J. Gaudin

Does prenatal diagnosis modify neonatal treatment and early outcome of children with esophageal atresia

OBJECTIVE Our study aimed at (1) evaluating neonatal treatment and outcome of neonates with either a prenatal or a postnatal diagnosis of esophageal atresia (EA) and (2) analyzing the impact of prenatal diagnosis on outcome based on the type of EA. STUDY DESIGN We conducted a population-based study using data from the French National Register for infants with EA born from 2008-2010. We compared prenatal, maternal, and neonatal characteristics among children with prenatal vs postnatal diagnosis and EA types I and III. We defined a composite variable of morbidity (anastomotic esophageal leaks, recurrent fistula, stenosis) and death at 1 year. RESULTS Four hundred sixty-nine live births with EA were recorded with a prenatal diagnosis rate of 24.3%; 82.2% of EA type I were diagnosed prenatally compared with 17.9% of EA type III (P < .001). Transfer after birth was lower in case of prenatal diagnosis (25.6% vs 82.5%; P < .001). The delay between birth and first intervention did not differ significantly among groups. The defect size was longer among the prenatal diagnosis group (2.61 vs 1.48 cm; P < .001). The composite variables were higher in prenatal diagnosis subset (44% vs 27.6%; P = .003) and in EA type I than in type III (58.1% vs 28.3%; P < .001). CONCLUSION Despite the excellent survival rate of EA, cases with antenatal detection have a higher morbidity rate related to the EA type (type I and/or long gap). Even though it does not modify neonatal treatment and the 1-year outcome, prenatal diagnosis allows antenatal parental counselling and avoids postnatal transfers.

Prevalence of Barrett Esophagus in Adolescents and Young Adults With Esophageal Atresia.

Objective: To study the prevalence of Barrett esophagus (BE) (gastric and/or intestinal metaplasia) in adolescents treated for esophageal atresia (EA). Summary of Background Data: EA patients are at high risk of BE. Methods: This multicenter prospective study included EA patients aged 15 to 19 years. All eligible patients were proposed an upper endoscopy with multistaged esophageal biopsies under general anesthesia. Histological suspicion of metaplasia was confirmed centrally. Results: One hundred twenty patients [mean age, 16.5 years (±1.4)] were included; 70% had been treated for gastroesophageal reflux disease (GERD) during infancy. At evaluation, 8% were undernourished, 41% had received antireflux surgery, and 41% presented with GERD symptoms, although only 28% were receiving medical treatment. Esophagitis was found at endoscopy in 34% and confirmed at histology in 67%. BE was suspected after endoscopy in 37% and was confirmed by histology for 43% of patients (50 gastric and 1 intestinal metaplasia). No endoscopic or histological anomalies were found at the anastomosis site. BE was not significantly related to clinical symptoms. In multivariate analysis, BE was associated with EA without fistula (P = 0.03), previous multiple antireflux surgery (P = 0.04), esophageal dilation (P = 0.04), suspicion of BE at endoscopy (P < 0.001), and histological esophagitis (P = 0.02). Conclusions: Patients with EA are at high risk of persistent GERD and BE. The development of BE is related to GERD history. Long-term systematic follow-up of the esophageal mucosa including multistaged biopsies is required, even in asymptomatic patients. (NCT02495051).

Thoracic skeletal anomalies following surgical treatment of esophageal atresia. Lessons from a national cohort

INTRODUCTION Thoracotomy as surgical approach for esophageal atresia treatment entails the risk of deformation of the rib cage and consequently secondary thoracogenic scoliosis. The aim of our study was to assess these thoracic wall anomalies on a large national cohort and search for factors influencing this morbidity. MATERIALS AND METHODS Pediatric surgery departments from our national network were asked to send recent thoracic X-ray and operative reports for patients born between 2008 and 2010 with esophageal atresia. The X-rays were read in a double-blind manner to detect costal and vertebral anomalies. RESULTS Among 322 inclusions from 32 centers, 110 (34.2%) X-rays were normal and 25 (7.7%) displayed thoracic malformations, including 14 hemivertebrae. We found 187 (58.1%) sequelae of surgery, including 85 costal hypoplasia, 47 other types of costal anomalies, 46 intercostal space anomalies, 21 costal fusions and 12 scoliosis, with some patients suffering from several lesions. The rate of patients with these sequelae was not influenced by age at intervention, weight at birth, type of atresia, number of thoracotomy or size of the center. The rate of sequelae was higher following a classical thoracotomy (59.1%), whatever the way that thoracotomy was performed, compared to nonconverted thoracoscopy (22.2%; p=0.04). CONCLUSION About 60 % of the patients suffered from a thoracic wall morbidity caused by the thoracotomy performed as part of surgical treatment of esophageal atresia. Minimally invasive techniques reduced thoracic wall morbidity. Further studies should be carried out to assess the potential benefit of minimally invasive approaches to patient pulmonary functions and on the occurrence of thoracogenic scoliosis in adulthood. LEVELS OF EVIDENCE Level III retrospective comparative treatment study.

SFCP CO-18 - Prévalence de l’œsophage de Barrett dans l’atrésie de l’œsophage

Objectifs Etudier la prevalence d’endobrachyœsophage (EBO) dans une population d’adolescents operes d’une atresie de l’œsophage (AO). Patients et methodes Cette etude prospective non-interventionnelle, multicentrique incluait 121 patients (15–19 ans) avec AO. Tous les patients beneficiaient d’un protocole standardise de biopsies œsophagiennes etagees (12 au minimum) sous anesthesie generale. Une relecture histologique centralisee etait effectuee pour toutes les lames avec metaplasie. Resultats L’âge moyen etait de 16,5 ans (±1,4) et 71% avaient un RGO persistant apres l’âge de 2 ans. Au moment de l’etude, 41% avaient eu une chirurgie antireflux mais 42% presentaient des symptomes de RGO (26% recevaient des anti-secretoires). Une oesophagite moderee et/ou ulceree etait visible a l’endoscopie chez 34% et confirmee en histologie chez 66% des patients. Un EBO etait suspecte a l’endoscopie chez 37%, et confirme a l’histologie chez 43% : 50 metaplasies gastriques et une metaplasie intestinale. Il n’existait pas de relation entre EBO et symptomatologie clinique. Conclusions Les patients avec AO ont un risque important de RGO persistant et d’EBO. Un suivi endoscopique a long terme, associe a des biopsies etagees est necessaire meme chez les patients asymptomatiques.

CL039 - Étude rétrospective multicentrique du GECI sur 114 duplications digestives opérées par thoracoscopie ou laparoscopie

Objectifs Determiner les resultats a court et moyen terme des duplications digestives de tout site operees par laparoscopie ou thoracoscopie chez l’enfant. Materiel et Methodes Etude retrospective multicentrique: 114 enfants provenant de 18 centres. P Resultats La localisation etait a l’œsophage(14 %), a l’estomac(12 %), au duodenum(6 %), a l’intestin grele(62 %), et au colon(6 %). Il y a eu 102 laparoscopies et 12 thoracoscopies. Le taux de conversion etait de 42 % chez les patients avec diagnostic antenatal(DAN) contre 20 % sans DAN (S). Il y a eu 29 % de patients symptomatiques avec DAN contre 63 % chez les patients sans DAN (S). Le taux de conversion etait de 48 % en cas d’intervention urgente contre 26 % si non urgente (S). L’abord a ete combine (exteriorisation de la duplication par orifice de trocart) pour 26 % des patients. Les complications post operatoires(7 %) ne dependaient pas de d’une conversion, de l’âge de l’enfant ou de l’urgence. Conclusion Le traitement des duplications digestives par thoraco/ laparoscopie comporte peu de complications. Le DAN permet de prevenir l’apparition des symptomes mais la thoraco/laparoscopie est plus difficile chez ces enfants. L’abord combine est une alternative a l’abord intracorporel pour les duplications du grele.

CL041 - Registre National de l’Atrésie de l’Œsophage : Résultats année 2008

Introduction l’incidence de l’atresie de l’œsophage (AO) est mal connue et varie entre 1/2500 a 1/4600 naissances. Le but de ce travail est de presenter les donnees 2008 du registre national de l’AO (metropole plus DOM TOM). Methodes des fiches d’inclusion ont ete remplies par tous les centres prenant en charge une AO et saisies et analysees par le centre de reference. Les DIM de chaque centre ont ete contactes ainsi que 4 registres regionaux de malformations pour augmenter le nombre et l’exhaustivite des sources. Resultats 142 nouveaux cas ont ete declares pour l’annee 2008 (incidence = 1/5824 naissances). Il existait une predominance de garcons ( n = 83), le poids de naissance moyen etait de 2527 g avec un terme de 37 SA. Un diagnostic antenatal etait possible dans 17 % des cas. Il y avait 15 atresies de type I et 123 de type III. Le diagnostic etait pose dans les 24h dans 89 % des cas et la chirurgie initiale realisee avant 48h dans 94 % pour le type III. Le taux des malformations associees etait de 53 % et la mortalite globale de 5 %. Conclusions Ces premiers resultats montrent une incidence de l’AO similaire a celle observee par le registre Europeen des malformations. Le diagnostic antenatal reste rare mais la prise en charge dans notre pays est precoce et la mortalite faible.