Bronchopulmonary and vascular anomalies are frequent in children with oesophageal atresia

The International Network on Oesophageal Atresia (INoEA) consensus guidelines on the transition of patients with oesophageal atresia-tracheoesophageal fistula

Oesophageal atresia-tracheoesophageal fistula (EA-TEF) is a common congenital digestive disease. Patients with EA-TEF face gastrointestinal, surgical, respiratory, otolaryngological, nutritional, psychological and quality of life issues in childhood, adolescence and adulthood. Although consensus guidelines exist for the management of gastrointestinal, nutritional, surgical and respiratory problems in childhood, a systematic approach to the care of these patients in adolescence, during transition to adulthood and in adulthood is currently lacking. The Transition Working Group of the International Network on Oesophageal Atresia (INoEA) was charged with the task of developing uniform evidence-based guidelines for the management of complications through the transition from adolescence into adulthood. Forty-two questions addressing the diagnosis, treatment and prognosis of gastrointestinal, surgical, respiratory, otolaryngological, nutritional, psychological and quality of life complications that patients with EA-TEF face during adolescence and after the transition to adulthood were formulated. A systematic literature search was performed based on which recommendations were made. All recommendations were discussed and finalized during consensus meetings, and the group members voted on each recommendation. Expert opinion was used when no randomized controlled trials were available to support the recommendation. The list of the 42 statements, all based on expert opinion, was voted on and agreed upon.

Type III congenital pulmonary airway malformation associated with oesophageal atresia and tracheoesophageal fistula. A case report and review of literature

Congenital pulmonary airway malformation (CPAM) together with oesophageal atresia and tracheoesophageal fistula (TOF) is a very rare condition in neonates. We presented a case of an infant with Gross type C oesophageal atresia with TOF coexisting with Stocker Type III CPAM in our centre. It is interesting to know that TOF associated with type III CPAM has never been reported in the literature. The child was delivered through caesarean section, and because of respiratory distress post-delivery, endotracheal intubation was carried out immediately. CPAM was diagnosed by a suspicious finding from the initial chest X-ray and the diagnosis was confirmed through computed tomography scan of the chest. The patient was initially stabilised in a neonatal intensive care unit (NICU), and after the successful ligation of fistula and surgical repair of TOF, lung recruitment was started by high flow oscillatory ventilation. The patient recovered well without complications and able to maintain good saturation without oxygen support through the stay in the neonatal unit. Early recognition of this rare association is essential for immediate transfer to NICU, the intervention of any early life-threatening complications, and for vigilant monitoring in the postoperative period.

Morphologic classification of tracheobronchial arborization in children with congenital tracheobronchial stenosis and the associated cardiovascular defects

Background

We sought to classify patients with congenital tracheal stenosis (CTS) according to tracheobronchial morphology and determine anatomic features associated with tracheobronchial anomalies (TBAs) and concurrent cardiovascular defects (CVDs).

Methods

We enrolled 254 patients who underwent tracheoplasty between November 1, 2009 and December 30, 2018. The anatomic features of the tracheobronchial tree and cardiovascular system were abstracted from bronchoscopy, echocardiography, computerized tomography, and operative reports.

Results

Four types of tracheobronchial morphology were identified: Type-1, which included normal tracheobronchial arborization (Type-1A, n = 29) and tracheal bronchus (Type-1B, n = 22); Type-2 (tracheal trifurcation; n = 49), and Type-3 (typical bridging bronchus; n = 47). Type-4 (bronchus with an untypical bridging pattern) was divided into Type-4A (involving bronchial diverticulum; n = 52) and Type-4B (absent bronchus; n = 55). Carinal compression and tracheomalacia were significantly more frequent in Type-4 patients than in the other patients (P < 0.01). CVDs were common in patients with CTS, especially in patients with Type-3 and Type-4 (P < 0.01). Persistent left superior vena cava was most common among patients with Type-3 (P < 0.01), and pulmonary artery sling was most frequent among those with Type-4 (P < 0.01). Outflow tract defects were most likely to occur in Type-1B. Early mortality was detected in 12.2% of all patients, and young age (P = 0.02), operation in the early era (P < 0.01), and bronchial stenosis (P = 0.03) were proven to be risk factors.

Conclusions

We demonstrated a useful morphological classification for CTS. Bridging bronchus was most closely linked with vascular anomalies, while tracheal bronchus was frequently associated with outflow tract defects. These results may provide a clue to CTS pathogenesis.

Lung adenocarcinoma concurrent with congenital pulmonary aplasia of the right upper lobe: A case report

Lung adenocarcinoma, the most common subtype of lung cancer, has been always imposed serious threat to human health. Congenital pulmonary dysplasia (CPD) lacking typical clinical manifestations is a rare developmental anomaly. Pulmonary aplasia, the rarest subtype of CPD, may present with a variety of symptoms and is frequently associated with other abnormalities. This report describes an 81-year-old woman who presented with an irritant cough. Chest computed tomography (CT) and three-dimensional (3D) reconstruction revealed an irregular mass with a diameter of 5 cm in right lower lobe adjacent to the hilum. CT also indicated a rightward mediastinal shift and the complete absence of ipsilateral upper lobar tissue with bronchus ending in a terminal cecum, resulting in a diagnosis of pulmonary aplasia. The patient accepted lobectomy and lymph node dissection without complication, histopathologic examination combined HE staining with immunohistochemistry identified the tumor as adenocarcinoma. Three months after surgery, the patient was free of respiratory symptoms without chest pain. This report highlights the necessity of comprehensive evaluation for lung malignancy concurrent with CPD and the importance of identifying the diagnosis of pulmonary dysplasia.

Should all babies with oesophageal atresia have routine screening for midgut malrotation anomalies? A systematic review in search of evidence

Background/Purpose Oesophageal Atresia (OA) is associated with co-existent anomalies. There is a controversy of literature pertaining to the risk (s) of intestinal malrotation. In order to guide management we critically evaluate the incidence of IM anomalies in OA newborns. Design MEDLINE and EMBASE databases were searched using keywords "(O)Esophageal Atresia and Malrotation/Associated Abnormalities/Associated Anomalies". Full texts of articles were screened if manuscripts exclusively reported patients with OA malrotation and/or associated anomalies. Larger case series (> 10patients) were included if abstract (s) showed that associated anomalies were systematically assessed. Full eligibility criteria required at least one case of malrotation in an OA index case. Data were collected on article type, number of patients and method (s) of diagnosis. Results 632 abstracts were screened of which 158 papers were analysed based on inclusion criteria-30 manuscripts documented the incidence (%) of malrotation. Incidence rate (s) were 0.5-13%. Malrotation was observed to have a higher incidence (10-44%) in OA babies with other gastrointestinal anomalies (VACTERL). Conclusion Newborns with OA appear to be at a higher risk (%) of having intestinal malrotation anomalies than healthy babies. Prospective studies are required to accurately quantify and define the ' true incidence ' of this association. Given the potential lethal consequences of midgut volvulus screening may be justified in OA babies. Consensus guidelines (DELPHI) exploring surgeons attitudes with regards management of ' asymptomatic malrotation ' disorders in OA newborns may further guide best practice.

Esophageal Atresia and Respiratory Morbidity

BACKGROUND AND OBJECTIVES

Respiratory diseases are common in children with esophageal atresia (EA), leading to increased morbidity and mortality in the first year. The primary study objective was to identify the factors associated with readmissions for respiratory causes in the first year in EA children.

METHODS

A population-based study. We included all children born between 2008 and 2016 with available data and analyzed factors at birth and 1 year follow-up. Factors with a P value <.10 in univariate analyses were retained in logistic regression models.

RESULTS

Among 1460 patients born with EA, 97 (7%) were deceased before the age of 1 year, and follow-up data were available for 1287 patients, who constituted our study population. EAs were Ladd classification type III or IV in 89%, preterm birth was observed in 38%, and associated malformations were observed in 52%. Collectively, 61% were readmitted after initial discharge in the first year, 31% for a respiratory cause. Among these, respiratory infections occurred in 64%, and 35% received a respiratory treatment. In logistic regression models, factors associated with readmission for a respiratory cause were recurrence of tracheoesophageal fistula, aortopexy, antireflux surgery, and tube feeding; factors associated with respiratory treatment were male sex and laryngeal cleft.

CONCLUSIONS

Respiratory morbidity in the first year after EA repair is frequent, accounting for >50% of readmissions. Identifying high risk groups of EA patients (ie, those with chronic aspiration, anomalies of the respiratory tract, and need for tube feeding) may guide follow-up strategies.

Vascular and pulmonary comorbidities in children with congenital EA/TEF

BACKGROUND

Esophageal atresia with tracheoesophageal fistula (EA/TEF) is associated with many congenital and vascular malformations; however, reports utilizing computed tomography (CT) and computed tomography angiography (CTA) are limited. The objective of this study is to review CT scans of the chest from patients with EA/TEF and report their pulmonary and vascular findings.

METHODS

We completed a retrospective chart review of children with congenital EA/TEF evaluated in the aerodigestive clinic at Children's Hospital Colorado. Results of the most recent CTA or CT of the chest were investigated. Demographics, medical conditions, and bronchoscopy findings were also recorded. The ratio of tracheal lumen area between inspiratory and expiratory CTA images was measured.

RESULTS

Of the patients with congenital EA/TEF seen in the program, 47 patients had a chest CT available for review. Eight patients (17%) had bronchiectasis. Of the contrast CT scans, 15 (58%) had a vascular abnormality and 16 (62%) demonstrated tracheal compression (38% at the level of the innominate artery, 35% from other structures). Nineteen of the CTAs had volumetric expiratory images of the trachea to evaluate tracheomalacia. The mean expiratory:inspiratory area was 0.57 (SD ± 0.23) at the level of the innominate.

CONCLUSION

Patients with EA/TEF frequently have vascular abnormalities that may alter airway mechanics as well as pulmonary comorbidities that may affect long-term management. For patients experiencing persistent respiratory symptoms, CTA of the chest should be considered adjunct to bronchoscopy to help with medical and surgical management of these children.

Diagnostic Challenge in a Symptomatic Patient of Arteria Lusoria with Retro-esophageal Right Subclavian Artery and Absent Brachiocephalic Trunk

A combination of absent brachiocepahlic trunk and anomalous left circumflex artery with a retro-esophageal right subclavian artery is an extremely rare finding. This can clinically manifest as episodic dysphagia and chest pain. Routine coronary angiography via femoral access could be misleading and right radial access in such cases can be particularly challenging and has never been reported in literature before.

We present a case of a 42-year-old female with symptoms of chest, back, and left neck pain. She also complained of occasional dysphagia, dizziness, and palpitations. Physical examination revealed a regular heart rhythm with no vascular bruits. An electrocardiogram (EKG) only showed normal sinus rhythm and incomplete right bundle branch block. Noninvasive testing included an echocardiogram and previously done exercise stress test, and myocardial perfusion scans were noted to be normal. A diagnostic cardiac catheterization via right radial approach was performed to delineate her coronary anatomy and rule out ischemic etiology. This led to diagnosis of anomalous coronary anatomy (retro-esophageal right subclavian artery arising from descending aorta in association with an anomalous right circumflex artery with absent innominate artery) through a technically difficult and risky procedure. Significant vessel tortuosity and abnormal catheter angulations were encountered and were overcome by using specific catheters. Meticulous use of 6 French MP, WR, JL, and JR4 catheters along with an exchange length wire was required to negotiate the anatomical variations and complete the coronary angiogram via right radial artery.

From a procedural stand-point, coronary angiography via right radial access in presence of such rare anatomical variations can be particularly challenging. Routine femoral catheterization may fail to depict this important anatomical variation.

Coronary angiogram via right radial access in the presence of a combination of anatomical variations of great vessels and anomalous coronary arteries is particularly challenging from a procedural stand point due to vessel tortuosity and shape of catheters. Choice of anatomically appropriate diagnostic catheters and specific maneuvers are imperative in these coronary angiographic procedures.