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Newland N, Snajdauf J, Kokesova A, Styblova J, Hradsky O, Meusel I, Kucerova B, Kyncl M, Simsova M, Mixa V, Rygl M. Anastomotic stricture prediction in patients with esophageal atresia with distal fistula. Pediatr Surg Int 2023; 39:136. [PMID: 36811679 PMCID: PMC9947071 DOI: 10.1007/s00383-023-05423-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/07/2023] [Indexed: 02/24/2023]
Abstract
PURPOSE To investigate potential early risk factors for anastomotic stricture formation and assess the predictive role of post-operative esophagrams. METHODS A retrospective study of patients with esophageal atresia with distal fistula (EA/TEF) operated between 2011 and 2020. Fourteen predictive factors were tested for stricture development. Esophagrams were used to calculate early (SI1) and late (SI2) stricture index (SI = anastomosis diameter/upper pouch diameter). RESULTS Of 185 patients operated for EA/TEF in the 10-year period, 169 patients met the inclusion criteria. Primary anastomosis was performed in 130 patients and delayed anastomosis in 39 patients. Stricture formed in 55 patients (33%) within 1 year from anastomosis. Four risk factors showed strong association with stricture formation in unadjusted models: long gap (p = 0.007), delayed anastomosis (p = 0.042), SI1 (p = 0.013) and SI2 (p < 0.001). A multivariate analysis showed SI1 as significantly predictive of stricture formation (p = 0.035). Cut-off values using a receiver operating characteristic (ROC) curve were 0.275 for SI1 and 0.390 for SI2. The area under the ROC curve demonstrated increasing predictiveness from SI1 (AUC 0.641) to SI2 (AUC 0.877). CONCLUSIONS This study identified an association between long gap and delayed anastomosis with stricture formation. Early and late stricture indices were predictive of stricture formation.
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Affiliation(s)
- Natalia Newland
- Department of Pediatric Surgery, 2nd Faculty of Medicine, Charles University in Prague and Motol University Hospital, Prague, Czech Republic.
| | - Jiri Snajdauf
- Department of Pediatric Surgery, 2nd Faculty of Medicine, Charles University in Prague and Motol University Hospital, Prague, Czech Republic
| | - Alena Kokesova
- Department of Pediatric Surgery, 2nd Faculty of Medicine, Charles University in Prague and Motol University Hospital, Prague, Czech Republic
| | - Jitka Styblova
- Department of Pediatric Surgery, 2nd Faculty of Medicine, Charles University in Prague and Motol University Hospital, Prague, Czech Republic
| | - Ondrej Hradsky
- Department of Pediatric Gastroenterology, 2nd Faculty of Medicine, Charles University in Prague and Motol University Hospital, Prague, Czech Republic
| | - Isabel Meusel
- Second Faculty of Medicine, Charles University in Prague and Motol University Hospital, Prague, Czech Republic
| | - Barbora Kucerova
- Department of Pediatric Surgery, 2nd Faculty of Medicine, Charles University in Prague and Motol University Hospital, Prague, Czech Republic
| | - Martin Kyncl
- Department of Radiology, 2nd Faculty of Medicine, Charles University in Prague and Motol University Hospital, Prague, Czech Republic
| | - Magdalena Simsova
- Department of Pediatric Surgery, 2nd Faculty of Medicine, Charles University in Prague and Motol University Hospital, Prague, Czech Republic
| | - Vladimir Mixa
- Department of Anesthesiology and ICM, 2nd Faculty of Medicine, Charles University in Prague and Motol University Hospital, Prague, Czech Republic
| | - Michal Rygl
- Department of Pediatric Surgery, 2nd Faculty of Medicine, Charles University in Prague and Motol University Hospital, Prague, Czech Republic
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2
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Aumar M, Sfeir R, Pierache A, Turck D, Gottrand F. Predictors of anastomotic strictures following œsophageal atresia repair. Arch Dis Child Fetal Neonatal Ed 2022; 107:545-550. [PMID: 35217569 DOI: 10.1136/archdischild-2021-322577] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 01/05/2022] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To identify the risk factors for anastomotic, refractory and recurrent strictures and to establish whether anastomotic stricture is associated with antireflux surgery. DESIGN This prospective national multicentre study included all infants born with oesophageal atresia (OA) over an 8-year period. Data on OA and complications were collected at birth and at 1 year old. Univariate and multivariate analyses were conducted. RESULTS 1082 patients from 37 centres were included in the study. The prevalence of anastomotic stricture at 1 year old was 23.2%. Anastomosis under tension (defined by the surgeon at the time of repair) and delayed anastomosis (defined as anastomosis performed more than 15 days after birth, excluding delays due to prematurity or severe cardiac diseases) were found to be independent risk factors for anastomotic stricture (2.3 (1.42-3.74) and 4.02 (2.12-7.63), respectively). Patients with anastomotic stricture had a 2.3-fold higher rate of fundoplication compared with others (p=0.001). Anastomosis under tension and delayed anastomosis were found to be independent risk factors for recurrent stricture (1.92 (1.10-3.34) and 5.73 (2.71-12.14), respectively), while delayed anastomosis was the only risk factor for refractory stricture (8.30 (3.34-20.64)). There was a 2.39-fold (1.42-4.04) higher rate of fundoplication in the anastomotic stricture group than in the group without anastomotic stricture (p=0.001). CONCLUSIONS Patient-related anatomical factors leading to anastomosis under tension and delayed anastomosis increase the risk of anastomotic stricture.
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Affiliation(s)
- Madeleine Aumar
- Univ Lille, CHU Lille, Reference Centre for Chronic and Malformative Esophageal Diseases (CRACMO), Inserm U1286 Infinite, CHU Lille Pôle Enfant, Lille, France .,Univ Lille, Inserm, CHU Lille, U1286 - Infinite - Institute for Translational Research in Inflammation, University of Lille, Lille, France
| | - Rony Sfeir
- Univ Lille, CHU Lille, Reference Centre for Chronic and Malformative Esophageal Diseases (CRACMO), Inserm U1286 Infinite, CHU Lille Pôle Enfant, Lille, France
| | - Adeline Pierache
- Univ Lille, CHU Lille, ULR 2694 - METRICS: évaluation des technologies de santé et des pratiques médicales, Lille University Hospital Center, Lille, France
| | - Dominique Turck
- Univ Lille, CHU Lille, Reference Centre for Chronic and Malformative Esophageal Diseases (CRACMO), Inserm U1286 Infinite, CHU Lille Pôle Enfant, Lille, France.,Univ Lille, Inserm, CHU Lille, U1286 - Infinite - Institute for Translational Research in Inflammation, University of Lille, Lille, France
| | - Frederic Gottrand
- Univ Lille, CHU Lille, Reference Centre for Chronic and Malformative Esophageal Diseases (CRACMO), Inserm U1286 Infinite, CHU Lille Pôle Enfant, Lille, France.,Univ Lille, Inserm, CHU Lille, U1286 - Infinite - Institute for Translational Research in Inflammation, University of Lille, Lille, France
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3
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Muensterer OJ, Evans LL, Sterlin A, Sahlabadi M, Aribindi V, Lindner A, König T, Harrison MR. Novel Device for Endoluminal Esophageal Atresia Repair: First-in-Human Experience. Pediatrics 2021; 148:peds.2020-049627. [PMID: 34615695 DOI: 10.1542/peds.2020-049627] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/20/2021] [Indexed: 12/22/2022] Open
Abstract
Thoracoscopic esophageal atresia (EA) repair affords many benefits to the patient; however, intracorporeal suturing of the anastomosis is technically challenging. Esophageal magnetic compression anastomosis (EMCA) is a compelling option for endoluminal EA repair, but available EMCA devices have prohibitive rates of recalcitrant stricture. Connect-EA is a new endoluminal EMCA device system that employs 2 magnetic anchors with a unique mating geometry designed to reliably create a robust anastomosis and decrease rates of leak and stricture. We describe our first-in-human experience with this novel endoluminal device for staged EA repair in 3 patients (Gross type A, B, and C) at high risk for conventional surgical repair. First, the esophageal pouches were approximated thoracoscopically. After acute tension subsided, the device anchors were endoscopically placed in the esophageal pouches and mated. Anchors were spontaneously excreted in 2 cases. Endoscopic repositioning and retrieval of the anchors were required in 1 patient because of narrowed esophageal anatomy. There were no perioperative complications. Patients were managed for 14 to 18 months. The strictures that developed in the patients were membranous and responded well to dilation alone, resolving after 4 to 5 outpatient dilations. Gastrostomies were closed between 6 and 11 months and all patients are tolerating full oral nutrition. Early experience with this new endoluminal EMCA device system is highly favorable. The device offers considerable benefit over conventional handsewn esophageal anastomosis and anastomotic outcomes are superior to available EMCA devices.
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Affiliation(s)
- Oliver J Muensterer
- Department of Pediatric Surgery, Johannes Gutenberg University Mainz, Mainz, Germany .,Department of Pediatric Surgery, Dr. von Hauner Children's Hospital, Ludwig-Maximilians-University of Munich, Munich, Germany
| | - Lauren L Evans
- Division of Pediatric Surgery, Department of Surgery, University of California San Francisco, San Francisco, California
| | - Alexander Sterlin
- Department of Pediatric Surgery, Johannes Gutenberg University Mainz, Mainz, Germany
| | - Mohammad Sahlabadi
- Division of Pediatric Surgery, Department of Surgery, University of California San Francisco, San Francisco, California
| | - Vamsi Aribindi
- Division of Pediatric Surgery, Department of Surgery, University of California San Francisco, San Francisco, California
| | - Andreas Lindner
- Department of Pediatric Surgery, Johannes Gutenberg University Mainz, Mainz, Germany.,Department of Pediatric Surgery, Dr. von Hauner Children's Hospital, Ludwig-Maximilians-University of Munich, Munich, Germany
| | - Tatjana König
- Department of Pediatric Surgery, Johannes Gutenberg University Mainz, Mainz, Germany
| | - Michael R Harrison
- Division of Pediatric Surgery, Department of Surgery, University of California San Francisco, San Francisco, California
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4
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Huang J, Liao J, Yang S, Zhang Y, Zhao Y, Gu Y, Hua K, Li S, Xia L, Cai S. Anastomotic stricture indexes for endoscopic balloon dilation after esophageal atresia repair: a single-center study. Dis Esophagus 2021; 34:5907946. [PMID: 32944735 DOI: 10.1093/dote/doaa103] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 07/25/2020] [Accepted: 08/21/2020] [Indexed: 12/11/2022]
Abstract
We investigated changes in anastomotic stricture indexes (SIs) and stricture diameter (SD) between before and 6 months after the first dilatation in children with anastomotic stricture after esophageal atresia (EA) repair and identified predictors of medium-term dilatation success (success for at least 3 months). We retrospectively reviewed the records and measurement indexes of patients who underwent post-EA repair endoscopic balloon dilatation between November 2017 and August 2019 in our hospital. We identified diagnostic and performance indicators that predicted medium-term dilatation success by univariate and multivariate analyses and receiver operator characteristic (ROC) curve analysis. Sixty patients (34 boys and 26 girls) showed post-EA repair anastomotic stricture. Paired sample t-tests showed that SD (P < 0.001), upper pouch SI (U-SI, P < 0.001), lower pouch SI (L-SI, P < 0.001), upper pouch esophageal anastomotic SI (U-EASI, P < 0.001) and lower pouch EASI (L-EASI, P < 0.001) were significantly better at 6 months after than before the first dilatation. Logistic regression analysis showed that dilatation number (P = 0.002) and U-SI at 6 months after the first dilatation (P = 0.019) significantly predicted medium-term dilatation success. ROC curve analysis revealed that combining U-SI (cut-off value = 55.6%) and dilatation number (cut-off value = 10) had good accuracy in predicting medium-term dilatation success 6 months after the first dilatation (area under the curve-ROC: 0.95). In conclusion, endoscopic balloon dilatation significantly improved SD and SIs in children with post-EA repair anastomotic stricture. Dilatation number and U-SI at 6 months after the first dilatation were useful in predicting medium-term dilatation success and could represent a supplementary method to improve judgment regarding whether further dilatation is needed 6 months after the first dilatation.
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Affiliation(s)
- Jinshi Huang
- Department of Neonatal Surgery, The Affiliated Children's Hospital of Nanchang University, Nanchang, China
| | - Junmin Liao
- Department of Neonatal Surgery, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Shen Yang
- Department of Neonatal Surgery, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Yanan Zhang
- Department of Neonatal Surgery, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Yong Zhao
- Department of Neonatal Surgery, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Yichao Gu
- Department of Neonatal Surgery, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Kaiyun Hua
- Department of Neonatal Surgery, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Shuangshuang Li
- Department of Neonatal Surgery, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Leizhen Xia
- Assisted Reproductive Center, Jiangxi Maternal and Child Health Hospital, Nanchang, China
| | - Siyu Cai
- Center for Clinical Epidemiology & Evidence-based Medicine, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
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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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6
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Baghdadi O, Clark S, Ngo P, Yasuda J, Staffa S, Zendejas B, Hamilton T, Jennings R, Manfredi M. Initial Esophageal Anastomosis Diameter Predicts Treatment Outcomes in Esophageal Atresia Patients With a High Risk for Stricture Development. Front Pediatr 2021; 9:710363. [PMID: 34557459 PMCID: PMC8452953 DOI: 10.3389/fped.2021.710363] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Accepted: 08/04/2021] [Indexed: 12/14/2022] Open
Abstract
Background and Aims: Children with esophageal atresia (EA) who undergo surgical repair are at risk for anastomotic stricture, which may need multiple dilations or surgical resection if the stricture proves refractory to endoscopic therapy. To date, no studies have assessed the predictive value of anastomotic diameter on long-term treatment outcomes. Our aim was to evaluate the relationship between anastomotic diameter in the early postoperative period and need for frequent dilations and stricture resection within 1 year of surgical repair. Methods: A retrospective chart review was performed of patients who had EA repair or stricture resection (SR). Medical records were reviewed to evaluate the diameter of the anastomosis at the first endoscopy after surgery, number and timing of dilations needed to treat the anastomotic stricture, and need for stricture resection. A generalized estimating equations (GEE) modeling with a logit link and binomial family was done to analyze the relationship between initial endoscopic anastomosis diameter and the outcome of needing a stricture resection. Median regression was implemented to estimate the association between number of dilations needed based on initial diameter. Results: A total of 121 patients (56 females) with a history of EA (64% long-gap EA) were identified who either underwent Foker repair at 46% or stricture resection with end-to-end esophageal anastomosis at 54%. The first endoscopy occurred a median of 22 days after surgery. Among all cases, a narrower anastomoses were more likely to need stricture resection with an OR of 12.9 (95% CI, 3.52, 47; p < 0.001) in patients with an initial diameter of <3 mm. The number of dilations that patients underwent also decreased as anastomotic diameter increased. This observation showed a significant difference when comparing all diameter categories when looking at all surgeries taken as a whole (p < 0.008). Conclusion: Initial anastomotic diameter as assessed via endoscopy performed after high-risk EA repair predicts which patients will require more esophageal dilations as well as the likelihood for stricture resection. This data may serve to stratify patients into different endoscopic treatment plans.
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Affiliation(s)
- Osama Baghdadi
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA, United States
- *Correspondence: Osama Baghdadi
| | - Susannah Clark
- Department of Surgery, Boston Children's Hospital, Boston, MA, United States
| | - Peter Ngo
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA, United States
| | - Jessica Yasuda
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA, United States
| | - Steven Staffa
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA, United States
| | - Benjamin Zendejas
- Department of Surgery, Boston Children's Hospital, Boston, MA, United States
| | - Thomas Hamilton
- Department of Surgery, Boston Children's Hospital, Boston, MA, United States
| | - Russell Jennings
- Department of Surgery, Boston Children's Hospital, Boston, MA, United States
| | - Michael Manfredi
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA, United States
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7
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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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Takahashi N, Fuchimoto Y, Mori T, Abe K, Yamada Y, Koinuma G, Kuroda T. Post-esophageal atresia repair double acquired tracheoesophageal fistulas treated successfully by gastric transposition: a case report. Surg Case Rep 2020; 6:224. [PMID: 32975613 PMCID: PMC7519015 DOI: 10.1186/s40792-020-01004-7] [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: 07/17/2020] [Accepted: 09/19/2020] [Indexed: 11/27/2022] Open
Abstract
Background Postoperative recurrence of tracheoesophageal fistula (TEF) is a frequent complication in the repair of esophageal atresia (EA). Based on the recent etiologic classification, a TEF that develops in a different new pathway from the original one is categorized as an acquired TEF. The TEFs that fall into this category have been reported to be refractory and their mechanisms have not been fully understood. Here, we report the complicated case of an acquired TEF derived from mediastinitis after the original TEF repair developed an anastomotic stricture. The TEF contained double fistulas, both towards the right lobe bronchi, and was repaired by gastric transposition through a retrosternal route. Case presentation The patient was diagnosed with Gross C esophageal atresia after birth and underwent tracheoesophageal fistula banding during the neonatal period. He experienced an intractable anastomotic stenosis after surgery which was treated with repeated balloon dilation therapy. By the age of 11 months, he developed a mediastinal abscess that improved with conservative treatment. At 18 months old, a fistula from the esophagus to the right superior lobe bronchus was identified. The patient underwent a right upper lobectomy to resect the fistula. However, at 21 months old, another fistula to the right lower lobe was revealed. An esophageal banding was done to relieve the respiratory symptoms. This was followed by esophagectomy and gastric transposition through the retrosternal route at 26 months old. The patient started rehabilitation and oral intake gradually after surgery. By 3 years after gastric transposition, he could already take blended food orally with the support of small amounts of enteral feeding. Conclusion Cases of TEF derived from severe inflammation have the potential to form a complicated network and lead to recurrence. Surgeons should consider the possibility of multiple tiny fistulas in cases of severe acquired TEF. These may be repaired successfully by gastric transposition through the retrosternal route.
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Affiliation(s)
- Nobuhiro Takahashi
- Department of Pediatric Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Yasushi Fuchimoto
- Department of Pediatric Surgery, Keio University School of Medicine, Tokyo, Japan. .,Department of Pediatric Surgery, International University of Health and Welfare, 852 Hatakeda, Narita, Chiba, Japan.
| | - Teizaburo Mori
- Department of Pediatric Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Kiyotomo Abe
- Department of Pediatric Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Yohei Yamada
- Department of Pediatric Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Goro Koinuma
- Department of Pediatrics, Keio University School of Medicine, Tokyo, Japan.,Pediatric Pulmonology, National Center for Child Health and Development, Tokyo, Japan
| | - Tatsuo Kuroda
- Department of Pediatric Surgery, Keio University School of Medicine, Tokyo, Japan
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9
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Parente G, Gargano T, Ruggeri G, Maffi M, D'Antonio S, Sacchet E, Lima M. Anastomotic Stricture Definition After Esophageal Atresia Repair: Role of Endoscopic Stricture Index. J Surg Res 2020; 257:572-578. [PMID: 32927323 DOI: 10.1016/j.jss.2020.08.035] [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] [Received: 06/10/2020] [Revised: 07/30/2020] [Accepted: 08/03/2020] [Indexed: 12/27/2022]
Abstract
BACKGROUND To evaluate the feasibility and efficacy of endoscopic stricture index (SIEN) to define anastomotic strictures (ASs) and to predict the need of dilatations. MATERIALS AND METHODS A retrospective longitudinal study was conducted on patients who underwent esophageal atresia repair from 1998-2020 (ethical committee approval CHPED-05-20-AS). SIEN was calculated on the first endoscopy performed as follows: (D - d)/D, where D is the maximum diameter of lumen of the upper esophagus close to the AS and d is the diameter of lumen of the stricture. Nonparametric variables were examined using Wilcoxon-Mann-Whitney test, and continuous variables were analyzed using Spearman's test and regression analysis. A P value <0.05 was considered statistically significant. The sensitivity, specificity, and positive and negative predictive values of SIEN were also calculated, and a receiver operating characteristic curve was designed. RESULTS A total of 46 patients were included in the study. A statistically significant correlation was found between SIEN and number of dilations (Spearman's correlation rate, 0.7; P < 0.0005). A SIEN threshold value ≥0.6 showed sensitivity of 100%, specificity of 80%, positive predictive value of 54%, negative predictive value of 100%, and the area under the curve of 84%. CONCLUSIONS SIEN seems to be a good AS definer and prognostic tool; our study suggests that an AS could be defined by a SIEN ≥0.6.
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Affiliation(s)
- Giovanni Parente
- Department of Pediatric Surgery, Sant'Orsola-Malpighi University Hospital, Bologna, Italy.
| | - Tommaso Gargano
- Department of Pediatric Surgery, Sant'Orsola-Malpighi University Hospital, Bologna, Italy
| | - Giovanni Ruggeri
- Department of Pediatric Surgery, Sant'Orsola-Malpighi University Hospital, Bologna, Italy
| | - Michela Maffi
- Department of Pediatric Surgery, Sant'Orsola-Malpighi University Hospital, Bologna, Italy
| | - Simone D'Antonio
- Department of Pediatric Surgery, Sant'Orsola-Malpighi University Hospital, Bologna, Italy
| | - Elisa Sacchet
- Department of Pediatric Surgery, Sant'Orsola-Malpighi University Hospital, Bologna, Italy
| | - Mario Lima
- Department of Pediatric Surgery, Sant'Orsola-Malpighi University Hospital, Bologna, Italy
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10
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Bawazir O, Almaimani MO. Complications of esophageal strictures dilatation in children. A tertiary-center experience. Saudi Med J 2020; 41:720-725. [PMID: 32601640 PMCID: PMC7502932 DOI: 10.15537/smj.2020.7.25166] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES To report the results of endoscopic dilatation of esophageal strictures in children, its complications, and their management. The outcomes of esophageal dilatation differ according to the underlying etiology. METHODS The study included 46 patients who underwent esophageal dilatation between 2014-2019. All patients underwent a contrast study of the esophagus before endoscopic dilation to determine the location, number, and length of the narrowing. In addition, the type of dilators (balloon versus semi-rigid dilators), the number of dilatation sessions, the interval between them, and the duration of follow-up were also documented. The median age was 2.47 years, and 26 patients were females. Dysphagia was the main presenting symptom, and the leading cause of stricture was esophageal atresia. RESULTS The main treatment modality was endoscopic balloon dilatation (n=29, 63%). The esophageal diameter was significantly increased after dilation (9 [7-11] versus 12 [10-12.8]) mm; p less than 0.001). Topical mitomycin-C was used as adjuvant therapy in 3 patients (6.5%). Esophageal perforation was reported in 2 cases (4.3%). Patients needed a median of 3 dilatation sessions, 25-75th percentiles: 1-5, and the median duration between the first and last dilatation was 2.18 years 25-75th percentiles: 0.5-4.21. CONCLUSION Esophageal dilatation is effective for the management of children with esophageal stricture; however, repeated dilatation is frequent, especially in patients with corrosive strictures. Complications are not common, and open surgery is not frequently required.
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Affiliation(s)
- Osama Bawazir
- Department of Surgery, Faculty of Medicine, Umm Al-Qura University, Makkah, Kingdom of Saudi Arabia. E-mail.
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11
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Chiang CM, Hsu WM, Chang MH, Hsu HY, Ni YH, Chen HL, Wu JF. Risk factors and management for anastomotic stricture after surgical reconstruction of esophageal atresia. J Formos Med Assoc 2020; 120:404-410. [PMID: 32586720 DOI: 10.1016/j.jfma.2020.06.020] [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] [Received: 02/06/2020] [Revised: 06/01/2020] [Accepted: 06/17/2020] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND/PURPOSE Anastomotic stricture (AS) is a major morbidity of patients with esophageal atresia (EA) after surgical reconstruction. Our study determined the risk factors of AS after EA reconstruction. The therapeutic efficacy and complications of esophageal dilatation for children with AS were also evaluated. METHODS Forty children treated for EA between January 2008 and December 2018 were included in this retrospective analysis. Esophageal dilatation was performed when AS was diagnosed. The therapeutic effect of esophageal dilatation was determined based on nutritional status, as assessed by the weight-for-age z-score. RESULTS Sixteen EA patients developed AS. A gap >1.5 cm between the esophageal pouches (P = 0.02) in patients with EA and type A EA was a risk factor for developing AS. A mean of 7.7 sessions of esophageal dilatation were performed per patient, and no complications occurred. The nutritional status of EA children with AS after dilatation was not inferior to that of the children without AS at the 6-month follow-up. CONCLUSION A gap >1.5 cm between the esophageal pouches and type A EA are risk factors for AS after esophageal reconstruction. Esophageal dilatation is both safe and effective for managing strictures and improves nutritional status in EA children with AS.
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Affiliation(s)
- Che-Ming Chiang
- Department of Pediatrics, National Taiwan University Hospital, National Taiwan University, Taipei, Taiwan; Department of Pediatrics, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Wen-Ming Hsu
- Pediatric Surgery, National Taiwan University Hospital, National Taiwan University, Taipei, Taiwan.
| | - Mei-Hwei Chang
- Department of Pediatrics, National Taiwan University Hospital, National Taiwan University, Taipei, Taiwan
| | - Hong-Yuan Hsu
- Department of Pediatrics, National Taiwan University Hospital, National Taiwan University, Taipei, Taiwan
| | - Yen-Hsuan Ni
- Department of Pediatrics, National Taiwan University Hospital, National Taiwan University, Taipei, Taiwan
| | - Huey-Ling Chen
- Department of Pediatrics, National Taiwan University Hospital, National Taiwan University, Taipei, Taiwan
| | - Jia-Feng Wu
- Department of Pediatrics, National Taiwan University Hospital, National Taiwan University, Taipei, Taiwan.
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12
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Vergouwe FWT, Vlot J, IJsselstijn H, Spaander MCW, van Rosmalen J, Oomen MWN, Hulscher JBF, Dirix M, Bruno MJ, Schurink M, Wijnen RMH. Risk factors for refractory anastomotic strictures after oesophageal atresia repair: a multicentre study. Arch Dis Child 2019; 104:152-157. [PMID: 30007949 DOI: 10.1136/archdischild-2017-314710] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2017] [Revised: 05/15/2018] [Accepted: 06/13/2018] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To determine the incidence of refractory anastomotic strictures after oesophageal atresia (OA) repair and to identify risk factors associated with refractory strictures. METHODS Retrospective national multicentre study in patients with OA born between 1999 and 2013. Exclusion criteria were isolated fistula, inability to obtain oesophageal continuity, death prior to discharge and follow-up <6 months. A refractory oesophageal stricture was defined as an anastomotic stricture requiring ≥5 dilations at maximally 4-week intervals. Risk factors for development of refractory anastomotic strictures after OA repair were identified with multivariable logistic regression analysis. RESULTS We included 454 children (61% male, 7% isolated OA (Gross type A)). End-to-end anastomosis was performed in 436 (96%) children. Anastomotic leakage occurred in 13%. Fifty-eight per cent of children with an end-to-end anastomosis developed an anastomotic stricture, requiring a median of 3 (range 1-34) dilations. Refractory strictures were found in 32/436 (7%) children and required a median of 10 (range 5-34) dilations. Isolated OA (OR 5.7; p=0.012), anastomotic leakage (OR 5.0; p=0.001) and the need for oesophageal dilation ≤28 days after anastomosis (OR 15.9; p<0.001) were risk factors for development of a refractory stricture. CONCLUSIONS The incidence of refractory strictures of the end-to-end anastomosis in children treated for OA was 7%. Risk factors were isolated OA, anastomotic leakage and the need for oesophageal dilation less than 1 month after OA repair.
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Affiliation(s)
- Floor W T Vergouwe
- Department of Paediatric Surgery and Intensive Care Children, Erasmus MC University Medical Center-Sophia Children's Hospital, Rotterdam, The Netherlands.,Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - John Vlot
- Department of Paediatric Surgery and Intensive Care Children, Erasmus MC University Medical Center-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Hanneke IJsselstijn
- Department of Paediatric Surgery and Intensive Care Children, Erasmus MC University Medical Center-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Manon C W Spaander
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Joost van Rosmalen
- Department of Biostatistics, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Matthijs W N Oomen
- Department of Paediatric Surgery, Paediatric Surgical Center of Amsterdam (Academic Medical Center and VU Medical Center), Amsterdam, The Netherlands
| | - Jan B F Hulscher
- Department of Paediatric Surgery, University Medical Center Groningen-Beatrix Children's Hospital, Groningen, The Netherlands
| | - Marc Dirix
- Department of Paediatric Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Marco J Bruno
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Maarten Schurink
- Department of Paediatric Surgery, Radboud University Medical Center-Amalia Children's Hospital, Nijmegen, The Netherlands
| | - René M H Wijnen
- Department of Paediatric Surgery and Intensive Care Children, Erasmus MC University Medical Center-Sophia Children's Hospital, Rotterdam, The Netherlands
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13
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Abstract
PURPOSE Gastroesophageal reflux after surgical repair of esophageal atresia (EA) can be associated with complications, such as esophageal stricture. Recent guidelines recommend prophylactic anti-reflux medication (PARM) after EA repair. However, the effectiveness of PARM is still unclear. The aim of this study was to review evidence surrounding the use of PARM in children operated for EA. METHODS We performed a systematic review and meta-analysis. We searched Medline, EMBASE, and the Cochrane Databases from inception until the end of 2016 for comparative studies of PARM versus no PARM (control). Primary outcome was postoperative esophageal stricture. Quality of evidence was assessed using GRADE system. RESULTS We identified four observational studies that focused on esophageal stricture as an outcome. A total of 362 patients were included in meta-analysis. There was no significant difference in esophageal stricture rates between PARM and control (OR = 1.14; 95% CI = 0.61-2.13; p = 0.68; I2 = 38%). The quality of the evidence was very low, due to lack of precision as a consequence of small study sizes. CONCLUSIONS Our results indicate that PARM does not reduce the incidence of esophageal stricture after EA repair. Future well-controlled prospective studies are needed to obtain higher quality evidence.
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14
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Abstract
PURPOSE OF REVIEW Guidelines were recently published highlighting why esophageal atresia (EA) patients are prone to complication risks, and the need for long-term follow-up. In this review, we will focus on how to investigate and treat potential complications, as well as the pros and cons of different investigative and treatment modalities, and what areas continue to need further research. RECENT FINDINGS EA patients are at high risk for gastroesophageal reflux and esophageal strictures, and the sequela that result. Extraintestinal manifestations of gastroesophageal reflux disease (GERD) can appear similar to other pathologic diagnoses commonly found in EA patients, such as congenital stricture, eosinophilic esophagitis, esophageal dysmotility, tracheomalacia, recurrent fistula, aspiration, etc. Therefore, it is important to have a standardized way to monitor for these issues. pH impedance allows for detection of nonacid reflux and the height of reflux, which are important in correlating symptoms with reflux episodes. A multidisciplinary approach is beneficial in evaluating and monitoring EA patients in the long term.
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15
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Respiratory Morbidity in Children with Repaired Congenital Esophageal Atresia with or without Tracheoesophageal Fistula. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2017; 14:ijerph14101136. [PMID: 28953251 PMCID: PMC5664637 DOI: 10.3390/ijerph14101136] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/06/2017] [Revised: 09/21/2017] [Accepted: 09/25/2017] [Indexed: 12/19/2022]
Abstract
Congenital esophageal atresia with or without tracheoesophageal fistula (CEA ± TEF) is a relatively common malformation that occurs in 1 of 2500–4500 live births. Despite the refinement of surgical techniques, a considerable proportion of children experience short- and long-term respiratory complications, which can significantly affect their health through adulthood. This review focuses on the underlying mechanisms and clinical presentation of respiratory morbidity in children with repaired CEA ± TEF. The reasons for the short-term pulmonary impairments are multifactorial and related to the surgical complications, such as anastomotic leaks, stenosis, and recurrence of fistula. Long-term respiratory morbidity is grouped into four categories according to the body section or function mainly involved: upper respiratory tract, lower respiratory tract, gastrointestinal tract, and aspiration and dysphagia. The reasons for the persistence of respiratory morbidity to adulthood are not univocal. The malformation itself, the acquired damage after the surgical repair, various co-morbidities, and the recurrence of lower respiratory tract infections at an early age can contribute to pulmonary impairment. Nevertheless, other conditions, including smoking habits and, in particular, atopy can play a role in the recurrence of infections. In conclusion, our manuscript shows that most children born with CEA ± TEF survive into adulthood, but many comorbidities, mainly esophageal and respiratory issues, may persist. The pulmonary impairment involves many underlying mechanisms, which begin in the first years of life. Therefore, early detection and management of pulmonary morbidity may be important to prevent impairment in pulmonary function and serious long-term complications. To obtain a successful outcome, it is fundamental to ensure a standardized follow-up that must continue until adulthood.
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Cairo SB, Tabak B, Harmon CM, Bass KD. Novel use of porcine extracellular matrix in recurrent stricture following repair of tracheoesophageal fistula. Pediatr Surg Int 2017; 33:1027-1033. [PMID: 28756526 DOI: 10.1007/s00383-017-4130-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/24/2017] [Indexed: 01/07/2023]
Abstract
Anastomotic stricture is a common complication following repair of esophageal atresia (EA). Many factors are thought to contribute to stricture formation and a variety of management techniques have been developed. In this case report, we describe the treatment of a recurrent anastomotic stricture following repair of long-gap esophageal atresia. Porcine bladder extracellular matrix (ECM) was mounted on a stent and delivered endoscopically to the site of recurrent stricture. An appropriate positioning was confirmed using direct endoscopic visualization and intra-operative fluoroscopy. The patient recovered well with persistent radiographic and functional improvements in previous stricture.
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Affiliation(s)
- Sarah B Cairo
- Department of Pediatric Surgery, Women and Children's Hospital of Buffalo, 219 Bryant Street, Buffalo, NY, 14222, USA.
| | - Benjamin Tabak
- Department of Pediatric Surgery, Women and Children's Hospital of Buffalo, 219 Bryant Street, Buffalo, NY, 14222, USA
| | - Carroll M Harmon
- Department of Pediatric Surgery, Women and Children's Hospital of Buffalo, 219 Bryant Street, Buffalo, NY, 14222, USA.,Department of Surgery, University at Buffalo, State University of New York School of Medicine and Bioscience, Buffalo, NY, USA
| | - Kathryn D Bass
- Department of Pediatric Surgery, Women and Children's Hospital of Buffalo, 219 Bryant Street, Buffalo, NY, 14222, USA.,Department of Surgery, University at Buffalo, State University of New York School of Medicine and Bioscience, Buffalo, NY, USA
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17
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Utilizing stricture indices to predict dilation of strictures after esophageal atresia repair. J Surg Res 2017; 216:172-178. [PMID: 28807203 DOI: 10.1016/j.jss.2017.04.024] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Revised: 03/24/2017] [Accepted: 04/27/2017] [Indexed: 01/21/2023]
Abstract
BACKGROUND Anastomotic stricture is the most common postoperative complication in infants undergoing repair of esophageal atresia with or without tracheoesophageal fistula (EA/TEF). Stricture indices (SIs) are used to predict infants at risk for stricture requiring dilation. We sought to determine the most accurate SI and optimal timing for predicting anastomotic dilation. MATERIALS AND METHODS A retrospective study of infants undergoing repair of EA/TEF between 2008 and 2013 was performed. Esophagrams were used to calculate four SIs (upper pouch esophageal anastomotic stricture index [U-EASI], lower pouch esophageal anastomotic stricture index [L-EASI], lateral SI, and anterior/posterior SI). The best performing SI was identified. Logistic regression analysis was performed to determine if a first or second esophagram SI threshold was associated with dilation. A receiver operating characteristic curve measured the accuracy of the model using SIs to predict dilation. RESULTS Of 45 EA/TEF infants included, 20 (44%) had postoperative strictures requiring dilation. As the best performing SI, logistic regression analysis showed that U-EASI as a continuous variable was predictive of dilation (P = 0.03) but was not significant at U-EASI ≤ 0.37. However, U-EASI ≤ 0.37 was associated with needing earlier dilation. On second esophagram (median, 38 days), U-EASI of ≤0.39 was significantly associated with dilation (OR: 7.8, 95% CI: 1.05-57.58, P = 0.04). The area under the receiver operating characteristic curve of the U-EASI model controlling for days to esophagram demonstrated improved predictive ability from first (AUC 0.73) to second esophagram (AUC 0.81). CONCLUSIONS Calculation of the SI utilizing a U-EASI ≤ 0.39 on the delayed esophagram is associated with future anastomotic dilation. A multi-institutional study is necessary to confirm the predictive ability of the U-EASI.
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18
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Tambucci R, Angelino G, De Angelis P, Torroni F, Caldaro T, Balassone V, Contini AC, Romeo E, Rea F, Faraci S, Federici di Abriola G, Dall'Oglio L. Anastomotic Strictures after Esophageal Atresia Repair: Incidence, Investigations, and Management, Including Treatment of Refractory and Recurrent Strictures. Front Pediatr 2017; 5:120. [PMID: 28611969 PMCID: PMC5447026 DOI: 10.3389/fped.2017.00120] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Accepted: 05/04/2017] [Indexed: 01/10/2023] Open
Abstract
Improved surgical techniques, as well as preoperative and postoperative care, have dramatically changed survival of children with esophageal atresia (EA) over the last decades. Nowadays, we are increasingly seeing EA patients experiencing significant short- and long-term gastrointestinal morbidities. Anastomotic stricture (AS) is the most common complication following operative repair. An esophageal stricture is defined as an intrinsic luminal narrowing in a clinically symptomatic patient, but no symptoms are sensitive or specific enough to diagnose an AS. This review aims to provide a comprehensive view of AS in EA children. Given the lack of evidence-based data, we critically analyzed significant studies on children and adults, including comments on benign strictures with other etiologies. Despite there is no consensus about the goal of the luminal diameter based on the patient's age, esophageal contrast study, and/or endoscopy are recommended to assess the degree of the narrowing. A high variability in incidence of ASs is reported in literature, depending on different definitions of AS and on a great number of pre-, intra-, and postoperative risk factor influencing the anastomosis outcome. The presence of a long gap between the two esophageal ends, with consequent anastomotic tension, is determinant for stricture formation and its response to treatment. The cornerstone of treatment is endoscopic dilation, whose primary aims are to achieve symptom relief, allow age-appropriate capacity for oral feeding, and reduce the risk of pulmonary aspiration. No clear advantage of either balloon or bougie dilator has been demonstrated; therefore, the choice is based on operator experience and comfort with the equipment. Retrospective evidences suggest that selective dilatations (performed only in symptomatic patients) results in significantly less number of dilatation sessions than routine dilations (performed to prevent symptoms) with equal long-term outcomes. The response to dilation treatment is variable, and some patients may experience recurrent and refractory ASs. Adjunctive treatments have been used, including local injection of steroids, topical application of mitomycin C, and esophageal stenting, but long-term studies are needed to prove their efficacy and safety. Stricture resection or esophageal replacement with an interposition graft remains options for AS refractory to conservative treatments.
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Affiliation(s)
- Renato Tambucci
- Digestive Endoscopy and Surgery Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy.,University of L'Aquila, L'Aquila, Italy
| | - Giulia Angelino
- 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
| | - Filippo Torroni
- 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
| | - Valerio Balassone
- Digestive Endoscopy and Surgery Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Anna Chiara Contini
- Digestive Endoscopy and Surgery Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Erminia Romeo
- 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
| | - Simona Faraci
- Digestive Endoscopy and Surgery Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | | | - Luigi Dall'Oglio
- Digestive Endoscopy and Surgery Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
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ESPGHAN-NASPGHAN Guidelines for the Evaluation and Treatment of Gastrointestinal and Nutritional Complications in Children With Esophageal Atresia-Tracheoesophageal Fistula. J Pediatr Gastroenterol Nutr 2016; 63:550-570. [PMID: 27579697 DOI: 10.1097/mpg.0000000000001401] [Citation(s) in RCA: 210] [Impact Index Per Article: 26.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Esophageal atresia (EA) is one of the most common congenital digestive anomalies. With improvements in surgical techniques and intensive care treatments, the focus of care of these patients has shifted from mortality to morbidity and quality-of-life issues. These children face gastrointestinal (GI) problems not only in early childhood but also through adolescence and adulthood. There is, however, currently a lack of a systematic approach to the care of these patients. The GI working group of International Network on Esophageal Atresia comprises members from ESPGHAN/NASPGHAN and was charged with the task of developing uniform evidence-based guidelines for the management of GI complications in children with EA. METHODS Thirty-six clinical questions addressing the diagnosis, treatment, and prognosis of the common GI complications in patients with EA were formulated. Questions on the diagnosis, and treatment of gastroesophageal reflux, management of "cyanotic spells," etiology, investigation and management of dysphagia, feeding difficulties, anastomotic strictures, congenital esophageal stenosis in EA patients were addressed. The importance of excluding eosinophilic esophagitis and associated GI anomalies in symptomatic patients with EA is discussed as is the quality of life of these patients and the importance of a systematic transition of care to adulthood. A systematic literature search was performed from inception to March 2014 using Embase, MEDLINE, the Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Clinical Trials, and PsychInfo databases. The approach of the Grading of Recommendations Assessment, Development and Evaluation was applied to evaluate outcomes. During 2 consensus meetings, all recommendations were discussed and finalized. The group members voted on each recommendation, using the nominal voting technique. Expert opinion was used where no randomized controlled trials were available to support the recommendation.
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21
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Gottrand M, Michaud L, Sfeir R, Gottrand F. Motility, digestive and nutritional problems in Esophageal Atresia. Paediatr Respir Rev 2016; 19:28-33. [PMID: 26752295 DOI: 10.1016/j.prrv.2015.11.005] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Accepted: 11/16/2015] [Indexed: 12/11/2022]
Abstract
Esophageal atresia (EA) with or without tracheoesophageal fistula (TEF) is a rare congenital malformation. Digestive and nutritional problems remain frequent in children with EA both in early infancy and at long-term follow-up. These patients are at major risk of presenting with gastroesophageal reflux and its complications, such as anastomotic strictures. Esophageal dysmotility is constant, and can have important consequences on feeding and nutritional status. Patients with EA need a systematic follow-up with a multidisciplinary team.
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Affiliation(s)
- Madeleine Gottrand
- CHU Lille, University Lille, National reference center for congenital malformation of the esophagus, Department of Pediatrics, F-59000 Lille, France.
| | - Laurent Michaud
- CHU Lille, University Lille, National reference center for congenital malformation of the esophagus, Department of Pediatrics, F-59000 Lille, France.
| | - Rony Sfeir
- CHU Lille, University Lille, National reference center for congenital malformation of the esophagus, Department of Pediatrics, F-59000 Lille, France.
| | - Frédéric Gottrand
- CHU Lille, University Lille, National reference center for congenital malformation of the esophagus, Department of Pediatrics, F-59000 Lille, France.
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22
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Dall’Oglio L, Caldaro T, Foschia F, Faraci S, Federici di Abriola G, Rea F, Romeo E, Torroni F, Angelino G, De Angelis P. Endoscopic management of esophageal stenosis in children: New and traditional treatments. World J Gastrointest Endosc 2016; 8:212-219. [PMID: 26962403 PMCID: PMC4766254 DOI: 10.4253/wjge.v8.i4.212] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2015] [Revised: 10/14/2015] [Accepted: 12/18/2015] [Indexed: 02/05/2023] Open
Abstract
Post-esophageal atresia anastomotic strictures and post-corrosive esophagitis are the most frequent types of cicatricial esophageal stricture. Congenital esophageal stenosis has been reported to be a rare but typical disease in children; other pediatric conditions are peptic, eosinophilic esophagitis and dystrophic recessive epidermolysis bullosa strictures. The conservative treatment of esophageal stenosis and strictures (ES) rather than surgery is a well-known strategy for children. Before planning esophageal dilation, the esophageal morphology should be assessed in detail for its length, aspect, number and level, and different conservative strategies should be chosen accordingly. Endoscopic dilators and techniques that involve different adjuvant treatment strategies have been reported and depend on the stricture’s etiology, the availability of different tools and the operator’s experience and preferences. Balloon and semirigid dilators are the most frequently used tools. No high-quality studies have reported on the differences in the efficacies and rates of complications associated with these two types of dilators. There is no consensus in the literature regarding the frequency of dilations or the diameter that should be achieved. The use of adjuvant treatments has been reported in cases of recalcitrant stenosis or strictures with evidence of dysphagic symptoms. Corticosteroids (either systemically or locally injected), the local application of mitomycin C, diathermy and laser ES sectioning have been reported. Some authors have suggested that stenting can reduce both the number of dilations and the treatment length. In many cases, this strategy is effective when either metallic or plastic stents are utilized. Treatment complications, such esophageal perforations, can be conservatively managed, considering surgery only in cases with severe pleural cavity involvement. In cases of stricture relapse, even if such relapses occur following the execution of well-conducted conservative strategies, surgical stricture resection and anastomosis or esophageal substitution are the only remaining options.
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23
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Parolini F, Armellini A, Boroni G, Bagolan P, Alberti D. The management of newborns with esophageal atresia and right aortic arch: A systematic review or still unsolved problem. J Pediatr Surg 2016; 51:304-9. [PMID: 26592954 DOI: 10.1016/j.jpedsurg.2015.10.043] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2015] [Revised: 08/01/2015] [Accepted: 10/01/2015] [Indexed: 10/22/2022]
Abstract
AIM OF THE STUDY The management of newborns with esophageal atresia (EA) and right aortic arch (RAA) is still an unsolved problem. This study provides a systematic review of epidemiology, diagnosis, management and short-term results of children with EA and RAA. MATERIALS AND METHODS The PubMed database was searched for original studies on children with EA and RAA. In each study, data were extracted for the following outcomes: number of patients, associated anomalies, type of surgical repair, morbidity and mortality rate. RESULTS Eight studies were selected, including 54 patients with EA and RAA. RAA was encountered in 3.6% of infants. Preoperative detection of RAA was reported in 7 of them. In these patients, primary anastomosis was achieved through the right approach in 3 (thoracotomy in 2 and thoracoscopy in 1) while the left approach was the primary choice in 4 (thoracotomy in 2 and thoracoscopy in 2). No significant differences were found between the right and left approaches with regard to leaks (P=0.89), strictures (P=1) or mortality (P=1). In 47/54 patients (87%) RAA was noted during right thoracotomy, and primary anastomosis was achieved through the same approach in 29 (61.7%); conversion to other approaches (left thoracotomy or esophageal substitution) was performed in 15 children (38.3%). No significant differences were found between primary left thoracotomy (LT) and LT after RT with regard to leaks (P=0.89), strictures (P=1) or mortality (P=1). CONCLUSIONS Skills and preferences of the surgeon still guide the choice of surgical approach even when preoperatively faced with RAA. A multicenter, prospective randomized study is strongly required.
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Affiliation(s)
- Filippo Parolini
- Department of Paediatric Surgery, "Spedali Civili" Hospital, Brescia, Italy.
| | - Andrea Armellini
- Department of Paediatric Surgery, "Spedali Civili" Hospital, Brescia, Italy
| | - Giovanni Boroni
- Department of Paediatric Surgery, "Spedali Civili" Hospital, Brescia, Italy
| | - Pietro Bagolan
- Department of Medical and Surgical Neonatology, Bambino Gesu' Research Children's Hospital, Rome, Italy
| | - Daniele Alberti
- Department of Paediatric Surgery, "Spedali Civili" Hospital, Brescia, Italy; Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
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Manfredi MA. Endoscopic Management of Anastomotic Esophageal Strictures Secondary to Esophageal Atresia. Gastrointest Endosc Clin N Am 2016; 26:201-19. [PMID: 26616905 DOI: 10.1016/j.giec.2015.09.002] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The reported incidence of anastomotic stricture after esophageal atresia repair has varied in case series from as low as 9% to as high as 80%. The cornerstone of esophageal stricture treatment is dilation with either balloon or bougie. The goal of esophageal dilation is to increase the luminal diameter of the esophagus while also improving dysphagia symptoms. Once a stricture becomes refractory to esophageal dilation, there are several treatment therapies available as adjuncts to dilation therapy. These therapies include intralesional steroid injection, mitomycin C, esophageal stent placement, and endoscopic incisional therapy.
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Affiliation(s)
- Michael A Manfredi
- Esophageal and Airway Atresia Treatment Center, Boston Children's Hospital, Boston, MA 02132, USA; Pediatrics Harvard Medical School, Boston, MA 02115, USA.
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Zhu H, Shen C, Xiao X, Dong K, Zheng S. Reoperation for anastomotic complications of esophageal atresia and tracheoesophageal fistula. J Pediatr Surg 2015; 50:2012-5. [PMID: 26388130 DOI: 10.1016/j.jpedsurg.2015.08.015] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Accepted: 08/24/2015] [Indexed: 12/19/2022]
Abstract
BACKGROUND/PURPOSE The purpose of the study was to review our experience in the re-operative management of anastomotic complications (ACs) following primary repair of esophageal atresia (EA) and tracheoesophageal fistula (TEF) and to assess the outcomes after reoperation. METHODS We retrospectively reviewed 21 EA patients who underwent reoperation from 2005 to 2014. Clinical features, reasons for reoperation, diagnosis of ACs, re-operative procedures and outcomes, as well as long-term follow-up of reoperation were analyzed. RESULTS Reoperation occurred in 16 recurrent TEF (RTEF) cases (76.2%), 4 severe anastomotic strictures (AS), and 1 anastomotic leakage (AL) cases (19% and 4.8%, respectively). All of AS and AL were confirmed by esophagography. RTEF were confirmed by esophagoscopy and bronchoscopy. All of the cases underwent reoperation successfully. The average operative time and length of post-operative hospital stay were 2.7 ± 0.8 hours and 15.4 ± 3.3 days, respectively. The mortality rate was 4.8%. All of the cases were followed up from 1 to 107 months after reoperation. No patients experienced respiratory or feeding issues. No severe postoperative complications were shown in all re-operative cases. CONCLUSIONS ACs including severe AS and AL as well as RTEF are the significant indications for reoperation after EA repair. The reoperation was effective to treat multiple anastomotic complications.
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Affiliation(s)
- Haitao Zhu
- Department of Pediatric Surgery, Children's Hospital of Fudan University, Shanghai, China
| | - Chun Shen
- Department of Pediatric Surgery, Children's Hospital of Fudan University, Shanghai, China
| | - Xianmin Xiao
- Department of Pediatric Surgery, Children's Hospital of Fudan University, Shanghai, China
| | - Kuiran Dong
- Department of Pediatric Surgery, Children's Hospital of Fudan University, Shanghai, China
| | - Shan Zheng
- Department of Pediatric Surgery, Children's Hospital of Fudan University, Shanghai, China.
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González Villarello M, Valencia Romero JA, Díaz Oyola M, López Acevedo H, Sosa López ADJ, Rodríguez Ruiz G, Bello Guerrero JA, Oña Ortiz FM, Mata Quintero CJ, Luna Aguilar FJ, Farell Rivas J, Pineda Oliva O, Cuevas Osorio VJ. Utilización de stent esofágico totalmente cubierto para el tratamiento de estenosis recidivante de anastomosis esofagocolónica en una paciente de 17 años de edad: reporte de un caso. ENDOSCOPIA 2015. [DOI: 10.1016/j.endomx.2015.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Sun LYC, Laberge JM, Yousef Y, Baird R. The Esophageal Anastomotic Stricture Index (EASI) for the management of esophageal atresia. J Pediatr Surg 2015; 50:107-10. [PMID: 25598104 DOI: 10.1016/j.jpedsurg.2014.10.008] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2014] [Accepted: 10/06/2014] [Indexed: 12/26/2022]
Abstract
BACKGROUND Anastomotic stricture is the most common complication following repair of esophageal atresia. An Esophageal Anastomotic Stricture Index (EASI) based on the postoperative esophagram may identify patients at high risk of stricture formation. METHODS Digital images of early postoperative esophagrams of patients undergoing EA repair from 2005 to 2013 were assessed. Demographics and outcomes including dilations were prospectively collected. Upper (U-EASI) and lower (L-EASI) pouch ratios were generated using stricture diameter divided by maximal respective pouch diameter. Score performances were evaluated with area under the receiver operator curves (AUC) and the Fisher's exact test for single and multiple (>3) dilatations. Interrater agreement was evaluated using the intraclass correlation coefficient (ICC). RESULTS Forty-five patients had esophagrams analyzed; 28 (62%) required dilatation and 19 received >3 (42%). U-EASI and L-EASI ratios ranged from 0.17 to 0.70, with L-EASI outperforming the U-EASI as follows: L-EASI AUC: 0.66 for a single dilatation, 0.65 for >3 dilatations; U-EASI AUC: 0.56 for a single dilatation, 0.67 for >3 dilatations. All patients with an L-EASI ratio of ≤0.30 (n=8) required multiple esophageal dilatations, p=0.0006. The interrater ICC was 0.87. CONCLUSION The EASI is a simple, reproducible tool to predict the development and severity of anastomotic stricture after esophageal atresia repair and can direct postoperative surveillance.
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Affiliation(s)
| | - Jean-Martin Laberge
- Division of Pediatric Surgery, Montreal Children's Hospital; Faculty of Medicine, McGill University, Montreal, QC, Canada
| | | | - Robert Baird
- Division of Pediatric Surgery, Montreal Children's Hospital; Faculty of Medicine, McGill University, Montreal, QC, Canada.
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28
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Oral viscous budesonide as a first-line approach to esophageal stenosis in epidermolysis bullosa: an open-label trial in six children. Paediatr Drugs 2014; 16:391-5. [PMID: 25138121 DOI: 10.1007/s40272-014-0086-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Esophageal and pharyngeal problems are common in the majority of patients with epidermolysis bullosa (EB). Repeated blister formation and ulceration, coupled with chronic inflammation, result in scarring and development of esophageal strictures. OBJECTIVE This study aimed to evaluate whether oral viscous budesonide (OVB) was useful for treating esophageal structures in six pediatric patients (aged 8-17 years) with EB who were affected by dysphagia and esophageal strictures. METHODS Patients were treated for 4 months with twice-daily oral budesonide nebulizer solution 0.5 mg/2 mL mixed with maltodextrin 5 g and artificial sweeteners. RESULTS One patient developed a severe oral mycotic infection and discontinued treatment. The other five patients completed the treatment regimen and displayed significantly lower stricture indices (SIs) post-treatment (mean SI ± standard deviation 0.736 ± 0.101 pre-treatment versus 0.558 ± 0.162 post-treatment; p = 0.008). Patients experienced a mean SI decrease of 0.178 (range 0.026-0.296), as well as improved dietary habits in the absence of side effects. CONCLUSION These findings indicated that topical corticosteroids may significantly alleviate strictures in pediatric patients with EB, thereby limiting the need for endoscopic dilation and considerably improving patients' quality of life.
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Parolini F, Morandi A, Macchini F, Gentilino V, Zanini A, Leva E. Cervical/thoracotomic/thoracoscopic approaches for H-type congenital tracheo-esophageal fistula: a systematic review. Int J Pediatr Otorhinolaryngol 2014; 78:985-9. [PMID: 24856837 DOI: 10.1016/j.ijporl.2014.04.011] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2014] [Revised: 04/02/2014] [Accepted: 04/04/2014] [Indexed: 01/05/2023]
Abstract
PURPOSE Aim of this systematic review is to investigate the thoracic and cervical surgical approaches of H-type tracheo-esophageal fistula (TEF) according to the position of the fistula. METHODS The PubMed database was searched for original studies on H-type TEF treatment published between 1977 and 2012. Manuscripts finally included were divided into open and thoracoscopic surgery groups. RESULTS Seventeen studies were selected for open surgery group, and most of them agree on the importance of pre-operative diagnosis of the fistula by preliminary tracheoscopy. Right cervicotomy was used in 70 cases (76.9%), left cervicotomy in 12 (13.2%), and thoracotomy only in 9 (9.9%). Five studies were included in thoracoscopic group (6 patients). Indications for the surgical approach (cervical vs thoracic) according to the position of the TEF were clearly described in 10 manuscripts, and all stated differences in surgical technique details. Complications and mortality rates were not statistically correlated to the different surgical approaches. CONCLUSIONS The evidence base in regard to the treatment of H-type fistula in children is poor and the skills and preferences of the surgeons guide the choice of the procedure. Surgical division of the fistula is curative, and the key to a successful repair is the pre-operatively identification of the level of the fistula with tracheoscopy. Right cervicotomy seems to be the approach of choice in the majority of case, with the thoracic approach appropriate only for fistulae opening below T2. Further well-designed prospective studies which take into account of selection and performance bias are strongly required.
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Affiliation(s)
- Filippo Parolini
- Department of Paediatric Surgery, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milano, Italy; Department of Paediatric Surgery, Azienda Ospedaliera Spedali Civili Brescia, Italy.
| | - Anna Morandi
- Department of Paediatric Surgery, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milano, Italy
| | - Francesco Macchini
- Department of Paediatric Surgery, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milano, Italy
| | - Valerio Gentilino
- Department of Paediatric Surgery, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milano, Italy
| | - Andrea Zanini
- Department of Paediatric Surgery, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milano, Italy
| | - Ernesto Leva
- Department of Paediatric Surgery, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milano, Italy
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Sulkowski JP, Cooper JN, Lopez JJ, Jadcherla Y, Cuenot A, Mattei P, Deans KJ, Minneci PC. Morbidity and mortality in patients with esophageal atresia. Surgery 2014; 156:483-91. [PMID: 24947650 DOI: 10.1016/j.surg.2014.03.016] [Citation(s) in RCA: 94] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2013] [Accepted: 03/09/2014] [Indexed: 12/18/2022]
Abstract
BACKGROUND This study reports national estimates of population characteristics and outcomes for patients with esophageal atresia with or without tracheoesophageal fistula (EA/TEF) and evaluates the relationships between hospital volume and outcomes. METHODS Patients admitted within 30 days of life who had International Classification of Diseases, 9th Edition, Clinical Modification diagnosis and procedure codes relevant to EA/TEF during 1999-2012 were identified with the Pediatric Health Information System database. Baseline demographics, comorbidities, and postoperative outcomes, including predictors of in-hospital mortality, were examined up to 2 years after EA/TEF repair. RESULTS We identified 3,479 patients with EA/TEF treated at 43 children's hospitals; 37% were premature and 83.5% had ≥1 additional congenital anomaly, with cardiac anomalies (69.6%) being the most prevalent. Within 2 years of discharge, 54.7% were readmitted, 5.2% had a repeat TEF ligation, 11.4% had a repeat operation for their esophageal reconstruction, and 11.7% underwent fundoplication. In-hospital mortality was 5.4%. Independent predictors of mortality included lower birth weight, congenital heart disease, other congenital anomalies, and preoperative mechanical ventilation. There was no relationship between hospital volume and mortality or repeat TEF ligation. CONCLUSION This study describes population characteristics and outcomes, including predictors of in-hospital mortality, in EA/TEF patients treated at children's hospitals across the United States. Across these hospitals, rates of mortality or repeat TEF ligation were not dependent on hospital volume.
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Affiliation(s)
- Jason P Sulkowski
- Center for Surgical Outcomes Research, The Research Institute at Nationwide Children's Hospital, Columbus, OH; Department of Surgery, Nationwide Children's Hospital, Columbus, OH
| | - Jennifer N Cooper
- Center for Surgical Outcomes Research, The Research Institute at Nationwide Children's Hospital, Columbus, OH
| | - Joseph J Lopez
- Center for Surgical Outcomes Research, The Research Institute at Nationwide Children's Hospital, Columbus, OH
| | - Yamini Jadcherla
- Center for Surgical Outcomes Research, The Research Institute at Nationwide Children's Hospital, Columbus, OH
| | - Alissabeth Cuenot
- Center for Surgical Outcomes Research, The Research Institute at Nationwide Children's Hospital, Columbus, OH
| | - Peter Mattei
- Department of Surgery, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Katherine J Deans
- Center for Surgical Outcomes Research, The Research Institute at Nationwide Children's Hospital, Columbus, OH; Department of Surgery, Nationwide Children's Hospital, Columbus, OH
| | - Peter C Minneci
- Center for Surgical Outcomes Research, The Research Institute at Nationwide Children's Hospital, Columbus, OH; Department of Surgery, Nationwide Children's Hospital, Columbus, OH.
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Huh YJ, Kim HY, Lee SC, Park KW, Jung SE. Comparison of outcomes according to the operation for type A esophageal atresia. Ann Surg Treat Res 2014; 86:83-90. [PMID: 24761413 PMCID: PMC3994598 DOI: 10.4174/astr.2014.86.2.83] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2013] [Revised: 10/13/2013] [Accepted: 10/23/2013] [Indexed: 02/08/2023] Open
Abstract
Purpose The purpose was to evaluate outcomes according to different operative strategies of type A esophageal atresia (EA). Methods All patients who underwent surgery for type A EA between 1980 and 2011 were included. Patients were divided into 2 groups: E-E group included patients who received esophageal end-to-end anastomosis, whereas E-G group included patients who received esophago-gastric tube anastomosis. Results Twenty-two patients were included. The median gestational age was 37.5 weeks. The median birth weight was 2.5 kg. Twenty-one patients underwent gastrostomy as initial procedures, and one patient underwent primary esophageal end-to-end anastomosis. The median gap between both esophageal ends was six vertebral distance (VD). Seven patients underwent primary anastomosis of the esophagus, and 14 patients underwent gastric replacement. Three patients (13.6%) had anastomotic leakage and 10 patients (45.5%) had anastomotic stenosis. Most of the patients (90.9%) had gastroesophageal reflux, but only two patients required antireflux surgery. The median VD was significantly shorter in E-E group than in E-G group (3 VD vs. 6 VD). Stenosis was significantly more often in E-E group, but there was no significant difference in leakage and reflux symptoms. Conclusion The treatment for type A EA can include E-E anastomosis or E-G anastomosis, depending on the length of the end-to-end interval after performing gastrostomy. Appropriate tension and blood flow in the anastomosis site are essential for preventing postoperative stenosis and leakage, and esophageal replacement with gastric tube is believed to be feasible and safe in cases where excessive tension is present.
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Affiliation(s)
- Yeon-Ju Huh
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Hyun-Young Kim
- Division of Pediatric Surgery, Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Seong-Cheol Lee
- Division of Pediatric Surgery, Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Kwi-Won Park
- Division of Pediatric Surgery, Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Sung-Eun Jung
- Division of Pediatric Surgery, Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
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