Dominique Lévesque

Anastomotic Stricture after Esophageal Atresia Repair: A Critical Review of Recent Literature

Anastomotic strictures (ASs) complicate the postoperative course of roughly one-third of all patients with esophageal atresia with or without tracheoesophageal fistula. Its development is multifactorial, but is due in part to tension on the anastomosis, gastroesophageal reflux disease, and the presence of a leak in the early postoperative period. Efforts at reducing the rate of AS have been largely unsuccessful, although meticulous technique and aggressive acid suppression remain the cornerstones of perioperative care. Once an AS has been confirmed, the first-line treatment remains a course of esophageal dilatation. Adjuncts to dilatation are frequently required, including steroid injection or the topical application of mitomycin C. Currently, there is insufficient evidence to promote one at the expense of the other. Esophageal stenting has recently been added to the algorithm of treatment, although additional literature is required to confirm its safety and efficacy. Finally, stricture resection followed by primary esophageal anastomosis or, rarely, esophageal replacement with an interposition graft remain options for AS refractory to all other forms of treatment.

Characterization of Esophageal Motility Following Esophageal Atresia Repair Using High-Resolution Esophageal Manometry

Background: Esophageal dysmotility, a considerable issue following esophageal atresia (EA) repair, has been reported but has not been precisely described and characterized. Using high-resolution esophageal manometry (HREM), we characterized the esophageal motility patterns in children with repaired EA and compared these patterns of dysmotility with symptomatology. Methods: HREM was performed as an outpatient procedure in patients with repaired EA. The tracings were analyzed using the software provided by the company and were then reviewed visually. Charts were reviewed for medical/surgical histories and symptoms were assessed by a standardized questionnaire. Results: Forty patients (25 boys, 15 girls) with a median age of 8 years (11 months–18 years) underwent an HREM. Thirty-five patients had type C EA and 5 had type A EA. Only 7 patients were asymptomatic at the time of the examination. HREM results were abnormal in all of the patients. Three different esophageal motility patterns were derived from HREM tracing analysis: aperistalsis (15 patients, 38%), pressurization (6 patients, 15%), and distal contractions (19 patients, 47%). Distal contractions pattern was found exclusively in type C EA. Dysphagia was encountered in the 3 groups. Gastroesophageal reflux disease-related symptoms predominated in the aperistalsis group. Conclusions: HREM improves our understanding and allows precise characterization of esophageal dysmotility in patients who have undergone EA repair.

Refractory strictures post-esophageal atresia repair: what are the alternatives?

Esophageal strictures remain the most frequent complication after esophageal atresia (EA) repair despite refinements in operative techniques. With an incidence of anastomotic stricture between 8% and 49%, EA is the most frequent cause of benign esophageal stricture in children. The mainstay of treatment for esophageal stricture is dilatation with a 58-96% success rate. In order to relieve dysphagia, between 1 and 15 dilatations will be required in each EA patient with an esophageal stricture. However dilatations may lead to complications including perforation (0.1-0.4% of all esophageal benign strictures) and sociopsychological morbidity. Fifty percent of EA strictures will improve in 6 months. However, 30% will persist and require repeat dilatations. The present article explores the variety of non-surgical alternative treatments for anastomotic strictures after EA repair, focusing on triamcinolone acetonide, mitomycin C and esophageal stents. We propose an algorithm for a more standardized therapeutic approach, with the hope that an international panel of experts could meet and establish a consensus.

Congenital esophageal stenosis associated with esophageal atresia

Congenital esophageal stenosis (CES) is a rare clinical condition but is frequently associated with esophageal atresia (EA). The aim of this study is to report the diagnosis, management, and outcome of CES associated with EA. Medical charts of CES-EA patients from Lille University Hospital, Sainte-Justine Hospital, and Montreal Childrens Hospital were retrospectively reviewed. Seventeen patients (13 boys) were included. The incidence of CES in patients with EA was 3.6%. Fifteen patients had a type C EA, one had a type A EA, and one had an isolated tracheoesophageal fistula. Seven patients had associated additional malformations. The mean age at diagnosis was 11.6 months. All but two patients had non-specific symptoms such as regurgitations or dysphagia. One CES was diagnosed at the time of surgical repair of EA. In 12 patients, CES was suspected based on abnormal barium swallow. In the remaining four, the diagnostic was confirmed by esophagoscopy. Eleven patients were treated by dilation only (1-3 dilations/patient). Six patients underwent surgery (resection and anastomosis) because of failure of attempted dilations (1-7 dilations/patient). Esophageal perforation was encountered in three patients (18%). Three patients had histologically proven tracheobronchial remnants. CES associated with EA is frequent. A high index of suspicion for CES must remain in the presence of EA. Dilatation may be effective to treat some of them, but perforation is frequent. Surgery may be required, especially in CES secondary to ectopic tracheobronchial remnants.

Association of Gastric Heterotopic Pancreas and Esophageal Atresia in Children

Objectives: Esophageal atresia with or without tracheo-esophageal fistula is a frequent malformation that occurs in about 1 of 3000 live births. It can be associated with other congenital malformations. The aim of this study was to measure the frequency of heterotopic pancreas (HP) in children with esophageal atresia (EA) and to evaluate possible linkage with other malformations. Materials and Methods: All patients with EA were prospectively followed since 2005 at Hôpital Sainte-Justine and since 2006 at the Montreal Childrens Hospital. We compared 91 patients who underwent gastroscopy during that period with 182 control patients who submitted to gastroscopy for other indications. The presence or the absence of HP and its localization were noted in both groups. The following data were also collected on patients with EA: sex, gestational age, EA type, and other malformations. Results: Seventeen (18.7%) of the 91 patients with EA had gastric HP compared with 1 (0.5%) in the control group (OR 42, 95% confidence interval 7–249, P < 0.001). There were no differences between patients with or without HP regarding sex, prematurity, EA type, and the presence or absence of other congenital abnormalities. Conclusions: This study demonstrates, for the first time, that gastric HP is associated with EA irrespective of other malformations.

Esophageal length: esophageal manometry remains superior to mathematical equations.

Background and Objectives: Many mathematical equations based on height have been developed to estimate the esophageal length (EL) in children. The aim of this study was to confirm whether the preexisting and most frequently used equation by Strobel et al is accurate in calculating the EL in our pediatric population. Our secondary goal was to evaluate whether a new formula could be developed using our nonsurgical and surgical populations’ data for the correlation between patients’ height and measured EL by esophageal manometry (EM). Methods: From 2000 to 2009, 116 children between the ages of 3 and 18 years without previous esophageal surgery underwent EM (n = 31) at the Montreal Childrens Hospital. During the same period, 55 EMs were performed on 34 children with a previous history of esophageal surgery. For both groups, we collected the following data: height, EL calculated by the Strobel formula, and EL measured by EM. Results: The Strobel equation was inaccurate in predicting the EL. The calculated EL was 3.0 ± 0.32 cm longer than the EM measurements (P < 0.001). The height (H) of nonsurgical children was found to be highly predictive of the lower esophageal sphincter location (L), and the derived linear regression equation is L = 0.216 (H) + 7.13 [r2 = 0.85]. Conclusions: This study confirmed that the Strobel formula is not sufficiently accurate to predict EL in the pediatric population that is between 3 and 18 years old. A correlation exists between height and esophageal sphincter location position. If EM is unavailable, the use of a new mathematical equation like ours can be considered.

Transition care in inflammatory bowel disease: A needs assessment survey of Quebec gastroenterologists and allied nurses

AIM To determine the tools needed and problems encountered during the transition of inflammatory bowel disease (IBD) patients from pediatric to adult gastroenterologists (GIs) in Québec, Canada. METHODS We conducted a needs assessment survey of Quebec health care professionals (HCPs). The survey was handed out to 136 Québec HCPs at a local conference in 2013. Additionally, it was emailed to any other HCPs in Quebec involved in caring for IBD patients. The completed surveys were compiled to derive descriptive data. Further specific subgroup analysis was then conducted. RESULTS Among the conference attendees and individuals emailed 77 (28.2%) completed the questionnaire. Respondents included adult GIs (61.3%), pediatric GIs (20.8%) and IBD nurses (18.3%). The majority of respondents believed that a standardized structure is important for a successful transition. Adult and pediatric GIs equally felt that patients were inadequately prepared for the transition (P = 0.6). There were significant differences between adult and pediatric GIs when it came to resource availability (55.6% vs 90.9%, P = 0.002) and perceived need of a formal transition clinic (21.7% vs 68.8%, P = 0.0006). Both transition program and medical summaries were identified as the most valuable tools to improve transition. CONCLUSION As described in previous studies, our survey reinforces the importance of a transition program, education for young adult IBD patients and the need to improve communication between adult and pediatric GIs.