Parental risk factors for oesophageal atresia

BACKGROUND

An Oesophageal atresia (OA) affects almost 1 in 3500 newborn and its aetiology for development between 4th to 6th pregnancy weeks had not yet been clarified.

METHODS

This retrospective, observational control group-supported (n = 30) examination was performed with OA mothers (n = 20) who were interrogated via specialized questionnaires and interviews to evaluate data on medical pregnancy history including hormonal treatment, changing of life habits (nutrition, diet, medication), drug consumption (alcohol, smoking, illicit drugs) as well as exposure to nuclear waste or poisonous substance exposition. Aim was to assess risk factors during pregnancy and in particular in the first trimester.

RESULTS

The body mass index (BMI) prior pregnancy of OA mothers was significant lower (p = 0.022) and the number of mothers with obesity (BMI>30) did not differ to control group mothers (p = 0.081). They had additionally more pre-existing illnesses (p = 0.009) and allergies (p = 0.001). Control group mothers changed dietary habits with higher meat (p = 0.032) and caffeine intake (p = 0.012) compared to OA mothers, which had higher rates of abnormalities during pregnancy (p < 0.001) and 38.7% of them suffered of ≥1 abortion in the past. The ethnical background of OA mothers was more often German (p < 0.033), while OA fathers had a lower socioeconomic status (p = 0.039).

CONCLUSION

Maternal factors like previous abortions, obesity and immunological predispositions like existence of allergies combined with increased daily dairy consumption influenced obviously the occurrence of OA.

Pierre Robin Sequence with Esophageal Atresia and Congenital Radioulnar Synostosis

A wide spectrum of anomalies can be associated with Pierre Robin sequence. This report presents a 3-day-old infant with micrognathia, U-shaped cleft palate, low-set right ear with microtia, glossoptosis, esophageal atresia, and right congenital radioulnar synostosis. The association of congenital radioulnar synostosis and esophageal atresia with Pierre Robin sequence has not been previously described.

[Esophageal atresia in the Goldenhar syndrome]

Among the multiple congenital defects associated to esophagueal atresia, the characteristic ones of the Goldenhar syndrome usually are not included. The high incidence has been reported, about 5% of esophagueal atresia in patients with Goldenhar syndrome. Our experience includes two patients with this association who presented anesthetic problems and surgical complications associated with gastroesophageal reflux and esophageal anastomosis.

Maternal periconceptional exposure to cigarette smoking and alcohol and esophageal atresia +/- tracheo-esophageal fistula

BACKGROUND

Esophageal atresia (EA) is a moderately frequent birth defect that often occurs with tracheo-esophageal fistula (TEF). Etiologic studies for EA+/-TEF have produced inconsistent results.

METHODS

This study used data from the National Birth Defects Prevention Study (NBDPS) to examine the association between maternal periconceptional exposure to cigarette smoking and alcohol and EA+/-TEF. Cases of EA+/-TEF and unaffected controls with an estimated date of delivery from October 1997 through December 2003 were identified, and telephone interview reports for smoking and alcohol exposure were obtained from birth mothers of 334 cases and 4,967 controls. Odds ratios (OR)s and 95% confidence intervals (CI)s, adjusted for several covariates, were calculated to assess associations.

RESULTS

ORs were near unity for all EA+/-TEF cases combined and any periconceptional exposure to cigarette smoking (OR = 1.1; CI = 0.8,1.6) or alcohol (OR = 1.2; CI = 0.8,1.8). For cigarette smoking, some elevated ORs were found but varied by type of smoking exposure. No consistent patterns were identified for number of cigarettes smoked per day. For alcohol, ORs were weak to moderately elevated with increasing number of drinks consumed and for binge drinkers compared to non-binge drinkers. ORs were further elevated among mothers who reported active+passive exposure to cigarette smoking and alcohol (OR = 2.5; CI = 1.1,5.6). For both exposures, ORs were higher for cases with additional major defects compared to isolated cases.

CONCLUSIONS

These results, based on one of the largest published samples of EA+/-TEF cases, suggest a role for these exposures in the etiology of EA+/-TEF, although further study is needed to replicate the observed associations.

Aortopexy in Infants and Children—Long-term Follow-up in Twenty Patients

BACKGROUND

Aortopexy has become an established surgical procedure for the treatment of tracheomalacia (TM) in infants and children. The aim of the present study was to evaluate the clinical outcome and respiratory function after aortopexy in the long term.

METHODS

Between 1992 and 2006, 20 patients (6 female, 14 male) with TM were treated by bronchoscopically monitored pexis of the aorta via a right anterior thoracotomy. Patient age ranged from 4 months to 11 years (mean: 29 months). Five infants had previous surgery of esophageal atresia or tracheo-esophageal fistulae, and five other patients were operated on for gastroesophageal reflux. Postoperative tidal expiratory flow (TEF25%) was compared to age-related values.

RESULTS

Mean follow-up was 7.8 years (range: 13 months to 10.7 years). There was no early or late mortality. Most patients (n = 16) showed immediate and permanent relief of symptoms. Compared to corresponding age groups, median TEF25% was slightly but not significantly decreased after aortopexy (p = 0.15). In one patient a re-aortopexy was necessary. Another patient experienced recurrent tracheo-esophageal fistula 3 years after aortopexy.

CONCLUSIONS

The bronchoscopically guided aortopexy is an efficient and simple method in the surgical treatment of TM in infants and children. The follow-up data in this series of 20 patients showed improvement of respiratory function and permanent relief of symptoms in the long term.

Esophageal atresia and diverticulum of Kommerell

Diverticulum of Kommerell is an outpouching from the descending aorta that, along with an aberrant subclavian artery and ductus arteriosus, may form a vascular ring compressing the trachea and/or the esophagus. It has been reported as an incidental finding as well as the cause of persistent dysphagia, cough, "asthma," or airway compromise at various ages but has never been reported as a cause of esophageal atresia in a newborn. We present a newborn with diverticulum of Kommerell, a vascular ring, and esophageal atresia.

Chromosomal anomalies in the aetiology of oesophageal atresia and tracheo-oesophageal fistula

Oesophageal atresia (OA) and tracheo-oesophageal fistula (TOF) are severe congenital anomalies of which the aetiology is largely unknown. Several chromosomal anomalies have been described in patients presenting with these anatomical malformations, but until now none of these has led to the identification of a single aetiological factor. This paper reviews the chromosomal abnormalities reported in cases of OA/TOF and serves as a starting point to identify chromosomal regions harbouring genes involved in the aetiology of OA/TOF.

Esophageal atresia. Lessons I have learned in a 40-year experience

A brief resume of the highlights in the history of oesophageal atresia is presented. This is followed by research into the etiology, ontogeny and embryology, and microbiological studies. A revised classification of risk factors with consequent survival statistics is presented. Lessons learned in the management of the condition over a 40-year period are reported with particular emphasis on the management of the preterm infant with associated severe respiratory distress, right-side aortic arch, upper pouch fistula, 'long-gap' atresia, and the use of gastrostomy and intercostals drains. The incidence and treatment of early and late complications is discussed.

Pathogenesis of apparent life-threatening events in infants with esophageal atresia

Many infants with a repaired esophageal atresia (EA) undergo fundoplication, aortopexy, or glossopexy because the mechanisms most responsible for airway obstruction and/or apparent life-threatening event (AO/ALTE) syndrome are considered to be gastroesophageal reflux (GER), tracheal compression (TC), or obstructive apnea, respectively. In the present study, we investigated whether these mechanisms are independent or interrelated. We developed a database of 120 consecutive patients with EA treated by the senior author between 1967-2002. We studied the clinical manifestations of patients with a cervical esophagostomy and/or blind lower esophageal stump, which ruled out TC and/or proximal esophageal GER as a mechanism for AO/ALTE. Of 25 neonates who underwent section/ligation of lower tracheo-esophageal fistula and/or feeding gastrostomy, 10 critically ill neonates died. Of 15 survivors, 9 infants had a feeding gastrostomy without an esophagostomy. Of these, 6 infants presented one or more episodes of AO, and 8 presented ALTE with or without AO. Subsequently, 5 of the 9 infants underwent an esophagostomy. Eventually, 11 infants had a feeding gastrostomy with an esophagostomy. Of the latter, 5 infants presented one or more episodes of AO, and 6 presented ALTE without AO. In conclusion, oral feeding, proximal esophageal GER, and TC are not essential for AO/ALTE syndrome to occur. They are probably factors which offer evidence of an underlying problem with control of upper airway patency.

Mortality and long term morbidity in esophageal atresia: the reduced impact of low birth weight and maturity on surgical outcome

Progress in perinatal and postoperative techniques has reduced the prognostic role of traditional risk factors in esophageal atresia (EA). This paper reports on 75 cases of esophageal anomalies observed between 1992 and 2002 and followed after surgery from a minimum of six months to a maximum of ten years (mean five years). The impact on survival of birth weight, week of delivery, associated anomalies and need of ventilatory support at birth are discussed. Twenty-four patients were born before 37 weeks of gestation, 18 weighed less than 2000 g.; major anomalies affected 11 neonates, 23 cases required mechanical ventilation at birth. Seventy-four patients were operated on with a 90.6% survival rate; no deaths were related to surgical treatment. Three cases required reoperation for postoperative complications. Birth weight and week of delivery did not seem to influence outcome; this is affected by severe associated cardiovascular anomalies and the need of ventilation at birth. Follow up at 24 months on 51 patients, revealed respiratory problems in 12 cases and severe gastro-esophageal reflux in 16. This affected quality of life of EA patients and required long term medical attention; improvement with growth was observed. No correlation between perinatal conditions and late sequelae could be demonstrated in our series.

Defective sonic hedgehog signaling in esophageal atresia with tracheoesophageal fistula

BACKGROUND

The pathogenesis of esophageal atresia and tracheoesophageal fistula (EA/TEF) remains unknown. We have found previously that an initial esophageal atresia, followed by an abnormal (absent) branching pattern of the middle branch of a trifurcation of the lung/tracheal bud, leads to the neonatal finding of TEF. Mice null mutant for hedgehog signaling can experience the development of EA/TEF, but the mechanism for this development is also unknown. Given that EA/TEF in humans appears not to be due to genetic defects, a hedgehog mutation cause seems very unlikely. However, defective hedgehog signaling that is caused by environmental effects in the human embryo likely could be implicated. We studied a teratogen-induced model of EA/TEF to determine the mechanism by which defective hedgehog signaling may lead to EA/TEF.

METHODS

We injected Adriamycin into pregnant rats to induce EA/TEF in rat embryos. We first quantified sonic hedgehog (Shh) signaling pathway molecule expression using real-time, semiquantitative reverse-transcriptase polymerase chain reaction for Shh, Shh receptors (patched and smoothened), and downstream intracellular targets of those receptors (Gli family members). On the basis of these findings, we then developed an in vitro culture system for the day-12 embryonic TEF and manipulated Shh signaling using either exogenous Shh or Shh inhibitors.

RESULTS

By reverse transcriptase-polymerase chain reaction, a unique difference between the fistula tract and control tissues was that Gli-2 (downstream signaling molecule of Shh) messenger RNA levels were much lower in the fistula tract than in the adjacent esophagus (P =.002). Surprisingly, in the culture experiments, the fistula tract was induced to branch by exogenous Shh. Such branching of the fistula was unexpected and further supports the presumed respiratory origin of the fistula tract because the normal lung, but not normal esophagus, branched in response to Shh. The Shh inhibitor had no effect, which indicated that defective signaling, rather than hyperfunctioning Shh, is critical to the nonbranching phenotype of the fistula tract in TEF.

CONCLUSIONS

The recapitulation of respiratory developmental morphogenesis by the fistula tract of TEF in the presence of exogenous Shh, together with the quantitative reduction in normal, endogenous levels of Gli-2, strongly suggests that 1 mechanism for the formation of the fistula tract is the lack of proper Shh signaling because of Gli-2 deficiency, with subsequent straight, nonbranching caudal growth of the fistula tract. This deficiency can be rescued by excess exogenous Shh, thus reestablishing respiratory morphogenesis.

DEB test for Fanconi anemia detection in patients with atypical phenotypes

Pancytopenia, hyperpigmentation, small stature, congenital abnormalities, and predisposition to neoplasia characterize Fanconi anemia (FA). The clinical phenotype is extremely variable, therefore the diagnosis is frequently delayed until the pancytopenia appears, making diagnosis difficult on the basis of clinical manifestations alone. Hypersensitivity of FA cells to the clastogenic effect of diepoxybutane (DEB) provides a unique marker for the diagnosis before the beginning of hematological manifestations. Our aim in this study was to detect FA in children with atypical manifestations to define which conditions should be routinely included in the DEB test screening. We performed the chromosomal breakage test in 34 patients with probable FA and 83 patients with clinical conditions that could suggest FA, but are not usually screened by the DEB test: 20 patients with aplastic anemia, 20 patients with VACTERL association, 20 with radial ray abnormalities, 7 with tracheo-esophageal fistulae, 12 with anal atresia, and 4 with myelodysplastic syndrome. We found 18 DEB-positive patients: 12 were in the group of probable FA and 6 in the other groups. Among the last ones: three were included because of aplastic anemia, without any other sign of FA, however when re-examined, other anomalies were detected. The third patient had anal atresia, renal hypoplasia, pre-axial polydactyly, and normal blood cell counts and was diagnosed as having VACTERL association. The other two patients lacking physical or hematological signs were identified among the group of radial ray abnormalities. Thus, our results highlight the need to increase the number of abnormalities indicating need for a DEB test. Delay in the diagnosis of FA may have serious consequences for the patients and their family members.

Radionuclide scintigraphy in the evaluation of gastro-oesophageal reflux in post-operative oesophageal atresia and tracheo-oesophageal fistula patients

Gastro-oesophageal reflux (GOR) is a major cause of morbidity in children who undergo surgical repair for oesophageal atresia with tracheo-oesophageal fistula (OA/TOF). We performed a retrospective analysis to determine the incidence of GOR on radionuclide scintigraphy in symptomatic and asymptomatic OA/TOF patients in the first post-operative year. A total of 124 patients (74 males, 50 females), with a mean age of 3.5 months (range, 20 days to 12 months), were studied. Of these 124 patients, 67 were symptomatic and 57 were asymptomatic. On radionuclide scintigraphy, 73 patients (48 symptomatic and 25 asymptomatic) had reflux. Of the 48 symptomatic patients with scintigraphic studies positive for reflux, 79.2% (38) had proximal reflux and 20.8% (10) had distal reflux, whereas, of the 57 asymptomatic patients, 48% (12) had proximal reflux and 52% (13) had distal reflux. There was a significantly higher incidence of GOR in symptomatic children than in asymptomatic children (P<0.01). In particular, there was a significantly higher incidence of proximal GOR in symptomatic children than in asymptomatic children (P<0.001). In conclusion, the severity and incidence of GOR were significantly higher in symptomatic than asymptomatic OA/TOF patients in their first post-operative year. Scintigraphic evidence of proximal reflux correlates with the presence of symptomatic GOR.

A role for sonic hedgehog signaling in the pathogenesis of human tracheoesophageal fistula

BACKGROUND/PURPOSE

Many theories of the pathogenesis of esophageal atresia with tracheoesophageal fistula (EA/TEF) have been proposed, but no specific mechanism has been demonstrated. The authors previously reported data suggesting a respiratory origin of the fistula tract in the rat model and in humans. Sonic hedgehog (Shh) "knockout" mice have the VACTERL association, and thus it was hypothesized that defects in Shh signaling may exist in the human neonatal EA/TEF fistula tract.

METHODS

With IRB approval, human proximal esophageal pouch and distal fistula samples were removed at the time of standard repair of EA/TEF in accordance with what the surgeons deemed appropriate in preparation for anastomosis. Tissues were processed for HE, reverse-transcriptase polymerase chain reaction (RT-PCR), and immunohistochemistry. Normal embryonic lung cDNA was used as a positive control for the RT-PCR reactions.

RESULTS

As expected, Shh was present by immunohistochemistry in the proximal esophageal pouch, but was specifically absent in the distal fistula tract. Gli-1, -2, and -3 (all intracellular mediators of Shh signaling) were present in the proximal pouch and distal esophagus by RT-PCR.

CONCLUSIONS

The absence of Shh signaling in the developing fistula tract of the human neonate was surprising given that Shh normally is present in esophagus and other gut components. These results support the conclusion that the fistula tract is not an esophaguslike structure, despite both its histologic appearance and its use as an esophageal replacement. Also, like in Shh-null mutant mice, aberrant Shh signaling may play a critical role in the pathogenesis of EA/TEF in humans.

Gastrointestinal malformations in two infants born to women with hyperthyroidism untreated in the first trimester

We report two infants with gastrointestinal anomalies: one with esophageal atresia and tracheo-esophageal fistula and the other with biliary tree atresia, born to hyperthyroid women diagnosed and treated with methimazole after 14 weeks' gestation. Euthyroidism was documented in both infants. These cases raise the issue of whether untreated hyperthyroidism and not methimazole intake is the teratogen.

Evidence of a common pathogenesis for foregut duplications and esophageal atresia with tracheo-esophageal fistula

The pathogenesis of the alimentary tract duplications, including foregut duplications (FgD) remains speculative. The accidental finding of FgD in fetal rats with esophageal atresia and tracheoesophageal fistula (EA-TEF) induced by Adriamycin provided an animal model to investigate a possible relationship between these two entities. Timed-pregnant rats were intraperitoneally injected with Adriamycin (1.75 mg/kg) on gestational Days 6 to 9. Their embryos were harvested by Caesarean section from gestational Days 14 to 21. Forty-six of embryos were processed and serially sectioned in the transverse or sagittal planes. EA-TEF occurred in 43/46 (93%) embryos of which 11 (24%) were found to have an associated FgD located at the level where the esophagus was absent. Six FgDs communicated with the foregut or the trachea. Five noncommunicating FgDs were located between the foregut and the vertebral column. In the control embryo, the notochord was located in the centre of the vertebral column from Day 11 of the gestation. In Day 14, 15 and 16, however, embryos exposed to Adriamycin, an abnormal notochord or branch frequently was located within the mesenchyme of the maldeveloped foregut or attached to the duplication cyst. In some, it appeared that the notochord was drawing the cyst-like structure away from the foregut. The present study confirms that duplications adjacent to the esophagus arise from the foregut and that failure of the foregut to detach from the notochord at the normal time may contribute to the development of foregut duplications.

[Tracheomalacia and tracheal dyskinesias]

Tracheomalacia is characterized by an expiratory tracheal collapse. The revealing clinical features usually occur after a symptom-free period during the first year of life (during the first three months in 60% of cases): mainly stridor, wheezing, chronic cough, apnoeic attacks, and difficult breathing. Tracheoscopy allows the differentiation of primary tracheomalacia and tracheomalacia secondary to pressure on the trachea from the vascular ring or mediastinal tumour. Tracheomalacia is also frequently associated with oesophageal atresia. Surgical treatment is indicated in severe and secondary forms.

[Congenital esophageal obstruction caused by complete mucous membrane: a clinical case]

The authors report a case of membranous atresia of the esophagus. Diagnosis of this rare malformation was made intraoperatively, and resection and primary anastomosis were performed immediately. A brief review of the literature is included on the various types of esophageal atresia.

Neural crest-derived defects in experimental esophageal atresia

Esophageal atresia (EA) is often associated with cardiovascular and other malformations that are likely neural crest derived. The present study tests the hypothesis that the heart and great vessels and the thymus and parathyroids may be abnormal in the rat model of EA as a result of disturbed neural crest development. Time-mated pregnant rats received intraperitoneally on d 8 and 9 of gestation either 2 mg/kg adriamycin or vehicle. Esophageal, heart, and thymic malformations were sought under the microscope in term fetuses. The parathyroids were histologically investigated. Control fetuses had no malformations, whereas 69 of 109 fetuses exposed to adriamycin had EA and 45 of 69 had 15 right aortic arches, nine aberrant right subclavia, eight ventricular septal defects, six narrow pulmonary outflow tracts, five tetralogies of Fallot, three double outflow right ventricles, three double aortic arches, three atrial septal defects, three right ductus arteriosus, and two truncus. The thymus was absent in 19, hypoplastic in 12, and ectopic in five out of 36 fetuses with EA in which it was studied, whereas the parathyroid glands were absent in 16, single in four, and ectopic in one of the 23 fetuses with EA in which they were studied. In conclusion, the nature of the cardiovascular, thymic, and parathyroid malformations associated with EA in rats is consistent with the hypothesis of neural crest participation in their pathogenesis. Mechanisms simultaneously disturbing foregut septation, somitic segmentation, and neural crest development should be sought to explain the combined occurrence of malformations in EA.

Relationship of the notochord to foregut development in the fetal rat model of esophageal atresia

BACKGROUND/PURPOSE

The notochord (Nt) is thought to act as a primary organizer for adjacent axial embryonic organs. The current study used the Adriamycin-induced fetal rat model of esophageal atresia and tracheoesophageal fistula (EA-TEF) to determine whether anomalies of the foregut (FG) were associated with an abnormal Nt.

METHODS

Eight experimental female Sprague-Dawley rats received intraperitoneal injection of Adriamycin (1.75 mg/kg) on gestational days 6 to 9 inclusive, and 4 control rats received saline injection only. Their embryos were harvested on gestational days 11, 12, 13, and 14. Embryos from each age subgroup were serially sectioned and stained with H&E. The FG and Nt were traced from the primitive pharynx to the level of the stomach.

RESULTS

By day 11, the Nt of control embryos had completely separated from the FG and was located immediately ventral to the neural tube. On gestational day 12, the Nt detached from the neural tube, and the trachea and esophagus were separating. On day 11, in the Adriamycin-treated embryos, the Nt was still attached to an FG that was narrowed or occluded. On day 12, the Nt remained adherent to the FG from the primitive pharynx to the level above the primitive respiratory buds, at which point it became thicker and branched sagittally, with the anterior branch contacting or merging with the FG. The FG usually loses its lumen or continuity when in contact with the Nt.

CONCLUSIONS

Exposure of rat embryos to Adriamycin leads to abnormal development of the Nt, including prolonged attachment to or fusion with the FG, and abnormal branching. Traction on the FG by the Nt produces occlusion of its lumen and may result in its complete interruption. Separation of the Nt from the FG would appear to be a prerequisite for the normal development of the FG into its derivatives: the esophagus and trachea.

Oesophageal atresia, VACTERL association: Fanconi's anaemia related spectrum of anomalies

Oesophageal atresia usually occurs without any genetic background. Three cases associated with Fanconi's anaemia are reported. One neonate had growth retardation and numerous malformations including oesophageal atresia and four other components of the VACTERL association. In the two others, oesophageal atresia was isolated. In patients with such malformations an early diagnosis of Fanconi's anaemia may have important genetic and therapeutic implications.

A complex communicating bronchopulmonary foregut malformation: diagnostic imaging and pathogenesis

We report a newborn with an esophageal lung, a rare type of communicating bronchopulmonary foregut malformation (CBPFM). Associated findings included esophageal atresia, tracheoesophageal fistula (TEF) to the distal esophagus, duodenal stenosis with annular pancreas, imperforate anus, vertebral anomalies and ambiguous genitalia. Radiologic evaluation included chest radiographs, esophagrams, chest ultrasound and chest CT. After colostomy and surgical repair of duodenal stenosis and TEF, a right thoracotomy was performed to treat an esophageal lung. Radiologic features of this unusual variant of CBPFM are presented. Accurate preoperative imaging diagnosis is essential for planning surgical treatment of an esophageal lung.

Descriptive epidemiology of alimentary tract atresia

A study has been made on certain epidemiological characteristics of infants with alimentary tract atresia: esophageal atresia, small and large gut atresia, and anal atresia. Data were collected from three malformation registries and represent a material of more than 4.5 million births. A total of 3,550 infants with alimentary atresia were identified corresponding to a total rate of about 8 per 10,000 births. In 167 infants (4.7%) more than one of the major atresia types were present simultaneously. Racial differences were found (based on data from California) for esophageal atresia where whites had a higher rate than other races. For gastrointestinal atresia, a high rate in blacks was found, while no differences between races were seen for anal atresia. Also, differences in registered rates between the three programs were found, at least partly explainable by different ascertainment. The different forms of atresia were compared from the point of view of sex ratio, twinning rate, maternal age and parity distribution, presence of chromosome anomalies, and types of associated malformations. The pathogenesis and etiology of the various types of atresia are discussed based on these observations. The conclusion is that although undoubtedly other pathogenetic mechanisms may exist for gastrointestinal atresia, a substantial proportion of all infants with alimentary atresia had their malformations as a result of early disturbances of intestinal morphogenesis. Within each subgroup, apparently different etiologies may exist, resulting in differences in epidemiological characteristics.

Recurrent tracheo-oesophageal fistula: experience with 24 patients

Over an 11 year period, 275 infants with oesophageal atresia and tracheo-oesophageal fistula were treated. Of these, 22 (8%) developed a recurrent fistula. An additional two patients with an established recurrent fistula were referred for secondary surgery. Infants who develop respiratory symptoms associated with feeding following repair of an oesophageal atresia should be investigated urgently with cine-radiography and/or bronchoscopy. Once the diagnosis of a recurrent fistula has been firmly established, operative repair should be undertaken. In our series of 24 patients, there were three deaths (12.5%), four patients developed a second recurrence (16.6%), while a secondary oesphageal replacement was carried out on five patients.

Etiological study on isolated esophageal atresia

A study group of 160 index patients with isolated esophageal atresia, a control group of 160 matched healthy controls, and the first-degree relatives of patients and controls were examined; epidemiological, family planning, teratological, and genetic data were obtained by personal interview in the study and control groups. One half of the index patients were male. Intrauterine growth retardation, a higher proportion of mothers under 19 or over 30 years of age, and less skilled professions of the parents were found in the study group. There were more extramarital conceptions, more pregnancies in spite of the use of contraceptive pills, and more delayed conceptions in index patients' mothers. The teratogens studied did not have an obvious pathological effect here. The sib occurrence of isolated esophageal atresia was 0.43%, which did not correspond too well to the expected figure of 1.34% based on the polygenic model.

The effect of chick embryo hyperflexion on tracheoesophageal development

Chick embryos were hyperflexed by placement of a ligature at two critical stages in the development of the foregut, in order to test the theory that esophageal atresia and tracheoesophageal fistula result from embryonic hyperflexion. Only one "H-type" tracheoesophageal fistula was found. There were no significant disturbances of either tracheal or esophageal growth.

[Atresia of the esophagus caused by bands]

Authors report clinical and anatomopathological findings in two cases esophageal atresia. Authors found in one of them an anomalous vessel crossing the atresic cord and gastric epithelium in the lower pouch. Authors try to explain the pathogenesis of this atresia.

An epidemiologic study of tracheoesophageal fistula and esophageal atresia in North Carolina

Two hundred and eighty-five cases of TEF/EA occurring in North Carolina from 1952-1978 were reviewed. Except for a greater incidence of low-birth-weight infants and hydramnios during pregnancy, the cases appeared to be representative of the population. Clustering of cases over time was statistically confirmed. The cyclic variation suggested an association with an infectious agent. The variation of reported infectious hepatitis cases during the period of this study resembled the variation of TEF/EA cases that had no other documented congenital malformations.