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

Detection of Oesophageal Fistula by Radionuclide Salivagram SPECT/CT

Purpose

Videofluoroscopic swallowing study (VFSS) is currently the most widely used clinical examination method for diagnosis of oesophageal fistula, but it has many limitations. Therefore, we evaluated radionuclide salivagram single-photon emission computed tomography (SPECT/CT) as a new method of oesophageal fistula diagnosis.

Methods

We retrospectively evaluated the data of 11 patients (10 men and 1 woman, aged 41 to 70 years, with an average age of 58.6 years) who had clinically suspected oesophageal fistula from January 2019 to October 2020. They underwent radionuclide salivagram SPECT/CT and VFSS examinations, and we analysed and compared the results of the two examinations.

Results

A total of 11 patients were included in this study. Ten underwent both salivagram and VFSS examinations. One patient was unable to swallow the contrast agent; therefore, only salivagram was performed, and we excluded this patient from the VFSS analysis. A total of 11 patients underwent salivagram examinations, of which 6 were positive and 5 were negative. A total of 10 patients were tested by VFSS, of which 6 results were positive and 4 were negative.

Conclusion

Radionuclide salivagram SPECT/CT and VFSS are complementary, which can greatly improve the clinical diagnosis and prognosis of oesophageal fistula. When the patient cannot perform the VFSS, or the clinical symptoms are inconsistent with the VFSS imaging findings, the salivagram is an ideal test method.

Esophageal morbidity in patients following repair of esophageal atresia: A systematic review

BACKGROUND

Esophageal atresia (EA) is a life-threatening congenital condition, affecting one in 2600 newborns. Morbidity remains high, with many patients experiencing complications, including anastomotic leak/stricture, and gastro-esophageal reflux disease (GERD). Increased understanding of esophageal motility patterns may help explain the etiology of these complications.

AIMS

We aimed to review knowledge regarding esophageal motility and related complications in children with EA, evaluate patients' symptomatology and relate this to esophageal motility.

METHODS

We performed a systematic review (PROSPERO: CRD42018092277), according to the PRISMA protocol. Two investigators independently conducted search strategies (OvidMEDLINE, PubMed, Cochrane Review, BMJ BestPractice), identifying complications in patients following EA repair. Rates of esophageal dysmotility, GERD, dysphagia, anastomotic leak, anastomotic stricture, recurrent fistula formation, and esophagitis were sought.

RESULTS

A total of 65 publications met selection criteria (n = 4882). Rates of morbidity were high: esophageal dysmotility (78%), GERD (43%), dysphagia (44%), anastomotic leak (19%), anastomotic stricture (26%), recurrent fistula formation (7%), and esophagitis (47%). No correlation appeared to exist with severity of symptoms.

CONCLUSIONS

This systematic review identified high rates of complications in children with EA, with esophageal dysmotility present in the majority of patients. Increasing survival, with resultant longer timeframes to develop morbidities, makes standardized follow-up regimens crucial.

TYPE OF STUDY

Prognosis study.

LEVEL OF EVIDENCE

Level 3.

The burden of esophageal dilatations following repair of esophageal atresia

AIM

To describe the burden of esophageal dilatations in patients following esophageal atresia (EA) repair.

METHOD

A retrospective review was performed at The Royal Children's Hospital, Melbourne, of all neonates undergoing operative repair for EA over a 17-year period (1999-2015). Stricture was defined by radiological and/or intra-operative findings of narrowing at the esophageal anastomosis. Data recorded included EA type, perinatal details, operative approach, esophageal anastomosis outcome, dilatation requirement, and survival. Key endpoints were anastomotic leakage and tension, esophageal dilatation technique, dilatation frequency, fundoplication, and complications.

RESULTS

During the study period, 287 newborn EA patients were admitted, of which 258 underwent operative repair and survived to primary discharge. Excluding 11 patients with isolated tracheoesophageal fistula, 247 patients were included in the final analysis. Intra-operative anastomotic tension was documented in 41/247 (16.6%), anastomotic leak occurred in 48/247 (19.4%), and fundoplication was performed in 37/247 (15.0%). Dilatations were performed in 149/247 (60.3%). Techniques included bougie-alone (92/149, 61.7%), combination of bougie and balloon (51/149, 34.2%), and balloon-alone (6/149, 4.0%). These patients underwent 1128 dilatations; median number of dilatations per patient was 4 (interquartile range 2-8). Long-gap EA and anastomotic tension were risk factors (p < 0.01) for multiple dilatations. Complications occurred in 13/1128 (1.2%) dilatation episodes: 11/13 esophageal perforation, 2/13 clinically significant aspiration. Perforations were rare events in both balloon (6/287, 2.1%) and bougie dilatations (4/841, 0.5%); one patient had a perforation from guidewire insertion.

CONCLUSIONS

Esophageal dilatation occurred in a majority of EA patients. Long-gap EA was associated with an increased burden of esophageal dilatation. Perforations were rare events in balloon and bougie dilatations.

TYPE OF STUDY

Original article - retrospective review.

LEVEL OF EVIDENCE

II.

Post-surgical gastrointestinal reflux disease: Status quo and treatment

Reflux is a common and tricky morbidity after gastrointestinal surgery which is caused by the destruction of physiological anti-reflux barriers, greatly affecting patients' postoperative quality of life. Gastroenterologists are now actively trying very hard to explore feasible, effective, and safe anti-reflux approaches. Conservative medical treatment, typically with proton pump inhibitors, is easily accepted by patients, however, its long-term adverse events are noteworthy. In the surgical aspect, laparoscopic anti-reflux surgery is gaining more and more popularity, after the first case of fundoplication. Besides, other operations, such as bariatric surgery, pediatric surgery, and pulmonary transplantation, are also frequently complicated by post-operative digestive reflux. Herein we systematically review the status quo and treatment modalities for post-surgical reflux disease, with the hope to facilitate surgeons to cope with this challenging issue appropriately.

Quality of reporting of the literature on gastrointestinal reflux after repair of esophageal atresia-tracheoesophageal fistula

OBJECTIVES

There is variation in the management of postoperative gastroesophageal reflux (GER) in esophageal atresia-tracheoesophageal fistula (EA-TEF). Well-reported literature is important for clinical decision-making. We assessed the quality of reporting (QOR) of postoperative GER management in EA-TEF.

METHODS

A comprehensive search of MEDLINE, EMBASE, CINHAL, CENTRAL databases and gray literature was conducted. Included articles reported a primary diagnosis of EA-TEF, a secondary diagnosis of postoperative GER, and primary treatment of GER with antireflux medications. The QOR was assessed using the STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) checklist.

RESULTS

Retrieval of 2910 articles resulted in 48 relevant articles (N=2592 patients) with an overall quality percentage score of 48%-95% (median=65%). The best reported items were "participants" and "outcome data" (93.8% each), "generalisability" (91.7%) and "background/rationale" (89.6%). Less than 20% of studies provided detailed "main results"; less than 5% of studies reported adequately on "bias" or "funding." Sample size calculation and study limitations were included in 17 (35.4%) and 16 (33.3%) studies respectively. Follow-up time was inconsistently reported.

CONCLUSIONS

Although the overall QOR is moderate using STROBE, important areas are underreported. Inadequate methodological reporting may lead to inappropriate clinical decisions. Awareness of STROBE, emphasizing proper reporting is needed.

The management of postoperative reflux in congenital esophageal atresia-tracheoesophageal fistula: a systematic review

PURPOSE

Esophageal atresia (EA), with or without tracheoesophageal fistula (TEF), is associated with postoperative gastroesophageal reflux (GER). We performed a systematic review of the literature regarding routine anti-reflux medication post EA-TEF repair and its impact on postoperative GER and associated complications.

METHODS

A comprehensive search was conducted using MEDLINE, EMBASE, CINHAL, CENTRAL (Cochrane library) electronic databases and gray literature. Full-text screening was performed in duplicate. Included articles reported a primary diagnosis of EA-TEF, a secondary diagnosis of postoperative GER, and primary treatment of GER with anti-reflux medications.

RESULTS

Screening of 2,910 articles resulted in 25 articles (1,663 patients) for analysis. Most were single-center studies (92%) and retrospective (76%); there were no randomized control trials. Fifteen studies named the class of anti-reflux agent used, 3 the duration of therapy, and none either the dose prescribed or number of doses. Complications were inconsistently reported. Anti-reflux surgery was performed in 433/1,663 (26.0%) patients. Average follow-up was 53.2 months (14 studies).

CONCLUSION

The quality of literature regarding anti-reflux medication for GER post EA-TEF repair is poor. There are no well-outlined algorithms for anti-reflux agents, doses, or duration of therapy. Standardized protocols and reliable reporting are necessary to develop guidelines to better manage postoperative GER in EA-TEF patients.

Diagnostic modalities for gastro-esophageal reflux in infantile wheezers

OBJECTIVE

To compare the diagnostic value of Gastro-intestinal (GI) scintiscan with 24-h pH study in detecting gastro-esophageal reflux (GER) among infantile wheezers.

SUBJECTS

Fifty-two children < 2 years of age.

METHODS

All patients, irrespective of symptom underwent study to evaluate for GER.

RESULTS

GER studies were positive in almost 45% of cases. The agreement between positivity of these two tests is best among children between 7 and 12 months of age (κ = 0.591, p = 0.002). Overall GI scintiscan was a better test with higher sensitivity and specificity as compared to 24-h pH study when compared with the history suggestive of reflux and clinical response with anti-reflux treatment as standard (p ≤ .001).

CONCLUSION

Both GER scan and 24-h pH study are complimentary to each other, however, if both the tests are available then GI scintiscan is better as a single test for GER in these early wheezers.

Gastro-esophageal reflux in early childhood wheezers

Wheezing is common among infants and young children due to peculiar anatomical and physiological properties of their lungs. Gastro-oesophageal reflux (GER) has been incriminated as one of the cause of non-asthmatic wheezing in this age group. The present study evaluates the magnitude of GER and its causal relationship with wheezing in early childhood. All recurrent and persistent wheezers (under two years) were investigated for GER and treated medically where tests were positive. The subjects were further profiled to identify any predictors for GER. Sixty-seven children of less than 2 years age with recurrent or persistent wheezing were evaluated for GER. Mean age of the study subjects at enrolment was 10.8 months and at onset of wheezing was 7.1 (± 3.8 S.D) months. Asthma and wheeze associated lower respiratory tract infection (WALRI) was diagnosed in about 1/3 each of the patients studied. GER studies were positive in over one-third (25/67) of cases. Forty-two percent of children who wheezed by 1 year of age had a positive GER study. Interestingly, nearly half (12/25) of the patients with an abnormal study did not have any clinical suggestion of regurgitation ("silent" GERs). The severity of wheezing was higher among those who had GER versus those who did not (p ≤ 0.048; OR: 3.2). However, only 32% patients showed significant response to anti reflux treatment alone while others had partial response. GER, therefore, is an important cause for recurrent wheezing among children less than 2 years of age, either singularly or as a co-morbidity. The study findings justify investigations for GER among early wheezers; particularly for those who have onset of symptoms by 12 months of age or those who have severe disease.

Midterm follow-up of esophageal anastomosis for esophageal atresia repair: long-gap versus non-long-gap

Current approaches to the repair of long-gap esophageal atresia (EA) favor esophageal anastomosis. This investigation provides a midterm follow-up of long-gap EA with a primary repair to determine whether this procedure affects symptom severity and whether symptom severity may predict worsening of dysmotility. Fifteen children at least 1-year post primary repair were divided into group 1 (long-gap) and group 2 (non-long-gap). The severity of their symptoms was graded using a questionnaire focused on their eating habits and gastroesophageal motor dysfunction symptoms. Esophageal transit time and gastric emptying were assessed by scintigraphy and used to grade esophagogastric dysmotility. At midterm follow-up the majority of patients in both groups were asymptomatic (66% in group 1 vs 77.7% in group 2; P > 0.05). Esophagogastric dysmotility grades for group 1 were more severe than for group 2 (median 2.5, range from 1 to 4 vs median 1, range from 1 to 2, respectively; P > 0.05). We found no relationship between the severity of the symptoms and the presence or severity of esophagogastric dysmotility. At midterm follow-up in patients with long-gap atresia that underwent primary repair, this study showed scintigraphic evidence of silent and serious esophagogastric dysmotility in symptom-free or minimally symptomatic children. It may therefore be unreliable to use symptoms in assessing the severity of esophagogastric dysmotility, since both groups showed similar clinical findings but different scintigraphic findings.

Investigation of regurgitation and other symptoms of gastroesophageal reflux in Indonesian infants

AIM: To evaluate the incidence of regurgitation and other symptoms of gastroesophageal reflux in Indonesian infants.

METHODS: In a cross-sectional study at the University Outpatient Clinic for vaccination in Jakarta, 138 mothers of healthy infants less than 12-mo old were prospectively asked to report the frequency of regurgitation.

RESULTS: Whatever the age was, some infants did not regurgitate (from 10% during the first month of life to 67% in 1-year-old infants). Regurgitation of at least once a day was reported in 77% of infants younger than 3 mo. Daily regurgitation decreased to 12% in the 9-12 mo old group. Reported peak prevalence was 81% (26/32) during the first month of life. Regurgitation decreased sharply between the 4-6 and 7-9 mo old groups (from 44% to 9%). The longer the regurgitation persisted, the more frequently the mother perceived regurgitation as a problem. Volume and frequency of regurgitation, back arching, irritability, crying and refusal of feeding were the symptoms causing maternal anxiety. The longer the regurgitation persisted, the more frequently the mothers viewed it as a health problem.

CONCLUSION: Regurgitation occurs frequently in Indonesian infants, and is a frequent cause of concern to mothers.