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Kamran A, Smithers CJ, Izadi SN, Staffa SJ, Zurakowski D, Demehri FR, Mohammed S, Shieh HF, Ngo PD, Yasuda J, Manfredi MA, Hamilton TE, Jennings RW, Zendejas B. Surgical Treatment of Esophageal Anastomotic Stricture After Repair of Esophageal Atresia. J Pediatr Surg 2023; 58:2375-2383. [PMID: 37598047 DOI: 10.1016/j.jpedsurg.2023.07.014] [Citation(s) in RCA: 2] [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: 04/10/2023] [Revised: 07/17/2023] [Accepted: 07/24/2023] [Indexed: 08/21/2023]
Abstract
BACKGROUND Anastomotic strictures (AS) after esophageal atresia (EA) repair are common. While most respond to endoscopic therapy, some become refractory and require surgical intervention, for which the outcomes are not well established. METHODS All EA children with AS who were treated surgically at two institutions (2011-2022) were retrospectively reviewed. Surgical repair was performed for those with AS that were either refractory to endoscopic therapy or clinically symptomatic and undergoing surgery for another indication. Anastomotic leak, need for repeat stricture resection, and esophageal replacement were considered poor outcomes. RESULTS 139 patients (median age: 12 months, range 1.5 months-20 years; median weight: 8.1 kg) underwent 148 anastomotic stricture repairs (100 refractory, 48 non-refractory) in the form of stricturoplasty (n = 43), segmental stricture resection with primary anastomosis (n = 96), or stricture resection with a delayed anastomosis after traction-induced lengthening (n = 9). With a median follow-up of 38 months, most children (92%) preserved their esophagus, and the majority (83%) of stricture repairs were free of poor outcomes. Only one anastomotic leak occurred in a non-refractory stricture. Of the refractory stricture repairs (n = 100), 10% developed a leak, 9% required repeat stricture resection, and 13% required esophageal replacement. On multivariable analysis, significant risk factors for any type of poor outcome included anastomotic leak, stricture length, hiatal hernia, and patient's weight. CONCLUSIONS Surgery for refractory AS is associated with inherent yet low morbidity and high rates of esophageal preservation. Surgical repair of non-refractory symptomatic AS at the time of another thoracic operation is associated with excellent outcomes. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Ali Kamran
- Department of Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Charles J Smithers
- Department of Surgery, Boston Children's Hospital, Boston, MA, USA; Department of Surgery, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
| | - Shawn N Izadi
- Department of Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Steven J Staffa
- Department of Surgery, Boston Children's Hospital, Boston, MA, USA; Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA, USA
| | - David Zurakowski
- Department of Surgery, Boston Children's Hospital, Boston, MA, USA; Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Farokh R Demehri
- Department of Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Somala Mohammed
- Department of Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Hester F Shieh
- Department of Surgery, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
| | - Peter D Ngo
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA, USA
| | - Jessica Yasuda
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA, USA
| | - Michael A Manfredi
- Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Thomas E Hamilton
- Department of General, Thoracic and Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Russell W Jennings
- Department of Surgery, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
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Krasaelap A, Duncan DR, Sabe RMM, Bhardwaj V, Lerner DG, Gold BD, Boesch RP, Faure C, von Allmen D, Williams D, Chiou E, DeBoer E, Hysinger E, Maybee J, Khlevner J, Larson K, Morris K, Jalali L, McSweeney M, Brigger MT, Greifer M, Rutter M, Williams N, Subramanyan RK, Ryan MJ, Acra S, Pentiuk S, Friedlander J, Sobol SE, Kaul A, Dorfman L, Darbari A, Prager JD, Rosen R, Cocjin JT, Mousa H. Pediatric Aerodigestive Medicine: Advancing Collaborative Care for Children With Oropharyngeal Dysphagia. J Pediatr Gastroenterol Nutr 2023; 77:460-467. [PMID: 37438891 DOI: 10.1097/mpg.0000000000003882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/14/2023]
Abstract
OBJECTIVES Aerodigestive disorders encompass various pathological conditions affecting the lungs, upper airway, and gastrointestinal tract in children. While advanced care has primarily occurred in specialty centers, many children first present to general pediatric gastroenterologists with aerodigestive symptoms necessitating awareness of these conditions. At the 2021 Annual North American Society for Pediatric Gastroenterology, Hepatology and Nutrition meeting, the aerodigestive Special Interest Group held a full-day symposium entitled, Pediatric Aerodigestive Medicine: Advancing Collaborative Care of Children with Aerodigestive Disorders. The symposium aimed to underline the significance of a multidisciplinary approach to achieve better outcomes for these complex patients. METHODS The symposium brought together leading experts to highlight the growing aerodigestive field, promote new scientific and therapeutic strategies, share the structure and benefits of a multidisciplinary approach in diagnosing common and rare aerodigestive disorders, and foster multidisciplinary discussion of complex cases while highlighting the range of therapeutic and diagnostic options. In this article, we showcase the diagnostic and therapeutic approach to oropharyngeal dysphagia (OPD), one of the most common aerodigestive conditions, emphasizing the role of a collaborative model. CONCLUSIONS The aerodigestive field has made significant progress and continues to grow due to a unique multidisciplinary, collaborative model of care for these conditions. Despite diagnostic and therapeutic challenges, the multidisciplinary approach has enabled and greatly improved efficient, high-quality, and evidence-based care for patients, including those with OPD.
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Affiliation(s)
- Amornluck Krasaelap
- From the Division of Pediatric Gastroenterology, Hepatology and Nutrition, Children's Mercy Kansas City, Kansas City, MO
| | - Daniel R Duncan
- the Aerodigestive Center, Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Ramy M M Sabe
- the Department of Pediatric Gastroenterology, Hepatology and Nutrition, University Hospitals Rainbow Babies and Children's Hospital, Cleveland, OH
| | - Vrinda Bhardwaj
- the Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital Los Angeles, Keck School of Medicine of the University of Southern California, Los Angeles, CA
| | - Diana G Lerner
- the Division of Pediatric Gastroenterology, Hepatology and Nutrition, Medical College of Wisconsin, Milwaukee, WI
| | - Benjamin D Gold
- the Children's Center for Digestive Health Care, LLC, GI Care for Kids, LLC, Aerodigestive Center and Program, Children's Healthcare of Atlanta, Atlanta, GA
| | - Richard Paul Boesch
- the Division of Pediatric Pulmonology, Department of Pediatrics and Adolescent Medicine, Mayo Clinic Children's Center, Rochester, MN
| | - Christophe Faure
- the Division of Pediatric Gastroenterology, Sainte-Justine University Health Center, Université de Montréal, Montréal, QC, Canada
| | - Daniel von Allmen
- the Division of Pediatric Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Dana Williams
- the Department of Pediatric Gastroenterology and Nutrition, Phoenix Children's Hospital, Phoenix, AZ
| | - Eric Chiou
- the Division of Pediatric Gastroenterology, Hepatology & Nutrition, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, TX
| | - Emily DeBoer
- the Department of Pediatrics, Section of Pulmonary and Sleep Medicine, Children's Hospital Colorado Breathing Institute, University of Colorado Denver, Aurora, CO
| | - Erik Hysinger
- Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Jennifer Maybee
- Children's Hospital Colorado, University of Colorado, Aurora, CO
| | - Julie Khlevner
- the Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Columbia University Vagelos College of Physicians and Surgeons and NewYork-Presbyterian, New York, NY
| | - Kara Larson
- the Division of Otolaryngology, Boston Children's Hospital, Boston, MA
| | - Kimberly Morris
- the Department of Speech Pathology, Rady Children's Hospital, San Diego, CA
| | - Lauren Jalali
- the Aerodigestive Center, Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Maireade McSweeney
- the Aerodigestive Center, Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Matthew T Brigger
- the Division of Pediatric Otolaryngology, Department of Surgery, Rady Children's Hospital San Diego, University of California San Diego, San Diego, CA
| | - Melanie Greifer
- the Department of Pediatrics, Division of Pediatric Gastroenterology, New York University Grossman School of Medicine, New York, NY
| | - Michael Rutter
- the Division of Pediatric Otolaryngology, Aerodigestive and Esophageal Center, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Nina Williams
- the Center for Airway Disorders, Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital, Boston, MA
| | - Ram Kumar Subramanyan
- the University of Nebraska Medical Center, Children's Hospital and Medical Center, Omaha, NE
| | - Matthew J Ryan
- the Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Sari Acra
- the Division of Pediatric Gastroenterology, Hepatology and Nutrition, Vanderbilt University Medical Center, Nashville, TN
| | - Scott Pentiuk
- the Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | | | - Steven E Sobol
- the Division of Otolaryngology, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Ajay Kaul
- the Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Lev Dorfman
- the Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Anil Darbari
- Children's National Hospital, George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Jeremy D Prager
- the Department of Otolaryngology, University of Colorado School of Medicine; Pediatric Otolaryngology, Children's Hospital Colorado, Aurora, CO
| | - Rachel Rosen
- the Aerodigestive Center, Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Jose T Cocjin
- the Division of Pediatric Gastroenterology, Sainte-Justine University Health Center, Université de Montréal, Montréal, QC, Canada
| | - Hayat Mousa
- the Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
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Nakagawa Y, Uchida H, Hinoki A, Shirota C, Sumida W, Makita S, Yokota K, Amano H, Yasui A, Kato D, Gohda Y, Maeda T. Refractory esophageal anastomotic stricture after esophageal atresia surgery improved with retrograde balloon dilatation through gastrostomy followed by laparoscopic fundoplication: a case report. Surg Case Rep 2023; 9:169. [PMID: 37737524 PMCID: PMC10516835 DOI: 10.1186/s40792-023-01754-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 09/17/2023] [Indexed: 09/23/2023] Open
Abstract
BACKGROUND An esophageal anastomotic stricture (EAS) after an esophageal atresia surgery occurs in approximately 4-60% of the cases, and its first-line therapy includes balloon dilatation. Oral balloon dilatation cannot be performed in some EAS cases; conversely, even if dilatation is possible, these strictures recur in some cases, necessitating a surgical procedure for repairing the stenosis. However, these procedures are invasive and have short- and long-term complications. If an EAS recurs repeatedly after multiple balloon dilations, gastroesophageal reflux disease (GERD) may be the underlying cause. A fundoplication procedure may be effective for treating a refractory EAS, as in the present case. CASE PRESENTATION A neonatal patient with type D esophageal atresia underwent thoracoscopic esophago-esophageal anastomosis at the age of 1 day, and her postoperative course was uneventful. Thereafter, the patient underwent gastrostomy for poor oral intake at the age of 3 months. After gastrostomy, the patient presented with a complete obstructive EAS. Balloon dilatation via the oral route was attempted; however, a guidewire could not be inserted into the EAS site. Hence, retrograde balloon dilatation via gastrostomy was performed successfully. However, the EAS recurred easily thereafter, and laparoscopic anti-reflux surgery was performed to prevent GERD. The anti-reflux surgery cured the otherwise refractory EAS and prevented its recurrence. CONCLUSIONS Retrograde balloon dilatation is another treatment option for an EAS. When an EAS recurs soon after dilatation, the patient must be evaluated for GERD; if severe GERD is observed, an appropriate anti-reflux surgery is required before dilating the EAS.
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Affiliation(s)
- Yoichi Nakagawa
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan
| | - Hiroo Uchida
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan.
| | - Akinari Hinoki
- Department of Rare/Intractable Cancer Analysis Research, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan
| | - Chiyoe Shirota
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan
| | - Wataru Sumida
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan
| | - Satoshi Makita
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan
| | - Kazuki Yokota
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan
| | - Hizuru Amano
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan
| | - Akihiro Yasui
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan
| | - Daiki Kato
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan
| | - Yousuke Gohda
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan
| | - Takuya Maeda
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan
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4
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Yasuda JL, Taslitsky GN, Staffa SJ, Ngo PD, Meisner J, Mohammed S, Hamilton T, Zendejas B, Manfredi MA. Predictors of enteral tube dependence in pediatric esophageal atresia. Dis Esophagus 2023; 36:6692452. [PMID: 36065605 DOI: 10.1093/dote/doac060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 08/10/2022] [Accepted: 08/15/2022] [Indexed: 12/11/2022]
Abstract
Children with esophageal atresia (EA) may require enteral tube feedings in infancy and a subset experience ongoing feeding difficulties and enteral tube dependence. Predictors of enteral tube dependence have never been systematically explored in this population. We hypothesized that enteral tube dependence is multifactorial in nature, with likely important contributions from anastomotic stricture. Cross-sectional clinical, feeding, and endoscopic data were extracted from a prospectively collected database of endoscopies performed in EA patients between August 2019 and August 2021 at an international referral center for EA management. Clinical factors known or hypothesized to contribute to esophageal dysphagia, oropharyngeal dysphagia, or other difficulties in meeting caloric needs were incorporated into regression models for statistical analysis. Significant predictors of enteral tube dependence were statistically identified. Three-hundred thirty children with EA were eligible for analysis. Ninety-seven were dependent on enteral tube feeds. Younger age, lower weight Z scores, long gap atresia, neurodevelopmental risk factor(s), significant cardiac disease, vocal fold movement impairment, and smaller esophageal anastomotic diameter were significantly associated with enteral tube dependence in univariate analyses; only weight Z scores, vocal fold movement impairment, and anastomotic diameter retained significance in a multivariable logistic regression model. In the current study, anastomotic stricture is the only potentially modifiable significant predictor of enteral tube dependence that is identified.
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Affiliation(s)
- Jessica L Yasuda
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA, USA
| | - Gabriela N Taslitsky
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA, USA
| | - Steven J Staffa
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Peter D Ngo
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA, USA
| | - Jay Meisner
- Department of Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Somala Mohammed
- Department of Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Thomas Hamilton
- Department of Surgery, Boston Children's Hospital, Boston, MA, USA
| | | | - Michael A Manfredi
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA, USA
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5
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Abstract
Esophageal dilations in children are performed by several pediatric and adult professionals. We aim to summarize improvements in safety and new technology used for the treatment of complex and refractory strictures, including triamcinolone injection, endoscopic electro-incisional therapy, topical mitomycin-C application, stent placement, functional lumen imaging probe assisted dilation, and endoscopic vacuum-assisted closure in the pediatric population.
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6
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Durakbasa CU, Ersoy F, Pirim A, Oskayli MC. Clinical outcome of endoscopic balloon dilatations employed in benign paediatric oesophageal pathologies. J Minim Access Surg 2023; 19:62-68. [PMID: 35915522 PMCID: PMC10034793 DOI: 10.4103/jmas.jmas_79_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
Background Oesophageal dilatations can be done either by bougies or balloons for differing aetiologies in children. We investigated the efficacy and safety of endoscopic balloon dilatations (EBDs) employed by a single surgeon. Patients and Methods Relevant data over 12 years were retrospectively evaluated with an ethical committee approval. Results Ninety-seven children underwent 514 EBD with a median EBD of 3 (1-50). The primary diagnoses were oesophageal atresia (OA) in 51 children, corrosive ingestion in 21, peptic strictures in 13, achalasia in 8 and congenital oesophageal stenosis in 4. The balloon size varied between 3 and 30 mm. The EBD was successfully ended in 72 patients and unsuccessful in six patients. Six children are still under EBD and 13 are lost to follow-up. The overall success rate was 92%. The age at the time of first dilatation was the youngest in OA group followed by corrosive strictures. The balloon sizes differed regarding the age of the patients with larger balloons used as the patient age increased. The sizes of the balloons used at the first and the last EBD differed among diagnostic groups. The total number of dilatations or the time interval between the first and the last EBD dilatation did not show a statistically significant difference among groups. The anatomical type of OA or the height of corrosive stricture revealed no significant difference in any of the above parameters. A transmural oesophageal perforation occurred during 2 (0.4%) EBD sessions. Conclusions EBD is an effective mean in relieving paediatric oesophageal pathologies with a variety of aetiologies and has a low complication rate.
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Affiliation(s)
- Cigdem Ulukaya Durakbasa
- Department of Pediatric Surgery, Istanbul Medeniyet University Faculty of Medicine, Goztepe Dr. Suleyman Yalcin Sehir Hospital, Istanbul, Turkey
| | - Furkan Ersoy
- Department of Pediatric Surgery, Istanbul Medeniyet University Faculty of Medicine, Goztepe Dr. Suleyman Yalcin Sehir Hospital, Istanbul, Turkey
| | - Ahmet Pirim
- Department of Pediatric Surgery, Istanbul Medeniyet University Faculty of Medicine, Goztepe Dr. Suleyman Yalcin Sehir Hospital, Istanbul, Turkey
| | - Meltem Caglar Oskayli
- Department of Pediatric Surgery, Istanbul Medeniyet University Faculty of Medicine, Goztepe Dr. Suleyman Yalcin Sehir Hospital, Istanbul, Turkey
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7
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Mohammed S, Hamilton TE. Advances in Complex Congenital Tracheoesophageal Anomalies. Clin Perinatol 2022; 49:927-941. [PMID: 36328608 DOI: 10.1016/j.clp.2022.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Esophageal atresia with or without tracheoesophageal fistula and tracheobronchomalacia encompass 2 of the most common complex congenital intrathoracic anomalies. Tailoring interventions to address the constellation of problems present in each patient is essential. Due to advances in neonatology, anesthesia, pulmonary, gastroenterology, nutrition and surgery care for patients with complex congenital tracheoesophageal disorders has improved dramatically. Treatment strategies tailored to the individual patient needs are best implimented under the aegis of a comprehensive longitudinal multidisciplinary care team.
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Affiliation(s)
- Somala Mohammed
- Harvard Medical School, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Thomas E Hamilton
- Perelman School of Medicine at the University of Pennsylvania, Department of General, Thoracic and Fetal Surgery, Children's Hospital of Philadelphia, The Hub for Clinical Collaboration, 2nd Floor, 3500 Civic Center Boulevard, Philadelphia, PA 19104, USA.
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8
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Meisner JW, Kamran A, Staffa SJ, Mohammed S, Yasuda JL, Ngo P, Manfredi M, Zurakowski D, Jennings RW, Hamilton TE, Zendejas B. Qualitative features of esophageal fluorescence angiography and anastomotic outcomes in children. J Pediatr Surg 2022:S0022-3468(22)00455-9. [PMID: 35934523 DOI: 10.1016/j.jpedsurg.2022.07.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 06/29/2022] [Accepted: 07/06/2022] [Indexed: 10/17/2022]
Abstract
BACKGROUND Indocyanine green (ICG) is commonly used to assess perfusion, but quality defining features are lacking. We sought to establish qualitative features of esophageal ICG perfusion assessments, and develop an esophageal anastomotic scorecard to risk-stratify anastomotic outcomes. METHODS Single institution, retrospective analysis of children with an intraoperative ICG perfusion assessment of an esophageal anastomosis. Qualitative perfusion features were defined and a perfusion score developed. Associations between perfusion and clinical features with poor anastomotic outcomes (PAO, leak or refractory stricture) were evaluated with logistic and time-to-event analyses. Combining significant features, we developed and tested an esophageal anastomotic scorecard to stratify PAO risk. RESULTS From 2019 to 2021, 53 children (median age 7.4 months) underwent 55 esophageal anastomoses. Median (IQR) follow-up was 14 (10-19.9) months; mean (SD) perfusion score was 13.2 (3.4). Fifteen (27.3%) anastomoses experienced a PAO and had significantly lower mean perfusion scores (11.3 (3.3) vs 14.0 (3.2), p = 0.007). Unique ICG perfusion features, severe tension, and primary or rescue traction-induced esophageal lengthening [Foker] procedures were significantly associated with PAO on both logistic and Cox regression. The scorecard (range 0-7) included any Foker (+2), severe tension (+1), no arborization on either segment (+1), suture line hypoperfusion >twice expected width (+2), and segmental or global areas of hypoperfusion (+1). A scorecard cut-off >3 yielded a sensitivity of 73% and specificity of 93% (AUC 0.878 [95%CI 0.777 to 0.978]) in identifying a PAO. CONCLUSIONS A scoring system comprised of qualitative ICG perfusion features, tissue quality, and anastomotic tension can help risk-stratify esophageal anastomotic outcomes accurately. LEVELS OF EVIDENCE Diagnostic - II.
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Affiliation(s)
- Jay W Meisner
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States
| | - Ali Kamran
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States
| | - Steven J Staffa
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States; Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States
| | - Somala Mohammed
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States
| | - Jessica L Yasuda
- Department of Gastroenterology, Hepatology, and Nutrition, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States
| | - Peter Ngo
- Department of Gastroenterology, Hepatology, and Nutrition, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States
| | - Michael Manfredi
- Department of Gastroenterology, Hepatology, and Nutrition, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States
| | - David Zurakowski
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States; Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States
| | - Russell W Jennings
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States
| | - Thomas E Hamilton
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States
| | - Benjamin Zendejas
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States.
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9
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Harrington AW, Riebold J, Hernandez K, Staffa SJ, Meisner JW, Zurakowski D, Jennings R, Hamilton T, Zendejas B. Feeding and Growth Outcomes in Infants with Type C Esophageal Atresia Who Undergo Early Primary Repair. J Pediatr 2022; 241:77-82.e1. [PMID: 34687688 DOI: 10.1016/j.jpeds.2021.10.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Revised: 10/03/2021] [Accepted: 10/14/2021] [Indexed: 02/07/2023]
Abstract
OBJECTIVES To describe growth and feeding outcomes in patients with type C esophageal atresia who underwent early primary repair and to identify predictors for poor growth. STUDY DESIGN This single-center, retrospective, cohort study included all patients with type C esophageal atresia who underwent early primary repair from 2013 to 2019. Weight-for-age z score (WAZ) was calculated at birth, and every 6 months until 3 years postoperatively. Longitudinal median regression was used to evaluate WAZ over time. A multivariable logistic regression model explored predictors of growth outcomes. RESULTS Of 46 infants who met the inclusion criteria, 72% were term. The median age at repair was 1.5 days of life (IQR, 1-2 days of life) and the hospital length of stay was 20 days (IQR-14, 30 days). Two patients had esophageal leak (4.3%). The median WAZ at birth was below average (-0.72; IQR, -1.37 to -0.40), but improved to reach average by 3 years (-0.025; IQR, -0.85 to 0.97, P < .001). At discharge, 72% of patients were receiving full oral nutrition, which improved to 95% by 3 years. The only independent predictor of poor growth at 1 year (WAZ < -1 [33%]) was WAZ at discharge (P = .02). CONCLUSIONS Infants with esophageal atresia who undergo early primary repair are capable of achieving standard growth curves by 3 years of age. However, poor discharge WAZ score was predictive of poor WAZ score at 1 year. Efforts to identify at-risk patients and institute targeted inpatient and outpatient nutrition interventions are needed to improve their growth trajectory.
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Affiliation(s)
| | - Jane Riebold
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA
| | - Kayla Hernandez
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA
| | - Steven J Staffa
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA
| | - Jay W Meisner
- Department of Surgery, Boston Children's Hospital, Boston, MA
| | - David Zurakowski
- Department of Surgery, Boston Children's Hospital, Boston, MA; Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA
| | | | - Thomas Hamilton
- Department of Surgery, Boston Children's Hospital, Boston, MA
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10
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Koivusalo A, Mutanen A, Suominen J, Pakarinen M. Anastomotic Stricture in End-to-End Anastomosis-Risk Factors in a Series of 261 Patients with Esophageal Atresia. Eur J Pediatr Surg 2022; 32:56-60. [PMID: 34823265 DOI: 10.1055/s-0041-1739422] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
AIM To assess the risk factors for anastomotic stricture (AS) in end-to-end anastomosis (EEA) in patients with esophageal atresia (EA). METHODS With ethical consent, hospital records of 341 EA patients from 1980 to 2020 were reviewed. Patients with less than 3 months survival (n = 30) with Gross type E EA (n = 24) and with primary reconstruction (n = 21) were excluded. Outcome measures were revisional surgery for anastomotic stricture (RSAS) and number of dilatations required for anastomotic patency without RSAS. The factors that were tested for risk of RSAS or dilatations were distal tracheoesophageal fistula (TEF) at the carina in C-type EA (congenital TEF [CTEF]), type A/B EA, antireflux surgery (ARS), anastomotic leakage, recurrent TEF, and Spitz group and congenital heart disease. MAIN RESULTS A total of 266 patients, Gross type A (n = 17), B (n = 3), C (n = 237), or D (n = 9) underwent EEA (early n = 240, delayed n = 26). Early anastomotic breakdown required secondary reconstruction in five patients. Of the remaining 261 patients, 17 (6.1%) had RSAS, whereas 244 patients with intact end to end required a median of five (interquartile range: 2-8) dilatations for anastomotic patency. Main risk factors for RSAS or (> 8) dilatations were CTEF, type A/B, ARS, and anastomotic leakage that increased the risk of RSAS or dilatations from 4.6- to 11-fold. CONCLUSION The risk of severe AS is associated with long-gap EA, significant gastroesophageal reflux, and anastomotic leakage.
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Affiliation(s)
- Antti Koivusalo
- Department of Pediatric Surgery, Children's Hospital, Helsinki, Finland
| | - Annika Mutanen
- Division of General and Thoracic Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Janne Suominen
- Department of Pediatric Surgery, Children's Hospital, Helsinki, Finland
| | - Mikko Pakarinen
- Department of Pediatric Surgery, Hospital for Children and Adolescents, University of Helsinki, Helsinki, Finland
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11
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Baghdadi O, Yasuda J, Staffa S, Ngo P, Zendejas B, Hamilton T, Jennings R, Manfredi M. Predictors and Outcomes of Fully Covered Stent Treatment for Anastomotic Esophageal Strictures in Esophageal Atresia. J Pediatr Gastroenterol Nutr 2022; 74:221-226. [PMID: 34694266 DOI: 10.1097/mpg.0000000000003330] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND AND AIMS Anastomotic strictures following surgical repair is one of the most common complications in esophageal atresia (EA). The utility of esophageal stenting to treat anastomotic esophageal strictures in pediatrics is unclear. Our primary aim was to evaluate whether esophageal stenting, in conjunction with dilation and other endoscopic therapies, prevented surgical stricture resection (SR). Our secondary aims were to evaluate predictors of successful esophageal stenting and evaluate adverse events from stent placement. METHODS A retrospective review of pediatric patients with EA complicated by esophageal strictures was performed. The change in stricture diameter in millimeters from the time of stent removal to subsequent endoscopy was defined as delta diameter (ΔD). A receiver operating characteristic (ROC) curve analysis was performed to determine the discriminatory ability of ΔD. Youden J index was used to identify optimal cutoff-point in predicting stent success. A univariate and multivariate analysis were done to assess predictors of success. RESULT Forty-nine esophageal anastomoses were stented to treat esophageal strictures. Stents prevented SR in 41% of patients. ROC curve analysis utilizing Youden J index identified ΔD of ≤4 mm (area under the curve = 0.790; 95% confidence interval: 0.655-0.924; P < 0.001) as the optimal cutoff point in differentiating stent success. The most common adverse events were erosions/ulcerations, granulation tissue formation, and vomiting/retching. CONCLUSION Stent therapy in preventing SR at the site of EA repair was successful in 41% in our population with good long term follow-up. The most significant predictor of success in this study was the change in luminal diameter (≤4 mm) at initial poststent follow-up.
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Affiliation(s)
| | | | - Steven Staffa
- Division of Anesthesiology, Perioperative and Pain Medicine
| | - Peter Ngo
- Division of Gastroenterology, Hepatology and Nutrition
| | - Benjamin Zendejas
- Department of General Surgery, Boston Children's Hospital, Boston, MA
| | - Thomas Hamilton
- Department of General Surgery, Boston Children's Hospital, Boston, MA
| | - Russell Jennings
- Department of General Surgery, Boston Children's Hospital, Boston, MA
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12
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Madeleine A, Audrey N, Rony S, David S, Frédéric G. Long term digestive outcome of œsophageal atresia. Best Pract Res Clin Gastroenterol 2021; 56-57:101771. [PMID: 35331402 DOI: 10.1016/j.bpg.2021.101771] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 10/13/2021] [Indexed: 02/07/2023]
Abstract
Œsophageal atresia is a rare neonatal malformation consisting in an interruption of the continuity of the œsophagus, with or without a tracheo-œsophageal fistula. Although mortality rate is now low and most cases can benefit from successful surgical repair soon after birth, morbidity -specially digestive and nutritional-remains high. Many of the adults born with œsophageal atresia will suffer from dysphagia, gastro-œsophageal reflux and/or œsophageal dysmotility, leading to nutritional consequences and quality of life impairment. Barrett's œsophagus, potential risk of œsophageal cancer as well as risk of anastomotic stenosis and eosinophilic œsophagitis justify transition to adulthood and a lifelong prolonged follow-up.
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Affiliation(s)
- Aumar Madeleine
- Univ. Lille, Reference Centre for rare œsophageal diseases, CHU Lille, U 1286 INFINITE, F59000, Lille, France.
| | - Nicolas Audrey
- Univ. Lille, Reference Centre for rare œsophageal diseases, CHU Lille, U 1286 INFINITE, F59000, Lille, France.
| | - Sfeir Rony
- Univ. Lille, Reference Centre for rare œsophageal diseases, CHU Lille, U 1286 INFINITE, F59000, Lille, France.
| | - Seguy David
- Univ. Lille, Reference Centre for rare œsophageal diseases, CHU Lille, U 1286 INFINITE, F59000, Lille, France.
| | - Gottrand Frédéric
- Univ. Lille, Reference Centre for rare œsophageal diseases, CHU Lille, U 1286 INFINITE, F59000, Lille, France.
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13
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Gao XJ, Huang JX, Chen Q, Hong SM, Hong JJ, Ye H. The timing of oesophageal dilatations in anastomotic stenosis after one-stage anastomosis for congenital oesophageal atresia. J Cardiothorac Surg 2021; 16:284. [PMID: 34627318 PMCID: PMC8501525 DOI: 10.1186/s13019-021-01656-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 09/19/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In infants with congenital oesophageal atresia, anastomotic stenosis easily occurs after one-stage oesophageal anastomosis, leading to dysphagia. In severe cases, oesophageal dilatation is required. In this paper, the timing of oesophageal dilatation in infants with anastomotic stenosis was investigated through retrospective data analysis. METHODS The clinical data of 107 infants with oesophageal atresia who underwent one-stage anastomosis in our hospital from January 2015 to December 2018 were retrospectively analysed. Data such as the timing and frequency of oesophageal dilatation under gastroscopy after surgery were collected to analyse the timing of oesophageal dilatation in infants with different risk factors. RESULTS For infants with refractory stenosis, the average number of dilatations in the early dilatation group (the first dilatation was performed within 6 months after the surgery) was 5.75 ± 0.5, which was higher than the average of 7.40 ± 1.35 times in the normal dilatation group (the first dilatation was performed 6 months after the surgery), P = 0.038. For the infants with anastomotic fistula and anastomotic stenosis, the number of oesophageal dilatations in the early dilatation group was 2.58 ± 2.02 times, which was less than the 6.38 ± 2.06 times in the normal dilatation group, P = 0.001. For infants with non-anastomotic fistula stenosis, early oesophageal dilatation could not reduce the total number of oesophageal dilatations. CONCLUSION Starting to perform oesophageal dilatation within 6 months after one-stage anastomosis for congenital oesophageal atresia can reduce the required number of dilatations in infants with postoperative anastomotic fistula and refractory anastomotic stenosis.
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Affiliation(s)
- Xue-Jie Gao
- Department of Pediatrics, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China.,Department of Pediatrics, Fujian Branch of Shanghai Children's Medical Center, Fuzhou, China
| | - Jin-Xi Huang
- Department of Cardiothoracic Surgery, Fujian Branch of Shanghai Children's Medical Center, Fuzhou, China
| | - Qiang Chen
- Department of Cardiothoracic Surgery, Fujian Branch of Shanghai Children's Medical Center, Fuzhou, China
| | - Song-Ming Hong
- Department of Cardiothoracic Surgery, Fujian Branch of Shanghai Children's Medical Center, Fuzhou, China
| | - Jun-Jie Hong
- Department of Cardiothoracic Surgery, Fujian Branch of Shanghai Children's Medical Center, Fuzhou, China
| | - Hong Ye
- Department of Pediatrics, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China. .,Department of Pediatrics, Fujian Branch of Shanghai Children's Medical Center, Fuzhou, China.
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14
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Angelino G, Tambucci R, Torroni F, De Angelis P, Dall'Oglio L. New therapies for esophageal strictures in children. Curr Opin Pediatr 2021; 33:503-508. [PMID: 34354006 DOI: 10.1097/mop.0000000000001049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The present review aims at describing recent advances in therapeutic strategies for the treatment of benign esophageal strictures in children. We discuss current knowledge and practice on esophageal dilations, which are still the mainstream of treatment. We present new evidence about adjuvant treatments for recurrent and refractory strictures, including endoscopic incisional therapy, esophageal stenting, intralesional or topical mytomicin C and intralesional, systemic or topical steroids. RECENT FINDINGS Current evidence on esophageal dilations is not sufficient to establish superiority of one of the available techniques, especially the use of balloon or bougie dilators, but a prospective international cohort study on anastomotic stricture in esophageal atresia is underway to address this issue. Recurrent and refractory strictures still represent a challenge, since none of the adjuvant pharmacological and mechanical interventions has shown to be enough feasible, effective and safe to revolutionize clinical practice. SUMMARY In the last couple of years, several encouraging results have been published on management of esophageal strictures in children. Further research is needed, hopefully directed toward secure, easily reproducible and minimally invasive measures.
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Affiliation(s)
- Giulia Angelino
- Digestive Endoscopy and Surgery Unit, Bambino Gesù Children's Hospital - Scientific Institute for Research and Healthcare, Rome, Italy
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15
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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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