d.H.); (T.B.); (Y.v.B.)
| | - Michail Doukas
- Department of Pathology, Erasmus MC, 3000 CA Rotterdam, The Netherlands;
| | - Antti Koivusalo
- Department of Pediatric Surgery, University of Helsinki, Children’s Hospital, 281, 000290 Helsinki, Finland; (A.K.); (M.P.P.)
| | - Mikko P. Pakarinen
- Department of Pediatric Surgery, University of Helsinki, Children’s Hospital, 281, 000290 Helsinki, Finland; (A.K.); (M.P.P.)
| | - Robert van der Helm
- Department of Clinical Genetics, Erasmus MC Sophia Children’s Hospital, 3000 CA Rotterdam, The Netherlands; (A.d.K.); (B.M.d.G.); (R.v.d.H.); (T.B.); (Y.v.B.)
| | - Tom Brands
- Department of Clinical Genetics, Erasmus MC Sophia Children’s Hospital, 3000 CA Rotterdam, The Netherlands; (A.d.K.); (B.M.d.G.); (R.v.d.H.); (T.B.); (Y.v.B.)
| | - Hanneke IJsselstijn
- Department of Pediatric Surgery and Intensive Care Children, Erasmus MC-Sophia Children’s Hospital, 3000 CA Rotterdam, The Netherlands; (C.A.t.K.); (H.I.); (R.M.H.W.)
| | - Yolande van Bever
- Department of Clinical Genetics, Erasmus MC Sophia Children’s Hospital, 3000 CA Rotterdam, The Netherlands; (A.d.K.); (B.M.d.G.); (R.v.d.H.); (T.B.); (Y.v.B.)
| | - René M.H. Wijnen
- Department of Pediatric Surgery and Intensive Care Children, Erasmus MC-Sophia Children’s Hospital, 3000 CA Rotterdam, The Netherlands; (C.A.t.K.); (H.I.); (R.M.H.W.)
| | - Manon C.W. Spaander
- Department of Gastroenterology and Hepatology, Erasmus MC Cancer Institute, 3000 CA Rotterdam, The Netherlands;
| | - Erwin Brosens
- Department of Clinical Genetics, Erasmus MC Sophia Children’s Hospital, 3000 CA Rotterdam, The Netherlands; (A.d.K.); (B.M.d.G.); (R.v.d.H.); (T.B.); (Y.v.B.)
- Correspondence: ; Tel.: +31-10-70-37643
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Madeleine A, Audrey N, Rony S, David S, Frédéric G. Long term digestive outcome of œsophageal atresia. Best Pract Res Clin Gastroenterol 2021; 56-57:101771. [PMID: 35331402 DOI: 10.1016/j.bpg.2021.101771] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 10/13/2021] [Indexed: 02/07/2023]
Abstract
Œsophageal atresia is a rare neonatal malformation consisting in an interruption of the continuity of the œsophagus, with or without a tracheo-œsophageal fistula. Although mortality rate is now low and most cases can benefit from successful surgical repair soon after birth, morbidity -specially digestive and nutritional-remains high. Many of the adults born with œsophageal atresia will suffer from dysphagia, gastro-œsophageal reflux and/or œsophageal dysmotility, leading to nutritional consequences and quality of life impairment. Barrett's œsophagus, potential risk of œsophageal cancer as well as risk of anastomotic stenosis and eosinophilic œsophagitis justify transition to adulthood and a lifelong prolonged follow-up.
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Affiliation(s)
- Aumar Madeleine
- Univ. Lille, Reference Centre for rare œsophageal diseases, CHU Lille, U 1286 INFINITE, F59000, Lille, France.
| | - Nicolas Audrey
- Univ. Lille, Reference Centre for rare œsophageal diseases, CHU Lille, U 1286 INFINITE, F59000, Lille, France.
| | - Sfeir Rony
- Univ. Lille, Reference Centre for rare œsophageal diseases, CHU Lille, U 1286 INFINITE, F59000, Lille, France.
| | - Seguy David
- Univ. Lille, Reference Centre for rare œsophageal diseases, CHU Lille, U 1286 INFINITE, F59000, Lille, France.
| | - Gottrand Frédéric
- Univ. Lille, Reference Centre for rare œsophageal diseases, CHU Lille, U 1286 INFINITE, F59000, Lille, France.
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Tullie L, Kelay A, Bethell GS, Major C, Hall NJ. Barrett's oesophagus and oesophageal cancer following oesophageal atresia repair: a systematic review. BJS Open 2021; 5:6346856. [PMID: 34370830 PMCID: PMC8405903 DOI: 10.1093/bjsopen/zrab069] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 06/17/2021] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Concern exists that patients born with oesophageal atresia (OA) may be at high risk for Barrett's oesophagus (BO), a known malignant precursor to the development of oesophageal adenocarcinoma. Screening endoscopy has a role in early BO identification but is not universal in this population. This study aimed to determine prevalence of BO after OA repair surgery, to quantify the magnitude of this association and inform the need for screening and surveillance. METHODS A systematic review, undertaken according to PRISMA guidelines, was preregistered on PROSPERO (CRD42017081001). PubMed and EMBASE were interrogated using a standardized search strategy on 31 July 2020. Included papers, published in English, reported either: one or more patients with either BO (gastric/intestinal metaplasia) or oesophageal cancer in patients born with OA; or long-term (greater than 2 years) follow-up after OA surgery with or without endoscopic screening or surveillance. RESULTS Some 134 studies were identified, including 19 case reports or series and 115 single- or multi-centre cohort studies. There were 13 cases of oesophageal cancer (9 squamous cell carcinoma, 4 adenocarcinoma) with a mean age at diagnosis of 40.5 (range 20-47) years. From 6282 patients under long-term follow-up, 317 patients with BO were reported. Overall prevalence of BO was 5.0 (95 per cent c.i. 4.5 to 5.6) per cent, with a mean age at detection of 13.8 years (range 8 months to 56 years). Prevalence of BO in series reporting endoscopic screening or surveillance was 12.8 (95 per cent c.i. 11.3 to 14.5) per cent. CONCLUSION Despite a limited number of cancers, the prevalence of BO in patients born with OA is relatively high. While limited by the quality of available evidence, this review suggests endoscopic screening and surveillance may be warranted, but uncertainties remain over the design and effectiveness of any putative programme.
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Affiliation(s)
- L Tullie
- Department of Paediatric Surgery and Urology, Southampton Children's Hospital, Southampton, UK.,National Institute for Health Research Great Ormond Street Hospital Biomedical Research Centre, University College London Great Ormond Street Institute for Child Health, London, UK.,Stem Cell and Cancer Biology Laboratory, The Francis Crick Institute, London, UK
| | - A Kelay
- Department of Paediatric Surgery and Urology, Southampton Children's Hospital, Southampton, UK
| | - G S Bethell
- Department of Paediatric Surgery and Urology, Southampton Children's Hospital, Southampton, UK.,University Surgery Unit, Faculty of Medicine, University of Southampton, Southampton, UK
| | - C Major
- Department of Paediatric Surgery and Urology, Southampton Children's Hospital, Southampton, UK
| | - N J Hall
- Department of Paediatric Surgery and Urology, Southampton Children's Hospital, Southampton, UK.,University Surgery Unit, Faculty of Medicine, University of Southampton, Southampton, UK
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Tambucci R, Isoldi S, Angelino G, Torroni F, Faraci S, Rea F, Romeo EF, Caldaro T, Guerra L, Contini ACI, Malamisura M, Federici di Abriola G, Francalanci P, Conforti A, Dall'Oglio L, De Angelis P. Evaluation of Gastroesophageal Reflux Disease 1 Year after Esophageal Atresia Repair: Paradigms Lost from a Single Snapshot? J Pediatr 2021; 228:155-163.e1. [PMID: 32918920 DOI: 10.1016/j.jpeds.2020.09.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 08/26/2020] [Accepted: 09/04/2020] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To analyze the findings of both multichannel intraluminal impedance with pH (MII-pH) and endoscopy/histopathology in children with esophageal atresia at age 1 year, according to current recommendations for the evaluation of gastroesophageal reflux disease (GERD) in esophageal atresia. STUDY DESIGN We retrospectively reviewed both MII-pH and endoscopy/histopathology performed in 1-year-old children with esophageal atresia who were followed up in accordance with international recommendations. Demographic data and clinical characteristics were also reviewed to investigate factors associated with abnormal GERD investigations. RESULTS In our study cohort of 48 children with esophageal atresia, microscopic esophagitis was found in 33 (69%) and pathological esophageal acid exposure on MII-pH was detected in 12 (25%). Among baseline variables, only the presence of long-gap esophageal atresia was associated with abnormal MII-pH. Distal baseline impedance was significantly lower in patients with microscopic esophagitis, and it showed a very good diagnostic performance in predicting histological changes. CONCLUSIONS Histological esophagitis is highly prevalent at 1 year after esophageal atresia repair, but our results do not support a definitive causative role of acid-induced GERD. Instead, they support the hypothesis that chronic stasis in the dysmotile esophagus might lead to histological changes. MII-pH may be a helpful tool in selecting patients who need closer endoscopic surveillance and/or benefit from acid suppression.
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Affiliation(s)
- Renato Tambucci
- Digestive Endoscopy and Surgery Unit, Bambino Gesù Children's Hospital-IRCCS, Rome, Italy; Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy.
| | - Sara Isoldi
- Digestive Endoscopy and Surgery Unit, Bambino Gesù Children's Hospital-IRCCS, Rome, Italy; Women's and Children's Health Department, Pediatric Gastroenterology and Hepatology Unit, Sapienza University of Rome, Rome, Italy
| | - Giulia Angelino
- Digestive Endoscopy and Surgery Unit, Bambino Gesù Children's Hospital-IRCCS, Rome, Italy
| | - Filippo Torroni
- Digestive Endoscopy and Surgery Unit, Bambino Gesù Children's Hospital-IRCCS, Rome, Italy
| | - Simona Faraci
- Digestive Endoscopy and Surgery Unit, Bambino Gesù Children's Hospital-IRCCS, Rome, Italy
| | - Francesca Rea
- Digestive Endoscopy and Surgery Unit, Bambino Gesù Children's Hospital-IRCCS, Rome, Italy
| | | | - Tamara Caldaro
- Digestive Endoscopy and Surgery Unit, Bambino Gesù Children's Hospital-IRCCS, Rome, Italy
| | - Luciano Guerra
- Digestive Endoscopy and Surgery Unit, Bambino Gesù Children's Hospital-IRCCS, Rome, Italy
| | | | - Monica Malamisura
- Digestive Endoscopy and Surgery Unit, Bambino Gesù Children's Hospital-IRCCS, Rome, Italy
| | | | - Paola Francalanci
- Department of Pathology, Bambino Gesù Children's Hospital-IRCCS, Rome, Italy
| | - Andrea Conforti
- Neonatal Surgery Unit, Department of Medical and Surgical Neonatology, Bambino Gesù Children's Hospital-IRCCS, Rome, Italy
| | - Luigi Dall'Oglio
- Digestive Endoscopy and Surgery Unit, Bambino Gesù Children's Hospital-IRCCS, Rome, Italy
| | - Paola De Angelis
- Digestive Endoscopy and Surgery Unit, Bambino Gesù Children's Hospital-IRCCS, Rome, Italy
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Abstract
OBJECTIVE Esophagitis is highly prevalent in patients with esophageal atresia (EA). Peptic esophagitis has long been assumed to be the primary cause of esophagitis in this population, and prolonged acid suppressive medication usage is common; such treatment is of unknown benefit and carries potential risk. METHODS To better understand the role of commonly used antireflux treatments in EA, we analyzed all patients with repaired EA who underwent endoscopy with biopsies at our institution between January 2016 and August 2018. Macroscopic erosive and histologic esophagitis on biopsy was graded per predefined criteria. Clinical characteristics including acid suppressive medication usage, type of EA and repair, presence of hiatal hernia, and history of fundoplication were reviewed. RESULTS There were 310 unique patients (33.5% long gap EA) who underwent 576 endoscopies with biopsies during the study period. Median age at endoscopy was 3.7 years (interquartile range 21-78 months). Erosive esophagitis was found in 8.7% of patients (6.1% of endoscopies); any degree of histologic eosinophilia (≥1 eosinophil/high power field [HPF]) was seen in 56.8% of patients (48.8% of endoscopies), with >15 eosinophils/HPF seen in 15.2% of patients (12.3% of endoscopies). Acid suppression was common; 86.9% of endoscopies were preceded by acid suppressive medication use. Fundoplication had been performed in 78 patients (25.2%). Proton pump inhibitor (PPI) and/or H2 receptor antagonist (H2RA) use were the only significant predictors of reduced odds for abnormal esophageal biopsy (P = 0.011 for PPI, P = 0.048 for H2RA, and P = 0.001 for PPI combined with H2RA therapy). However, change in intensity of acid suppressive therapy by either dosage or frequency was not significantly associated with change in macroscopic erosive or histologic esophagitis (P > 0.437 and P > 0.13, respectively). Presence or integrity of a fundoplication was not significantly associated with esophagitis (P = 0.236). CONCLUSIONS In EA patients, acid suppressive medication therapy is associated with reduced odds of abnormal esophageal biopsy, though histologic esophagitis is highly prevalent even with high rates of acid suppressive medication use. Esophagitis is likely multifactorial in EA patients, with peptic esophagitis as only one of multiple possible etiologies for esophageal inflammation. The clinical significance of histologic eosinophilia in this population warrants further investigation.
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13
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Koivusalo A, Suominen J, Rintala R, Pakarinen M. Location of TEF at the carina as an indicator of long-gap C-type esophageal atresia. Dis Esophagus 2018; 31:5040372. [PMID: 29931283 DOI: 10.1093/dote/doy044] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
We analyzed retrospectively the outcomes in long gap Gross type C esophageal atresia. We hypothesized that outcomes in type C (long gap) atresia differ from type C (normal gap) and be similar with outcomes in Gross type A and B esophageal atresia. Location of the distal tracheoesophageal fistula (TEF) at the carina was chosen as the hallmark of type C atresia (long gap). We compared the type of esophageal repair, major reoperations for anastomotic complications and gastroesophageal reflux, and long-term mucosal changes between type C (normal gap), type C (long gap), and type A/B. We analyzed the hospital charts of 247 successive patients from 1984 to 2014 who either underwent repair of esophageal atresia in our institution (n = 232) or were referred from elsewhere because of anastomotic complications (n = 15). Among the 232 patients of our institution, 181 had type C and 21 type A or B esophageal atresia. Twenty-two (12%) of type C patients had TEF at the carina and were considered as type C (long gap). The referred patients included a disproportionately high number (42%) of patients with type C (long gap). We attempted primary anastomosis in 98% of patients with type C (normal gap), in 95% with type C (long gap), and 53% with type A/B underwent delayed primary anastomosis. Leakage after primary anastomosis occurred in 40% of patients with type A/B and in 23% with type C (long gap) compared with 6% in patients with type C (normal gap) (P < 0.05). Recalcitrant anastomotic stricture that eventually required esophageal resection occurred in 30% of patients with type A/B and in 18% with type C (long gap) compared with 3% in patients with type C (normal gap) (P < 0.05). The overall rate of major reoperations for anastomotic complications after primary anastomosis, type A/B (36%), type C (long gap) (27%), and antireflux surgery, type A/B (100%) and type C (long gap) (61%) were higher than in type C (normal gap), (9% and 24%), (P < 0.05 in both). Ten (47%) patients with type A/B esophageal atresia (primary anastomosis not possible n = 10), three (14%) with type C (long gap) (primary anastomosis not possible n = 1, significant loss of esophageal length after complications n = 2) and two (1%) with type C (normal gap) (significant loss of esophageal length after complications n = 2) underwent esophageal reconstruction. Endoscopic follow-up, median length 7.0 (IQR: 3.0-14) years, disclosed gastric metaplasia in 31% and 33% of patients with type A/B and type C (long gap) compared with 11% in type C (normal gap) (P < 0.05). Intestinal metaplasia was found in one patient type C (normal gap) (0.7%) and one with type C (long gap) (5.6%), (P = 0.21), only. The outcomes of type C (long gap) esophageal atresia are associated with more frequent complications, gastroesophageal reflux and esophageal mucosal changes than outcomes in type C (normal gap). Outcomes in type C (long gap) esophageal atresia resemble those in type A/B. The percentage of patients who remain with their native esophagus is, however, higher in type C (long gap) atresia (86%) than in type A/B (53%).
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Affiliation(s)
- A Koivusalo
- Childrens' Hospital, Section of Paediatric Surgery, Helsinki, Finland
| | - J Suominen
- Childrens' Hospital, Section of Paediatric Surgery, Helsinki, Finland
| | - R Rintala
- Childrens' Hospital, Section of Paediatric Surgery, Helsinki, Finland
| | - M Pakarinen
- Childrens' Hospital, Section of Paediatric Surgery, Helsinki, Finland
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High Prevalence of Barrett's Esophagus and Esophageal Squamous Cell Carcinoma After Repair of Esophageal Atresia. Clin Gastroenterol Hepatol 2018; 16:513-521.e6. [PMID: 29133255 DOI: 10.1016/j.cgh.2017.11.008] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Revised: 10/30/2017] [Accepted: 11/04/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Esophageal atresia is rare, but improved surgical and intensive care techniques have increased rates of survival in children, so there are now many adults with this disorder. Many patients with esophageal atresia develop gastroesophageal reflux (GER), raising concerns about increased risk of Barrett's esophagus (BE; prevalence of 1.3%-1.6% in general population) and esophageal carcinoma. We assessed the prevalence of BE and esophageal carcinoma in this population. METHODS We performed a prospective study of 289 patients with esophageal atresia at the Department of Gastroenterology and Hepatology at Erasmus MC University Medical Center in The Netherlands, from May 2012 through March 2017. A total of 151 (median age, 25.4 y; age range, 16.8-68.6 y) underwent upper endoscopies as part of a surveillance program for (pre)malignant esophageal lesions. Biopsies were collected and analyzed by histology. We collected data on patients' use of medications, tobacco, and alcohol; gastrointestinal symptoms; ability to swallow; complaints of GER; and type of atresia and surgeries. Prevalence of esophageal squamous cell carcinoma (ESCC) was determined using data from The Netherlands Cancer Registry. The number of persons alive on January 1, 2016, in the esophageal atresia cohort and in the general Dutch population were used to calculate the 10-year prevalence of ESCC per 100,000 persons in both populations. RESULTS Forty-seven percent of patients with esophageal atresia had a history of GER and 20.5% had undergone fundoplication surgery. Endoscopy revealed normal esophagus in 68.2% of patients, esophagitis in 7.3%, and columnar-lined esophagus in 24.5%. Histology revealed normal mucosa in 50.3% of patients, esophagitis in 23.2%, gastric metaplasia in 17.2%, and BE in 6.6% (at a median age of 31.6 years). A history of fundoplication surgery was associated with BE (P = .03). Three ESCCs developed, in 2 men, at ages 42, 44, and 60 years. This corresponded to a prevalence of 0.7% in patients with esophageal atresia-a value 108-fold higher than in the same age group in the general population. CONCLUSIONS The prevalence of BE is 4-fold higher in young adults with esophageal atresia, and the prevalence of ESCC is 108-fold higher than in the general population. This finding could have important implications for transition of young adults from pediatric care to adult gastroenterology departments to receive life-long endoscopic follow-up evaluation to facilitate early diagnosis of relevant lesions.
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15
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Koivusalo AI, Rintala RJ, Pakarinen MP. Outcomes of fundoplication in oesophageal atresia associated gastrooesophageal reflux disease. J Pediatr Surg 2018; 53:230-233. [PMID: 29229483 DOI: 10.1016/j.jpedsurg.2017.11.011] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2017] [Accepted: 11/08/2017] [Indexed: 11/17/2022]
Abstract
AIM OF THE STUDY Conservative management of gastrooesophageal reflux (GORD) in oesophageal atresia (OA) is sometimes inefficient, and fundoplication is required. We assessed the outcomes of fundoplication among OA patients from 1980 to 2016. METHODS After ethical consent, hospital records of 290 patients, including 22 referred patients, were reviewed. Included were 262 patients with end-to-end repair. Excluded were patients who underwent oesophageal reconstruction (n=23) or no repair (n=5). Primary outcome measures included survival, retaining the native oesophagus, resolution of GGORD symptoms, failure of fundoplication, and long-term endoscopic results. MAIN RESULTS Gross types of OA in 262 patients were A (n=12), B (n=2), C (n=217), D (n=10), E (n=19), and F (n=2). Eighty-six (33%) patients, type A (n=12, 100%), B (n=2, 100%), C (n=69, 31%), D (n=3, 30%), and F (n=1, 50%), underwent fundoplication at the median age of 5.4 (IQR 3.1-16) months. Main indications included recalcitrant anastomotic stenosis (RAS) in 41 (48%), respiratory symptoms in 16 (19%), and acute life threatening events (ALTE) in 15 (17%) of patients. Associated tracheomalacia in 25 (29%) patients were treated with aortopexy. Median follow-up was 7.5 (IQR 1.8-15) years. RAS resolved in 30 (73%) patients, whereas 11 (27%) with unresolved RAS underwent oesophageal resection (n=8) or replacement (n=3). Six (7%) patients died of heart failure (n=4), bolus impaction (n=1), and ALTE (n=1). Fundoplication failed in 27 (31%) patients, and 13 (15%) underwent redo fundoplication. Fundoplication failure was predicted by long-gap OA RR=3.8 (95%CI=1.1-13), P=0.04. In total GORD associated symptoms persisted in 7 (8%) patients, including one with permanent feeding jejunostomy. Latest endoscopy showed moderate or severe oesophagitis in 7% of fundoplicated and in 3% nonfundoplicated patients and intestinal metaplasia in 3% and 1% (p=0.20-0.29). CONCLUSION Fundoplication provided a safe and relatively effective control of OA associated symptomatic GORD and oesophagitis. The failure rate of fundoplication was high in those with long-gap OA. TYPE OF STUDY Treatment study. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Antti I Koivusalo
- Children's Hospital, Section of Paediatric Surgery, University of Helsinki, Helsinki, Finland.
| | - Risto J Rintala
- Children's Hospital, Section of Paediatric Surgery, University of Helsinki, Helsinki, Finland
| | - Mikko P Pakarinen
- Children's Hospital, Section of Paediatric Surgery, University of Helsinki, Helsinki, Finland
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Abstract
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.
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Abstract
OBJECTIVES Patients with esophageal atresia/tracheoesophageal fistula (EA-TEF) can develop Barrett esophagus as a long-term consequence of their condition. Intestinal metaplasia (IM), a risk factor for developing adenocarcinoma of the esophagus, has not been well characterized in the pediatric population. METHODS Retrospective review of patients with EA-TEF followed at 3 academic pediatric centers between the years 1997 and 2014. RESULTS Among 542 children and adolescents, 1.3% (7 patients, 5 girls) were diagnosed with IM based on endoscopy and pathology. Six of the patients had EA-TEF type C, whereas the last patient had a "long gap" type A atresia. Patients were diagnosed with gastric metaplasia either before the IM diagnosis in 4 patients or concomitantly in 3. The median (range) age of diagnosis for gastric metaplasia was 7.9 (range 2-17.2) and for IM 10.9 (2-17.2) years. Gastroesophageal reflux (GER) symptoms were nonspecific. Five patients were on proton pump inhibitor therapy for symptomatic GER at the time of diagnosis of IM. 2 of the 7 patients had previously undergone Nissen fundoplication. One patient, who had undergone a Nissen fundoplication, was restarted on proton pump inhibitor once the diagnosis of IM was made. All patients had repeated endoscopy and dysplasia was not observed with a median follow-up of 1.7 (range 1-4.9) years. CONCLUSIONS IM occurs in patients with EA-TEF, some as young as 2 years. Therefore, early endoscopic surveillance should be considered in this GER-prone population.
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18
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Friedmacher F, Kroneis B, Huber-Zeyringer A, Schober P, Till H, Sauer H, Höllwarth ME. Postoperative Complications and Functional Outcome after Esophageal Atresia Repair: Results from Longitudinal Single-Center Follow-Up. J Gastrointest Surg 2017; 21:927-935. [PMID: 28424985 DOI: 10.1007/s11605-017-3423-0] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2016] [Accepted: 04/03/2017] [Indexed: 01/31/2023]
Abstract
BACKGROUND Esophageal atresia (EA) and tracheoesophageal fistula (TEF) represent major therapeutic challenges, frequently associated with serious morbidities following surgical repair. The aim of this longitudinal study was to assess temporal changes in morbidity and mortality of patients with EA/TEF treated in a tertiary-level center, focusing on postoperative complications and their impact on long-term gastroesophageal function. METHODS One hundred nine consecutive patients with EA/TEF born between 1975 and 2011 were followed for a median of 9.6 years (range, 3-27 years). Comparative statistics were used to evaluate temporal changes between an early (1975-1989) and late (1990-2011) study period. RESULTS Gross types of EA were A (n = 6), B (n = 5), C (n = 89), D (n = 7), and E (n = 2). Seventy (64.2%) patients had coexisting anomalies, 13 (11.9%) of whom died before EA correction was completed. In the remaining 96 infants, surgical repair was primary (n = 66) or delayed (n = 25) anastomosis, closure of TEF in EA type E (n = 2), and esophageal replacement with colon interposition (n=2) or gastric transposition (n=1). Long-gap EA was diagnosed in 23 (24.0%) cases. Postoperative mortality was 4/96 (4.2%). Overall survival increased significantly between the two study periods (42/55 vs. 50/54; P = 0.03). Sixty-nine (71.9%) patients presented postoperatively with anastomotic strictures requiring a median of 3 (range, 1-15) dilatations. Revisional surgery was required for anastomotic leakage (n = 5), recurrent TEF with (n = 1) or without (n=9) anastomotic stricture, undetected proximal TEF (n = 4), and refractory anastomotic strictures with (n = 1) or without (n = 2) fistula. Normal dietary intake was achieved in 89 (96.7%) patients, while 3 (3.3%) remained dependent on gastrostomy feedings. Manometry showed esophageal dysmotility in 78 (84.8%) infants at 1 year of age, increasing to 100% at 10-year follow-up. Fifty-six (60.9%) patients suffered from dysphagia with need for endoscopic foreign body removal in 12 (13.0%) cases. Anti-reflux medication was required in 43 (46.7%) children and 30 (32.6%) underwent fundoplication. The rate of gastroesophageal reflux increased significantly between the two study periods (29/42 vs. 44/50; P = 0.04). Twenty-two (23.9%) cases of endoscopic esophagitis and one Barrett's esophagus were identified. CONCLUSIONS Postoperative complications after EA/TEF repair are common and should be expertly managed to reduce the risk of long-term morbidity. Regular multidisciplinary surveillance with transitional care into adulthood is recommended in all patients with EA/TEF.
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Affiliation(s)
- Florian Friedmacher
- Department of Pediatric and Adolescent Surgery, Medical University of Graz, Auenbruggerplatz 34, 8036, Graz, Austria.
| | - Birgit Kroneis
- Department of Pediatric and Adolescent Surgery, Medical University of Graz, Auenbruggerplatz 34, 8036, Graz, Austria
| | - Andrea Huber-Zeyringer
- Department of Pediatric and Adolescent Surgery, Medical University of Graz, Auenbruggerplatz 34, 8036, Graz, Austria
| | - Peter Schober
- Department of Pediatric and Adolescent Surgery, Medical University of Graz, Auenbruggerplatz 34, 8036, Graz, Austria
| | - Holger Till
- Department of Pediatric and Adolescent Surgery, Medical University of Graz, Auenbruggerplatz 34, 8036, Graz, Austria
| | - Hugo Sauer
- Department of Pediatric and Adolescent Surgery, Medical University of Graz, Auenbruggerplatz 34, 8036, Graz, Austria
| | - Michael E Höllwarth
- Department of Pediatric and Adolescent Surgery, Medical University of Graz, Auenbruggerplatz 34, 8036, Graz, Austria
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Abstract
PURPOSE OF REVIEW Esophageal atresia/tracheoesophageal fistula (EA/TEF) is a congenital aerodigestive anomaly with high survival rates after surgical repair. Care should now be focused on prevention of long-term complications using appropriate surveillance techniques. RECENT FINDINGS The incidence of gastroesophageal reflux disease (GERD) is high in patients with EA/TEF. Consequences of untreated GERD include esophagitis, strictures, and Barrett esophagus. Subjective symptoms are an unreliable indicator of presence or severity of GERD, and therefore, diagnostic testing is needed to assess esophageal heath and monitor the effectiveness of anti-reflux treatment. Esophagogastroduodenoscopy with biopsy remains the primary surveillance tool, but is invasive and not without risks. Less-invasive modalities such as multichannel intraluminal impedance and pH monitoring to assess GERD appear to correlate strongly with esophageal histology and may provide sufficient information to guide treatment. EA/TEF patients face numerous challenges that need to be considered. Routine surveillance protocols and close monitoring are warranted to assess complications. Further research is needed to delineate the frequency of esophagogastroduodenoscopy versus less-invasive and promising modalities such as multichannel intraluminal impedance-pH monitoring.
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Rintala RJ. Fundoplication in Patients with Esophageal Atresia: Patient Selection, Indications, and Outcomes. Front Pediatr 2017; 5:109. [PMID: 28555181 PMCID: PMC5430410 DOI: 10.3389/fped.2017.00109] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Accepted: 04/25/2017] [Indexed: 11/16/2022] Open
Abstract
Patients with esophageal atresia (EA) suffer from abnormal and permanent esophageal intrinsic and extrinsic innervation that affects severely esophageal motility. The repair of EA also results in esophageal shortening that affects distal esophageal sphincter mechanism. Consequently, gastroesophageal reflux (GER) is common in these patients, overall approximately half of them suffer from symptomatic reflux. GER in EA patients often resists medical therapy and anti-reflux surgery in the form of fundoplication is required. In patients with pure and long gap EA, the barrier mechanisms against reflux are even more damaged, therefore, most of these patients undergo fundoplication during first year of life. Other indications for anti-reflux surgery include recalcitrant anastomotic stenoses and apparent life-threatening episodes. In short term, fundoplication alleviates symptoms in most patients but recurrences are common occurring in at least one third of the patients. Patients with fundoplication wrap failure often require redo surgery, which may be complicated and associated with significant morbidity. A safe option in a subset of patients with failed anti-reflux surgery appears to be long-term medical treatment with proton pump inhibitors.
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Affiliation(s)
- Risto J Rintala
- Children's Hospital, Helsinki University Central Hospital, Helsinki, Finland
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