BAPS paper
The cumulative incidence of significant gastrooesophageal reflux in patients with oesophageal atresia with a distal fistula—a systematic clinical, pH-metric, and endoscopic follow-up study

https://doi.org/10.1016/j.jpedsurg.2006.10.010Get rights and content

Abstract

Background and Aim

Gastrooesophageal reflux (GER) is common in patients with oesophageal atresia (OA). Complicated GER often manifests itself early after the primary repair (PR) and frequently requires antireflux surgery (ARS). How many patients will be later affected is unknown. We conducted an objective long-term follow-up for the cumulative incidence of OA-associated GER based on pH-metry and histology.

Materials and Methods

Sixty-one consecutive patients with their native oesophagus, who underwent PR for OA with a distal fistula from 1989 to 2004, were included. These children were grouped according to the Spitz classification with 77% as type I, 20% as type II, and 3% as type III. Significant heart disease, tracheomalacia, or gastric outlet obstruction occurred in 18.0 %, 9.8%, and 17.3% respectively, and a wide gap between esophageal segments occurred in 13.1%. Endoscopy and pH-metry at 1 year were followed up by endoscopy and selective pH-metry at 3, 5, and 10 years. Gastrooesophageal reflux was considered significant (sGER) when a patient underwent ARS, endoscopic biopsies disclosed at least moderate oesophagitis, or when total or preprandial reflux index were greater than 10% or 5%, respectively, with or without long (>5 minutes) reflux periods). Significant GER was considered resolved if, without need for ARS or medication, pH-metry or biopsies returned to normal and the patient was symptomless for at least 3 years.

Results

The incidence of sGER/(number of assessed patients) at 6 months, 1 year, 3 years, 5 years, and 10 years was 16.3% (61), 39.3% (61), 44.2% (52), 51.2 % (43), and 44.4% (27). Overall, 28/61 (45.9%) of patients had sGER, and 18/28 (64.3%) patients underwent ARS. In one patient, sGER resolved during the follow-up.

Conclusion

The number of children with sGER associated with OA more than doubled from 6 months to 1 year after PR. Thereafter, there is a progressive increase in the incidence of sGER with age up to 5 years. Spontaneous resolution of sGER is rare.

Section snippets

Patients and methods

Sixty-one consecutive patients who underwent primary repair (PR) for OADF during the period from 1989 to 2004 were included in the study. All patients had survived at least one year with their native oesophagus. These patients were grouped according to the Spitz classification, as follows: type I (n = 47, 77%), type II (n = 12, 20%), and type III (n = 2, 3%). The incidence of heart disease, tracheomalacia, gastric outlet obstruction, and other significant congenital anomalies are shown in Table

Results

The median length of the patient follow-up was 5 (range,1-10) years. The number of patients available for assessment after OADF repair was 61 at six months, 61 at one year, 52 at 3 years, 43 at 5 years and 27 at 10 years. During the follow up, sGER was detected in a total of 28 (45.9%) of 61 patients. Eighteen patients (29.5% of the total of 61 and 64.3% of 28 with sGER) underwent ARS. Ten patients underwent ARS under 6 months of age, 2 between 6 months to 1 year, 5 between 1 and 3 years, and

Discussion

Gastrooesophageal reflux is a significant long-term sequel of OADF. The reported incidence of OADF associated GER varies depending whether the diagnostic criteria are based on symptoms, radiological findings, pH-metry, or endoscopy, from 35% to 60% [1], [6]. The 46% overall incidence of GER detected in the present study falls between these percentages. The portion of our patients with sGER to whom ARS was performed during the 10-year follow-up period was high (64%), but ARS rates, varying from

Q&A

    Höllwarth, Graz, Austria

    Thank you very much for presenting your very interesting data. I must confess that I am a little bit doubtful in regard to the change in incidence of gastro-oesophageal reflux between the infancy and later age. pH Monitoring alone is heavily underestimating the real amount of reflux in children mainly fed with milk because milk buffers gastric acid for quite a long time. Especially in patients with oesophageal atresia, motility not only of the oesophagus but also of the

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Presented at the British Association of Paediatric Surgeons 53rd Annual International Congress, Stockholm, Sweden, July 18-22, 2006.

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