Seine Ekkelkamp

Gastroesophageal reflux: prevalence in adults older than 28 years after correction of esophageal atresia.

Objective: To study the incidence of gastroesophageal reflux (GER)related complications after correction of esophageal atresia (EA). Summary Background Data: The association of EA and GER in children is well known. However, little is known about the prevalence of GER and its potential complications in adults who have undergone correction of EA as a child. Methods: Prospective analysis of the prevalence of GER and its complications over 28 years after correction of EA by means of a questionnaire, esophagogastroscopy, and histologic evaluation of esophageal biopsies. Results: The questionnaire was returned by 38 (95%) of 40 patients. A quarter of the patients had no complaints. Swallowing solid food was a problem for 13 patients (34%), and mashed foods for 2 (5%). Heartburn was experienced by 7 patients (18%), retrosternal pain by 8 (21%). However, none of the patients were using antireflux medication. Twenty-three patients (61%) agreed to undergo esophagogastroscopy, which showed macroscopic Barrett esophagus in 1 patient, which was confirmed by histology. One patient developed complaints of dysphagia at the end of the study. A squamous cell esophageal carcinoma was diagnosed and treated by transthoracic subtotal esophagectomy. Conclusions: This study shows a high incidence of GER-related complications after correction of EA, but it is still very disputable if all EA patients should be screened at an adult age.

Esophageal atresia: historical evolution of management and results in 371 patients

BACKGROUND It has been more than 50 years since the first successful surgical reconstruction of esophageal atresia was performed in The Netherlands. We reviewed the historical changes in management and treatment results of patients born with esophageal atresia. METHODS We developed and analyzed a database of 371 consecutive patients treated for esophageal atresia in our center between 1947 and 2000. RESULTS The mean birthweight decreased from 2,723 g (1947 to 1968) to 2,494 g (1994 to 2000), the mean gestational age decreased from 39 weeks (1947 to 1968) to 37 weeks (1994 to 2000). The number of patients with associated congenital malformations increased from 34% (1947 to 1968) to 66% (1994 to 2000). Most patients underwent primary repair of their atresia. Clinically significant tracheomalacia was present in 34 of 269 patients (13%). Gastroesophageal reflux was present in 90 of 277 patients (33%). Mortality decreased from 61% (1947 to 1968) to 11% (1994 to 2000). CONCLUSIONS The patients who are treated nowadays for esophageal atresia in a pediatric surgical center are born earlier, weigh less, and have more associated anomalies than those treated 50 years ago. Still, the mortality rate is much lower thanks to earlier diagnosis, better supportive care and improved surgical techniques. Therefore, further significant reduction will be difficult to achieve.

Risks and benefits of antireflux operations in neurologically impaired children

Gastro-oesophageal reflux (GER) in neurologically impaired children often causes feeding problems and complications of oesophagitis and is frequently resistant to medical treatment. Fifty neurologically impaired children underwent anterior gastropexy as anti-reflux operation, combined with gastrostomy in 23, between 1976 and 1992. There was no operative mortality. There were 25 early complications in 14 patients and 9 late complications in 9 patients. Twelve patients needed 17 re-operations for delayed gastric emptying [4], intestinal obstruction [3], para-oesophageal hernia [3], oesophageal stenosis [4], and recurrent GER, revision of gastrostomy, subphrenic abcess (one each). Nine patients died during the follow up period. Death in two children was related to the operation (incarcerated para-oesophageal hernia and blowout of the stomach). Out of 41 survivors, the operation was judged successful in 35. It is concluded that antireflux operations in neurologically impaired children carry a high risk of complications. Preoperative identification of risk factors is not possible. The improvements in the quality of life achieved in the majority of patients outweigh the risks.

Hypertension associated with skeletal traction in children

Since traction-associated hypertension seems to be a relatively unknown phenomenon, a survey was done of its incidence in children treated with skeletal traction for fractures and orthopaedic diseases. The correlation with hypercalcaemia, a possible aetiological factor, was also explored. Blood pressure was recorded three times a day with an automatic oscillometric unit during the stay in the hospital. Serum calcium, creatinine and total protein concentrations were measured once a week. Patients with pre-existing diseases or renal trauma were excluded. Arterial hypertension (systolic and/or diastolic) was found in 31/50 children (62%). In almost half of these the rise in systolic blood pressure was 10 mmHg or more above the 95th percentile. Hypertension occurred in most cases within the first 3 weeks of treatment; in 7 children it developed after 3 or more weeks of traction. All children became normotensive within 1 week after discontinuation of traction. Clinical symptoms were rare: two children complained of headache. In no instance had traction to be discontinued before the planned date because of hypertension. In the hypertensive group were more preschool children and more humeral fractures as compared to the normotensive group (n=19). Hypercalcaemia occurred in 11 children and was equally distributed in hypertensive and in normotensive children. It is concluded that arterial hypertension is a frequent finding in children in traction, but its clinical relevance is uncertain. Hypercalcaemia is not a rare finding in immobilized children, but probably plays no causative role in traction-related hypertension.

Oesophageal atresia in premature infants: an analysis of morbidity and mortality over a period of 20 years

Aim: To determine the morbidity and mortality of premature infants born with oesophageal atresia (OA) and to evaluate historical changes in morbidity and mortality over time. Methods: Retrospective analysis of morbidity and mortality of all patients admitted for OA, with or without tracheo‐oesophageal fistula, between 1982 and 2002. Results: The study group consisted of 197 consecutive patients, of whom 55 (28%) were premature and 21 (11%) very premature. Type A atresia was found more often in very premature and premature infants than in those born at term (p= 0.02). Type E atresia was not found in the premature group (p= 0.004). At least one associated congenital anomaly was also present in 121 patients (61%). Postoperative complications developed more often in very premature and premature infants than in those born at term (p < 0.001). Gastro‐oesophageal reflux was diagnosed in 32/76 premature infants and in 41/121 term infants (p= 0.001). Mortality among very premature and premature infants was higher than among those born at term (p= 0.003). Withdrawal of treatment was the most frequent cause of death.

Prognostic factors for mortality of oesophageal atresia patients: Waterston revived

This study shows that the effect of medical progress on mortality is considerable and that the three factors of the Waterston classification still had a high impact on mortality in the most recent years. In 1962, Waterston et al. [5] proposed a prognostic classification for patients born with oesophageal atresia (OA) based on low birth weight, presence of pneumonia, and associated congenital malformations. Over the last decades, much progress has been made and several authors have questioned the validity of Waterston’s classification [1, 3, 4]. This study analyses the influence of several clinical characteristics on mortality of OA patients, and investigates the value of the Waterston classification within the past and current time frame. We studied all patients who were treated at the Paediatric Surgical Centre of Amsterdam for OA and/or tracheo-oesophageal fistula between 1947 and 2000 (n=371) [2]. Data were collected from patient charts, operative reports, and office notes, and were entered into a database. Medical progress was modelled by dividing the time interval arbitrarily into five time periods with approximately equal numbers of patients. Disease specific mortality was defined as mortality during the 1st year of life. To determine the independent impact of factors on disease specific mortality over the total time period (1947–2000), a multivariate logistic regression model was performed. Effect sizes were expressed as odds ratios (OR’s) and their 95% confidence limits; an OR >1 refers to an increased risk for mortality. To study the five separate time periods (and specifically the most recent time period), separate models were made for each of these time periods. Considering the total time period, the type of OA, associated malformations, low birth weight and medical progress modelled by the five time periods, all had an independent impact on mortality (Fig. 1). The OR depicting the medical progress were not significantly different for the two most recent time periods, suggesting a similar improvement between 1994 and 2000, compared to the reference time period. In the most recent time period (1994–2000), ‘birth weight <1500 g’ had a strong impact on mortality (OR 54.7). Factors with a less strong, but still clinically significant impact on mortality were ‘other malformations’ and ‘pre-operative