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O'Shea D, Schmoke N, Porigow C, Murray LP, Chung WK, Kattan M, Jang M, Antosy A, Middlesworth W, Khlevner J. Recent Advances in the Genetic Pathogenesis, Diagnosis, and Management of Esophageal Atresia and Tracheoesophageal Fistula: A Review. J Pediatr Gastroenterol Nutr 2023; 77:703-712. [PMID: 37771007 DOI: 10.1097/mpg.0000000000003952] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/30/2023]
Abstract
Infants born with esophageal atresia and tracheoesophageal fistula, a complex congenital malformation occurring in 1/2500-4000 live births, may suffer threats to their cardiac, respiratory, and digestive health in addition to anomalies that may exist in the genitourinary and musculoskeletal systems. Optimal care for these patients throughout their lives is best achieved through a coordinated, multidisciplinary approach that our health care system is not always well-equipped to provide. This review, though not exhaustive, highlights the components of care that pertain to initial surgical reconstruction and subsequent diagnosis and management of the complications that are most frequently encountered. Authors from among the many specialties involved in the care of these patients summarize the current best practice with attention to the most recent advances. Assessment and improvement of quality of life and transition to adult specialists as children grow to adulthood is also reviewed.
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Affiliation(s)
- Delia O'Shea
- From the Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Columbia University Vagelos College of Physicians and Surgeons/NewYork-Presbyterian Morgan Stanley Children's Hospital, New York, NY
| | - Nicholas Schmoke
- the Division of Pediatric Surgery, Department of Surgery, Columbia University Vagelos College of Physicians and Surgeons/NewYork-Presbyterian Morgan Stanley Children's Hospital, New York, NY
| | - Chloe Porigow
- the Division of Pediatric Surgery, Department of Surgery, Columbia University Vagelos College of Physicians and Surgeons/NewYork-Presbyterian Morgan Stanley Children's Hospital, New York, NY
| | - Laurie P Murray
- the Division of Pediatric Pulmonology, Department of Pediatrics, Columbia University Irving Medical Center/NewYork-Presbyterian Morgan Stanley Children's Hospital, New York, NY
| | - Wendy K Chung
- the Department of Pediatrics and Medicine, Columbia University Irving Medical Center, New York, NY
| | - Meyer Kattan
- the Division of Pediatric Pulmonology, Department of Pediatrics, Columbia University Irving Medical Center/NewYork-Presbyterian Morgan Stanley Children's Hospital, New York, NY
| | - Minyoung Jang
- the Department of Otolaryngology Head and Neck Surgery, Columbia University Vagelos College of Physicians and Surgeons/NewYork-Presbyterian Morgan Stanley Children's Hospital, New York, NY
| | - Alexandra Antosy
- From the Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Columbia University Vagelos College of Physicians and Surgeons/NewYork-Presbyterian Morgan Stanley Children's Hospital, New York, NY
| | - William Middlesworth
- the Division of Pediatric Surgery, Department of Surgery, Columbia University Vagelos College of Physicians and Surgeons/NewYork-Presbyterian Morgan Stanley Children's Hospital, New York, NY
| | - Julie Khlevner
- From the Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Columbia University Vagelos College of Physicians and Surgeons/NewYork-Presbyterian Morgan Stanley Children's Hospital, New York, NY
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Management of Adults With Esophageal Atresia. Clin Gastroenterol Hepatol 2023; 21:15-25. [PMID: 35952943 DOI: 10.1016/j.cgh.2022.07.037] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 07/26/2022] [Accepted: 07/27/2022] [Indexed: 02/07/2023]
Abstract
Esophageal atresia (EA) with or without trachea-esophageal fistula is relatively common congenital malformation with most patients living into adulthood. As a result, care of the adult patient with EA is becoming more common. Although surgical repair has changed EA from a fatal to a livable condition, the residual effects of the anomaly may lead to a lifetime of complications. These include effects related to the underlying deformity such as atonicity of the esophageal segment, fistula recurrence, and esophageal cancer to complications of the surgery including anastomotic stricture, gastroesophageal reflux, and coping with an organ transposition. This review discusses the occurrence and management of these conditions in adulthood and the role of an effective transition from pediatric to adult care to optimize adult care treatment.
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Tan Tanny SP, Roring JEA, Situmorang NY, King SK, Teague WJ. Preexisting neural factors that contribute to dysmotility in esophageal atresia: a systematic review. Pediatr Surg Int 2022; 39:68. [PMID: 36580151 DOI: 10.1007/s00383-022-05353-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/19/2022] [Indexed: 12/30/2022]
Abstract
Esophageal dysmotility in esophageal atresia (EA) relates to abnormal development of esophageal innervation and musculature and to the esophageal repair. Few studies have investigated the preexisting dysmotility in EA, present prior to surgery. This systematic review aims to summarize the literature on neuronal studies in EA, to understand the causative factors for esophageal dysmotility. We performed a systematic review (PubMed, EMBASE, EBM, CINAHL databases; January 1947-February 2021) in accordance with PRISMA (PROSPERO number CRD42020171014). Fourteen studies were identified (eleven human, 187 EA patients; three animal, 64 EA rat specimens). Neural factors affecting esophageal dysmotility in human and animal studies included proteins, enzymes, growth factors, and genes, which play a role in the nervous system or neuroendocrine system, some of which have functions as neuromodulators or neurotransmitters. This systematic review has identified neural factors that affect esophageal dysmotility and contributes toward our understanding of the underlying dysmotility in patients with EA. The studies identified are important and essential for successful translation of basic science knowledge to impact clinical practice and understanding. Level of evidence: III.
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Affiliation(s)
- Sharman P Tan Tanny
- Department of Paediatric Surgery, The Royal Children's Hospital, 50 Flemington Road, Parkville, Melbourne, VIC, 3052, Australia. .,F. Douglas Stephens Surgical Research Group, Murdoch Children's Research Institute, 50 Flemington Road, Melbourne, VIC, 3052, Australia. .,Department of Paediatrics, The University of Melbourne, Melbourne, VIC, 3010, Australia.
| | - Jonez E A Roring
- Melbourne Medical School, The University of Melbourne, Melbourne, VIC, 3010, Australia
| | - Natasha Y Situmorang
- Melbourne Medical School, The University of Melbourne, Melbourne, VIC, 3010, Australia
| | - Sebastian K King
- Department of Paediatric Surgery, The Royal Children's Hospital, 50 Flemington Road, Parkville, Melbourne, VIC, 3052, Australia.,F. Douglas Stephens Surgical Research Group, Murdoch Children's Research Institute, 50 Flemington Road, Melbourne, VIC, 3052, Australia.,Department of Paediatrics, The University of Melbourne, Melbourne, VIC, 3010, Australia
| | - Warwick J Teague
- Department of Paediatric Surgery, The Royal Children's Hospital, 50 Flemington Road, Parkville, Melbourne, VIC, 3052, Australia.,F. Douglas Stephens Surgical Research Group, Murdoch Children's Research Institute, 50 Flemington Road, Melbourne, VIC, 3052, Australia.,Department of Paediatrics, The University of Melbourne, Melbourne, VIC, 3010, Australia
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Utility of Functional Lumen Imaging Probe in Long-Term Follow-Up of Children with Esophageal Atresia: A Single-Center Retrospective Study. CHILDREN 2022; 9:children9101426. [PMID: 36291362 PMCID: PMC9600905 DOI: 10.3390/children9101426] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 09/16/2022] [Accepted: 09/17/2022] [Indexed: 11/23/2022]
Abstract
Long term follow-up of patients with esophageal atresia (EA) may be hampered by esophageal dysmotility, which affects quality of life and might lead to late complications. The endoluminal functional lumen imaging probe (EndoFlip™ Medtronic, Crospon Inc.) is an innovative diagnostic tool that assesses esophageal distensibility. Our aim was to report the use of EndoFlip™ in an EA follow-up, in order to describe distensibility patterns and to determine its possible role for functional evaluation of patients. We retrospectively collected data of EA patients, with a minimum follow-up of 9 years, who required endoscopic evaluation and underwent EndoFlip™. An adaptation of the Medtronic EF-322 protocol was applied and distensibility data were compared to those reported by Pandolfino et al. Nine patients (median age 13 years) were included in the study. The median minimum distensibility was 2.58 mm2/mmHg. Signs of peristalsis were observed in three patients. In one case, the esophagogastric junction (EGJ) after Toupet fundoplication showed low distensibility. EGJ distensibility values of 2.58 mm2/mmHg (median) confirmed both good esophagogastric continence and compliance. Esophagitis and absent peristalsis were found in one patient together with partial stenosis of the fundoplication, confirming the importance of surgical adaptation. Esophageal body distensibility was higher than that of the EGJ. Considering the presence of symptoms, the EndoFlip™ results seem to correlate better with the clinical picture. EndoFlip™ use was safe and feasible in children. It allowed for the measurement of esophageal distensibility and diameter and the acquisition of indirect information on motility with clinical implications. The routine use of EndoFlip™ could be part of EA follow-up, although considerable research is needed to correlate Endoflip™ system measurements to EA patient outcomes.
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van Lennep M, Singendonk MMJ, Dall'Oglio L, Gottrand F, Krishnan U, Terheggen-Lagro SWJ, Omari TI, Benninga MA, van Wijk MP. Oesophageal atresia. Nat Rev Dis Primers 2019; 5:26. [PMID: 31000707 DOI: 10.1038/s41572-019-0077-0] [Citation(s) in RCA: 69] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Oesophageal atresia (EA) is a congenital abnormality of the oesophagus that is caused by incomplete embryonic compartmentalization of the foregut. EA commonly occurs with a tracheo-oesophageal fistula (TEF). Associated birth defects or anomalies, such as VACTERL association, trisomy 18 or 21 and CHARGE syndrome, occur in the majority of patients born with EA. Although several studies have revealed signalling pathways and genes potentially involved in the development of EA, our understanding of the pathophysiology of EA lags behind the improvements in surgical and clinical care of patients born with this anomaly. EA is treated surgically to restore the oesophageal interruption and, if present, ligate and divide the TEF. Survival is now ~90% in those born with EA with severe associated anomalies and even higher in those born with EA alone. Despite these achievements, long-term gastrointestinal and respiratory complications and comorbidities in patients born with EA are common and lead to decreased quality of life. Oesophageal motility disorders are probably ubiquitous in patients after undergoing EA repair and often underlie these complications and comorbidities. The implementation of several new diagnostic and screening tools in clinical care, including high-resolution impedance manometry, pH-multichannel intraluminal impedance testing and disease-specific quality of life questionnaires now provide better insight into these problems and may contribute to better long-term outcomes in the future.
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Affiliation(s)
- Marinde van Lennep
- Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Pediatric Gastroenterology and Nutrition, Amsterdam, The Netherlands
| | - Maartje M J Singendonk
- Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Pediatric Gastroenterology and Nutrition, Amsterdam, The Netherlands
| | - Luigi Dall'Oglio
- Digestive Endoscopy and Surgery Unit, Bambino Gesu Children's Hospital-IRCCS, Rome, Italy
| | - Fréderic Gottrand
- CHU Lille, University Lille, National Reference Center for Congenital Malformation of the Esophagus, Department of Pediatric Gastroenterology Hepatology and Nutrition, Lille, France
| | - Usha Krishnan
- Department of Paediatric Gastroenterology, Sydney Children's Hospital, Sydney, New South Wales, Australia
- Discipline of Paediatrics, School of Women's and Children's Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Suzanne W J Terheggen-Lagro
- Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Pediatric Pulmonology, Amsterdam, The Netherlands
| | - Taher I Omari
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
- Center for Neuroscience, Flinders University, Adelaide, South Australia, Australia
| | - Marc A Benninga
- Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Pediatric Gastroenterology and Nutrition, Amsterdam, The Netherlands.
| | - Michiel P van Wijk
- Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Pediatric Gastroenterology and Nutrition, Amsterdam, The Netherlands
- Emma Children's Hospital, Amsterdam UMC, Vrije Universiteit, Pediatric Gastroenterology, Amsterdam, The Netherlands
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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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Pedersen RN, Markøw S, Kruse-Andersen S, Qvist N, Gerke O, Husby S, Agertoft L. Long-term pulmonary function in esophageal atresia-A case-control study. Pediatr Pulmonol 2017; 52:98-106. [PMID: 27164020 DOI: 10.1002/ppul.23477] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2015] [Revised: 04/06/2016] [Accepted: 04/24/2016] [Indexed: 11/12/2022]
Abstract
BACKGROUND Esophageal atresia (EA) is a congenital anomaly associated with substantial pulmonary morbidity throughout childhood. AIM The aim of this study was to evaluate pulmonary complications among 59 five to 15-year-old children and adolescents with surgically corrected congenital EA. METHODS Participants underwent a structured interview, spirometry, body plethysmography, mannitol challenge test, skin prick test, as well as measurements of the diffusion capacity, airway resistance, fraction of exhaled NO, and specific immunoglobulin E in serum. A control group consisted of 25 children being evaluated for gastroesophageal reflux disease. RESULTS Among the EA patients 33 (55.9%) had respiratory symptoms, 31 (53.4%) had a history of at least three pneumonias, and 32 (54.2%) reported more frequent cough episodes than peers. The Forced Vital Capacity (FVC) was 84.9% ± 13.2% of predicted, forced expiratory volume 1 sec (FEV1) was 78.2% ± 12.4% of predicted, and forced expiratory fraction 25-75% (FEF25-75%) was 71.5 ± 17.8% of predicted in EA patients, lower than disease controls (P < 0.0001 for all). In addition, the total lung capacity (TLC) was lower in patients with EA than in the controls (P < 0.0001). Fifteen patients (28.8%) with EA had obstructive ventilatory impairment, compared to nine patients (17.3%) with restrictive ventilatory impairment, while one had a combination. CONCLUSIONS The present study demonstrated significantly decreased pulmonary characteristics in EA patients. Restrictive ventilatory impairment occurring in EA is probably due to poor lung growth after thoracotomy. No single factor predicted ventilatory impairment in children and adolescents with EA. Pediatr Pulmonol. 2017;52:98-106. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Rikke N Pedersen
- Hans Christian Andersen Children's Hospital, Odense University Hospital, Odense, Denmark
| | - Simone Markøw
- Hans Christian Andersen Children's Hospital, Odense University Hospital, Odense, Denmark
| | | | - Niels Qvist
- Department of Surgery, Odense University Hospital, Odense, Denmark
| | - Oke Gerke
- Department of Nuclear Medicine, Odense University Hospital and Health Economics Research, University of Southern Denmark, Odense, Denmark
| | - Steffen Husby
- Hans Christian Andersen Children's Hospital, Odense University Hospital, Odense, Denmark
| | - Lone Agertoft
- Hans Christian Andersen Children's Hospital, Odense University Hospital, Odense, Denmark
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Faure C, Righini Grunder F. Dysmotility in Esophageal Atresia: Pathophysiology, Characterization, and Treatment. Front Pediatr 2017; 5:130. [PMID: 28620599 PMCID: PMC5450509 DOI: 10.3389/fped.2017.00130] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Accepted: 05/15/2017] [Indexed: 01/19/2023] Open
Abstract
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.
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Affiliation(s)
- Christophe Faure
- Esophageal Atresia Clinic, CHU Sainte-Justine, Montreal, QC, Canada
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Abstract
Esophageal atresia patients are predisposed to gastroesophageal reflux as a result of the altered esophageal anatomy and motility. These patients experience significant morbidity from gastroesophageal reflux. As a result, an effective way to diagnose and monitor for reflux is crucial. pH-metry is able to quantify acid burden, ensure that acid suppression is adequate during long-term follow-up, and correlate acid reflux to symptoms. pH with impedance is additionally able to detect non-acid reflux as well as volume clearance, both of which also correlate with patient symptoms. It is also able to correlate extra-gastrointestinal symptoms to reflux, which may help guide treatment. If complications associated with uncontrolled reflux are identified, aggressive reflux management is necessary, oftentimes requiring surgical intervention.
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Affiliation(s)
- Maheen Hassan
- Department of Pediatric Gastroenterology, University of California San Diego, San Diego, CA, USA
| | - Hayat Mousa
- Department of Pediatric Gastroenterology, University of California San Diego, San Diego, CA, USA
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ESPGHAN-NASPGHAN Guidelines for the Evaluation and Treatment of Gastrointestinal and Nutritional Complications in Children With Esophageal Atresia-Tracheoesophageal Fistula. J Pediatr Gastroenterol Nutr 2016; 63:550-570. [PMID: 27579697 DOI: 10.1097/mpg.0000000000001401] [Citation(s) in RCA: 210] [Impact Index Per Article: 26.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
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.
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Gottrand M, Michaud L, Sfeir R, Gottrand F. Motility, digestive and nutritional problems in Esophageal Atresia. Paediatr Respir Rev 2016; 19:28-33. [PMID: 26752295 DOI: 10.1016/j.prrv.2015.11.005] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Accepted: 11/16/2015] [Indexed: 12/11/2022]
Abstract
Esophageal atresia (EA) with or without tracheoesophageal fistula (TEF) is a rare congenital malformation. Digestive and nutritional problems remain frequent in children with EA both in early infancy and at long-term follow-up. These patients are at major risk of presenting with gastroesophageal reflux and its complications, such as anastomotic strictures. Esophageal dysmotility is constant, and can have important consequences on feeding and nutritional status. Patients with EA need a systematic follow-up with a multidisciplinary team.
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Affiliation(s)
- Madeleine Gottrand
- CHU Lille, University Lille, National reference center for congenital malformation of the esophagus, Department of Pediatrics, F-59000 Lille, France.
| | - Laurent Michaud
- CHU Lille, University Lille, National reference center for congenital malformation of the esophagus, Department of Pediatrics, F-59000 Lille, France.
| | - Rony Sfeir
- CHU Lille, University Lille, National reference center for congenital malformation of the esophagus, Department of Pediatrics, F-59000 Lille, France.
| | - Frédéric Gottrand
- CHU Lille, University Lille, National reference center for congenital malformation of the esophagus, Department of Pediatrics, F-59000 Lille, France.
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12
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Al-Shraim MM, Eid RA, Musalam AO, Radad K, Ibrahim AHM, Malki TA. Ultrastructural Changes of the Smooth Muscle in Esophageal Atresia. Ultrastruct Pathol 2015; 39:413-8. [PMID: 26548437 DOI: 10.3109/01913123.2015.1066913] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Esophageal atresia (EA) with or without tracheo-esophageal fistula (TEF) is a relatively rare congenital anomaly. Despite the advances in the management techniques and neonatal intensive care, esophageal dysmotility remains a very common problem following EA/TEF repair. Our current study aimed to describe the most significant ultrastructural changes of the smooth muscle cells (SMCs) trying to highlight some of the underlying mechanisms of esophageal dysmotility following EA/TEF repair. Twenty-three biopsies were obtained from the tip of the lower esophageal pouch (LEP) of 23 patients during primary repair of EA/TEF. Light microscopic examination was performed with hematoxylin and eosin (HE), and Van Gieson's stains. Ultrastructural examination was done using transmission electron microscopy (TEM). Histopathological examination showed distortion of smooth muscle layer and deposition of an abundant amount of fibrous tissue in-between smooth muscles. Using TEM, SMCs exhibited loss of the cell-to-cell adhesion, mitochondrial vacuolation, formation of myelin figures, and apoptotic fragmentation. There were also plasmalemmal projections and formation of ghost bodies. Interestingly, SMCs were found extending pseudopodia-like projections around adjacent collagen fibers. Engulfed collagen fibers by SMCs underwent degradation within autophagic vacuoles. Degeneration of SMCs and deposition of abundant extracellular collagen fibers are prominent pathological changes in LEP of EA/TEF. These changes might contribute to the pathogenesis of esophageal dysmotility in patients who have survived EA/TEF.
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Affiliation(s)
- Mubarak M Al-Shraim
- a Department of Pathology , College of Medicine, King Khalid University , Abha , Saudi Arabia
| | - Refaat A Eid
- a Department of Pathology , College of Medicine, King Khalid University , Abha , Saudi Arabia
| | - Adel Osman Musalam
- a Department of Pathology , College of Medicine, King Khalid University , Abha , Saudi Arabia
| | - Khaled Radad
- a Department of Pathology , College of Medicine, King Khalid University , Abha , Saudi Arabia
| | - Ashraf H M Ibrahim
- b Department of Surgery, Division of Pediatric Surgery , Armed Forces Hospital Southern Region , Khamis Mushait , Saudi Arabia , and
| | - Talal A Malki
- c Department of Pediatric Surgery , College of Medicine and Medical Sciences, Taif University , Taif , Saudi Arabia
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Baird R, Levesque D, Birnbaum R, Ramsay M. A pilot investigation of feeding problems in children with esophageal atresia. Dis Esophagus 2015; 28:224-8. [PMID: 24467447 DOI: 10.1111/dote.12178] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
While many long-term complications of esophageal atresia (EA) have been well investigated, little is known about feeding difficulties in children after surgical correction of EA and its impact on caregivers. This study investigates the feeding behaviors of children with EA through a validated feeding questionnaire. The Montreal Children's Hospital Feeding Scale (MCH-FS) was filled out by the primary caregiver during patient follow-up visits in the multidisciplinary EA clinic. Demographic information, EA subtype, associated anomalies and outcomes were recorded. Results were compared between groups and to a normative sample. Thirty caregivers have completed the MCH-FS; 26 patients had type C atresia (86.7%). In comparison to controls, 17.5% of EA cases are one standard deviation above the mean feeding difficulty score, while 6.7% (n = 2) cases are greater than two standard deviations above normative values. Typical EA patients (type C who were not born <30 weeks) had mean MCH-FS scores in the subclinical range, whereas one extremely premature child and the patients with non-type C EA (n = 4) all had scores in the severe range. Feeding difficulties of patients with typical EA appear mild. Likely explanations include the use of early protocolized care and intensive multidisciplinary care in follow up. Nonetheless, patients with complicated EA (non-type C) and their caregivers tend to experience significant feeding difficulties. Early targeted care may be required for this patient subset, and additional cases will be investigated to confirm these preliminary findings and explore further risk factors of feeding problem in this cohort.
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Affiliation(s)
- R Baird
- Department of Pediatric General and Thoracic Surgery, Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
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14
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Capeto FA, Lima FJB, Okoba W, Ramos FL, Messias TFA, Rigonatto GA, Sbragia L, Magalhães PJC, Melo-Filho AA. Contractile profile of esophageal and gastric fundus strips in experimental doxorubicin-induced esophageal atresia. Braz J Med Biol Res 2015; 48:458-64. [PMID: 25760030 PMCID: PMC4445670 DOI: 10.1590/1414-431x20144305] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2014] [Accepted: 12/11/2014] [Indexed: 01/13/2023] Open
Abstract
Esophageal atresia (EA) is characterized by esophageal and gastric motility changes
secondary to developmental and postsurgical damage. This study evaluated the
in vitro contractile profile of the distal esophagus and gastric
fundus in an experimental model of EA induced by doxorubicin (DOXO). Wistar pregnant
rats received DOXO 2.2 mg/kg on the 8th and 9th gestational days. On day 21.5,
fetuses were collected, sacrificed, and divided into groups: control, DOXO without EA
(DOXO-EA), and DOXO with EA (DOXO+EA). Strips from the distal esophagus and gastric
fundus were mounted on a wire myograph and isolated organ-bath system, respectively,
and subjected to increasing concentrations of carbamylcholine chloride (carbachol,
CCh). The isolated esophagus was also stimulated with increasing concentrations of
KCl. In esophagus, the concentration-effect curves were reduced in response to CCh in
the DOXO+EA and DOXO-EA groups compared to the control group (P<0.05). The maximum
effect values (Emax) for DOXO+EA and DOXO-EA were significantly lower than
control (P<0.05), but the half-maximal effective concentration (EC50)
values were not significantly different when the three groups were compared
(P>0.05). In response to KCl, the distal esophagus samples in the three groups
were not statistically different with regard to Emax or EC50
values (P>0.05). No significant difference was noted for EC50 or
Emax values in fundic strips stimulated with CCh (P>0.05). In
conclusion, exposure of dams to DOXO during gestation inhibited the contractile
behavior of esophageal strips from offspring in response to CCh but not KCl,
regardless of EA induction. The gastric fundus of DOXO-exposed offspring did not have
altered contractile responsiveness to cholinergic stimulation.
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Affiliation(s)
- F A Capeto
- Departamento de Cirurgia, Faculdade de Medicina, Universidade Federal do Ceará, Fortaleza, CE, Brasil
| | - F J B Lima
- Departamento de Fisiologia e Farmacologia, Faculdade de Medicina, Universidade Federal do Ceará, Fortaleza, CE, Brasil
| | - W Okoba
- Departamento de Fisiologia e Farmacologia, Faculdade de Medicina, Universidade Federal do Ceará, Fortaleza, CE, Brasil
| | - F L Ramos
- Departamento de Cirurgia, Faculdade de Medicina, Universidade Federal do Ceará, Fortaleza, CE, Brasil
| | - T F A Messias
- Departamento de Cirurgia, Faculdade de Medicina, Universidade Federal do Ceará, Fortaleza, CE, Brasil
| | - G A Rigonatto
- Departamento de Cirurgia, Faculdade de Medicina, Universidade Federal do Ceará, Fortaleza, CE, Brasil
| | - L Sbragia
- Departamento de Cirurgia e Anatomia, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brasil
| | - P J C Magalhães
- Departamento de Fisiologia e Farmacologia, Faculdade de Medicina, Universidade Federal do Ceará, Fortaleza, CE, Brasil
| | - A A Melo-Filho
- Departamento de Cirurgia, Faculdade de Medicina, Universidade Federal do Ceará, Fortaleza, CE, Brasil
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15
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Wang XY, Chen JH, Li K, Zhu YF, Wright GWJ, Huizinga JD. Discrepancies between c-Kit positive and Ano1 positive ICC-SMP in the W/Wv and wild-type mouse colon; relationships with motor patterns and calcium transients. Neurogastroenterol Motil 2014; 26:1298-310. [PMID: 25039457 DOI: 10.1111/nmo.12395] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2013] [Accepted: 06/13/2014] [Indexed: 12/22/2022]
Abstract
BACKGROUND Interstitial cells of Cajal associated with the submuscular plexus (ICC-SMP) generate omnipresent slow-wave activity in the colon and are associated with prominent motor patterns. Our aim was to investigate colon motor dysfunction in W/W(v) mice in which the ICC are reportedly reduced. METHODS Whole organ colon motility was studied using spatio-temporal mapping; immunohistochemical staining was carried out for c-Kit and Ano1; calcium imaging was applied to ICC-SMP. KEY RESULTS Discrepancies between Ano1 and c-Kit staining were found in both wild-type and W/W(v) colon. ICC-SMP were reduced to ~50% in the W/W(v) mouse colon according to c-Kit immunohistochemistry, but Ano1 staining indicated a normal network of ICC-SMP. The latter was consistent with rhythmic calcium transients occurring at the submucosal border of the colon in W/W(v) mice, similar to the rhythmic transients in wild-type ICC-SMP. Furthermore, the motor pattern associated with ICC-SMP pacemaking, the so-called 'ripples' were normal in the W/W(v) colon. CONCLUSIONS & INFERENCES c-Kit is not a reliable marker for quantifying ICC-SMP in the mouse colon. Ano1 staining revealed a normal network of ICC-SMP consistent with the presence of a normal 'ripples' motor pattern. We detected a class of Ano1 positive c-Kit negative cells that do not depend on Kit expression for maintenance, a feature shared with ICC progenitors.
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Affiliation(s)
- Xuan-Yu Wang
- Department of Medicine, Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, ON, Canada
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16
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Singendonk MMJ, Rommel N, Omari TI, Benninga MA, van Wijk MP. Upper gastrointestinal motility: prenatal development and problems in infancy. Nat Rev Gastroenterol Hepatol 2014; 11:545-55. [PMID: 24890279 DOI: 10.1038/nrgastro.2014.75] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Deglutition, or swallowing, refers to the process of propulsion of a food bolus from the mouth into the stomach and involves the highly coordinated interplay of swallowing and breathing. At 34 weeks gestational age most neonates are capable of successful oral feeding if born at this time; however, the maturation of respiration is still in progress at this stage. Infants can experience congenital and developmental pharyngeal and/or gastrointestinal motility disorders, which might manifest clinically as gastro-oesophageal reflux (GER) symptoms, feeding difficulties and/or refusal, choking episodes and airway changes secondary to micro or overt aspiration. These problems might lead to impaired nutritional intake and failure to thrive. These gastrointestinal motility disorders are mostly classified according to the phase of swallowing in which they occur, that is, the oral preparatory, oral, pharyngeal and oesophageal phases. GER is a common phenomenon in infancy and is referred to as GERD when it causes troublesome complications. GER is predominantly caused by transient relaxation of the lower oesophageal sphincter. In oesophageal atresia, oesophageal motility disorders develop in almost all patients after surgery; however, a congenital origin of disordered motility has also been proposed. This Review highlights the prenatal development of upper gastrointestinal motility and describes the most common motility disorders that occur in early infancy.
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Affiliation(s)
- Maartje M J Singendonk
- Department of Paediatric Gastroenterology and Nutrition, Emma Children's Hospital, Academic Medical Centre, Meibergdreef 9, 1105 AZ Amsterdam, Netherlands
| | - Nathalie Rommel
- Department of Neurosciences, ExpORL, KU Leuven, O&N II Herenstraat 49, Box 721, 3000 Leuven, Belgium
| | - Taher I Omari
- Gastroenterology Unit, Women's and Children's Health Network, 72 King William Street, 5006 SA, Australia
| | - Marc A Benninga
- Department of Paediatric Gastroenterology and Nutrition, Emma Children's Hospital, Academic Medical Centre, Meibergdreef 9, 1105 AZ Amsterdam, Netherlands
| | - Michiel P van Wijk
- Department of Paediatric Gastroenterology and Nutrition, Emma Children's Hospital, Academic Medical Centre, Meibergdreef 9, 1105 AZ Amsterdam, Netherlands
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17
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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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18
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Scholes MA, McEvoy T, Mousa H, Wiet GJ. Cricopharyngeal achalasia in children: botulinum toxin injection as a tool for diagnosis and treatment. Laryngoscope 2013; 124:1475-80. [PMID: 24122834 DOI: 10.1002/lary.24464] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2013] [Revised: 08/15/2013] [Accepted: 10/07/2013] [Indexed: 01/17/2023]
Abstract
OBJECTIVES/HYPOTHESIS Characteristics and outcomes of pediatric patients undergoing cricopharyngeus injection with botulinum toxin for the treatment of cricopharyngeal achalasia were reviewed. A parental telephone survey was performed to assess improvement and satisfaction. STUDY DESIGN Retrospective review of patients who underwent injection of the cricopharyngeus with botulinum toxin for cricopharyngeal achalasia. A prospective survey of postoperative symptoms and parental satisfaction was also performed. METHODS After institutional review board approval, children with cricopharyngeal achalasia who underwent injection with botulinum toxin were identified. Specific parameters were recorded for each patient. A survey of the parents' satisfaction and subjective improvement was then conducted. RESULTS Six children were identified with cricopharyngeal achalasia, with an age range of 3 months to 10 years. Symptoms varied and five of the six children required some form of altered nutrition. Preoperative studies varied, and the number of injections ranged from one to three per patient. One child had transient worsening of aspiration. Two children benefited from injections and went on to myotomy, while four children did not require myotomy and their symptoms were treated with injections alone. A parental survey was performed via telephone. All parents were satisfied with the procedure. Three children were symptom-free, and three children still exhibit some dysphagia. CONCLUSIONS Botulinum toxin injection is a useful tool to help diagnose and treat pediatric cricopharyngeal achalasia. More research is needed to elucidate optimal dosing, frequency of injections, and when to move on to surgical intervention. LEVEL OF EVIDENCE 4.
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Affiliation(s)
- Melissa A Scholes
- Department of Pediatric Otolaryngology, Children's Hospital Colorado, Aurora, Colorado; Department of Otolaryngology, University of Colorado School of Medicine, Aurora, Colorado
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19
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Abstract
Esophageal dysmotility is a considerable long-term issue in patients born with esophageal atresia (EA). To better characterize it, the normal esophageal motility is briefly reviewed with emphasis on the specific defects in EA. Multiple studies attempted to describe the dysmotility seen in patients with operated EA using esophageal manometry. Recently, high-resolution manometry has improved our understanding of normal esophageal motility. Using this new technology, it is now possible to better characterize the esophageal motility of patients operated on for EA. Three different patterns are described and presented: aperistalsis, pressurization, and distal peristalsis. Up to now, it has not been possible to find a correlation between the dysmotility severity and the patient's symptomatology. Different pathophysiological hypotheses of esophageal dysmotility in that population are discussed. Developmental neuronal defects are certainly present from the beginning. Surgical trauma can also contribute to the dysmotility. Finally, defective esophageal acid clearance capacity is a cause of gastroesophageal reflux disease, but the resultant esophagitis can also impair the normal esophageal function. The evolution of esophageal dysmotility in patients with repaired EA is not known and further studies will be necessary to clarify it.
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Affiliation(s)
- A Aspirot
- Division of Pediatric Surgery, Sainte-Justine University Health Center, Montreal, Quebec, Canada H3T 1C5.
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