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Stewart A, Govender R, Eaton S, Smith CH, De Coppi P, Wray J. The characteristics of eating, drinking and oro-pharyngeal swallowing difficulties associated with repaired oesophageal atresia/tracheo-oesophageal fistula: a systematic review and meta-proportional analysis. Orphanet J Rare Dis 2024; 19:253. [PMID: 38965635 PMCID: PMC11225380 DOI: 10.1186/s13023-024-03259-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 06/16/2024] [Indexed: 07/06/2024] Open
Abstract
INTRODUCTION Eating, drinking and swallowing difficulties are commonly reported morbidities for individuals born with OA/TOF. This study aimed to determine the nature and prevalence of eating, drinking and oro-pharyngeal swallowing difficulties reported in this population. METHOD A systematic review and meta-proportional analysis were conducted (PROSPERO: CRD42020207263). MEDLINE, EMBASE, CINAHL, Pubmed, Scopus, Web of Science databases and grey literature were searched. Quantitative and qualitative data were extracted relating to swallow impairment, use of mealtime adaptations and eating and drinking-related quality of life. Quantitative data were summarised using narrative and meta-proportional analysis methods. Qualitative data were synthesised using a meta-aggregation approach. Where quantitative and qualitative data described the same phenomenon, a convergent segregated approach was used to synthesise data. RESULTS Sixty-five studies were included. Six oro-pharyngeal swallow characteristics were identified, and pooled prevalence calculated: aspiration (24%), laryngeal penetration (6%), oral stage dysfunction (11%), pharyngeal residue (13%), nasal regurgitation (7%), delayed swallow initiation (31%). Four patient-reported eating/drinking difficulties were identified, and pooled prevalence calculated: difficulty swallowing solids (45%), difficulty swallowing liquids (6%), odynophagia (30%), coughing when eating (38%). Three patient-reported mealtime adaptations were identified, and pooled prevalence calculated: need for water when eating (49%), eating slowly (37%), modifying textures (28%). Mixed methods synthesis of psychosocial impacts identified 34% of parents experienced mealtime anxiety and 25% report challenging mealtime behaviours reflected in five qualitative themes: fear and trauma associated with eating and drinking, isolation and a lack of support, being aware and grateful, support to cope and loss. CONCLUSIONS Eating and drinking difficulties are common in adults and children with repaired OA/TOF. Oro-pharyngeal swallowing difficulties may be more prevalent than previously reported. Eating, drinking and swallowing difficulties can impact on psychological well-being and quality of life, for the individual and parents/family members. Long-term, multi-disciplinary follow-up is warranted.
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Affiliation(s)
- Alexandra Stewart
- Department of Language and Cognition, University College London, Chandler House,2 Wakefield Street, London, WC1N 1PF, UK.
- Great Ormond Street Hospital for Children, Great Ormond Street, London, WC1N 3JH, UK.
| | - Roganie Govender
- Head and Neck Academic Centre, Division of Surgery and Interventional Science, University College London, Charles Bell House, 43-47 Foley Street, London, W1W 7TS, UK
- University College London Hospital, 250 Euston Road, London, NW1 2PG, UK
| | - Simon Eaton
- Stem Cells and Regenerative Medicine Section, University College London Institute of Child Health, 30 Guilford Street, London, WC1N 1EH, UK
| | - Christina H Smith
- Department of Language and Cognition, University College London, Chandler House,2 Wakefield Street, London, WC1N 1PF, UK
| | - Paolo De Coppi
- Great Ormond Street Hospital for Children, Great Ormond Street, London, WC1N 3JH, UK
- Stem Cells and Regenerative Medicine Section, University College London Institute of Child Health, 30 Guilford Street, London, WC1N 1EH, UK
| | - Jo Wray
- Great Ormond Street Hospital for Children, Great Ormond Street, London, WC1N 3JH, UK
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Tan Tanny SP, Senior ND, Comella A, McCall L, Hutson JM, Finch S, Safe M, Teague WJ, Omari TI, King SK. Esophago-gastric junction findings on high resolution impedance manometry in children with esophageal atresia. J Pediatr Gastroenterol Nutr 2024; 78:1225-1233. [PMID: 38623953 DOI: 10.1002/jpn3.12213] [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: 07/06/2023] [Revised: 02/11/2024] [Accepted: 03/06/2024] [Indexed: 04/17/2024]
Abstract
OBJECTIVES Using high resolution impedance manometry (HRIM), this study characterized the esophago-gastric junction (EGJ) dynamics in children with esophageal atresia (EA). METHOD Esophageal HRIM was performed in patients with EA aged less than 18 years. Objective motility patterns were analyzed, and EGJ data reported. Controls were pediatric patients without EA undergoing investigations for consideration of fundoplication surgery. RESULTS Seventy-five patients (M:F = 43:32, median age 1 year 3 months [3 months-17 years 4 months]) completed 133 HRIM studies. The majority (64/75, 85.3%) had EA with distal tracheo-esophageal fistula. Compared with controls, liquid swallows were poorer in patients with EA, as evident by significant differences in distension pressure emptying and bolus flow time (BFT). The integrated relaxation pressure for thin liquid swallows was significantly different between EA types, as well as when comparing patients with EA with and without previous esophageal dilatations. The BFT for solid swallows was significantly different when compared with EA types. CONCLUSIONS We have utilized HRIM in patients with EA to demonstrate abnormalities in their long-term EGJ function. These abnormalities correlate with poorer esophageal compliance and reduced esophageal peristalsis across the EGJ. Understanding the EGJ function in patients with EA will allow us to tailor long-term management to specific patients.
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Affiliation(s)
- Sharman P Tan Tanny
- Department of Paediatric Surgery, The Royal Children's Hospital, Parkville, Victoria, Australia
- F. Douglas Stephens Surgical Research Group, Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Department of Paediatrics, The University of Melbourne, Parkville, Victoria, Australia
| | - Nicholas D Senior
- Department of Paediatric Surgery, The Royal Children's Hospital, Parkville, Victoria, Australia
- F. Douglas Stephens Surgical Research Group, Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Department of Paediatrics, The University of Melbourne, Parkville, Victoria, Australia
| | - Assia Comella
- Department of Paediatric Surgery, The Royal Children's Hospital, Parkville, Victoria, Australia
- F. Douglas Stephens Surgical Research Group, Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Monash Medical School, Monash University, Clayton, Victoria, Australia
| | - Lisa McCall
- Department of Human Physiology, Flinders University, Bedford Park, South Australia, Australia
| | - John M Hutson
- Department of Paediatric Surgery, The Royal Children's Hospital, Parkville, Victoria, Australia
- F. Douglas Stephens Surgical Research Group, Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Department of Paediatrics, The University of Melbourne, Parkville, Victoria, Australia
| | - Sue Finch
- Melbourne Statistical Consulting Platform, The University of Melbourne, Parkville, Victoria, Australia
| | - Mark Safe
- Department of Paediatric Surgery, The Royal Children's Hospital, Parkville, Victoria, Australia
| | - Warwick J Teague
- Department of Paediatric Surgery, The Royal Children's Hospital, Parkville, Victoria, Australia
- F. Douglas Stephens Surgical Research Group, Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Department of Paediatrics, The University of Melbourne, Parkville, Victoria, Australia
| | - Taher I Omari
- Department of Human Physiology, Flinders University, Bedford Park, South Australia, Australia
| | - Sebastian K King
- Department of Paediatric Surgery, The Royal Children's Hospital, Parkville, Victoria, Australia
- F. Douglas Stephens Surgical Research Group, Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Department of Paediatrics, The University of Melbourne, Parkville, Victoria, Australia
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Cullis PS, Fouad D, Goldstein AM, Wong KKY, Boonthai A, Lobos P, Pakarinen MP, Losty PD. Major surgical conditions of childhood and their lifelong implications: comprehensive review. BJS Open 2024; 8:zrae028. [PMID: 38776252 PMCID: PMC11110943 DOI: 10.1093/bjsopen/zrae028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 12/18/2023] [Accepted: 01/30/2024] [Indexed: 05/24/2024] Open
Abstract
BACKGROUND In recent decades, the survival of children with congenital anomalies and paediatric cancer has improved dramatically such that there has been a steady shift towards understanding their lifelong health outcomes. Paediatric surgeons will actively manage such conditions in childhood and adolescence, however, adult surgeons must later care for these 'grown-ups' in adulthood. This article aims to highlight some of those rare disorders encountered by paediatric surgeons requiring long-term follow-up, their management in childhood and their survivorship impact, in order that the adult specialist may be better equipped with skills and knowledge to manage these patients into adulthood. METHODS A comprehensive literature review was performed to identify relevant publications. Research studies, review articles and guidelines were sought, focusing on the paediatric management and long-term outcomes of surgical conditions of childhood. The article has been written for adult surgeon readership. RESULTS This article describes the aforementioned conditions, their management in childhood and their lifelong implications, including: oesophageal atresia, tracheo-oesophageal fistula, malrotation, short bowel syndrome, duodenal atresia, gastroschisis, exomphalos, choledochal malformations, biliary atresia, Hirschsprung disease, anorectal malformations, congenital diaphragmatic hernia, congenital lung lesions and paediatric cancer. CONCLUSION The increasing survivorship of children affected by surgical conditions will translate into a growing population of adults with lifelong conditions and specialist healthcare needs. The importance of transition from childhood to adulthood is becoming realized. It is hoped that this timely review will enthuse the readership to offer care for such vulnerable patients, and to collaborate with paediatric surgeons in providing successful and seamless transitional care.
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Affiliation(s)
- Paul S Cullis
- Department of Paediatric Surgery, Royal Hospital for Children Edinburgh, Edinburgh, UK
- College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK
| | - Dina Fouad
- Department of Paediatric Surgery, Leicester Children’s Hospital, Leicester, UK
| | - Allan M Goldstein
- Department of Paediatric Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Kenneth K Y Wong
- Department of Paediatric Surgery, Queen Mary’s Hospital, University of Hong Kong, Hong Kong, Hong Kong SAR
| | - Ampaipan Boonthai
- Department of Paediatric Surgery, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Pablo Lobos
- Department of Paediatric Surgery, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Mikko P Pakarinen
- The New Children’s Hospital, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
- Department of Women’s and Children’s Health, Karolinska Institute, Stockholm, Sweden
- Department of Surgery, University of Southern Denmark, Odense, Denmark
| | - Paul D Losty
- Department of Paediatric Surgery, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
- Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
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Umair Javaid M, Ikrama M, Abbas S, Saad Javaid M, Danial Khalid M, Riaz N, Ahsan Safdar M. Exploring Roemheld syndrome: a comprehensive review with proposed diagnostic criteria. Herz 2024:10.1007/s00059-024-05249-y. [PMID: 38714552 DOI: 10.1007/s00059-024-05249-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Revised: 01/31/2024] [Accepted: 04/03/2024] [Indexed: 05/10/2024]
Abstract
Roemheld syndrome (RS) is a condition that triggers cardiac symptoms due to gastrointestinal compression of the heart. It is often misdiagnosed as other types of cardiac or digestive disorders, leading to unnecessary treatments and reduced quality of life. Here, we provide a thorough review of RS, covering its pathogenesis, etiology, diagnosis, treatment, and outcome. We found that a number of conditions, including gallstones, hiatal hernia, excessive gas, and gastroesophageal reflux syndrome, can cause RS. The symptoms of RS can include chest pain, palpitations, shortness of breath, nausea, vomiting, bloating, and abdominal pain. Clinical history, physical examination, electrocardiograms, and improvement in symptoms following gastrointestinal therapy can all be used to identify RS. We also propose a set of criteria, the IKMAIR criteria, to improve the diagnostic approach for this condition. Dietary changes, lifestyle adjustments, pharmaceutical therapies, and surgical procedures can all be used to control RS. Depending on the underlying etiology and the outcome of treatment, RS has a varying prognosis. We conclude that RS is a complicated and understudied disorder that needs more attention from researchers and patients as well as from medical professionals. We recommend the inclusion of RS in the differential diagnosis for individuals with gastrointestinal problems and unexplained cardiac symptoms. Additionally, we advise treating RS holistically by attending to its cardiac and gastrointestinal components.
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Affiliation(s)
| | | | - Shafqat Abbas
- Services Institute of Medical Sciences, Lahore, Pakistan
| | | | | | - Nabeel Riaz
- Services Institute of Medical Sciences, Lahore, Pakistan
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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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Antoine M, Krishnan U, Manfredi M, Cervinskiene J, Viala J, Brendel J, Tzivinikos C, Vanrenterghem A, Dimitrov G, Hauser B, Laverdure N, Rohmer B, Behal H, Nicolas A, Gottrand F. Endoscopic management of esophageal mucosal bridges in children with esophageal atresia. Surg Endosc 2023; 37:9167-9172. [PMID: 37831175 PMCID: PMC10709217 DOI: 10.1007/s00464-023-10492-1] [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] [Received: 06/08/2023] [Accepted: 09/23/2023] [Indexed: 10/14/2023]
Abstract
BACKGROUND AND STUDY AIMS Esophageal mucosal bridge (EMB) may be diagnosed at the anastomotic site in children operated on for esophageal atresia (EA) but so far only a few cases (n = 4) have been reported. This study aimed to characterize EMB in children with EA, risk factors, and treatment. PATIENTS AND METHODS This retrospective multicenter study recorded patient's characteristics, EMB diagnosis circumstances, endoscopic management, follow-up, and EMB recurrence in children with EA aged less than 18 years, compared with paired EA patients without EMB. RESULTS Thirty patients were included (60% male, 90% EA/tracheoesophageal fistula, 43% associated malformations). Compared to 44 paired controls, EMB was associated with a history of nasogastric tube feeding (31% vs. 9.1%, p = 0.02) and severe gastroesophageal reflux disease (history of fundoplication: 41.4% vs. 13.6%, p < 0.01). 77% had symptoms (food impaction and/or dysphagia). Endoscopic management was performed in 53% of patients (83% electrocoagulation) with no technical difficulties or complications. 80% of the symptomatic patients with EMB improved after endoscopic treatment, independently of anastomotic stricture dilatation or not. CONCLUSION EMB endoscopic management by electrocoagulation is safe and often leads to symptom improvement.
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Affiliation(s)
- Matthieu Antoine
- Division of Gastroenterology, Hepatology and Nutrition, Department of Paediatrics, University of Lille, Inserm, CHU Lille, U1286 - INFINITE, 59000, Lille, France.
- Lille University Jeanne de Flandre Children's Hospital, Avenue Eugène Avinée, 59000, Lille, France.
| | - Usha Krishnan
- Pediatric Gastroenterology, Sydney Children's Hospital, Sydney, Australia
- School of Women's and Children's Health, University of New South Wales, Sydney, Australia
| | - Michael Manfredi
- Gastroenterology, Hepatology & Nutrition, Boston Children's Hospital, Boston, USA
| | - Julija Cervinskiene
- Endoscopy, Children's Hospital, Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania
| | - Jérôme Viala
- Gastroentérologie Pédiatrique, Hôpital Universitaire Robert-Debré, AP-HP, Paris, France
| | - Julia Brendel
- Klinik für Kinderchirurgie, Medizinische Hochschule Hannover, Hannover, Germany
| | - Christos Tzivinikos
- Pediatric Gastroenterology and Nutrition, Al Jalila Children's Specialty Hospital, Dubai, United Arab Emirates
| | | | | | - Bruno Hauser
- Gastroentérologie, Hépatologie et Nutrition Pédiatrique, UZ Brussel, Brussels, Belgique
| | - Noémie Laverdure
- Hépato-Gastroentérologie et Nutrition Pédiatrique, Hôpital Femme Mère Enfant, Lyon, Lyon, France
| | - Barbara Rohmer
- Hépato-Gastroentérologie et Nutrition Pédiatrique, Hôpital Femme Mère Enfant, Lyon, Lyon, France
| | - Hélène Behal
- ULR 2694 - METRICS: Évaluation des Technologies de Santé et des Pratiques Médicales, University of Lille, CHU Lille, 59000, Lille, France
| | - Audrey Nicolas
- Division of Gastroenterology, Hepatology and Nutrition, Department of Paediatrics, University of Lille, Inserm, CHU Lille, U1286 - INFINITE, 59000, Lille, France
- Lille University Jeanne de Flandre Children's Hospital, Avenue Eugène Avinée, 59000, Lille, France
| | - Frédéric Gottrand
- Division of Gastroenterology, Hepatology and Nutrition, Department of Paediatrics, University of Lille, Inserm, CHU Lille, U1286 - INFINITE, 59000, Lille, France
- Lille University Jeanne de Flandre Children's Hospital, Avenue Eugène Avinée, 59000, Lille, France
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Feeding and Swallowing Characteristics of Children With Esophageal Atresia and Tracheoesophageal Fistula. J Pediatr Gastroenterol Nutr 2023; 76:288-294. [PMID: 36728731 DOI: 10.1097/mpg.0000000000003697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVES This study aimed to characterize feeding/swallowing difficulties in children with esophageal atresia and/or tracheoesophageal fistula (EA/TEF) and evaluate associations among feeding difficulties, pharyngeal dysphagia (PD), and other aerodigestive evaluation findings. METHODS This was a retrospective cohort study of feeding/swallowing characteristics of 44 patients with EA/TEF treated in the aerodigestive program of a single academic medical institution from 2010 to 2015. Demographics, comorbidities, presence and characteristics of feeding/swallowing difficulties, and results of relevant diagnostic tests [videofluoroscopic swallow studies (VFSS), clinical feeding evaluations (CFEs), chest computerized tomography (CT) scans, pulmonary bronchoscopies, and upper GI (UGI)/esophagrams] were reviewed. RESULTS Fifty percent of the cohort had PD and 88.6% had feeding difficulties. Across 118 encounters (87 VFSS and 31 CFEs), feeding difficulties suggestive of esophageal dysphagia were most frequently seen in children over 48 months and feeding difficulties suggestive of developmental feeding problems were most frequently seen in children from 24 to 48 months. Abnormal findings were present in 59.8% of VFSS, with aspiration (34.5%) and pharyngeal residue (26.4%) the most frequently observed signs of dysphagia. Abnormal UGI/esophagram findings were not associated with significantly increased risk of feeding difficulties during visits within 3 months (risk ratio, RR = 1.33). Presence of dysphagia was associated with increased risk for some abnormal CT findings (RR= 3.0 for airspace and 3.0 for bronchiectasis). CONCLUSIONS Feeding/swallowing difficulties are common in EA/TEF, and types of feeding difficulties vary by patient age. The presence of abnormal findings on UGI/esophagram did not increase the risk of feeding complaints; however, the presence of dysphagia increased the risk of abnormal chest CT.
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Yasuda JL, Taslitsky GN, Staffa SJ, Ngo PD, Meisner J, Mohammed S, Hamilton T, Zendejas B, Manfredi MA. Predictors of enteral tube dependence in pediatric esophageal atresia. Dis Esophagus 2023; 36:6692452. [PMID: 36065605 DOI: 10.1093/dote/doac060] [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: 05/24/2022] [Revised: 08/10/2022] [Accepted: 08/15/2022] [Indexed: 12/11/2022]
Abstract
Children with esophageal atresia (EA) may require enteral tube feedings in infancy and a subset experience ongoing feeding difficulties and enteral tube dependence. Predictors of enteral tube dependence have never been systematically explored in this population. We hypothesized that enteral tube dependence is multifactorial in nature, with likely important contributions from anastomotic stricture. Cross-sectional clinical, feeding, and endoscopic data were extracted from a prospectively collected database of endoscopies performed in EA patients between August 2019 and August 2021 at an international referral center for EA management. Clinical factors known or hypothesized to contribute to esophageal dysphagia, oropharyngeal dysphagia, or other difficulties in meeting caloric needs were incorporated into regression models for statistical analysis. Significant predictors of enteral tube dependence were statistically identified. Three-hundred thirty children with EA were eligible for analysis. Ninety-seven were dependent on enteral tube feeds. Younger age, lower weight Z scores, long gap atresia, neurodevelopmental risk factor(s), significant cardiac disease, vocal fold movement impairment, and smaller esophageal anastomotic diameter were significantly associated with enteral tube dependence in univariate analyses; only weight Z scores, vocal fold movement impairment, and anastomotic diameter retained significance in a multivariable logistic regression model. In the current study, anastomotic stricture is the only potentially modifiable significant predictor of enteral tube dependence that is identified.
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Affiliation(s)
- Jessica L Yasuda
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA, USA
| | - Gabriela N Taslitsky
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA, USA
| | - Steven J Staffa
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Peter D Ngo
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA, USA
| | - Jay Meisner
- Department of Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Somala Mohammed
- Department of Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Thomas Hamilton
- Department of Surgery, Boston Children's Hospital, Boston, MA, USA
| | | | - Michael A Manfredi
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA, USA
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Marks KT, Higano NS, Kotagal M, Woods JC, Kingma PS. Magnetic Resonance Imaging-Based Evaluation of Anatomy and Outcome Prediction in Infants with Esophageal Atresia. Neonatology 2023; 120:185-195. [PMID: 36812903 PMCID: PMC10118939 DOI: 10.1159/000526794] [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: 03/24/2022] [Accepted: 08/24/2022] [Indexed: 02/24/2023]
Abstract
INTRODUCTION There is currently no validated diagnostic modality to characterize the anatomy and predict outcomes of tracheal esophageal defects, such as esophageal atresia (EA) and tracheal esophageal fistulas (TEFs). We hypothesized that ultra-short echo-time MRI would provide enhanced anatomic information allowing for evaluation of specific EA/TEF anatomy and identification of risk factors that predict outcome in infants with EA/TEF. METHODS In this observational study, 11 infants had pre-repair ultra-short echo-time MRI of the chest completed. Esophageal size was measured at the widest point distal to the epiglottis and proximal to the carina. Angle of tracheal deviation was measured by identifying the initial point of deviation and the farthest lateral point proximal to the carina. RESULTS Infants without a proximal TEF had a larger proximal esophageal diameter (13.5 ± 5.1 mm vs. 6.8 ± 2.1 mm, p = 0.07) when compared to infants with a proximal TEF. The angle of tracheal deviation in infants without a proximal TEF was larger than infants with a proximal TEF (16.1 ± 6.1° vs. 8.2 ± 5.4°, p = 0.09) and controls (16.1 ± 6.1° vs. 8.0 ± 3.1°, p = 0.005). An increase in the angle of tracheal deviation was positively correlated with duration of post-operative mechanical ventilation (Pearson r = 0.83, p < 0.002) and total duration of post-operative respiratory support (Pearson r = 0.80, p = 0.004). DISCUSSION These results demonstrate that infants without a proximal TEF have a larger proximal esophagus and a greater angle of tracheal deviation which is directly correlated with the need for longer post-operative respiratory support. Additionally, these results demonstrate that MRI is a useful tool to assess the anatomy of EA/TEF.
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Affiliation(s)
- Kaitlyn T. Marks
- The Perinatal Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Nara S. Higano
- Center for Pulmonary Imaging Research, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Radiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
- Division of Pulmonary Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Meera Kotagal
- Division of General and Thoracic Surgery, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio; Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Jason C. Woods
- Center for Pulmonary Imaging Research, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Radiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
- Division of Pulmonary Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Paul S. Kingma
- The Perinatal Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
- Center for Pulmonary Imaging Research, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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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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12
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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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13
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Celtik U, Eyigor S, Divarci E, Sezgin B, Dokumcu Z, Ozcan C, Ozturk K, Erdener A. Fiberoptic endoscopic evaluation of swallowing (FEES) study: the first report in children to evaluate the oropharyngeal dysphagia after esophageal atresia repair. Pediatr Surg Int 2022; 38:1227-1233. [PMID: 35836013 DOI: 10.1007/s00383-022-05169-0] [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: 06/28/2022] [Indexed: 10/17/2022]
Abstract
BACKGROUND The aim of this study was to evaluate the swallowing problems by fiberoptic endoscopic evaluation of swallowing (FEES) study in both short- and long-gap patients after esophageal atresia (EA) repair. METHODS Hospital records of patients who had undergone surgery for EA were reviewed retrospectively. Patients were divided into two groups as short-gap (SG) group (n:16) and long-gap (LG) group (n:10) to compare the swallowing problems. FEES study was performed, and the results were discussed in detail. RESULTS There were twenty-six (16 M/10 F) patients with a mean age at evaluation was 7.52 ∓ 3.68 years. Mean follow-up period was 75.35 ∓ 44.48 months. In FEES study, pharyngeal phase abnormalities were detected in 10 patients (38.4%). Pharyngeal phase abnormalities were detected significantly higher in LG group (p:0.015). Laryngeal penetration/aspiration was seen in four patients on FEES study (15.3%). All of them was in LG group (40%). Laryngeal penetration/aspiration was seen significantly higher in LG group (p:0.014). CONCLUSION This is the first study to conduct FEES study in children after esophageal atresia repair to evaluate their swallowing conditions. Even though our sample is small, swallowing problems are more common than expected in the cases of LG when compared to SG.
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Affiliation(s)
- Ulgen Celtik
- Faculty of Medicine, Department of Pediatric Surgery, Ege University, Bornova, 35100, Izmir, Turkey.
| | - Sibel Eyigor
- Faculty of Medicine, Department of Physical Therapy and Rehabilitation, Ege University, Bornova, 35100, Izmir, Turkey
| | - Emre Divarci
- Faculty of Medicine, Department of Pediatric Surgery, Ege University, Bornova, 35100, Izmir, Turkey
| | - Baha Sezgin
- Department of Otorhinolaryngology, Izmir Ekol Hospital, Cigli, Izmir, Turkey
| | - Zafer Dokumcu
- Faculty of Medicine, Department of Pediatric Surgery, Ege University, Bornova, 35100, Izmir, Turkey
| | - Coskun Ozcan
- Faculty of Medicine, Department of Pediatric Surgery, Ege University, Bornova, 35100, Izmir, Turkey
| | - Kerem Ozturk
- Faculty of Medicine, Department of Otorhinolaryngology, Ege University, Bornova, 35100, Izmir, Turkey
| | - Ata Erdener
- Faculty of Medicine, Department of Pediatric Surgery, Ege University, Bornova, 35100, Izmir, Turkey
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14
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Prachasitthisak N, Purcell M, Krishnan U. Role of Esophageal High-Resolution Manometry in Pediatric Patients. Pediatr Gastroenterol Hepatol Nutr 2022; 25:300-311. [PMID: 35903488 PMCID: PMC9284111 DOI: 10.5223/pghn.2022.25.4.300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Revised: 01/23/2022] [Accepted: 05/02/2022] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Dysphagia, vomiting and feeding difficulties are common symptoms, with which children present. Esophageal function testing with high resolution manometry can help in diagnosing and treating these patients. We aim to access the clinical utility of high-resolution manometry of esophagus in symptomatic pediatric patients. METHODS A retrospective chart review was done on all symptomatic patients who underwent esophageal high-resolution manometry between 2010 and 2019 at Sydney Children's Hospital, Australia. Manometry results were categorized based on Chicago classification. Demographic data, indication of procedure, manometric findings, and details of treatment changes were obtained and analyzed. RESULTS There were 62 patients with median age of 10 years (9 months-18 years). The main indication for the procedure was dysphagia (56%). Thirty-two percent of patients had a co-morbid condition, with esophageal atresia accounting for 16%. The majority (77%) of patients had abnormal manometry which included, ineffective esophageal motility in 45.2%. In esophageal atresia cohort, esophageal pressurization was seen in 50%, aperistalsis in 40% and 10% with prior fundoplication had esophago-gastric junction obstruction. Patients with esophago-gastric junction obstruction or achalasia were treated by either pneumatic dilation or Heller's myotomy. Patients with ineffective esophageal motility and rumination were treated with a trial of prokinetics/dietary texture modification and diaphragmatic breathing. CONCLUSION Esophageal high-resolution manometry has a role in the evaluation of symptomatic pediatric patients. The majority of our patients had abnormal results which led to change in treatments, with either medication, surgery and/or feeding modification with resultant improvement in symptoms.
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Affiliation(s)
- Noparat Prachasitthisak
- Department of Pediatric Gastroenterology, Sydney Children's Hospital, Randwick, Australia.,Division of Gastroenterology, Department of Pediatrics, Queen Sirikit National Institute of Child Health, Ministry of Public Health, College of Medicine, Rangsit University, Bangkok, Thailand
| | - Michael Purcell
- Department of Pediatric Gastroenterology, Sydney Children's Hospital, Randwick, Australia
| | - Usha Krishnan
- Department of Pediatric Gastroenterology, Sydney Children's Hospital, Randwick, Australia.,School of Women's and Children's Health, University of New South Wales, Sydney, Australia
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15
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Rayyan M, Omari T, Cossey V, Allegaert K, Rommel N. Characterizing Esophageal Motility in Neonatal Intensive Care Unit Patients Using High Resolution Manometry. Front Pediatr 2022; 10:806072. [PMID: 35237539 PMCID: PMC8882608 DOI: 10.3389/fped.2022.806072] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Accepted: 01/18/2022] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE To characterize esophageal motility and esophago-gastric junction (EGJ) function during feeding in neonatal intensive care unit (NICU) patients. PATIENTS AND METHODS High resolution manometry with impedance (HRIM) was used to investigate esophageal motility and EGJ function in patients admitted to the NICU. Twenty-eight preterm born infants with bronchopulmonary dysplasia (BPD), 12 born with isolated congenital diaphragmatic hernia (iCDH), and 10 with esophageal atresia (EA) were included. Thirteen healthy infants were included as controls. Esophageal motility and EGJ function were analyzed using objective esophageal bolus transport parameters. RESULTS Normal esophageal peristaltic wave patterns were observed in all investigated infants without EA. Nine of 10 patients with EA presented with abnormal esophageal motor wave patterns. A total of 224 nutritive swallows were analyzed (controls, n = 48; BPD, n = 96; iCDH, n = 60; EA, n = 20). Infants with BPD and iCDH had similar distal contractile strength (DCI) compared to healthy controls, while in patients with EA, DCI was significantly lower (Kruskal-Wallis test, p = 0.001). In most infants, EGJ relaxation after swallowing was unaffected. EGJ barrier function, in terms of EGJ-contractile integral, also appeared well-developed and did not differ significantly among patient groups. CONCLUSIONS We conclude that esophageal motility studies using pressure-impedance analysis are feasible in young infants. Bolus transport mechanisms following nutritive swallows appeared well-established in all investigated infants with the exception of those with EA. EGJ relaxation was also functional after deglutition and EGJ function as an anti-reflux barrier appeared well-developed in all investigated NICU groups.
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Affiliation(s)
- Maissa Rayyan
- Neonatal Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium.,Department of Development and Regeneration, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Taher Omari
- College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
| | - Veerle Cossey
- Neonatal Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium.,Department of Development and Regeneration, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Karel Allegaert
- Department of Development and Regeneration, Katholieke Universiteit Leuven, Leuven, Belgium.,Clinical Pharmacology and Pharmacotherapy, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium.,Department of Hospital Pharmacy, Erasmus Medical Center University Medical Center, Rotterdam, Netherlands
| | - Nathalie Rommel
- Department of Neurosciences, Experimental Otorhinolaryngeal, Deglutology, KU Leuven, Leuven, Belgium.,Neurogastroenterology and Motility, Gastroenterology, University Hospitals Leuven, Leuven, Belgium
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16
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Yasuda JL, Staffa SJ, Nurko S, Kane M, Wall S, Mougey EB, Franciosi JP, Manfredi MA, Rosen R. Pharmacogenomics fail to explain proton pump inhibitor refractory esophagitis in pediatric esophageal atresia. Neurogastroenterol Motil 2022; 34:e14217. [PMID: 34337835 DOI: 10.1111/nmo.14217] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 06/01/2021] [Accepted: 06/07/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND Esophagitis is prevalent in patients with esophageal dysmotility despite acid suppression, likely related to poor esophageal clearance. Esophageal atresia (EA) is a classic model of dysmotility where this observation holds true. In adult non-dysmotility populations, failure of esophagitis to respond to proton pump inhibitors (PPI) has been linked to variants in CYP2C19 that influence the activity of the encoded enzyme. It is unknown if CYP2C19 metabolizer phenotype contributes to PPI-refractory, non-allergic esophagitis in EA. METHODS We performed a cross-sectional study of 314 children with (N = 188) and without (N = 126) EA who were on PPI therapy at the time of endoscopy to evaluate for possible gastroesophageal reflux disease. Patients with eosinophilic esophagitis and/or fundoplication were excluded. Clinical and histology data were collected. Genomic DNA from biopsy samples was genotyped for polymorphisms in CYP2C19. RESULTS CYP2C19 metabolizer phenotypes were not associated with presence or severity of esophagitis (P = 0.994). In a multivariate logistic regression adjusted for potential confounders, EA was the strongest and only significant predictor of esophagitis (odds ratio 2.72, P = 0.023). Using negative binomial regression, we found that CYP2C19 phenotype was not a significant predictor of eosinophil count in children with PPI-refractory esophagitis. CONCLUSIONS Patients with EA are significantly more likely to experience PPI-refractory, non-allergic esophagitis than controls regardless of CYP2C19 metabolizer phenotype, suggesting that factors other than CYP2C19 genetics, including dysmotility, are the primary drivers of esophagitis in EA. CYP2C19 genotype failed to predict PPI-refractory, non-allergic esophagitis in both EA and non-EA children.
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Affiliation(s)
- Jessica L Yasuda
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA, USA
| | - Steven J Staffa
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Samuel Nurko
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA, USA
| | - Madeline Kane
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA, USA
| | - Stephanie Wall
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA, USA
| | - Edward B Mougey
- Center for Pharmacogenomics and Translational Research, Nemours Children's Health System, Jacksonville, FL, USA
| | - James P Franciosi
- Division of Gastroenterology, Hepatology, and Nutrition, Nemours Children's Hospital, Orlando, FL, USA.,Department of Pediatrics, University of Central Florida College of Medicine, Orlando, FL, USA
| | - Michael A Manfredi
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA, USA
| | - Rachel Rosen
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA, USA
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17
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Tan Tanny SP, Trajanovska M, Muscara F, Hutson JM, Hearps S, Omari TI, Teague WJ, King SK. Quality of Life Outcomes in Primary Caregivers of Children with Esophageal Atresia. J Pediatr 2021; 238:80-86.e3. [PMID: 34329689 DOI: 10.1016/j.jpeds.2021.07.055] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2021] [Revised: 07/15/2021] [Accepted: 07/21/2021] [Indexed: 01/21/2023]
Abstract
OBJECTIVE To investigate the quality of life (QoL) impact on primary caregivers of children with esophageal atresia. STUDY DESIGN We used a prospective cohort study design, inviting primary caregivers of children with esophageal atresia to complete the following questionnaires: Parent Experience of Child Illness (PECI), Patient-Reported Outcomes Measurement Information System (PROMIS) Anxiety, PROMIS Depression, 12-Item Short Form Survey (SF-12), and Pediatric Quality of Life Inventory (PedsQL). The PECI, PROMIS Anxiety and Depression, and SF-12 assessed caregiver QoL, and the PedsQL assessed patient QoL. Patients with Gross type E esophageal atresia served as controls. RESULTS The primary caregivers of 100 patients (64 males, 36 females; median age, 4.6 years; range, 3.5 months to 19.0 years) completed questionnaires. The majority (76 of 100) of patients had Gross type C esophageal atresia. A VACTERL (vertebral anomalies, anorectal malformation, cardiac anomalies, tracheoesophageal fistula, renal anomalies, limb anomalies) association was found in 30, ≥1 esophageal dilatation was performed in 57, and fundoplication was performed in 11/100. When stratified by esophageal atresia types, significant differences were found in 2 PECI subscales (unresolved sorrow/anger, P = .02; uncertainty, P = .02), in PROMIS Anxiety (P = .02), and in SF-12 mental health (P = .02) and mental component summary scores (P = .02). No significant differences were found for VACTERL association, nor esophageal dilatation. Requirement for fundoplication resulted in lower SF-12 general health score, and lower PedsQL social and physical functioning scores. CONCLUSIONS We have demonstrated that caring for a child with esophageal atresia and a previous requirement for fundoplication impacts caregiver QoL.
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Affiliation(s)
- Sharman P Tan Tanny
- Department of Paediatric Surgery, The Royal Children's Hospital, Parkville, Victoria, Australia; F. Douglas Stephens Surgical Research Group, Murdoch Children's Research Institute, Parkville, Victoria, Australia; Department of Paediatrics, The University of Melbourne, Parkville, Victoria, Australia.
| | - Misel Trajanovska
- F. Douglas Stephens Surgical Research Group, Murdoch Children's Research Institute, Parkville, Victoria, Australia; Department of Paediatrics, The University of Melbourne, Parkville, Victoria, Australia
| | - Frank Muscara
- Department of Paediatrics, The University of Melbourne, Parkville, Victoria, Australia; Brain and Mind Research Group, Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - John M Hutson
- Department of Paediatric Surgery, The Royal Children's Hospital, Parkville, Victoria, Australia; F. Douglas Stephens Surgical Research Group, Murdoch Children's Research Institute, Parkville, Victoria, Australia; Department of Paediatrics, The University of Melbourne, Parkville, Victoria, Australia
| | - Stephen Hearps
- Brain and Mind Research Group, Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Taher I Omari
- College of Medicine & Public Health, Flinders University, Bedford Park, South Australia, Australia
| | - Warwick J Teague
- Department of Paediatric Surgery, The Royal Children's Hospital, Parkville, Victoria, Australia; F. Douglas Stephens Surgical Research Group, Murdoch Children's Research Institute, Parkville, Victoria, Australia; Department of Paediatrics, The University of Melbourne, Parkville, Victoria, Australia
| | - Sebastian K King
- Department of Paediatric Surgery, The Royal Children's Hospital, Parkville, Victoria, Australia; F. Douglas Stephens Surgical Research Group, Murdoch Children's Research Institute, Parkville, Victoria, Australia; Department of Paediatrics, The University of Melbourne, Parkville, Victoria, Australia
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18
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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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19
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FANG LQ, HAN DX, LIN B, LI XL, ZHANG QA. Acupuncture for dysphagia after surgery for Esophageal Atresia with tracheoesophageal fistula: A case report. WORLD JOURNAL OF ACUPUNCTURE-MOXIBUSTION 2021. [DOI: 10.1016/j.wjam.2021.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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20
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Comella A, Tan Tanny SP, Hutson JM, Omari TI, Teague WJ, Nataraja RM, King SK. Esophageal morbidity in patients following repair of esophageal atresia: A systematic review. J Pediatr Surg 2021; 56:1555-1563. [PMID: 33051081 DOI: 10.1016/j.jpedsurg.2020.09.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 08/24/2020] [Accepted: 09/06/2020] [Indexed: 01/25/2023]
Abstract
BACKGROUND Esophageal atresia (EA) is a life-threatening congenital condition, affecting one in 2600 newborns. Morbidity remains high, with many patients experiencing complications, including anastomotic leak/stricture, and gastro-esophageal reflux disease (GERD). Increased understanding of esophageal motility patterns may help explain the etiology of these complications. AIMS We aimed to review knowledge regarding esophageal motility and related complications in children with EA, evaluate patients' symptomatology and relate this to esophageal motility. METHODS We performed a systematic review (PROSPERO: CRD42018092277), according to the PRISMA protocol. Two investigators independently conducted search strategies (OvidMEDLINE, PubMed, Cochrane Review, BMJ BestPractice), identifying complications in patients following EA repair. Rates of esophageal dysmotility, GERD, dysphagia, anastomotic leak, anastomotic stricture, recurrent fistula formation, and esophagitis were sought. RESULTS A total of 65 publications met selection criteria (n = 4882). Rates of morbidity were high: esophageal dysmotility (78%), GERD (43%), dysphagia (44%), anastomotic leak (19%), anastomotic stricture (26%), recurrent fistula formation (7%), and esophagitis (47%). No correlation appeared to exist with severity of symptoms. CONCLUSIONS This systematic review identified high rates of complications in children with EA, with esophageal dysmotility present in the majority of patients. Increasing survival, with resultant longer timeframes to develop morbidities, makes standardized follow-up regimens crucial. TYPE OF STUDY Prognosis study. LEVEL OF EVIDENCE Level 3.
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Affiliation(s)
- Assia Comella
- Department of Paediatric Surgery, The Royal Children's Hospital, Melbourne, Australia, 3052; Surgical Research, Murdoch Children's Research Institute, Melbourne, Australia, 3052; School of Medicine, Monash University, Melbourne, Australia, 3800.
| | - Sharman P Tan Tanny
- Department of Paediatric Surgery, The Royal Children's Hospital, Melbourne, Australia, 3052; Surgical Research, Murdoch Children's Research Institute, Melbourne, Australia, 3052; Department of Paediatrics, University of Melbourne, Melbourne, Australia, 3010; Department of Paediatric Surgery, Monash Children's Hospital, Melbourne, Australia, 3168
| | - John M Hutson
- Department of Paediatric Surgery, The Royal Children's Hospital, Melbourne, Australia, 3052; Surgical Research, Murdoch Children's Research Institute, Melbourne, Australia, 3052; Department of Paediatrics, University of Melbourne, Melbourne, Australia, 3010
| | - Taher I Omari
- Department of Human Physiology, Flinders University, Adelaide, Australia, 5042
| | - Warwick J Teague
- Department of Paediatric Surgery, The Royal Children's Hospital, Melbourne, Australia, 3052; Surgical Research, Murdoch Children's Research Institute, Melbourne, Australia, 3052; Department of Paediatrics, University of Melbourne, Melbourne, Australia, 3010
| | - Ramesh M Nataraja
- Department of Paediatric Surgery, Monash Children's Hospital, Melbourne, Australia, 3168; Department of Paediatrics, School of Clinical Sciences, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia, 3800
| | - Sebastian K King
- Department of Paediatric Surgery, The Royal Children's Hospital, Melbourne, Australia, 3052; Surgical Research, Murdoch Children's Research Institute, Melbourne, Australia, 3052; Department of Paediatrics, University of Melbourne, Melbourne, Australia, 3010
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21
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Primary anastomosis in difficult cases of type "C" esophageal atresia: The atraumatic microvascular clamp technique of minimal tension with good outcome. J Pediatr Surg 2021; 56:1076-1081. [PMID: 33342605 DOI: 10.1016/j.jpedsurg.2020.12.005] [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: 08/14/2020] [Revised: 11/17/2020] [Accepted: 12/06/2020] [Indexed: 11/21/2022]
Abstract
BACKGROUND Surgical maneuvers for esophageal anastomosis in difficult cases of Gross type "C" esophageal atresia (EA) are challenging. The methods of early primary anastomosis are technically difficult and staged surgeries expose the child to repeated general anesthesia with problems of nursing care. We describe a simple method of partial disconnection of the lower esophagus from the fistula followed by approximation by an atraumatic microvascular clamp. The suitability of this method and its outcomes are discussed. METHODS It was a prospective observational study that included 32 patients of type "C" EA between January 2014 and December 2016. Babies with birth weight more than 2 kg without cyanotic heart defects and requirement of intensive care were included. An early primary anastomosis using this technique was tried in all. A cervical esophagostomy with feeding gastrostomy was done where it was not possible. Analysis of the gap and post operative outcomes i.e. gastroesophageal reflux (GER), stricture, tracheomalacia, dysmotility, recurrence and survival were analyzed. RESULTS The mean gap between esophageal ends was 4.3 cm. Primary anastomosis was possible in 26 (81.25%). Minor and major leak occurred in 3 (11.54%) and 1 (3.85%) patients respectively. Survival was 84.62% (22/26). All mortalities were early post operative. During mean follow up of 23.73 months (till December 2019), GER decreased from 63.64% (14/22) to 13.64% (3/22), partial stricture was seen in 18.18% (4/22), tracheomalacia in 36.36% (8/22) and dysmotility in 77.27% (17/22). There was no recurrence of fistula. Complications with this method did not show any significant difference as mentioned with other methods. CONCLUSION This technique seems to be physiologically suitable as it enables anastomosis with minimal trauma to the esophageal ends. It is easy, reproducible and produces favorable outcomes comparable with other methods for difficult cases of type "C" esophageal atresia (EA).
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22
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Saxena AK, Biro E, Sommer G, Holzapfel GA. Esophagus stretch tests: Biomechanics for tissue engineering and possible implications on the outcome of esophageal atresia repairs performed under excessive tension. Esophagus 2021; 18:346-352. [PMID: 32816188 DOI: 10.1007/s10388-020-00769-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 08/13/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND Esophageal biomechanical studies are important to understand structural changes resulting from stretches during repair of esophageal atresias as well as to obtain values to compare with the biomechanics of tissue-engineered esophagus in the future. This study aimed to investigate light microscopic changes after uniaxial stretching of the ovine esophagus. METHODS In vitro uniaxial stretching was performed on esophagi (n = 20) of 1-month-old lambs within 4-6 h post-mortem. Esophagi were divided into 5 groups: control and stretched (1.1, 1.2, 1.3 and 1.4). Force and lengthening were measured with 5 cycles performed on every specimen using a PBS organ bath at 37 °C. Histological studies were performed on the 5 groups. RESULTS Low forces of ~ 2 N (N) were sufficient for a 1.2-1.25 stretch in the 1st cycle, whereas a three times higher force (~ 6 N) was needed for a stretch of 1.3. In the 2nd to 5th cycle, the tissue weakened and a force of ~ 3 N was sufficient for a stretch of 1.3. Histologically, in the 1.3-1.4 stretch groups, rupture of muscle fibers and capillaries were observed, respectively. Changes in mucosa and collagen fibers could not be observed. CONCLUSIONS These results offer norm values from the native esophagus to compare with the biomechanics of future tissue-engineered esophagus. Esophageal stretching > 1.3 leads to tears in muscle fibers and to rupture of capillaries. These findings can explain the decrease in microcirculation and scarring in mobilized tissue and possibly offer clues to impaired motility in esophagus atresias repaired under excessive tension.
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Affiliation(s)
- Amulya K Saxena
- Department of Pediatric Surgery, Chelsea Children's Hospital, Chelsea and Westminster Hospital NHS Fdn Trust, Imperial College London, 369 Fulham Road, London, SW10 9NH, UK.
| | - Ede Biro
- Department of Pediatric Surgery, Medical University of Pecs, Pecs, Hungary
| | - Gerhard Sommer
- Institute of Biomechanics, Graz University of Technology, Graz, Austria
| | - Gerhard A Holzapfel
- Institute of Biomechanics, Graz University of Technology, Graz, Austria.,Norwegian University of Science and Technology, Trondheim, Norway
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23
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van Lennep M, Leijdekkers ML, Oors JM, Benninga MA, van Wijk MP, Singendonk MM. Clinical Experience With Performing Esophageal Function Testing in Children. J Pediatr Gastroenterol Nutr 2021; 72:226-231. [PMID: 33230070 PMCID: PMC7815250 DOI: 10.1097/mpg.0000000000003000] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2020] [Accepted: 11/05/2020] [Indexed: 12/10/2022]
Abstract
OBJECTIVES Pediatric high-resolution manometry (HRM) and 24-hour pH-impedance with/without ambulatory manometry (pH-MII+/-mano) tests are generally performed using adult-derived protocols. We aimed to assess the feasibility of these protocols in children, the occurrence of patient-related imperfections and their influence on test interpretability. METHODS Esophageal function tests performed between 2015 and 2018 were retrospectively analyzed. All tests were subcategorized into uninterpretable or interpretable tests (regardless of occurrence of patient-related imperfections). For HRM, the following patient-related imperfections were scored: patient-related artefacts, multiple swallowing and/or inability to establish baseline characteristics. For pH-MII(+/-mano), incorrect symptom registration and/or premature catheter removal were scored. Results were compared between age-groups (0-3, 4-12, and >12 years). RESULTS In total 106 HRM, 60 pH-MII, and 23 pH-MII-mano could be fully analyzed. Of these, 94.8% HRM, 91.9% pH-MII, and 95.7% pH-MII-mano were interpretable. Overall, HRM contained imperfections in 78.3% overall and in 8/8 (100%) in the youngest age group, 36/42 (85.7%) in 4 to 12 years and in 37/56 (66.1%) in children above 12 years; P = 0.011. These imperfections led to uninterpretable results in 4 HRM (3.8%), of which 3 were in the youngest age group (3/8, 37.5%). Imperfections were found in 10% of pH-MII and 17.4% of pH-MII-mano. These led to uninterpretable results in 5.0% and 4.3%, respectively. No age-effect was found. CONCLUSIONS Esophageal function tests in children are interpretable in more than 90% overall. In children under the age of 4 years, all patients had imperfect HRM and 3/8 tests were uninterpretable. HRM in older children and pH-MII+/-mano were interpretable in the vast majority.
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Affiliation(s)
- Marinde van Lennep
- Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Pediatric Gastroenterology
| | - Marin L. Leijdekkers
- Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Pediatric Gastroenterology
| | - Jac M. Oors
- Amsterdam UMC, University of Amsterdam, Department of gastroenterology
| | - Marc A. Benninga
- Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Pediatric Gastroenterology
| | - Michiel P. van Wijk
- Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Pediatric Gastroenterology
- Emma Children's Hospital, Amsterdam UMC, Vrije Universiteit Amsterdam, Pediatric Gastroenterology, Amsterdam, The Netherlands
| | - Maartje M.J. Singendonk
- Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Pediatric Gastroenterology
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24
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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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25
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Caruso AM, Milazzo M, Tulone V, Acierno C, Girgenti V, Amoroso S, Bommarito D, Calcaterra V, Pelizzo G. High Resolution Manometry Guidance During Laparoscopic Fundoplication in Pediatric Surgically "Fragile" Patients: Preliminary Report. CHILDREN-BASEL 2020; 7:children7110215. [PMID: 33171722 PMCID: PMC7695016 DOI: 10.3390/children7110215] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 11/04/2020] [Accepted: 11/05/2020] [Indexed: 12/12/2022]
Abstract
Background: High resolution manometry (HRM), has been recently introduced in clinical practice to detect esophageal intraluminal pressure and esophageal motor function. We evaluated the feasibility and usefulness of intraoperative esophageal HRM during antireflux laparoscopic procedures in pediatric cases with neurological impairment (NI) or esophageal atresia (EA). Methods: From January to November 2019, seven children (5 NI, 2 EA) with gastroesophageal reflux (GER) were enrolled. Data on intraoperative pressure changes of the esophagogastric junction (EGJ) and postoperative follow-up data were collected. Results: Average preoperative LES pressures were not significantly different from postoperative pressures. A sliding hernia was detected in all patients as evidenced by EGJ double peak pressures. Hernia correction after esophageal traction was complete in 71.4% of the patients, and residual hernia (<2 cm) was detected in 28.6%. Postoperative EGJ pressures were higher compared to preoperative sphincteric pressures (p < 0.001); in NI patients, higher postoperative values were noted compared to EA (p = 0.05). No sliding hernia and/or GER relapses were recorded. Two patients reported dysphagia postoperatively. Conclusions: Intraoperative HRM may optimize esophageal pressure changes during laparoscopic fundoplication. Further studies are needed to confirm the usefulness of a tailored surgical approach to reduce postoperative complications.
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Affiliation(s)
- Anna Maria Caruso
- Pediatric Surgery Unit, Children’s Hospital, ARNAS Civico-Di Cristina-Benfratelli, 90127 Palermo, Italy; (A.M.C.); (M.M.); (V.T.); (C.A.); (V.G.); (S.A.); (D.B.)
| | - Mario Milazzo
- Pediatric Surgery Unit, Children’s Hospital, ARNAS Civico-Di Cristina-Benfratelli, 90127 Palermo, Italy; (A.M.C.); (M.M.); (V.T.); (C.A.); (V.G.); (S.A.); (D.B.)
| | - Vincenzo Tulone
- Pediatric Surgery Unit, Children’s Hospital, ARNAS Civico-Di Cristina-Benfratelli, 90127 Palermo, Italy; (A.M.C.); (M.M.); (V.T.); (C.A.); (V.G.); (S.A.); (D.B.)
| | - Carlo Acierno
- Pediatric Surgery Unit, Children’s Hospital, ARNAS Civico-Di Cristina-Benfratelli, 90127 Palermo, Italy; (A.M.C.); (M.M.); (V.T.); (C.A.); (V.G.); (S.A.); (D.B.)
| | - Vincenza Girgenti
- Pediatric Surgery Unit, Children’s Hospital, ARNAS Civico-Di Cristina-Benfratelli, 90127 Palermo, Italy; (A.M.C.); (M.M.); (V.T.); (C.A.); (V.G.); (S.A.); (D.B.)
| | - Salvatore Amoroso
- Pediatric Surgery Unit, Children’s Hospital, ARNAS Civico-Di Cristina-Benfratelli, 90127 Palermo, Italy; (A.M.C.); (M.M.); (V.T.); (C.A.); (V.G.); (S.A.); (D.B.)
| | - Denisia Bommarito
- Pediatric Surgery Unit, Children’s Hospital, ARNAS Civico-Di Cristina-Benfratelli, 90127 Palermo, Italy; (A.M.C.); (M.M.); (V.T.); (C.A.); (V.G.); (S.A.); (D.B.)
| | - Valeria Calcaterra
- Pediatric and Adolescent Unit, Department of Internal Medicine, University of Pavia, 27100 Pavia, Italy;
- Pediatric Unit, “V. Buzzi” Children’s Hospital, University of Milano, 20154 Milano, Italy
| | - Gloria Pelizzo
- Pediatric Surgery Unit, “V. Buzzi” Children’s Hospital, University of Milano, 20154 Milano, Italy
- Department of Biomedical and Clinical Science, “L. Sacco”, University of Milano, 20154 Milano, Italy
- Correspondence:
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26
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Omari TI, Krishnan U. What is the role of high-resolution oesophageal manometry in paediatrics? J Paediatr Child Health 2020; 56:1754-1759. [PMID: 33197976 DOI: 10.1111/jpc.15057] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 06/11/2020] [Accepted: 06/15/2020] [Indexed: 12/21/2022]
Abstract
Abnormal oesophageal motility may impair oesophageal bolus transport leading to symptoms of chest pain and regurgitation. Oesophageal pathophysiology may include neuromuscular and/or structural defects leading to weak, incoordinate or absent peristalsis and impaired oesophago-gastric junction relaxation. Understanding these mechanisms is important to determine the appropriate course of therapy. Whilst, barium oesophagram is the mainstay for clinical investigation of oesophageal motility, high-resolution manometry is now more widely available. This review describes the potential value of high-resolution manometry in paediatric gastroenterology practise.
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Affiliation(s)
- Taher I Omari
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Usha Krishnan
- Paediatric Gastroenterology, Sydney Children's Hospital, Sydney, New South Wales, Australia.,School of Women's and Children's Health, University of New South Wales, Sydney, New South Wales, Australia
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27
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Peña-Vélez R, Toro-Monjaraz E, Avelar-Rodríguez D, Cadena-León J, Ignorosa-Arellano K, Loredo-Mayer A, Zárate-Mondragón F, Cervantes-Bustamante R, Ramírez-Mayans J. Esophageal motility disorders in children with dysphagia: the utility of the Chicago classification. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2020; 112:850-853. [PMID: 33054306 DOI: 10.17235/reed.2020.6735/2019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
BACKGROUND esophageal manometry is the standard criterion for the evaluation of dysphagia and the diagnosis of a primary motor disorder of the esophagus in adults and children. AIMS to describe the diagnosis according to the Chicago classification (CC) v3.0 in children with dysphagia, in whom an esophageal motility disorder was documented. The associated comorbidities were also determined. METHODS an observational retrospective study was performed of 54 patients evaluated for dysphagia, who had undergone a high-resolution manometry (HREM). RESULTS a normal HREM was found in 52 % (n = 28) of the children, whereas 48 % (n = 26) had some esophageal motility disorder. The most frequent diagnosis was ineffective esophageal motility and achalasia. Excluding previously healthy children, most children had a history of autoimmune disease and intellectual disability. CONCLUSIONS an esophageal motor disorder can be diagnosed in nearly half of infants and children with dysphagia. In this study, all esophageal diseases could be classified according to the CC v3.0. HREM should be considered for the evaluation of children with dysphagia, in addition to other studies.
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Affiliation(s)
- Rubén Peña-Vélez
- Gastroenterología y Nutrición, Instituto Nacional de Pediatría, México
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28
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Characterization of Esophageal Motility in Children With Operated Esophageal Atresia Using High-resolution Impedance Manometry and Pressure Flow Analysis. J Pediatr Gastroenterol Nutr 2020; 71:304-309. [PMID: 32541198 DOI: 10.1097/mpg.0000000000002806] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Esophageal dysmotility is common in patients with esophageal atresia (EA). High-resolution impedance manometry and pressure flow analysis (PFA) allow characterization of biomechanical events that drive bolus flow. The aims were to assess esophageal motility in children with EA, using PFA, and to test whether there is a correlation between PFA parameters and symptoms or endoscopic/histologic findings. METHODS High-resolution impedance manometry was performed in 16 children with EA (median age 11 years), compared with 13 patient controls (median age 14 years; P = NS vs patients). Wet swallows were analyzed using PFA. Medical charts were reviewed for symptoms and pathology results of the attendant esophagoscopy. Patients with EA were arbitrarily subgrouped according to their motility pattern: group A with presence of distal contraction in ≥50% of the swallows and group B with presence of distal contractions in <50% of the swallows. RESULTS Esophageal peristaltic motor patterns were abnormal in all patients with EA. Bolus transport was impaired as shown by the higher impedance ratio in EA than in controls (0.47 vs 0.22; P < 0.001). Impedance ratio was also higher in group B (n = 8) versus group A (n = 8) (P < 0.001). Symptoms of dysphagia were not correlated with the PFA measures. Contractile segment impedance, a marker of mucosal integrity, was significantly lower in the EA group. CONCLUSIONS Bolus transport was severely altered in patients with EA but was not predictive of symptoms. The presence of residual distal contractions is associated with a more efficient bolus propulsion.
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29
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Ambartsumyan L, Khlevner J, Nurko S, Rosen R, Kaul A, Pandolfino JE, Ratcliffe E, Yacob D, Li BU, Punati J, Sood M, Rao SSC, Levitt MA, Cocjin J, Rodriguez L, Flores A, Rosen JM, Belkind-Gerson J, Saps M, Garza JM, Fortunato J, Schroedl RL, Keefer L, Friedlander J, Heuckeroth RO, Rao M, El-Chammas K, Vaz K, Chumpitazi BP, Sanghavi R, Matta S, Danialifar T, Di Lorenzo C, Darbari A. Proceedings of the 2018 Advances In Motility and In NeuroGastroenterology: AIMING for the Future Single Topic Symposium. J Pediatr Gastroenterol Nutr 2020; 71:e59-e67. [PMID: 32287151 PMCID: PMC8451965 DOI: 10.1097/mpg.0000000000002720] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVES Motility and functional disorders are common in children and often debilitating, yet these disorders remain challenging to treat effectively. At the 2018 Annual North American Society for Pediatric Gastroenterology, Hepatology and Nutrition meeting, the Neurogastroenterology and Motility Committee held a full day symposium entitled, 2018 Advances In Motility and In NeuroGastroenterology - AIMING for the future. The symposium aimed to explore clinical paradigms in pediatric gastrointestinal motility disorders and provided a foundation for advancing new scientific and therapeutic research strategies. METHODS The symposium brought together leading experts throughout North America to review the state of the art in the diagnosis and management of motility and functional disorders in children. Presentations were divided into esophageal, antral duodenal, and colorectal modules. Each module included oral presentations by experts in the respective fields, leading to thought-provoking discussions. There were 2 breakout sessions with small group discussions on select topics, focusing on defining scientific insights into the diagnosis and management of pediatric functional gastrointestinal and motility disorders in a systematic, segment-based approach. CONCLUSIONS The field of neurogastroenterology has made remarkable progress in the last decade. The current report summarizes the major learning points from the symposium highlighting the diagnosis and promising therapies on the horizon for pediatric neurogastrointestinal and motility disorders.
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Affiliation(s)
| | - Julie Khlevner
- Division of Gastroenterology, Hepatology and Nutrition, Columbia University College of Physicians and Surgeons, New York, NY
| | - Samuel Nurko
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children’s Hospital, Boston, MA
| | - Rachel Rosen
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children’s Hospital, Boston, MA
| | - Ajay Kaul
- Division of Gastroenterology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH 45229
| | - John E. Pandolfino
- Division of Gastroenterology and Hepatology, Northwestern University, Chicago, IL
| | | | - Desale Yacob
- Division of Gastroenterology, Nationwide Children’s Hospital, Columbus, OH
| | - B U.K. Li
- Division of Pediatric Gastroenterology and Nutrition, Medical College of Wisconsin, Milwaukee, WI
| | - Jaya Punati
- Division of Gastroenterology, Children’s Hospital of Los Angeles, Los Angeles, CA
| | - Manu Sood
- Division of Pediatric Gastroenterology and Nutrition, Medical College of Wisconsin, Milwaukee, WI
| | - Satish SC Rao
- Division of Gastroenterology, Department of Medicine, Augusta University Medical Center, Augusta, GA
| | - Marc A Levitt
- Division of Colorectal Surgery, Children’s National Hospital, Washington, DC
| | - Jose Cocjin
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Children’s Mercy Kansas City, Kansas City, MO
| | - Leonel Rodriguez
- Section of Pediatric Gastroenterology, Hepatology and Nutrition, Yale School of Medicine, New Haven, CT
| | - Alejandro Flores
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children’s Hospital, Boston, MA
| | - John M Rosen
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Children’s Mercy Kansas City, Kansas City, MO
| | - Jaime Belkind-Gerson
- Division of Gastroenterology, Hepatology and Nutrition, Children’s Hospital of Colorado, Aurora, CO
| | - Miguel Saps
- Division of Pediatric Gastroenterology and Nutrition, University of Miami, Miami, FL
| | - Jose M Garza
- Children’s Center for Digestive Health Care, Atlanta, GA
| | - John Fortunato
- Division of Gastroenterology, Ann & Robert H Lurie Children’s Hospital, Chicago, IL
| | - Rose L Schroedl
- Division of Gastroenterology, Nationwide Children’s Hospital, Columbus, OH
| | - Laurie Keefer
- Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Joel Friedlander
- Section of Pediatric Gastroenterology, Hepatology and Nutrition, Yale School of Medicine, New Haven, CT
| | - Robert O. Heuckeroth
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania and The Children's Hospital of Philadelphia - Research Institute, Philadelphia, PA
| | - Meenakshi Rao
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children’s Hospital, Boston, MA
| | - Khalil El-Chammas
- Division of Gastroenterology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH 45229
| | - Karla Vaz
- Division of Gastroenterology, Nationwide Children’s Hospital, Columbus, OH
| | | | - Rina Sanghavi
- Division of Pediatric Gastroenterology, University of Texas Southwestern Medical Center Dallas, TX
| | - Sravan Matta
- Pediatric Gastroenterology and Nutrition, Kaiser Permanente Sacramento Medical Center, Sacramento, CA
| | - Tanaz Danialifar
- Division of Gastroenterology, Children’s Hospital of Los Angeles, Los Angeles, CA
| | - Carlo Di Lorenzo
- Division of Gastroenterology, Nationwide Children’s Hospital, Columbus, OH
| | - Anil Darbari
- Division of Pediatric Gastroenterology and Nutrition, Children’s National Hospital, Washington, DC
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30
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Tambucci R, Rea F, Angelino G, Malamisura M, Mennini M, Riccardi C, Farello G, Valfré L, Dall’Oglio L, Markowitz JE, Fiocchi AG, De Angelis P. Eosinophilic esophagitis in esophageal atresia: Tertiary care experience of a "selective" approach for biopsy sampling. World Allergy Organ J 2020; 13:100116. [PMID: 32256942 PMCID: PMC7132091 DOI: 10.1016/j.waojou.2020.100116] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Revised: 03/03/2020] [Accepted: 03/05/2020] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND A high prevalence (9.5-30%) of eosinophilic esophagitis (EoE) in patients with esophageal atresia (EA) has been reported. The application of the EoE criteria to EA patients might be problematic. To date, only studies using a "routine" biopsy approach, even in asymptomatic patients, have been performed. The aim of the study was to establish the prevalence of EoE among symptomatic EA patients (EA/EoE group) without anastomotic stricture (AS) and to compare their characteristics with those of EoE patients from general population (EoE group). METHODS From 2005 to 2018, we reviewed charts of children with EA and EoE. "Selective" biopsy approach only in EA children without AS and/or endoscopic feature of EoE was performed. Characteristics of EA/EoE and EoE groups were compared. RESULTS Among 370 EA and 118 EoE, 15 EA/EoE patients were detected (4.0% of EA patients). Male predominance and a high prevalence of allergy without differences between EA/EoE and EoE groups was observed. EA/EoE children were significantly younger (p < 0.0001). PPI-responder patients were significantly more prevalent in EA/EoE group (p = 0.045). CONCLUSION Our data confirm that EA patients are at high risk for developing EoE. High incidence, early onset, and high prevalence of PPI-responders might suggest that esophageal motility disorders interact to increase propensity to EoE in EA patients. However, our study also suggests that overdiagnosis of EoE may occur in EA and that adapted criteria for EoE diagnosis should be developed for EA patients. TRIAL REGISTRATION Not applicable for this retrospective study.
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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
- Corresponding author. Digestive Endoscopy and Surgery Unit, Bambino Gesù Children's Hospital, IRCCS, Piazza Sant’Onofrio 4, 00165, Rome, Italy.
| | - Francesca Rea
- Digestive Endoscopy and Surgery Unit, Bambino Gesù Children's Hospital-IRCCS, Rome, Italy
| | - Giulia Angelino
- 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
| | - Maurizio Mennini
- Pediatric Allergology Unit, Bambino Gesù Children's Hospital-IRCCS, Rome, Italy
| | - Carla Riccardi
- Pediatric Allergology Unit, Bambino Gesù Children's Hospital-IRCCS, Rome, Italy
| | - Giovanni Farello
- Pediatric Unit, Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - Laura Valfré
- 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
| | - Jonathan E. Markowitz
- Pediatric Gastroenterology, Greenville Health System, University of South Carolina School of Medicine-Greenville, Clemson University School of Health Research, Greenville, SC, USA
| | | | - Paola De Angelis
- Digestive Endoscopy and Surgery Unit, Bambino Gesù Children's Hospital-IRCCS, Rome, Italy
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Should Proton Pump Inhibitors be Systematically Prescribed in Patients With Esophageal Atresia After Surgical Repair? J Pediatr Gastroenterol Nutr 2019; 69:45-51. [PMID: 30889131 DOI: 10.1097/mpg.0000000000002328] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To evaluate outcomes of patients with esophageal atresia (EA) on systematic treatment with proton pump inhibitors (PPI) since the neonatal period and to determine factors associated with successful discontinuation of PPI. STUDY DESIGN Longitudinal cohort study with prospective data collection of 73 EA patients, over 11 years systematically treated with PPI. Outcome and predictive factors for discontinuation of PPI treatment were evaluated at study end in February 2017. The incidence of anastomotic strictures was compared with a historical cohort of 134 EA patients followed in the same institution between 1990 and 2005 before the era of systematic PPI treatment. RESULTS PPI treatment was discontinued definitively in 48% of patients during follow-up. Prematurity, longer initial hospitalization, moderate-to-severe tracheomalacia, anastomotic leak and anastomotic stricture had a significant negative association with PPI discontinuation on univariate analysis (P < 0.05). On adjusted multivariable Cox regression analysis, moderate-to-severe tracheomalacia and anastomotic leak were negatively associated with discontinuation of PPI treatment (hazard ratio 0.26 [95% CI 0.12-0.59]; P = 0.001 and hazard ratio 0.38 [95% CI 0.16-0.93]; P = 0.03, respectively). There was no significant difference in the incidence of anastomotic strictures in the present cohort compared with the historical cohort (44% vs 39%); (P > 0.05). CONCLUSIONS PPI treatment does not prevent the formation of anastomotic strictures and appears to be over-prescribed in children with airway symptoms because of tracheomalacia. This suggests that PPI treatment could be prescribed more selectively. Close monitoring and long-term follow-up, however, of these vulnerable patients in specialized multidisciplinary clinics is imperative.
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Abstract
Purpose of the review Gastroesophageal reflux disease (GERD) is frequently implicated as a cause for respiratory disease. However, there is growing evidence that upper gastrointestinal dysmotility may play a significantly larger role in genesis of respiratory symptoms and development of underlying pulmonary pathology. This paper will discuss the differential diagnosis for esophageal and gastric dysmotility in aerodigestive patients and will review the key diagnostic and therapeutic interventions for this dysmotility. Recent findings Previous studies have shown an association between GERD and pulmonary pathology in children with aerodigestive disorders. Recent publications have demonstrated the presence of esophageal and gastric dysfunction, using fluoroscopic and nuclear medicine studies, in aerodigestive patients who commonly present to pulmonary and otolaryngology clinics. High-resolution impedance manometry (HRIM) has revolutionized our understanding of esophageal dysmotility and its role in pathogenesis of aspiration and esophageal dysfunction and subsequent respiratory compromise. Summary Esophageal and gastric dysmotility have a profound effect on development of respiratory symptoms and pulmonary sequalae in aerodigestive patients. However, our understanding of the pathophysiology is in its infancy. Prospective studies in are needed to address key clinical questions such as: What degree of dysmotility initiates respiratory compromise? What diagnostic tests and therapeutic options best predict aerodigestive outcomes?
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Abstract
OBJECTIVES High-resolution manometry (HRM) is the gold standard for diagnosis of esophageal motility disorders. However, clinical signs associated with these disorders are nonspecific, and it is difficult to correlate clinical signs with HRM data. The main objective of our study was to assess the positive predictive value (PPV) and negative predictive value (NPV) of each clinical sign, as well as their sensitivity and specificity in the diagnosis of esophageal motility disorders. METHODS This is a bicentric retrospective cohort study based on HRM data collected between May 2012 and May 2016. The studied symptoms were weight loss, feeding difficulties, swallowing disorders, dysphagia, food blockages, vomiting, gastroesophageal reflux disease (GERD), belching, and respiratory symptoms. HRM data were analyzed according to the Chicago Classification (3.0). RESULTS In total, 271 HRM data were analyzed, of which 90.4% showed abnormal results. HRM was well tolerated in 91% of the cases. The most common esophageal motility disorder was ineffective esophageal motility (38%). Weight loss was significantly associated (P = 0.003) with an abnormal HRM with a 96% PPV. CONCLUSIONS With nonspecific clinical signs suggesting an esophageal motility disorder, weight loss was a predictive sign of abnormal HRM results. HRM was well tolerated in pediatric patients, and ineffective esophageal motility appears to be the most frequent motility disorder in our cohort, as already observed in adult patient studies.
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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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Baxter KJ, Baxter LM, Landry AM, Wulkan ML, Bhatia AM. Structural airway abnormalities contribute to dysphagia in children with esophageal atresia and tracheoesophageal fistula. J Pediatr Surg 2018; 53:1655-1659. [PMID: 29429770 DOI: 10.1016/j.jpedsurg.2017.12.025] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Revised: 12/06/2017] [Accepted: 12/27/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Long-term dysphagia occurs in up to 50% of repaired esophageal atresia and tracheoesophageal fistula (EA/TEF) patients. The underlying factors are unclear and may include stricture, esophageal dysmotility, or associated anomalies. Our purpose was to determine whether structural airway abnormalities (SAA) are associated with dysphagia in EA/TEF. METHODS We conducted a retrospective chart review of children who underwent EA/TEF repair in our hospital system from 2007 to 2016. Children with identified SAA (oropharyngeal abnormalities, laryngeal clefts, laryngomalacia, vocal cord paralysis, and tracheomalacia) were compared to those without airway abnormalities. Dysphagia outcomes were determined by the need for tube feeding and the modified pediatric Functional Oral Intake Scale (FOIS) at 1 year. RESULTS SAA was diagnosed in 55/145 (37.9%) patients with EA/TEF. Oropharyngeal aspiration was more common in children with SAA (58.3% vs. 36.4%, p=0.028). Children with SAA were more likely to require tube feeding both at discharge (79.6% vs. 48.3%, p<0.001) and at 1 year (52.7% vs. 13.6%, p<0.001) and had lower mean FOIS (4.18 vs. 6.21, p<0.001). In the logistic regression model adjusting for gestational age, long gap EA, and esophageal stricture, the presence of SAA remained a significant risk factor for dysphagia (OR 4.17 (95% CI 1.58-11.03)). CONCLUSION SAA are common in children with EA/TEF and are associated with dysphagia, even after accounting for gestational age, esophageal gap and stricture. This study highlights the need for a multidisciplinary approach, including early laryngoscopy and bronchoscopy, in the evaluation of the EA/TEF child with dysphagia. LEVEL OF EVIDENCE Level II retrospective prognostic study.
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Affiliation(s)
- Katherine J Baxter
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, United States.
| | - Lauren M Baxter
- Department of Speech Pathology, Children's Healthcare of Atlanta, Atlanta, GA, United States
| | - April M Landry
- Department of Otolaryngology, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, United States
| | - Mark L Wulkan
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, United States
| | - Amina M Bhatia
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, United States
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Rosen R, Garza JM, Tipnis N, Nurko S. An ANMS-NASPGHAN consensus document on esophageal and antroduodenal manometry in children. Neurogastroenterol Motil 2018; 30:10.1111/nmo.13239. [PMID: 29178261 PMCID: PMC5823717 DOI: 10.1111/nmo.13239] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Accepted: 09/27/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND Upper gastrointestinal symptoms in children are common and motility disorders are considered in the differential diagnosis. High resolution esophageal manometry (HRM) has revolutionized the study of esophageal physiology, and the addition of impedance has provided new insights into esophageal function. Antroduodenal motility has provided insight into gastric and small bowel function. PURPOSE This review highlights some of the recent advances in pediatric esophageal and antroduodenal motility testing including indications, preparation, performance, and interpretation of the tests. This update is the second part of a two part series on manometry studies in children (first part was on anorectal and colonic manometry [Neurogastroenterol Motil. 2016;29:e12944]), and has been endorsed by the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) and the American Neurogastroenterology and Motility Society (ANMS).
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Affiliation(s)
- Rachel Rosen
- Aerodigestive Center, Boston Children’s Hospital
| | - Jose M. Garza
- Children’s Center for Digestive Health Care, and Children’s Healthcare of Atlanta, Atlanta, Georgia
| | - Neelesh Tipnis
- Department of Pediatrics University of Mississippi Medical Center
| | - Samuel Nurko
- Center for Motility and Functional Gastrointestinal Disorders, Boston Children’s Hospital
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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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Respiratory Morbidity in Children with Repaired Congenital Esophageal Atresia with or without Tracheoesophageal Fistula. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2017; 14:ijerph14101136. [PMID: 28953251 PMCID: PMC5664637 DOI: 10.3390/ijerph14101136] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/06/2017] [Revised: 09/21/2017] [Accepted: 09/25/2017] [Indexed: 12/19/2022]
Abstract
Congenital esophageal atresia with or without tracheoesophageal fistula (CEA ± TEF) is a relatively common malformation that occurs in 1 of 2500–4500 live births. Despite the refinement of surgical techniques, a considerable proportion of children experience short- and long-term respiratory complications, which can significantly affect their health through adulthood. This review focuses on the underlying mechanisms and clinical presentation of respiratory morbidity in children with repaired CEA ± TEF. The reasons for the short-term pulmonary impairments are multifactorial and related to the surgical complications, such as anastomotic leaks, stenosis, and recurrence of fistula. Long-term respiratory morbidity is grouped into four categories according to the body section or function mainly involved: upper respiratory tract, lower respiratory tract, gastrointestinal tract, and aspiration and dysphagia. The reasons for the persistence of respiratory morbidity to adulthood are not univocal. The malformation itself, the acquired damage after the surgical repair, various co-morbidities, and the recurrence of lower respiratory tract infections at an early age can contribute to pulmonary impairment. Nevertheless, other conditions, including smoking habits and, in particular, atopy can play a role in the recurrence of infections. In conclusion, our manuscript shows that most children born with CEA ± TEF survive into adulthood, but many comorbidities, mainly esophageal and respiratory issues, may persist. The pulmonary impairment involves many underlying mechanisms, which begin in the first years of life. Therefore, early detection and management of pulmonary morbidity may be important to prevent impairment in pulmonary function and serious long-term complications. To obtain a successful outcome, it is fundamental to ensure a standardized follow-up that must continue until adulthood.
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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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Edeani F, Malik A, Kaul A. Characterization of Esophageal Motility Disorders in Children Presenting With Dysphagia Using High-Resolution Manometry. Curr Gastroenterol Rep 2017; 19:13. [PMID: 28365899 DOI: 10.1007/s11894-017-0549-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
PURPOSE OF REVIEW The Chicago classification was based on metrics derived from studies in asymptomatic adult subjects. Our objectives were to characterize esophageal motility disorders in children and to determine whether the spectrum of manometric findings is similar between the pediatric and adult populations. RECENT FINDINGS Studies have suggested that the metrics utilized in manometric diagnosis depend on age, size, and manometric assembly. This would imply that a different set of metrics should be used for the pediatric population. There are no standardized and generally accepted metrics for use in the pediatric population, though there have been attempts to establish metrics specific to this population. Overall, we found that the distribution of esophageal motility disorders in children was like that described in adults using the Chicago classification. This analysis will serve as a prequel to follow-up studies exploring the individual metrics for variability among patients, with the objective of establishing novel metrics for the pediatric population.
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Affiliation(s)
- Francis Edeani
- Department of Internal Medicine, Good Samaritan Hospital, Cincinnati, OH, 45220, USA
| | - Adeel Malik
- Neurogastroenterology and Motility Disorders Program, Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA
| | - Ajay Kaul
- Neurogastroenterology and Motility Disorders Program, Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA.
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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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Perin S, McCann CJ, Borrelli O, De Coppi P, Thapar N. Update on Foregut Molecular Embryology and Role of Regenerative Medicine Therapies. Front Pediatr 2017; 5:91. [PMID: 28503544 PMCID: PMC5408018 DOI: 10.3389/fped.2017.00091] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Accepted: 04/11/2017] [Indexed: 01/07/2023] Open
Abstract
Esophageal atresia (OA) represents one of the commonest and most severe developmental disorders of the foregut, the most proximal segment of the gastrointestinal (GI) tract (esophagus and stomach) in embryological terms. Of intrigue is the common origin from this foregut of two very diverse functional entities, the digestive and respiratory systems. OA appears to result from incomplete separation of the ventral and dorsal parts of the foregut during development, resulting in disruption of esophageal anatomy and frequent association with tracheo-oesophageal fistula. Not surprisingly, and likely inherent to OA, are associated abnormalities in components of the enteric neuromusculature and ultimately loss of esophageal functional integrity. An appreciation of such developmental processes and associated defects has not only enhanced our understanding of the etiopathogenesis underlying such devastating defects but also highlighted the potential of novel corrective therapies. There has been considerable progress in the identification and propagation of neural crest stem cells from the GI tract itself or derived from pluripotent cells. Such cells have been successfully transplanted into models of enteric neuropathy confirming their ability to functionally integrate and replenish missing or defective enteric nerves. Combinatorial approaches in tissue engineering hold significant promise for the generation of organ-specific scaffolds such as the esophagus with current initiatives directed toward their cellularization to facilitate optimal function. This chapter outlines the most current understanding of the molecular embryology underlying foregut development and OA, and also explores the promise of regenerative medicine.
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Affiliation(s)
- Silvia Perin
- Stem Cells and Regenerative Medicine, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Conor J McCann
- Stem Cells and Regenerative Medicine, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Osvaldo Borrelli
- Neurogastroenterology and Motility Unit, Department of Gastroenterology, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Paolo De Coppi
- Stem Cells and Regenerative Medicine, UCL Great Ormond Street Institute of Child Health, London, UK.,Specialist Neonatal and Paediatric Surgery (SNAPS) Department, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Nikhil Thapar
- Stem Cells and Regenerative Medicine, UCL Great Ormond Street Institute of Child Health, London, UK.,Neurogastroenterology and Motility Unit, Department of Gastroenterology, Great Ormond Street Hospital NHS Foundation Trust, London, UK
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Rommel N, Rayyan M, Scheerens C, Omari T. The Potential Benefits of Applying Recent Advances in Esophageal Motility Testing in Patients with Esophageal Atresia. Front Pediatr 2017; 5:137. [PMID: 28680874 PMCID: PMC5478877 DOI: 10.3389/fped.2017.00137] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Accepted: 05/30/2017] [Indexed: 12/12/2022] Open
Abstract
Infants and children with esophageal atresia commonly present with swallowing dysfunction or dysphagia. Dysphagia can lead to a range of significant consequences such as aspiration pneumonia, malnutrition, dehydration, and food impaction. To improve oral intake, the clinical diagnosis of dysphagia in patients with esophageal atresia should focus on both the pharynx and the esophagus. To characterize the complex interactions of bolus flow and motor function between mouth, pharynx, and esophagus, a detailed understanding of normal and abnormal deglutition is required through the use of adequate and objective assessment techniques. As clinical symptoms do not correlate well with conventional assessment methods of motor function such as radiology or manometry but do correlate with bolus flow, the current state-of-the-art diagnosis involves high-resolution manometry combined with impedance measurements to characterize the interplay between esophageal motor function and bolus clearance. Using a novel pressure flow analysis (PFA) method as an integrated analysis method of manometric and impedance measurements, differentiation of patients with impaired esophago-gastric junction relaxation from patients with bolus outflow disorders is clinically relevant. In this, pressure flow matrix categorizing the quantitative PFA measures may be used to make rational therapeutic decisions in patients with esophageal atresia. Through more advanced diagnostics, improved understanding of pathophysiology may improve our patient care by directly targeting the failed biomechanics of both the pharynx and the esophagus.
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Affiliation(s)
- Nathalie Rommel
- Neurogastroenterology and Motility, Gastroenterology, University Hospitals Leuven, Leuven, Belgium.,Experimental Otorhinolaryngology, Department of Neurosciences, Deglutology, University of Leuven, Leuven, Belgium
| | - Maissa Rayyan
- Neonatal Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium.,Department of Development and Regeneration, University of Leuven, Leuven, Belgium
| | - Charlotte Scheerens
- Neurogastroenterology and Motility, Gastroenterology, University Hospitals Leuven, Leuven, Belgium.,Experimental Otorhinolaryngology, Department of Neurosciences, Deglutology, University of Leuven, Leuven, Belgium
| | - Taher Omari
- School of Medicine, Flinders University, Adelaide, SA, Australia
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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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45
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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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Mahoney L, Rosen R. Feeding Problems and Their Underlying Mechanisms in the Esophageal Atresia-Tracheoesophageal Fistula Patient. Front Pediatr 2017; 5:127. [PMID: 28620597 PMCID: PMC5449447 DOI: 10.3389/fped.2017.00127] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Accepted: 05/12/2017] [Indexed: 11/24/2022] Open
Abstract
Feeding difficulties such as dysphagia, coughing, choking, or vomiting during meals, slow eating, oral aversion, food refusal, and stressful mealtimes are common in children with repaired esophageal atresia (EA) and the reasons for this are often multifactorial. The aim of this review is to describe the possible underlying mechanisms contributing to feeding difficulties in patients with EA and approaches to management. Underlying mechanisms for these feeding difficulties include esophageal dysphagia, oropharyngeal dysphagia and aspiration, and aversions related to prolonged gastrostomy tube feeding. The initial diagnostic evaluation for feeding difficulties in a patient with EA may involve an esophagram, videofluoroscopic imaging or fiberoptic endoscopic evaluation during swallowing, upper endoscopy with biopsies, pH-impedance testing, and/or esophageal motility studies. The main goal of management is to reduce the factors contributing to feeding difficulties and may include reducing esophageal stasis, maximizing reflux therapies, treating underlying lung disease, dilating strictures, and altering feeding methods, routes, or schedules.
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Affiliation(s)
- Lisa Mahoney
- Aerodigestive Center, Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA, United States
| | - Rachel Rosen
- Aerodigestive Center, Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA, United States
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47
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Abstract
Neonatal surgery is recognized as an independent discipline in general surgery, requiring the expertise of pediatric surgeons to optimize outcomes in infants with surgical conditions. Survival following neonatal surgery has improved dramatically in the past 60 years. Improvements in pediatric surgical outcomes are in part attributable to improved understanding of neonatal physiology, specialized pediatric anesthesia, neonatal critical care including sophisticated cardiopulmonary support, utilization of parenteral nutrition and adjustments in fluid management, refinement of surgical technique, and advances in surgical technology including minimally invasive options. Nevertheless, short and long-term complications following neonatal surgery continue to have profound and sometimes lasting effects on individual patients, families, and society.
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Affiliation(s)
- Mauricio A Escobar
- Pediatric Surgery, Mary Bridge Children׳s Hospital, PO Box 5299, MS: 311-W3-SUR, 311 South, Tacoma, Washington 98415-0299.
| | - Michael G Caty
- Section of Pediatric Surgery, Department of Surgery, Yale-New Haven Children׳s Hospital, New Haven, Connecticut
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48
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Wessel LM, Fuchs J, Rolle U. The Surgical Correction of Congenital Deformities: The Treatment of Diaphragmatic Hernia, Esophageal Atresia and Small Bowel Atresia. DEUTSCHES ARZTEBLATT INTERNATIONAL 2016; 112:357-64. [PMID: 26051693 DOI: 10.3238/arztebl.2015.0357] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/13/2014] [Revised: 03/03/2015] [Accepted: 03/03/2015] [Indexed: 12/27/2022]
Abstract
BACKGROUND More than half of all congenital deformities can be detected in utero. The initial surgical correction is of paramount importance for the achievement of good long-term results with low surgical morbidity and mortality. METHODS Selective literature review and expert opinion. RESULTS Congenital deformities are rare, and no controlled trials have been performed to determine their optimal treatment. In this article, we present the prenatal assessment, treatment, and long-term results of selected types of congenital deformity. Congenital diaphragmatic hernia (CDH) affects one in 3500 live-born infants, while esophageal atresia affects one in 3000 and small-bowel atresia one in 5000 to 10,000. If a congenital deformity is detected and its prognosis can be reliably inferred from a prenatal assessment, the child should be delivered at a specialized center (level 1 perinatal center). The associated survival rates are 60-80% after treatment for CDH and well over 90% after treatment for esophageal or small-bowel atresia. Despite improvements in surgical correction over the years, complications and comorbidities still affect 20-40% of the treated children. These are not limited to surgical complications in the narrow sense, such as recurrence, postoperative adhesions and obstruction, stenoses, strictures, and recurrent fistulae, but also include pulmonary problems (chronic lung disease, obstructive and restrictive pulmonary dysfunction), gastrointestinal problems (dysphagia, gastro-esophageal reflux, impaired intestinal motility), and failure to thrive. Moreover, the affected children can develop emotional and behavioral disturbances. Minimally invasive surgery in experienced hands yields results as good as those of conventional surgery, as long as proper selection criteria are observed. CONCLUSION Congenital deformities should be treated in recognized centers with highly experienced interdisciplinary teams. As no randomized trials of surgery for congenital deformities are available, longitudinal studies and registries will be very important in the future.
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Affiliation(s)
- Lucas M Wessel
- Department of Pediatric Surgery, University Hospital Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Department of Pediatric Surgery and Pediatric Urology, University Children's Hospital Tübingen, Department of Pediatric Surgery and Pediatric Urology, University Hospital Frankfurt, Campus Niederrad,Frankfurt am Main
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49
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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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50
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Nikaki K, Ooi JLS, Sifrim D. Chicago Classification of Esophageal Motility Disorders: Applications and Limits in Adults and Pediatric Patients with Esophageal Symptoms. Curr Gastroenterol Rep 2016; 18:59. [PMID: 27738966 DOI: 10.1007/s11894-016-0532-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
The Chicago classification (CC) is most valued for its systematic approach to esophageal disorders and great impact in unifying practice for esophageal manometric studies. In view of the ever-growing wealth of knowledge and experience gained by the expanding use of high-resolution manometry (HRM) in various clinical scenarios, the CC is regularly updated. Its clinical impact and ability to predict clinical outcome, both in adults and pediatrics, will be further promoted by recognizing its current limitations, incorporating new metrics in its diagnostic algorithms and adjusting the HRM protocols based on the clinical question posed. Herein, we discuss the current limitations of the CC and highlight some areas of improvement for the future.
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Affiliation(s)
- Kornilia Nikaki
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, 26 Ashfield Street, E1 2AJ, London, UK
| | - Joanne Li Shen Ooi
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, 26 Ashfield Street, E1 2AJ, London, UK
| | - Daniel Sifrim
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, 26 Ashfield Street, E1 2AJ, London, UK.
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