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Okumuş M, Devecioğlu D, Çevik M, Tander B. Anastomotic leaks and the relationship with anastomotic strictures after esophageal atresia surgery; effects of patient characteristics. Acta Chir Belg 2024; 124:114-120. [PMID: 37243696 DOI: 10.1080/00015458.2023.2219521] [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: 01/02/2023] [Accepted: 05/25/2023] [Indexed: 06/02/2023]
Abstract
BACKGROUND This study aimed to evaluate the link between anastomotic leaks (AL) and anastomotic strictures (AS) after esophageal atresia surgery and the influence of patient demographics. MATERIALS AND METHODS The clinical data of neonates who underwent surgical repair for esophageal atresia were retrospectively reviewed. The results of AL treatment and the relationship with AS, also the effects of patient characteristics were examined with logistic regression analysis. RESULTS Primary repair was performed on 122 of 125 patients who underwent surgery for esophageal atresia. AL occurred in 25 patients and 21 were treated non-operatively. While 4 patients were re-operated, AL recurred in 3 and led to the death of one. There was no correlation between the development of AL and sex or the presence of additional anomalies. The gestational age and birth weight of patients with AL were significantly higher than those of patients without. AS developed in 45 patients. The mean gestational age was significantly higher in patients who developed AS (p < .001). While the development of AS was significantly higher in patients with AL (p = .001), the number of dilatation sessions needed was also significantly higher in these patients (p = .026). Complications related to anastomosis were less common in patients whose gestational age was ≤33 weeks. CONCLUSION Non-operative treatment remains effective for AL after esophageal atresia surgery. AL increases the risk of developing AS and significantly increases the number of dilatation sessions needed. Anastomotic complications are less common in patients with lower gestational age.NOVEL ASPECTSGestational age and birth weight were found to be significantly higher in patients with anastomotic leaks than in those without and fewer anastomotic complications were encountered in patients whose gestational age was ≤ 33 weeks.Anastomotic stricture development was significantly higher in patients with anastomotic leaks and the number of dilatation sessions needed for treatment was also significantly higher in these patients.
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Affiliation(s)
- Mustafa Okumuş
- Department of Pediatric Surgery, School of Medicine, Gaziosmanpaşa Hospital, Yeni Yüzyıl University, İstanbul, Turkey
| | - Değer Devecioğlu
- Department of Pediatric Surgery, Medilife Hospital, İstanbul, Turkey
| | - Muazzez Çevik
- Department of Pediatric Surgery, Atakent Hospital, Acıbadem University, School of Medicine, İstanbul, Turkey
| | - Burak Tander
- Department of Pediatric Surgery, Atakent Hospital, Acıbadem University, School of Medicine, İstanbul, Turkey
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Hall NJ, Kitteringham L, Ron O, Stedman F, Stanton M, Wheeler R, Jones C, Smyth R, Keys C. A Minimally Interventional Approach to Oesophageal Atresia Repair With Early Enteral Feeding is Safe, Optimises Neonatal Outcomes, and Reduces Resource use. J Pediatr Surg 2024; 59:6-9. [PMID: 37867045 DOI: 10.1016/j.jpedsurg.2023.09.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Accepted: 09/07/2023] [Indexed: 10/24/2023]
Abstract
PURPOSE Recent series of newborn Oesophageal Atresia (OA) repair continue to report widespread use of chest drains, gastrostomy, routine contrast studies and parenteral nutrition (PN) despite evidence suggesting these are superfluous. We report outcomes using a minimally interventional approach to post-operative recovery. METHODS Ethically approved (15/WA/0153), single-centre, retrospective case-note review of consecutive infants with OA 2000-2022. Infants with OA and distal trache-oesophageal fistula undergoing primary oesophageal anastomosis at initial surgery were included (including those with comorbidities such as duodenal atresia, anorectal malformation and cardiac lesions). Our practice includes routine use of a trans-anastomotic tube (TAT), no routine chest drain nor gastrostomy, early enteral and oral feeding, no routine PN and no routine contrast study. Data are median (IQR). RESULTS Of total 186 cases of OA treated during the time period, 157 met the inclusion criteria of which 2 were excluded as casenotes unavailable. TAT was used in 150 infants. A chest drain was required in 13 (8%) and two infants had a neonatal gastrostomy. Enteral feeds were started on postoperative day 2 (2-3), full enteral feeds established by day 4 (4-6) and oral feeds started on day 5 (4-8). PN was required in 15%. Median postoperative length of stay was 10 days (8-17). Progress was quicker in term infants than preterm. One infant died of cardiac disease prior to neonatal discharge. Two planned post-operative contrast studies were performed (surgeon preference) and a further 7 due to clinical suspicion of anastomotic leak. Contrast study was therefore avoided in 94%. There were 2 anastomotic leaks; both presented clinically at day 4 and day 8 after oral feeds had been started. CONCLUSION Our minimally interventional approach is safe. It facilitates prompt recovery with lower resource use, reduced demand on nursing staff, reduced radiation burden, and early discharge home compared to published series without adversely affecting outcomes. LEVEL OF EVIDENCE Level 4.
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Affiliation(s)
- Nigel J Hall
- University Surgery Unit, Faculty of Medicine, University of Southampton, Southampton, UK; Department of Paediatric Surgery and Urology, Southampton Children's Hospital, Southampton, UK.
| | - Lara Kitteringham
- Department of Paediatric Surgery and Urology, Southampton Children's Hospital, Southampton, UK
| | - Ori Ron
- Department of Paediatric Surgery and Urology, Southampton Children's Hospital, Southampton, UK
| | - Francesca Stedman
- Department of Paediatric Surgery and Urology, Southampton Children's Hospital, Southampton, UK
| | - Michael Stanton
- Department of Paediatric Surgery and Urology, Southampton Children's Hospital, Southampton, UK
| | - Robert Wheeler
- Department of Paediatric Surgery and Urology, Southampton Children's Hospital, Southampton, UK
| | - Ceri Jones
- Department of Paediatric Surgery and Urology, Southampton Children's Hospital, Southampton, UK
| | - Rachel Smyth
- Department of Paediatric Surgery and Urology, Southampton Children's Hospital, Southampton, UK
| | - Charles Keys
- Department of Paediatric Surgery and Urology, Southampton Children's Hospital, Southampton, UK
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3
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Establishment of a condition-specific quality-of-life questionnaire for children born with esophageal atresia aged 2-7 across 14 countries. Front Pediatr 2023; 11:1253892. [PMID: 37936889 PMCID: PMC10626467 DOI: 10.3389/fped.2023.1253892] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 10/03/2023] [Indexed: 11/09/2023] Open
Abstract
Background Esophageal atresia (EA) is a rare congenital anomaly characterized by a discontinuity of the esophagus. Following surgical repair, survival rates have improved dramatically the past decenniums and today exceed 90%, but the children commonly present with esophageal and respiratory morbidity. In 2018, a condition-specific quality-of-life questionnaire for children with esophageal atresia (EA) aged 2-7 in Sweden-Germany was finalized (The EA-QOL questionnaire). The study aim was to describe the evaluation of the new translations across 12 new countries in Europe, Asia, Africa, Central-and North America. Methods Following forward-backward translation into the new languages, the 17-item EA-QOL questionnaire was tested in cognitive debriefing interviews with parents of children with EA aged 2-7. Parents rated if each item was easy to understand (clarity) and sensitive to answer (interference with personal integrity). They could skip responding to a non-applicable/problematic item and give open comments. Predefined psychometric criteria were used; item clarity ≥80%/item sensitive to answer ≤20%/item feasibility ≤5% missing item responses. The decision to modify the translation was based on native expert, patient stakeholder, and instrument developer review, and the need for harmonization between translations. Results Similar to findings in the Swedish-German cognitive debriefing, the cross-cultural analysis of input from 116 parents from 12 new countries (4-14 parents, median 9 parents/country) showed that all items in the EA-QOL questionnaire fulfilled the criteria for item clarity ≥80% and sensitive to answer (ranging from 1%-4.5%), although results varied between countries. Four items had missing responses between 5.2% and 13.4%, three within the same domain and were in line with parents' explanations. Poor translations and feasibility were improved. Conclusions Based on parent input, the collaboration between native experts, patient stakeholders, and instrument developers, a linguistic version of the EA-QOL questionnaire for children aged 2-7 for use in and across 14 countries has been established. These efforts have set the conditions for a cross-cultural field test of the EA-QOL questionnaire and will open the doors for a new chapter in outcome research, registries, and clinical practice concerning children with EA. In the long-term, this will help increase knowledge of the disease's burden, promote patient-centeredness, exchange of information between nations, and strengthen evidence-based treatments for children born with EA.
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Dellenmark-Blom M, Reilly C, Öst E, Örnö Ax S, Svensson JF, Kassa AM, Jönsson L, Abrahamsson K, Gatzinsky V, Tollne AM, Omling E, Stenström P, Engstrand Lilja H. Schooling experiences in children with long-gap esophageal atresia compared with children with esophageal atresia and primary anastomosis: a Swedish study. Orphanet J Rare Dis 2023; 18:233. [PMID: 37550744 PMCID: PMC10408199 DOI: 10.1186/s13023-023-02846-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 07/26/2023] [Indexed: 08/09/2023] Open
Abstract
BACKGROUND Children with long-gap esophageal atresia (LGEA) risk living with aerodigestive morbidity and mental health difficulties. No previous study has investigated their experiences of schooling, despite the importance of schools in children's development, learning and social relationships. We aimed to describe experiences of schooling in children with LGEA in Sweden in comparison with children with EA who had primary anastomosis. METHOD Children with LGEA aged 3-17 were recruited nationwide in Sweden. One parent completed a survey on their child's school-based supports (according to definitions from the Swedish National Agency for Education), school absence, school satisfaction, school functioning (PedsQL 4.0), mental health (Strength and Difficulties Questionnaire) and current symptomatology. School data were compared between 26 children with LGEA to that from 95 children with EA who had PA, a hypothesized milder affected group. Mental health level was determined using validated norms; abnormal ≥ 90 percentile. Data were analyzed using descriptives, correlation and Mann-Whitney-U test. Significance level was p < 0.05. RESULTS Formal school-based support was reported in 17 (65.4%) children with LGEA and concerned support with nutritional intake (60%), education (50%) and medical/special health needs (35%). The prevalence of school-based support was significantly higher compared to children with PA overall (36.8%, p = 0.013) and regarding nutritional intake support (20%, p < 0.001). In children with LGEA, school-based support was related to low birth weight (p = 0.036), young child age (p = 0.014), height ≤ -2SD for age/sex (p = 0.024) and an increased number of aerodigestive symptoms (p < 0.05). All children with LGEA who had abnormal mental health scores had school-based support, except for one child. Nine children with LGEA (36%) had school absence ≥ 1times/month the past year, more frequently because of colds/airway infections (p = 0.045) and GI-specific problems compared to PA (p = 0.003). School functioning scores were not significantly different from children with PA (p = 0.34) but correlated negatively with school-based support (< 0.001) and school absence (p = 0.002). One parent out of 26 reported their child's school satisfaction as "not good". CONCLUSIONS Children with LGEA commonly receive school-based support, reflecting multifaceted daily needs and disease severity. School absence is frequent and related to poorer school functioning. Future research focusing on academic achievement in children with EA is needed.
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Affiliation(s)
- M Dellenmark-Blom
- Department of Pediatric Surgery, Queen Silvia Children's Hospital, Sahlgrenska University Hospital, Gothenburg, Sweden.
- Department of Pediatrics, Institute of Clinical Sciences, Queen Silvia Children's Hospital, Gothenburg University, 416 85, Gothenburg, Sweden.
| | - C Reilly
- Department of Pediatrics, Institute of Clinical Sciences, Queen Silvia Children's Hospital, Gothenburg University, 416 85, Gothenburg, Sweden
| | - E Öst
- Department of Pediatric Surgery, Karolinska University Hospital, Stockholm, Sweden
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - S Örnö Ax
- Department of Pediatric Surgery, Queen Silvia Children's Hospital, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Pediatrics, Institute of Clinical Sciences, Queen Silvia Children's Hospital, Gothenburg University, 416 85, Gothenburg, Sweden
| | - J F Svensson
- Department of Pediatric Surgery, Karolinska University Hospital, Stockholm, Sweden
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - A-M Kassa
- Department of Pediatric Surgery, University Children's Hospital, Uppsala, Sweden
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - L Jönsson
- Department of Pediatric Surgery, Queen Silvia Children's Hospital, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Pediatrics, Institute of Clinical Sciences, Queen Silvia Children's Hospital, Gothenburg University, 416 85, Gothenburg, Sweden
| | - K Abrahamsson
- Department of Pediatric Surgery, Queen Silvia Children's Hospital, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Pediatrics, Institute of Clinical Sciences, Queen Silvia Children's Hospital, Gothenburg University, 416 85, Gothenburg, Sweden
| | - V Gatzinsky
- Department of Pediatric Surgery, Queen Silvia Children's Hospital, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Pediatrics, Institute of Clinical Sciences, Queen Silvia Children's Hospital, Gothenburg University, 416 85, Gothenburg, Sweden
| | - A M Tollne
- Department of Pediatric Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - E Omling
- Department of Pediatrics, Clinical Sciences, Lund University, Lund, Sweden
- Department of Pediatric Surgery, Skane University Hospital Lund, Lund, Sweden
| | - P Stenström
- Department of Pediatrics, Clinical Sciences, Lund University, Lund, Sweden
- Department of Pediatric Surgery, Skane University Hospital Lund, Lund, Sweden
| | - H Engstrand Lilja
- Department of Pediatric Surgery, Karolinska University Hospital, Stockholm, Sweden
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
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Zouari M, Ameur HB, Krichen E, Saad NB, Dhaou MB, Mhiri R. Risk factors for adverse outcomes following surgical repair of esophageal atresia. A retrospective cohort study. Dis Esophagus 2023; 36:doac070. [PMID: 36214334 DOI: 10.1093/dote/doac070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 08/28/2022] [Accepted: 09/12/2022] [Indexed: 11/07/2022]
Abstract
Esophageal atresia (EA) is a life-threatening congenital malformation of the esophagus. Despite considerable recent advances in perinatal resuscitation and neonatal care, EA remains an important cause of mortality and morbidity, especially in low-income countries. The aim of this study was to assess risk factors for adverse outcomes following surgical repair of EA at a single center in Tunisia. We performed a retrospective analysis using medical records of neonates with surgical management of EA at our institution from 1 January 2007 to 31 December 2021. In total, 88 neonates were included with a mortality rate of 25%. There were 29 girls and 59 boys. The diagnosis of EA was suspected prenatally in 19 patients. The most common associated anomalies were congenital heart diseases. Prematurity, low birth weight, outborn birth, age at admission >12 hours, congenital heart disease, postoperative sepsis, and anastomotic leak were risk factors for mortality following surgical repair of EA. Anastomotic tension was the only factor associated with short-term complications and the occurrence of short-term complications was predictive of mid-term complications. This study provides physicians and families with contemporary information regarding risk factors for adverse outcomes following surgical repair of EA. Thus, any effort to reduce these risk factors would be critical to improving patient outcomes and reducing cost. Future multi-institutional studies are needed to identify, investigate, and establish best practices and clinical care guidelines for neonates with EA.
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Affiliation(s)
- Mohamed Zouari
- Faculty of Medicine of Sfax, University of Sfax, Sfax, Tunisia
- Department of Pediatric Surgery, Hedi Chaker Hospital, Sfax, Tunisia
| | - Hana Ben Ameur
- Faculty of Medicine of Sfax, University of Sfax, Sfax, Tunisia
- Department of Pediatric Surgery, Hedi Chaker Hospital, Sfax, Tunisia
| | - Emna Krichen
- Faculty of Medicine of Sfax, University of Sfax, Sfax, Tunisia
- Department of Pediatric Surgery, Hedi Chaker Hospital, Sfax, Tunisia
| | - Nesrine Ben Saad
- Faculty of Medicine of Sfax, University of Sfax, Sfax, Tunisia
- Department of Pediatric Surgery, Hedi Chaker Hospital, Sfax, Tunisia
| | - Mahdi Ben Dhaou
- Faculty of Medicine of Sfax, University of Sfax, Sfax, Tunisia
- Department of Pediatric Surgery, Hedi Chaker Hospital, Sfax, Tunisia
| | - Riadh Mhiri
- Faculty of Medicine of Sfax, University of Sfax, Sfax, Tunisia
- Department of Pediatric Surgery, Hedi Chaker Hospital, Sfax, Tunisia
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Holler AS, König TT, Chen C, Harrison MR, Muensterer OJ. Esophageal Magnetic Compression Anastomosis in Esophageal Atresia Repair: A PRISMA-Compliant Systematic Review and Comparison with a Novel Approach. CHILDREN (BASEL, SWITZERLAND) 2022; 9:children9081113. [PMID: 35892616 PMCID: PMC9394416 DOI: 10.3390/children9081113] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 07/12/2022] [Accepted: 07/22/2022] [Indexed: 12/29/2022]
Abstract
The use of magnet compression to endoscopically create an esophageal anastomosis is an intriguing approach to esophageal atresia repair, but published cases with an existing available device have demonstrated mixed success. One major shortcoming has been the formation of subsequent severe, recalcitrant strictures after primary repair. To address the limitations of the existing device, we recently introduced and reported success with specially designed bi-radial magnets that exhibit a novel geometry and unique tissue compression profile. The aim of this study is to compare the outcomes using our novel device (novel group, NG) with those of previous reports which utilized the historical device (historic group, HG) in a PRISMA-compliant systematic review. Seven studies were eligible for further analysis. Additionally, one of our previously unreported cases was included in the analysis. Esophageal pouch approximation prior to primary repair was performed more frequently in the NG than in the HG (100% NG vs. 21% HG; p = 0.003). There was no difference in the overall postoperative appearance of postoperative stricture (95% HG vs. 100% NG; p = 0.64). The number of postoperative dilatations trended lower in the NG (mean 4.25 NG vs. 9.5 HG; p = 0.051). In summary, magnetic compression anastomosis adds a new promising treatment option for patients with complex esophageal atresia. Prior approximation of pouches and a novel magnet design have the potential to lower the rate of stricture formation.
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Affiliation(s)
- Anne-Sophie Holler
- Department of Pediatric Surgery, Dr. von Hauner Children’s Hospital, University Hospital, LMU Munich, 55131 Mainz, Germany;
- Correspondence: ; Tel.: +49-894-4005-3101
| | - Tatjana Tamara König
- Department of Pediatric Surgery, Universitätsmedizin, Johannes-Gutenberg University, 55131 Mainz, Germany;
| | - Caressa Chen
- Department of Surgery and Bioengineering & Therapeutic Sciences, University of California, San Francisco, CA 94102, USA;
| | - Michael R. Harrison
- Division of Pediatric Surgery, Department of Surgery, University of California, San Francisco, CA 94102, USA;
| | - Oliver J. Muensterer
- Department of Pediatric Surgery, Dr. von Hauner Children’s Hospital, University Hospital, LMU Munich, 55131 Mainz, Germany;
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Dellenmark-Blom M, Örnö Ax S, Öst E, Svensson JF, Kassa AM, Jönsson L, Abrahamsson K, Gatzinsky V, Stenström P, Tollne A, Omling E, Engstrand Lilja H. Postoperative morbidity and health-related quality of life in children with delayed reconstruction of esophageal atresia: a nationwide Swedish study. Orphanet J Rare Dis 2022; 17:239. [PMID: 35725462 PMCID: PMC9207832 DOI: 10.1186/s13023-022-02381-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 06/06/2022] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND In 10-15% of children with esophageal atresia (EA) delayed reconstruction of esophageal atresia (DREA) is necessary due to long-gap EA and/or prematurity/low birth weight. They represent a patient subgroup with high risk of complications. We aimed to evaluate postoperative morbidity and health-related quality of life (HRQOL) in a Swedish national cohort of children with DREA. METHODS Postoperative morbidity, age-specific generic HRQOL (PedsQL™ 4.0) and condition-specific HRQOL (The EA-QOL questionnaires) in children with DREA were compared with children with EA who had primary anastomosis (PA). Factors associated with the DREA group's HRQOL scores were analyzed using Mann-Whitney U-test and Spearman's rho. Clinical data was extracted from the medical records. Significance level was p < 0.05. RESULTS Thirty-four out of 45 families of children with DREA were included and 30 returned the questionnaires(n = 8 children aged 2-7 years; n = 22 children aged 8-18 years). Compared to children with PA(42 children aged 2-7 years; 64 children aged 8-18 years), there were no significant differences in most early postoperative complications. At follow-up, symptom prevalence in children aged 2-7 with DREA ranged from 37.5% (heartburn) to 75% (cough). Further digestive and respiratory symptoms were present in ≥ 50%. In children aged 8-18, it ranged from 14.3% (vomiting) to 40.9% (cough), with other digestive and airway symptoms present in 19.0-27.3%. Except for chest tightness (2-7 years), there were no significant differences in symptom prevalence between children with DREA and PA, nor between their generic or condition-specific HRQOL scores (p > 0.05). More children with DREA underwent esophageal dilatations (both age groups), gastrostomy feeding (2-7 years), and antireflux treatment (8-18 years), p < 0.05. Days to hospital discharge after EA repair and a number of associated anomalies showed a strong negative correlation with HRQOL scores (2-7 years). Presence of cough, airway infection, swallowing difficulties and heartburn were associated with lower HRQOL scores (8-18 years), p < 0.05. CONCLUSIONS Although children with DREA need more treatments, they are not a risk group for postoperative morbidity and impaired HRQOL compared with children with PA. However, those with a long initial hospital stay, several associated anomalies and digestive or respiratory symptoms risk worse HRQOL. This is important information for clinical practice, families and patient stakeholders.
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Affiliation(s)
- Michaela Dellenmark-Blom
- Department of Pediatrics, Institute of Clinical Sciences, The Queen Silvia Children's Hospital, Gothenburg University, 416 85, Gothenburg, Sweden.
| | - Sofie Örnö Ax
- Department of Pediatrics, Institute of Clinical Sciences, The Queen Silvia Children's Hospital, Gothenburg University, 416 85, Gothenburg, Sweden.,Department of Pediatric Surgery, Queen Silvia Children's Hospital, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Elin Öst
- Department of Pediatric Surgery, Karolinska University Hospital, Stockholm, Sweden.,Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Jan F Svensson
- Department of Pediatric Surgery, Karolinska University Hospital, Stockholm, Sweden.,Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Ann-Marie Kassa
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden.,Department of Pediatric Surgery, University Children's Hospital, Uppsala, Sweden
| | - Linus Jönsson
- Department of Pediatrics, Institute of Clinical Sciences, The Queen Silvia Children's Hospital, Gothenburg University, 416 85, Gothenburg, Sweden.,Department of Pediatric Surgery, Queen Silvia Children's Hospital, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Kate Abrahamsson
- Department of Pediatrics, Institute of Clinical Sciences, The Queen Silvia Children's Hospital, Gothenburg University, 416 85, Gothenburg, Sweden.,Department of Pediatric Surgery, Queen Silvia Children's Hospital, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Vladimir Gatzinsky
- Department of Pediatrics, Institute of Clinical Sciences, The Queen Silvia Children's Hospital, Gothenburg University, 416 85, Gothenburg, Sweden.,Department of Pediatric Surgery, Queen Silvia Children's Hospital, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Pernilla Stenström
- Department of Pediatric Surgery, Skane University Hospital, Lund University, Lund, Sweden
| | - AnnaMaria Tollne
- Department of Pediatric Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Erik Omling
- Department of Pediatric Surgery, Skane University Hospital, Lund University, Lund, Sweden
| | - Helene Engstrand Lilja
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden.,Department of Pediatric Surgery, University Children's Hospital, Uppsala, Sweden
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8
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Factors of family impact in a Swedish-German cohort of children born with esophageal atresia. Orphanet J Rare Dis 2022; 17:207. [PMID: 35597964 PMCID: PMC9123694 DOI: 10.1186/s13023-022-02361-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Accepted: 05/08/2022] [Indexed: 11/17/2022] Open
Abstract
Background After repair of esophageal atresia (EA), childhood survivors commonly present with digestive and respiratory morbidity, and around 55% have associated anomalies. Although it is known that these problems can reduce health-related quality of life in children with EA, less is understood about the impact on the family. We aimed to identify factors related to family impact in children with EA. Methods One parent each of a child with EA (2–18 years) in 180 families from Sweden and Germany answered the PedsQL™ Family Impact Module as the dependent variable. The independent variables were the child’s parent-reported health-related quality of life as measured by PedsQL™ 4.0, current symptoms, school situation, and parent/family characteristics together with child clinical data from the medical records. Results Stepwise multivariable regression analysis showed a multifactorial model of the total family impact scores (R2 = 0.60), with independent factors being the child’s overall generic health-related quality of life, school-absence ≥ 1/month, severe tracheomalacia, a family receiving carer’s allowance, and a parent with no university/college education, p < 0.05. Logistic regression analysis showed that an increased number of symptoms in the child the preceding 4 weeks lowered the family impact scores; however, the child’s feeding (R2 = 0.35) and digestive symptoms (R2 = 0.25) explained more in the variation of scores than the child’s respiratory symptoms (R2 = 0.09), p < 0.0001. Conclusions Family functioning may be a contributing factor to the maintenance of child health. The study findings suggest multifactorial explanations to family impact in children with EA, which are essential when optimizing the support to these families in clinical and psychosocial practice. Future research should explore experiences of family impact from all family members’ perspectives and multicenter studies are warranted to understand better the effectiveness of psychosocial-educational interventions to families of children with EA.
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9
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van Hoorn CE, de Graaff JC, Vlot J, Wijnen RM, Stolker RJ, Schnater JM. Primary repair of esophageal atresia is followed by multiple diagnostic and surgical procedures. J Pediatr Surg 2021; 56:2192-2199. [PMID: 34229878 DOI: 10.1016/j.jpedsurg.2021.06.004] [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: 12/23/2020] [Revised: 05/19/2021] [Accepted: 06/09/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Children born with esophageal atresia (EA) face comorbidities and complications often requiring surgery and anesthesia. We aimed to assess all procedures performed under general anesthesia during their first 12 years of life. METHODS We performed a retrospective cohort study about subsequent surgeries and procedures requiring general anesthesia in children born with type C EA between January 2007 and December 2017, with follow-up to March 2019. RESULTS Of 102 eligible patients, 63 were diagnosed with comorbidities, of whom 18 had VACTERL association. Follow-up time for all patients varied between 14 months and 12 years (median 7 years). The patients underwent total 637 procedures, median 4 [IQR2-7] per patient. In the first year of life, 464 procedures were performed, in the second year 69 and in the third year 29. Thirteen patients underwent no other procedures than primary EA repair. In 57 patients, 228 dilatations were performed. Other frequently performed procedures were esophagoscopy (n=52), urologic procedures (n=44) and abdominal procedures (n=33). CONCLUSIONS Patients with EA frequently require multiple anesthetics for a variety of procedures related to the EA, complications and comorbidities. This study can help care providers when counselling parents of a patient with an EA by giving them more insight into possible procedures they can be confronted with during childhood.
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Affiliation(s)
- Camille E van Hoorn
- Department of Anesthesiology, Erasmus University Medical Centre -Sophia Children's Hospital, Rotterdam, The Netherlands; Department of Pediatric Surgery and Pediatric Intensive Care, Erasmus University Medical Centre -Sophia Children's Hospital, Rotterdam, The Netherlands.
| | - Jurgen C de Graaff
- Department of Anesthesiology, Erasmus University Medical Centre -Sophia Children's Hospital, Rotterdam, The Netherlands
| | - John Vlot
- Department of Pediatric Surgery and Pediatric Intensive Care, Erasmus University Medical Centre -Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Rene Mh Wijnen
- Department of Pediatric Surgery and Pediatric Intensive Care, Erasmus University Medical Centre -Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Robert Jan Stolker
- Department of Anesthesiology, Erasmus University Medical Centre -Sophia Children's Hospital, Rotterdam, The Netherlands
| | - J Marco Schnater
- Department of Pediatric Surgery and Pediatric Intensive Care, Erasmus University Medical Centre -Sophia Children's Hospital, Rotterdam, The Netherlands
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10
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The effect of azygos vein preservation on postoperative complications after esophageal atresia repair: Results from the Turkish Esophageal Atresia Registry. J Pediatr Surg 2021; 56:1940-1943. [PMID: 33353739 DOI: 10.1016/j.jpedsurg.2020.12.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 11/12/2020] [Accepted: 12/06/2020] [Indexed: 11/20/2022]
Abstract
AIM Preservation of the azygos vein (AV) maintains normal venous drainage of the mediastinum and decreases postoperative congestion. The modification of esophageal atresia (EA) repair by preserving AV may prevent postoperative complications and may lead to better outcomes. The data from the Turkish Esophageal Atresia Registry (TEAR) were evaluated to define the effect of AV preservation on postoperative complications of patients with EA. METHODS Data from TEAR for a period of five years were evaluated. Patients were enrolled into two groups according to the preservation of AV. Patients with divided (DAV) and preserved AV (PAV) were evaluated for demographic and operative features and postoperative complications for the first year of life. The DAV and PAV groups were compared according to the postoperative complications, such as fistula recanalization, symptomatic strictures, anastomotic leaks, total number of esophageal dilatations, and anti-reflux surgery. In addition, respiratory problems, which required treatment, were compared between groups. RESULTS Among 502 registered patients; the data from 315 patients with the information of AV ligation were included. The male female ratio of DAV (n = 271) and PAV (n = 44) groups were 150:121 and 21:23, respectively (p > 0.05). The mean body weight, height, gestational age, and associated anomalies were similar in both groups (p > 0.05). The esophageal repair with thoracotomy was significantly higher in DAV group, when compared to the PAV group (p < 0.05). The rates of primary anastomosis and tensioned anastomosis were similar in both groups (p > 0.05). There was no difference between DAV and PAV groups for anastomotic leaks, symptomatic anastomotic strictures, fistula recanalization, and the requirement for anti-reflux surgery (p > 0.05). The rate of respiratory problems, which required treatment, was significantly higher in the DAV group (p < 0.05) CONCLUSION: The data in the TEAR demonstrated that preserving the AV during EA repair led to no significant advantage on postoperative complications, with exception of respiratory problems. AV should be preserved as much as possible to maintain a normal mediastinal anatomy and to avoid respiratory complications.
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11
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Gao XJ, Huang JX, Chen Q, Hong SM, Hong JJ, Ye H. The timing of oesophageal dilatations in anastomotic stenosis after one-stage anastomosis for congenital oesophageal atresia. J Cardiothorac Surg 2021; 16:284. [PMID: 34627318 PMCID: PMC8501525 DOI: 10.1186/s13019-021-01656-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 09/19/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In infants with congenital oesophageal atresia, anastomotic stenosis easily occurs after one-stage oesophageal anastomosis, leading to dysphagia. In severe cases, oesophageal dilatation is required. In this paper, the timing of oesophageal dilatation in infants with anastomotic stenosis was investigated through retrospective data analysis. METHODS The clinical data of 107 infants with oesophageal atresia who underwent one-stage anastomosis in our hospital from January 2015 to December 2018 were retrospectively analysed. Data such as the timing and frequency of oesophageal dilatation under gastroscopy after surgery were collected to analyse the timing of oesophageal dilatation in infants with different risk factors. RESULTS For infants with refractory stenosis, the average number of dilatations in the early dilatation group (the first dilatation was performed within 6 months after the surgery) was 5.75 ± 0.5, which was higher than the average of 7.40 ± 1.35 times in the normal dilatation group (the first dilatation was performed 6 months after the surgery), P = 0.038. For the infants with anastomotic fistula and anastomotic stenosis, the number of oesophageal dilatations in the early dilatation group was 2.58 ± 2.02 times, which was less than the 6.38 ± 2.06 times in the normal dilatation group, P = 0.001. For infants with non-anastomotic fistula stenosis, early oesophageal dilatation could not reduce the total number of oesophageal dilatations. CONCLUSION Starting to perform oesophageal dilatation within 6 months after one-stage anastomosis for congenital oesophageal atresia can reduce the required number of dilatations in infants with postoperative anastomotic fistula and refractory anastomotic stenosis.
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Affiliation(s)
- Xue-Jie Gao
- Department of Pediatrics, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China.,Department of Pediatrics, Fujian Branch of Shanghai Children's Medical Center, Fuzhou, China
| | - Jin-Xi Huang
- Department of Cardiothoracic Surgery, Fujian Branch of Shanghai Children's Medical Center, Fuzhou, China
| | - Qiang Chen
- Department of Cardiothoracic Surgery, Fujian Branch of Shanghai Children's Medical Center, Fuzhou, China
| | - Song-Ming Hong
- Department of Cardiothoracic Surgery, Fujian Branch of Shanghai Children's Medical Center, Fuzhou, China
| | - Jun-Jie Hong
- Department of Cardiothoracic Surgery, Fujian Branch of Shanghai Children's Medical Center, Fuzhou, China
| | - Hong Ye
- Department of Pediatrics, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China. .,Department of Pediatrics, Fujian Branch of Shanghai Children's Medical Center, Fuzhou, China.
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12
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Huang JX, Hong SM, Chen Q, Wang ZC, Wu DM, Hong JJ, Zhou C. Risk factors for anastomotic complications after one-stage anastomosis for oesophageal atresia. J Cardiothorac Surg 2021; 16:176. [PMID: 34147095 PMCID: PMC8214267 DOI: 10.1186/s13019-021-01557-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 06/07/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Oesophageal atresia is a congenital malformation of the oesophagus and a serious malformation of the digestive system, postoperative complications include acute respiratory failure, pneumonia, anastomotic fistula, anastomotic stenosis, tracheal stenosis, gastroesophageal reflux and eosinophilic oesophagitis, anastomotic fistula is one of the important causes of postoperative death. The objective of this study is to identify the risk factors for anastomotic complications after one-stage anastomosis for oesophageal atresia. METHODS A retrospective analysis was performed on the clinical data of 107 children with congenital oesophageal atresia who underwent one-stage anastomosis in our hospital from January 2013 to December 2018. Single-factor and multivariate logistic regression analyses were performed to determine the risk factors for anastomotic fistula and anastomotic stenosis. RESULTS A total of 107 children with oesophageal atresia underwent one-stage anastomosis, and the incidence of anastomotic fistula was 26.2%. The probability of anastomotic stenosis in the long term was 52.3%, and the incidence of refractory stenosis (dilation ≥5 times) was 13.1%. Analysis of the clinical count data in the anastomotic fistula group and non-anastomotic fistula group showed that preoperative albumin (F = 4.199, P = 0.043), low birth weight (F = 7.668, P = 0.007) and long gap defects (F = 6.107, P = 0.015) were risk factors for postoperative anastomotic fistula. Further multivariate logistic regression analysis showed that low birth weight (Wald2 = 4.499, P = 0.034, OR = 2.775) and long gap defects (Wald2 = 6.769, P = 0.009, OR = 4.939) were independent risk factors for postoperative anastomotic fistula. Premature delivery (F = 5.338, P = 0.023), anastomotic fistula (F = 11.381, P = 0.001), endoscopic surgery (F = 6.343, P = 0.013), preoperative neutrophil count (F = 8.602, P = 0.004), preoperative low albumin (F = 8.410, P = 0.005), and a preoperative prognostic nutritional index < 54 (F = 5.54, P = 0.02) were risk factors for refractory anastomotic stenosis in children. Further multivariate logistic regression analysis showed that postoperative anastomotic fistula (Wald2 = 11.417, P = 0.001, OR = 8.798), endoscopic surgery (Wald2 = 9.633, P = 0.002, OR = 4.808), and a prognostic nutritional index < 54 (Wald2 = 4.540, P = 0.002, OR = 2.3798) were independent risk factors for refractory anastomotic stenosis. CONCLUSION Low birth weight and long gap defects are important predictors of postoperative anastomotic fistula, and the possibility of refractory anastomotic stenosis should be considered. The long-term risk of anastomotic stenosis was increased in children undergoing endoscopic surgery and in those with a preoperative prognostic nutritional index < 54.
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Affiliation(s)
- Jin-Xi Huang
- Department of Cardiothoracic Surgery, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China.,Fujian Key Laboratory of Women and Children's Critical Diseases Research, Fujian Maternity and Child Health Hospital, Fuzhou, China.,Fujian Branch of Shanghai Children's Medical Center, Fuzhou, China.,Fujian Children's Hospital, Fuzhou, China
| | - Song-Ming Hong
- Department of Cardiothoracic Surgery, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China.,Fujian Key Laboratory of Women and Children's Critical Diseases Research, Fujian Maternity and Child Health Hospital, Fuzhou, China.,Fujian Branch of Shanghai Children's Medical Center, Fuzhou, China.,Fujian Children's Hospital, Fuzhou, China
| | - Qiang Chen
- Department of Cardiothoracic Surgery, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China.,Fujian Key Laboratory of Women and Children's Critical Diseases Research, Fujian Maternity and Child Health Hospital, Fuzhou, China.,Fujian Branch of Shanghai Children's Medical Center, Fuzhou, China.,Fujian Children's Hospital, Fuzhou, China
| | - Zeng-Chun Wang
- Department of Cardiothoracic Surgery, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China.,Fujian Key Laboratory of Women and Children's Critical Diseases Research, Fujian Maternity and Child Health Hospital, Fuzhou, China.,Fujian Branch of Shanghai Children's Medical Center, Fuzhou, China.,Fujian Children's Hospital, Fuzhou, China
| | - Dian-Ming Wu
- Department of Cardiothoracic Surgery, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China.,Fujian Key Laboratory of Women and Children's Critical Diseases Research, Fujian Maternity and Child Health Hospital, Fuzhou, China.,Fujian Branch of Shanghai Children's Medical Center, Fuzhou, China.,Fujian Children's Hospital, Fuzhou, China
| | - Jun-Jie Hong
- Department of Cardiothoracic Surgery, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China.,Fujian Key Laboratory of Women and Children's Critical Diseases Research, Fujian Maternity and Child Health Hospital, Fuzhou, China.,Fujian Branch of Shanghai Children's Medical Center, Fuzhou, China.,Fujian Children's Hospital, Fuzhou, China
| | - Chaoming Zhou
- Department of Cardiothoracic Surgery, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China. .,Fujian Key Laboratory of Women and Children's Critical Diseases Research, Fujian Maternity and Child Health Hospital, Fuzhou, China. .,Fujian Branch of Shanghai Children's Medical Center, Fuzhou, China. .,Fujian Children's Hospital, Fuzhou, China.
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13
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Oztan MO, Soyer T, Oztorun CI, Firinci B, Durakbaşa ÇU, Dokumcu Z, Gollu G, Akkoyun I, Demirel D, Karaman A, Ciftci I, Ilhan H, Parlak A, Ozden O, Cömert HSY, Oral A, Tekant G, Kiyan G, Erginel B, Guvenc U, Erdem AO, Erturk N, Yildiz A. Outcome of Very Low and Low Birth Weight Infants with Esophageal Atresia: Results of the Turkish Esophageal Atresia Registry. Eur J Pediatr Surg 2021; 31:226-235. [PMID: 32629496 DOI: 10.1055/s-0040-1713663] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
INTRODUCTION The data of the Turkish Esophageal Atresia Registry (TEAR) was evaluated to define the outcome of very low birth weight (VLBW) and low BW (LWB) infants with esophageal atresia (EA). MATERIALS AND METHODS The data registered by 24 centers between 2014 and 2018 were evaluated for demographic features, prenatal findings, associated anomalies, surgical treatment, and outcome. Patients were enrolled in three groups according to their BWs (VLBW <1,500 g), LWB = 1,500-2,500 g), and normal BW (NBW; >2,500 g). RESULTS Among the 389 cases, there were 37 patients (9.5%) in the VLBW group, 165 patients (42.4%) in the LBW group, and 187 patients (48.1%) in the NBW group. Prenatal diagnosis rates were similar among the three groups (29.7, 34.5, and 24.6%, respectively). The standard primary anastomosis was achieved at a significantly higher rate in NWB cases than in the other groups (p < 0.05). In patients with tracheoesophageal fistula (TEF), patients of the NBW group had significantly higher rates of full oral feedings, when compared with VLBW and LBW cases (p < 0.05). At the end of the first year, when we evaluate all patients, the number of cases with fistula recanalization and esophageal anastomotic strictures (AS) requiring esophageal dilatation was similar among the groups. The weight and height measurements at 6 months and 1 year of age of the survivors were similar in all the groups. The overall mortality rate was significantly higher in the VLBW and LBW groups, when compared with the NBW patients, even in patients with tension-free anastomosis (p < 0.05). The incidence of the associated anomalies was 90.6% in cases with mortality, which was significantly higher than in survivors (59.6%; p < 0.05). According to Spitz's classification, the survival rate was 87.1% in class I, 55.3% in class II, and 16.7% in class III. The most common causes of mortality were associated with cardiovascular diseases, pneumonia, and sepsis. CONCLUSION The national data of TEAR demonstrates that the developmental and feeding parameters are better in NBW patients. Although VLBW patients have higher risk of developing fistula canalization than the LBW and NBW groups, long-term complications, such as anastomotic strictures, weight, and height values, after 1 year are similar in both groups. According to our results, associated anomalies and LBWs are still significant risk factors for mortality in cases with EA.
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Affiliation(s)
- Mustafa O Oztan
- Department of Pediatric Surgery, Izmir Katip Celebi University, Izmir, Turkey
| | - Tutku Soyer
- Department of Pediatric Surgery, Hacettepe University, Ankara, Turkey
| | - Can I Oztorun
- Department of Pediatric Surgery, Ankara Yildirim Beyazit Universitesi, Ankara, Turkey
| | - Binali Firinci
- Department of Pediatric Surgery, Ataturk University, Erzurum, Turkey
| | - Çiğdem U Durakbaşa
- Department of Pediatric Surgery, Istanbul Medeniyet University Goztepe Training and Research Hospital, Istanbul, Turkey
| | - Zafer Dokumcu
- Department of Pediatric Surgery, Ege University, Izmir, Turkey
| | - Gulnur Gollu
- Department of Pediatric Surgery, Ankara University, Ankara, Turkey
| | - Ibrahim Akkoyun
- Department of Pediatric Surgery, Konya Education and Research Hospital, Konya, Turkey
| | - Dilek Demirel
- Department of Pediatric Surgery, Ondokuz Mayıs University, Samsun, Turkey
| | - Ayşe Karaman
- Department of Pediatric Surgery, Dr. Sami Ulus Maternity and Children Health and Research Application Center, University of Health Sciences, Ankara, Turkey
| | - Ilhan Ciftci
- Department of Pediatric Surgery, Selçuk University, Konya, Turkey
| | - Huseyin Ilhan
- Department of Pediatric Surgery, Eskisehir Osmangazi University, Eskisehir, Turkey
| | - Ayse Parlak
- Department of Pediatric Surgery, Uludag University, Bursa, Turkey
| | - Onder Ozden
- Department of Pediatric Surgery, Cukurova University, Adana, Turkey
| | - Hatice S Y Cömert
- Department of Pediatric Surgery, Karadeniz Technical University, Trabzon, Turkey
| | - Akgun Oral
- Department of Pediatric Surgery, Dr. Behcet Uz Education and Research Hospital, Izmir, Turkey
| | - Gonca Tekant
- Department of Pediatric Surgery, Istanbul University-Cerrahpasa, Istanbul, Istanbul, Turkey
| | - Gursu Kiyan
- Department of Pediatric Surgery, Marmara University, Istanbul, Turkey
| | - Başak Erginel
- Department of Pediatric Surgery, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Unal Guvenc
- Department of Pediatric Surgery, Kanuni Sultan Suleyman Education and Research Hospital, Istanbul, Turkey
| | - Ali Onur Erdem
- Department of Pediatric Surgery, Adnan Menderes University, Aydin, Turkey
| | - Nazile Erturk
- Department of Pediatric Surgery, Mugla Sitki Kocman University Ringgold standard institution, Mugla, Turkey
| | - Abdullah Yildiz
- Department of Pediatric Surgery, Sisli Hamidiye Etfal Education and Research Hospital, Istanbul, Turkey
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14
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Thakkar H, Mullassery DM, Giuliani S, Blackburn S, Cross K, Curry J, De Coppi P. Thoracoscopic oesophageal atresia/tracheo-oesophageal fistula (OA/TOF) repair is associated with a higher stricture rate: a single institution’s experience. Pediatr Surg Int 2021; 37:397-401. [PMID: 33550454 PMCID: PMC7900027 DOI: 10.1007/s00383-020-04829-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/30/2020] [Indexed: 12/24/2022]
Abstract
PURPOSE Thoracoscopic OA/TOF repair was first described in 1999. Currently, less than 10% of surgeons routinely employ minimally access surgery. Our primary aim was to review our immediate-, early- and long-term outcomes with this technique compared with the open approach. METHODS A retrospective review of all patients undergoing primary OA/TOF (Type C) repair at our institution from 2009 was conducted. Outcome measures included length of surgery, conversion rate from thoracoscopy, early complications such as anastomotic leak and post-operative complications such as anastomotic strictures needing dilatations. Fisher's exact and Kruskal-Wallis tests were used for statistical analysis. RESULTS 95 patients in total underwent OA/TOF repair during the study period of which 61 (64%) were completed via an open approach. 34 were attempted thoracoscopically of which 11 (33%) were converted. There was only one clinically significant anastomotic leak in our series that took place in the thoracoscopic group. We identified a significantly higher stricture rate in our thoracoscopic cohort (72%) versus open surgery (43%, P < 0.05). However, the median number of dilations (3) performed was not significantly different between the groups. There was one recurrent fistula in the thoracoscopic converted to open group. Our median follow-up was 60 months across the groups. CONCLUSION In our experience, the clinically significant leak rate for both open and thoracoscopic repair as well as recurrent fistula is much lower than has been reported in the literature. We do not routinely perform contrast studies and are, thus, reporting clinically significant leaks only. The use of post-operative neck flexion, ventilation and paralysis is likely to be protective towards a leak. Thoracoscopic OA/TOF repair is associated with a higher stricture rate compared with open surgery; however, these strictures respond to a similar number of dilatations and are no more refractory. Larger, multicentre studies may be useful to investigate these finding further.
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Affiliation(s)
- H Thakkar
- Department of Specialist Neonatal and Paediatric Surgery, Great Ormond Street Hospital, London, UK
| | - D M Mullassery
- Department of Specialist Neonatal and Paediatric Surgery, Great Ormond Street Hospital, London, UK
| | - S Giuliani
- Department of Specialist Neonatal and Paediatric Surgery, Great Ormond Street Hospital, London, UK
| | - S Blackburn
- Department of Specialist Neonatal and Paediatric Surgery, Great Ormond Street Hospital, London, UK
| | - K Cross
- Department of Specialist Neonatal and Paediatric Surgery, Great Ormond Street Hospital, London, UK
| | - J Curry
- Department of Specialist Neonatal and Paediatric Surgery, Great Ormond Street Hospital, London, UK
| | - Paolo De Coppi
- Department of Specialist Neonatal and Paediatric Surgery, Great Ormond Street Hospital, London, UK.
- Stem Cells and Regenerative Medicine Section, Department of Paediatric Surgery, UCL Great Ormond Street Institute of Child Health, 30 Guilford Street, Holborn, London, WC1N 1EH, UK.
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15
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Ax SÖ, Abrahamsson K, Gatzinsky V, Jönsson L, Dellenmark-Blom M. Parent-Reported Feeding Difficulties among Children Born with Esophageal Atresia: Prevalence and Early Risk Factors. Eur J Pediatr Surg 2021; 31:69-75. [PMID: 33027836 DOI: 10.1055/s-0040-1716880] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
INTRODUCTION We aimed to describe the prevalence of observable feeding difficulties during mealtimes among children with repaired esophageal atresia (EA) and to determine their early predictors. MATERIALS AND METHODS A survey, based on parents' reports and concerning difficulties in EA children's nutritional intake, was performed with the help of 114 families of 2 to 17-year-old EA patients. Neonatal and clinical/surgical data were collected from medical records. Comparisons were made of the prevalence n (%) of feeding difficulties between children in three age groups (2 to 7 years, 8 to 12 years, or 13 to 17 years of age) using the Mantel-Haenszel chi-square test. Logistic regression identified outcome predictors (odds ratio: 95% confidence interval). Predictors with p ≤ 0.1 in the univariable analysis were included in multiple regression analysis (p < 0.05). RESULTS Seventy-five percent of the young children aged 2 to 7, (median number of feeding difficulties: 2), 61% of school-aged children aged 8 to 12 (median number of feeding difficulties: 1), and 60% patients in the teenage group, aged 13 to 17, (median number of feeding difficulties: 1), reported feeding difficulties. Surgical complications after EA repair independently predicted children having a gastrostomy (p ≤ 0.01), using a food infusion pump (p ≤ 0.01), taking small portions to facilitate eating (p = 0.01), and needing >30 minutes to finish a main meal (p = 0.02). Congenital independent predictors were VACTERL, low birth weight, and preterm birth. CONCLUSION Parentally observed feeding difficulties were commonly reported during early childhood, although prevalence decreases in older age groups. Several congenital and surgical factors were identified as independent predictors of complicated nutritional intake patterns.
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Affiliation(s)
- Sofie Örnö Ax
- Department of Pediatric Surgery, Queen Silvia Children's and Youth Hospital, Goteborg, Västra Götalandsregionen, Sweden
| | - Kate Abrahamsson
- Department of Pediatric Surgery, Queen Silvia Children's and Youth Hospital, Goteborg, Sweden
| | - Vladimir Gatzinsky
- Department of Pediatric Surgery, Queen Silvia Children's and Youth Hospital, Goteborg, Sweden
| | - Linus Jönsson
- Department of Pediatric Surgery, Queen Silvia Children's and Youth Hospital, Goteborg, Sweden
| | - Michaela Dellenmark-Blom
- Department of Pediatrics, University of Gothenburg Institute of Clinical Sciences, The Queen Silvia Children's Hospital, Goteborg, Sweden
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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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17
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van Hal ARL, Pulvirenti R, den Hartog FPJ, Vlot J. The Safety of Intralesional Steroid Injections in Young Children and Their Effectiveness in Anastomotic Esophageal Strictures-A Meta-Analysis and Systematic Review. Front Pediatr 2021; 9:825030. [PMID: 35165653 PMCID: PMC8837747 DOI: 10.3389/fped.2021.825030] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 12/27/2021] [Indexed: 12/03/2022] Open
Abstract
OBJECTIVE Intralesional steroid injections (ISI) are a widely used technique for various pediatric indications and represent a possible adjuvant treatment for anastomotic esophageal strictures. Yet, no consensus has been reached neither on their safety in the pediatric population or their effectiveness in esophageal atresia patients. This systematic review aimed to assess the safety of ISI in young children through a meta-analysis and to summarize the current knowledge on the effectiveness of ISI in anastomotic esophageal strictures. METHODS A systematic literature search was performed in Embase, Medline, Web of Science Core Collection, Cochrane Central Register of Controlled Trials and Google Scholar up to August 16 2021. Studies focusing on ISI and involving children up to 2 years were included in the meta-analysis for the safety assessment. All studies evaluating the use of ISI as adjuvant treatment in anastomotic esophageal strictures in children were included in the systematic review to assess the effectiveness of the intervention. RESULTS The literature search yielded 8,253 articles. A total of 57 studies were included, of which 55 for the safety and five for the effectiveness assessment. The overall complication rate was 7%, with a greater incidence of local complications compared to systemic complications. Six studies (with a total of 367 patients) evaluated adrenocorticotropic hormone and cortisol levels, of which four reported hypothalamic-pituitary axis suppression. Two children (0.6%) received replacement therapy and all patients recovered uneventfully. A mean number of 1.67 ISI were performed per esophageal atresia (EA) patient. A reduction of needed dilatations was seen after ISI, compared to the number of dilatations performed before the intervention (5.2 vs. 1.3). CONCLUSION The insufficient data emphasized the need for further prospective and comparative studies. Results from this meta-analysis and systematic review address ISI as a safe and effective technique. Close clinical follow-up and growth curve evaluation are advisable in patients receiving ISI. SYSTEMATIC REVIEW REGISTRATION PROSPERO, identifier: CRD42021281584.
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Affiliation(s)
- Annefleur R L van Hal
- Department of Pediatric Surgery and Intensive Care, Erasmus Medical Centre Sophia Children's Hospital, Rotterdam, Netherlands
| | - Rebecca Pulvirenti
- Pediatric Surgery Unit, Department of Women's and Children's Health, University Hospital of Padua, Padua, Italy
| | | | - John Vlot
- Department of Pediatric Surgery and Intensive Care, Erasmus Medical Centre Sophia Children's Hospital, Rotterdam, Netherlands
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Lu YH, Yen TA, Chen CY, Tsao PN, Lin WH, Hsu WM, Chou HC. Risk factors for digestive morbidities after esophageal atresia repair. Eur J Pediatr 2021; 180:187-194. [PMID: 32648144 DOI: 10.1007/s00431-020-03733-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Revised: 06/23/2020] [Accepted: 07/03/2020] [Indexed: 01/21/2023]
Abstract
Esophageal atresia with/without tracheoesophageal fistula (EA/TEF) is a congenital digestive tract anomaly that represents a major therapeutic challenge. Postoperative digestive morbidities such as gastroesophageal reflux disease (GERD) and esophageal stricture are common. The aim of this study was to identify the incidence of and potential risk factors for digestive morbidities after EA/TEF repair. We retrospectively reviewed all EA/TEF patients who underwent repair at a single institution between January 1999 and December 2018, excluding patients who died prior to discharge. Patient demographics, perioperative management, and postoperative GERD and esophageal stricture rates were collected. We performed univariate and multivariate analyses to examine risk factors associated with postoperative GERD and esophageal stricture. The study enrolled 58 infants (58.6% male, 17.2% with type A EA/TEF, 62.1% with associated anomalies). Postoperative GERD occurred in 67.2% of patients and was the most common digestive morbidity. Esophageal stricture occurred in 37.9% of patients after EA/TEF repair. Multivariate analysis showed that long-gap EA/TEF and postoperative GERD were independent risk factors for esophageal stricture after repair surgery.Conclusion: The incidence of postoperative GERD and esophageal stricture was 67.2% and 37.9%, respectively. The risk factors for postoperative esophageal stricture were long-gap EA/TEF and postoperative GERD. What is Known: • EA/TEF is a congenital digestive tract anomaly with a high postoperative survival rate but can be complicated by many long-term morbidities. What is New: • Long-gap EA/TEF and postoperative GERD are risk factors of anastomotic stricture after repair. • Surgeons and pediatricians should be highly experienced in managing anastomotic tension and the GERD.
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Affiliation(s)
- Yi-Hsuan Lu
- Department of Pediatrics, National Taiwan University Children Hospital, National Taiwan University College of Medicine, No. 8, Zhongshan S. Rd., Zhongzheng Dist., Taipei, 100, Taiwan
| | - Ting-An Yen
- Department of Pediatrics, National Taiwan University Children Hospital, National Taiwan University College of Medicine, No. 8, Zhongshan S. Rd., Zhongzheng Dist., Taipei, 100, Taiwan
| | - Chien-Yi Chen
- Department of Pediatrics, National Taiwan University Children Hospital, National Taiwan University College of Medicine, No. 8, Zhongshan S. Rd., Zhongzheng Dist., Taipei, 100, Taiwan
| | - Po-Nien Tsao
- Department of Pediatrics, National Taiwan University Children Hospital, National Taiwan University College of Medicine, No. 8, Zhongshan S. Rd., Zhongzheng Dist., Taipei, 100, Taiwan
| | - Wen-Hsi Lin
- Division of Pediatric Surgery, Department of Surgery, National Taiwan University Hospital, National Taiwan University College of Medicine, No. 7, Zhongshan S. Rd., Zhongzheng Dist., Taipei, 100, Taiwan
| | - Wen-Ming Hsu
- Division of Pediatric Surgery, Department of Surgery, National Taiwan University Hospital, National Taiwan University College of Medicine, No. 7, Zhongshan S. Rd., Zhongzheng Dist., Taipei, 100, Taiwan
| | - Hung-Chieh Chou
- Department of Pediatrics, National Taiwan University Children Hospital, National Taiwan University College of Medicine, No. 8, Zhongshan S. Rd., Zhongzheng Dist., Taipei, 100, Taiwan.
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An international survey on anastomotic stricture management after esophageal atresia repair: considerations and advisory statements. Surg Endosc 2020; 35:3653-3661. [PMID: 32748272 PMCID: PMC8195894 DOI: 10.1007/s00464-020-07844-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 07/24/2020] [Indexed: 11/11/2022]
Abstract
Background Endoscopic dilatation is the first-line treatment of stricture formation after esophageal atresia (EA) repair. However, there is no consensus on how to perform these dilatation procedures which may lead to a large variation between centers, countries and doctor’s experience. This is the first cross-sectional study to provide an overview on differences in endoscopic dilatation treatment of pediatric anastomotic strictures worldwide. Methods An online questionnaire was sent to members of five pediatric medical networks, experienced in treating anastomotic strictures in children with EA. The main outcome was the difference in endoscopic dilatation procedures in various centers worldwide, including technical details, dilatation approach (routine or only in symptomatic patients), and adjuvant treatment options. Descriptive statistics were performed with SPSS. Results Responses from 115 centers from 32 countries worldwide were analyzed. The preferred approach was balloon dilatation (68%) with a guidewire (66%), performed by a pediatric gastroenterologist (n = 103) or pediatric surgeon (n = 48) in symptomatic patients (68%). In most centers, hydrostatic pressure was used for balloon dilatation. The insufflation duration was standardized in 59 centers with a median duration of 60 (range 5–300) seconds. The preferred first-line adjunctive treatments in case of recurrent strictures were intralesional steroids and topical mitomycin C, in respectively 47% and 31% of the centers. Conclusions We found a large variation in stricture management in children with EA, which confirms the current lack of consensus. International networks for rare diseases are required for harmonizing and comparing the procedures, for which we give several suggestions. Electronic supplementary material The online version of this article (10.1007/s00464-020-07844-6) contains supplementary material, which is available to authorized users.
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Awolaran O, McGuirk S, Arul GS. Biodegradable Stents in the Management of Refractory Esophageal Strictures in Children. J Laparoendosc Adv Surg Tech A 2020; 30:919-922. [PMID: 32639188 DOI: 10.1089/lap.2019.0827] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Background: Management of refractory esophageal strictures in children is challenging and mostly involves frequent and prolonged dilatations that are associated with significant physical and psychological complications. Biodegradable stents (BDS) have recently been used and it is particularly attractive in children as stent removal is avoided due to their dissolution. Report of Cases: We report our experience with BDS use in 3 children with severe refractory esophageal strictures. Two of the patients had strictures as a result of caustic ingestion and 1 after long-gap esophageal atresia repair. Median number of dilatations prestent is 5 per year. Custom-made uncovered BDS were inserted under general anesthesia. Median follow-up period was 23 months. Results: Minor postprocedure complications occurred in 1 patient. Stent insertion led to temporary improvement in swallowing in all cases. However, all of the patients developed recurrent symptoms as severe as before stenting and need for dilatations remained unchanged. They also experienced mucosal hyperplasia that contributed to their recurrent symptoms. Conclusion: All of the cases in our series did not have a favorable outcome with BDS use. BDS is yet to be proven as an effective management option for refractory esophageal strictures in children from our experience as well as most other published reports.
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Affiliation(s)
- Olugbenga Awolaran
- Department of Surgery and Birmingham Children's Hospital, Birmingham, United Kingdom
| | - Simon McGuirk
- Department of Radiology, Birmingham Children's Hospital, Birmingham, United Kingdom
| | - G Suren Arul
- Department of Surgery and Birmingham Children's Hospital, Birmingham, United Kingdom
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21
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Intralesional Steroid Injection Therapy for Esophageal Anastomotic Stricture Following Esophageal Atresia Repair. J Pediatr Gastroenterol Nutr 2020; 70:462-467. [PMID: 31764412 DOI: 10.1097/mpg.0000000000002562] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES The role of intralesional steroid injection (ISI) in the treatment of anastomotic stricture in patients with esophageal atresia remains unclear. The aim of this study was to evaluate the efficacy and safety of ISI. METHODS A total of 158 patients with esophageal atresia with at least 1 ISI for the treatment of esophageal anastomotic stricture between 2010 and 2017 were identified. The change in stricture diameter (ΔD) was compared between procedures with dilation alone (ISI-) and dilation with steroid injection (ISI+). RESULTS A total of 1055 balloon dilations were performed (452 ISI+). The median ΔD was significantly greater in the ISI+ group: 1 mm (interquartile range [IQR] 0, 3) versus 0 mm (IQR -1, 1.5) (P < 0.0001). The ISI+ group had greater percentage of improved diameter (P < 0.0001) and lesser percentages of unchanged and decreased diameters at subsequent endoscopy (P = 0.0009, P = 0.003). Multivariable logistic regression confirmed the significance of ISI on increasing the likelihood of improved stricture diameter with an adjusted odds ratio of 3.24 (95% confidence interval: 2.15-4.88) (P < 0.001). The ΔD for the first 3 ISI+ procedures was greater than the ΔD for subsequent ISI+ procedures: 1 mm (IQR 0, 3) versus 0.5 mm (IQR-1.25, 2) (P = 0.001). There was no difference in perforation incidence between ISI+ and ISI- groups (P = 0.82). CONCLUSIONS ISI with dilation was well tolerated and improved anastomotic stricture diameter more than dilation alone. The benefit of ISI over dilation alone was limited to the first 3 ISI procedures.
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Ten Kate CA, Vlot J, Sloots CEJ, van den Akker ELT, Wijnen RMH. The effect of intralesional steroid injections on esophageal strictures and the child as whole: A case series. J Pediatr Surg 2020; 55:646-650. [PMID: 31196669 DOI: 10.1016/j.jpedsurg.2019.05.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Revised: 04/12/2019] [Accepted: 05/15/2019] [Indexed: 01/21/2023]
Abstract
BACKGROUND The most frequent complication after esophageal atresia repair remains anastomotic stricture formation. The initial treatment is endoscopic dilatation. Intralesional steroid injection (ISI) might be an effective adjuvant treatment in case of recurrent strictures. In this series we present our initial experience with this intervention. METHODS Data on primary surgery, stricture treatment, postoperative complications, outcome and growth were retrospectively collected from electronic patient records. Findings were analyzed by descriptive statistics and mixed model analysis. RESULTS Between 2014 and 2017, ISI was performed for severe recurrent anastomotic strictures in six patients (median age at injection 12.4 (2.1-34.7) months) after a median of 6 (2-20) dilatations. In five patients ISI was successful and the stenosis was cleared. No postoperative complications were reported, especially none related to acute adrenal suppression. Comparing the year before with the year after ISI, a significant positive change for weight (r = 0.70, p = 0.003) was calculated versus a negative change for height (r = -0.87, p = 0.003). CONCLUSIONS We found ISI to be an effective adjuvant treatment to recurrent anastomotic stricture dilatation after esophageal atresia repair, without postoperative complications or symptoms of adrenal suppression. It remains important, however, to monitor growth effects. Further evaluation is required in a large prospective study. TYPE OF STUDY Treatment study, Level IV (case series).
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Affiliation(s)
- Chantal A Ten Kate
- Department of Pediatric Surgery and Intensive Care, Erasmus University Medical Center - Sophia Children's Hospital, Rotterdam, The Netherlands.
| | - John Vlot
- Department of Pediatric Surgery and Intensive Care, Erasmus University Medical Center - Sophia Children's Hospital, Rotterdam, The Netherlands.
| | - Cornelius E J Sloots
- Department of Pediatric Surgery and Intensive Care, Erasmus University Medical Center - Sophia Children's Hospital, Rotterdam, The Netherlands.
| | - Erica L T van den Akker
- Department of Pediatric Endocrinology, Erasmus University Medical Center - Sophia Children's Hospital, Rotterdam, The Netherlands.
| | - Rene M H Wijnen
- Department of Pediatric Surgery and Intensive Care, Erasmus University Medical Center - Sophia Children's Hospital, Rotterdam, The Netherlands.
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Ten Kate CA, Vlot J, IJsselstijn H, Allegaert K, Spaander MCW, Poley MJ, van Rosmalen J, van den Akker ELT, Wijnen RMH. Intralesional steroid injections to prevent refractory strictures in patients with oesophageal atresia: study protocol for an international, multicentre randomised controlled trial (STEPS-EA trial). BMJ Open 2019; 9:e033030. [PMID: 31848172 PMCID: PMC6937109 DOI: 10.1136/bmjopen-2019-033030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Anastomotic stricture formation is the most common postoperative complication after oesophageal atresia (OA) repair. The standard of care is endoscopic dilatation. A possible adjuvant treatment is intralesional steroid injection, which is thought to inhibit scar tissue formation and thereby to prevent stricture recurrence. We hypothesise that this intervention could prevent refractory strictures and reduce the total number of dilatations needed in these children. METHODS AND ANALYSIS This is an international multicentre randomised controlled trial. Children with OA type C (n=110) will be randomised into intralesional steroid injection followed by balloon dilatation or dilatation only. Randomisation and intervention will take place when a third dilatation is performed. The indication for dilatation will be confirmed with an oesophagram. One radiologist-blinded for randomisation-will review all oesophagrams. The primary outcome parameter is the total number of dilatations needed with <28 days' interval, which will be analysed with a linear-by-linear χ2 association test. Secondary outcome parameters include the level of dysphagia, the luminal oesophageal diameter and stricture length (measured on the oesophagrams), the influence of comedication on stricture formation, systemic effects of intralesional steroids (cortisol levels, length and weight) and the cost-effectiveness. Patients will undergo a second oesophagram; length and weight will be measured repeatedly; a scalp hair sample will be collected; and three questionnaires will be administered. The follow-up period will be 6 months, with evaluation at 2-3 weeks, 3 and 6 months after the intervention. ETHICS AND DISSEMINATION Patients will be included after written parental informed consent. The risks and burden associated with this trial are minimal. The institutional review board of the Erasmus Medical Centre approved this protocol (MEC-2018-1586/NL65364.078.18). The results of the trial will be published in a peer-reviewed scientific journal and will be presented at international conferences. TRIAL REGISTRATION NUMBERS 2018-002863-24 and NTR7726/NL7484.
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Affiliation(s)
- Chantal A Ten Kate
- Department of Paediatric Surgery and Intensive Care, Erasmus University Medical Center, Sophia Children's Hospital, Rotterdam, The Netherlands
| | - John Vlot
- Department of Paediatric Surgery and Intensive Care, Erasmus University Medical Center, Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Hanneke IJsselstijn
- Department of Paediatric Surgery and Intensive Care, Erasmus University Medical Center, Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Karel Allegaert
- Department of Paediatrics, Division of Neonatology, Erasmus University Medical Center, Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Manon C W Spaander
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Marten J Poley
- Institute for Medical Technology Assessment, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Joost van Rosmalen
- Department of Biostatistics, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Erica L T van den Akker
- Department of Paediatric Endocrinology, Erasmus University Medical Center, Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Rene M H Wijnen
- Department of Paediatric Surgery and Intensive Care, Erasmus University Medical Center, Sophia Children's Hospital, Rotterdam, The Netherlands
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Evaluation of Gastroesophageal Reflux in Children Born With Esophageal Atresia Using pH and Impedance Monitoring. J Pediatr Gastroenterol Nutr 2019; 69:515-522. [PMID: 31490855 PMCID: PMC6855319 DOI: 10.1097/mpg.0000000000002468] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVES The aim of the study was to evaluate acid and nonacid gastroesophageal reflux in infants and school-aged children with esophageal atresia (EA) using pH-impedance (pH-MII) monitoring. METHODS Between 2012 and 2017, all 24-hour pH-MII studies performed in infants (≤18 months) and 8-year olds with EA were included. Antiacid therapy was discontinued before study. Exclusion criteria were: isolated tracheoesophageal fistula; esophageal replacement therapy; tube feeding; and monitoring <18 hours. Automatically detected retrograde bolus movements (RBM) were manually reviewed and modified/deleted if necessary. RESULTS We included 57 children (51% boys; 2% isolated EA; 44% thoracoscopic EA repair): 24 infants (median age 0.6 years) and 33 school-aged children (median age 8.2 years). Of the automatically detected 3313 RBM, 1292 were manually deleted from the tracings: 52% of nonacid RBM and 8% of acid RBM (mainly misinterpreted swallows or 1 event recognized as several events). In infants, median reflux index (RI; pH <4) was 2.6% (abnormal in n = 2), median RBM was 61 (62% nonacid, 58% mixed), and median of the mean BCT was 11 seconds. In older children, median RI was 0.3% (abnormal in n = 4), median RBM was 21 (64% nonacid; 75% mixed), and median of the mean BCT was 13 seconds. CONCLUSIONS Most children with EA off medication have a normal RI, yet experience a significant number of nonacid RBM. After manual revision of the tracings, a high percentage of RBM was deleted. Our data show that automated impedance analysis software needs refinement for use in infants and children with EA and question the need for standard antiacid therapy in these patients.
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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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