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Anastomotic leakage and stenosis after surgery for esophageal atresia is not related to the development of late functional sequelae

Kamilla Wodstrup Rost¹, Niels Qvist¹, Rikke Neess Pedersen²
¹Surgical Department A, Odense University Hospital, Denmark

 ²Hans Christian Andersen Children’s Hospital, Odense University Hospital, Denmark

 

Correspondence

Niels Qvist
Surgical Department A, Odense University Hospital
DK-5000 Odense C
Denmark
Phone: +45 29694625
Fax: +45 29694625
E-mail: This email address is being protected from spambots. You need JavaScript enabled to view it.

 

Abstract

Purpose: The aims of the present study were to evaluate the relationship between postoperative complications as anastomotic leakage and stricture and late sequelae in patients operated for esophageal atresia, and to evaluate the frequency of dyspepsia and recurrent abdominal pain in children operated for esophageal atrsia compared to a background population.

Materials and Methods: Medical records from sixty-two consecutive children operated for esophageal atresia with primary anastomosis in the period from 1990-2000 were reviewed and a follow-up questionnaire sent to the patients. The age at follow-up was 10.3 years (range 6-16 years).

Results: Perioperative anastomotic leakage occurred in 13% and symptomatic stricture in 73%. At follow-up late sequlae such as gastro-esophageal reflux disease was reported in 31%, pneumonia in 40%, asthmatic bronchitis in 27% and asthma in 8%. There were no significant correlation between late sequelae and postoperative complications. From the questionnaire dyspepsia was reported in 35% of patients operated for esophageal atresia compared to 5% in the background population (p<0.0001).

Conclusion: Further extensive physiological studies are needed to explore and explain the physiologic background for the high frequency of late sequelae in patients operated for esophageal atresia.

Keywords: esophageal atresia, anastomotic leakage, anastomotic stenosis, dyspepsia, recurrent abdominal pain, gastro-esophageal reflux, gastro-esophageal reflux disease

 

Introduction

Gastro-esophageal reflux disease (GERD) is common in patients operated for EA with a reported incidence up to 55% during a follow-up period of 10-20 years [1,4,5,6,8,10,13]. Extraesophageal manifestations of GERD are respiratory problems including asthma and recurrent pneumonia. Several factors may predispose to these late sequelae, but the relationship to the postoperative complications such as anastomotic leakage or stricture is unknown to our knowledge. In addition, other functional gastrointestinal symptoms such as dyspepsia and recurrent abdominal pain (RAP) may occur in patients operated for EA, but the frequency compared to the background population is unknown.

The aims of the present study were to evaluate the relationship between postoperative complications as anastomotic leakage and stricture and late sequelae in patients operated for EA, and to evaluate the frequency of dyspepsia and RAP compared to a background population.

Material and Methods

In the period January 1st 1990 to December 12th 2000, a total of 97 children underwent surgery for EA at Odense University Hospital, Denmark. At follow-up in October 2006, 18 children were registered as dead, and the study thus included 79 children.

A total of 69 patients answered a standardized questionnaire, response rate 87%. Seven patients were excluded. Five patients underwent delayed surgery of which 4 had a colonic interposition. The medical records were not available for two patients. Thus, a total of 62 patients were eligible for the study. There were 28 girls and 34 boys with an average age of 10.3 years at follow-up (range 6-16 years).

Medical records for each patient were reviewed, and the type of EA and associated congenital malformations were classified. Postoperative complications including anastomotic leakage, pneumothorax, respiratory distress syndrome, sepsis, mediastinitis and wound infections were registered. The development of anastomotic stricture, endoscopic examinations and pneumonia during the follow-up period was registered together with episodes of asthma and asthmatic bronchitis.

EA with tracheo-esophageal fistula Gross type A-C occurred in 98% of the patients. One patient had EA and a fistula to duodenum. Associated malformations were found in 28 patients (45%). Thirty-five per cent had a cardiovascular malformation, 18% a gastrointestinal, 13% a urogenital, and 18% other malformations. In 5 patients EA was part of a syndrome or association. Four patients had VACTERL association and one patient had Feingold syndrome.

Anastomotic leakage was defined as saliva or milk in the mediastinal drain, and stricture was defined as a symptomatic narrowing requiring endoscopic dilation. GERD was defined as macroscopic mucosal changes in distal oesophagus with redness or ulceration at endoscopy. All esophageal biopsies obtained were reviewed. A high reflux index (RI) with PH4, more than 6% of the time at 24 hour pH monitoring was considered abnormal [4,11]. The definition of pneumonia was radiological detected pulmonary infiltrate, positive culture of tracheal aspirate or antibiotic treatment for clinical signs of pneumonia during hospitalizing.

The standardized questionnaire contained 20 separate questions about abdominal pain and dyspepsia, which could be answered by yes or no. The questionnaire was designed according to the Rome II criteria for children [7]. The definition of RAP was at least three episodes of abdominal pain within the last three months and a pain, which had affected the child’s activity in a degree where the child had stoped playing, had gone to bed or was kept home from school. The definition of dyspepsia was, that the child over the last three months and with a total duration of at least three weeks, has had at least three of the following symptoms: difficulties in swallowing, nausea, coughing, epigastrial oppresion, vomiting, bad breath, epigastrial or retrosternal pain or early satiety feeling. Only patients with dyspepsia without simultaneous pulmonary symptoms were included in the calculations [2,3,9,12]. The frequency of RAP and dyspepsia in EA was compared to the results from a study using the same questionnaire in healthy school children age 9-13 years [2].

In the present study the questionnaire also included information on all prescribed drugs during the last 6 months with the type of medicine and indication. The medication of interest was divided into three different groups – asthma medicine, proton pump inhibitors (PPI) and antibiotics for pneumonia. Unanswered questions were recorded as no, where there was no information on the presence of the condition from the medical records. For statistical analysis X2-test was used. A pvalue less than 0.05 was considered as statistical significant.

Results

Anastomotic stricture that needed one or more dilatations was found in 45 children (73%), and anastomotic leakage occurred in 8 children (13%). Two of the patients with anastomotic leakage were re-operated. The other 6 patients were treated conservatively.

Endoscopy was performed in 24 of the children of which 16 showed endoscopic criteria for GERD. Esophageal biopsies were available in 11 of the patients with endoscopic GERD but only 2 showed inflammation. In 4 out of 6 of the patients with criteria for GERD who in addition underwent a 24-hour pH monitoring, a reflux index (RI) with PH4 more than 6% of the time was found. Another 3 children had an abnormal RI, but no endoscopy.

A total of 14 patients had a pHmetry. Thus GERD was diagnosed in 19 children (31%). Pneumonia was registered in 25 (40%), asthma in 5 (8%) and asthmatic bronchitis in 17 (27%). From the questionnaire 22 children (35%) fulfilled the criteria for dyspepsia and 13 (21%) the criteria for RAP (Table I). A total of 11 patients (18%) had no complaints at all according to questionnaire and information from the records. A total of 32 patients (52%) had received prescription of medicine within the last 6 months. Nineteen patients (31%) had received PPI, 26% medicine for asthma and 8% had received antibiotics for pneumonia (Table I). In the whole material fundoplication has been performed in one patient, only. In the background population of 849 school children (74% respondents) Dahl-Larsen et al [2] found that 12% had RAP, which was not significant different (P=0.07) from the 21% found in children operated for EA (Table II). As it appears from Table III, there were no significant differences in the frequency of any of the late conditions in the group of patients with or without anastomotic leakage or stricture. The same applies for early postoperative complications and associated anomalies (data not shown). In the group of patients with anastomotic leakage, the number of patients that had a prescription of PPI was significantly higher compared to the other groups.

Table I: Postoperative complications, status at follow-up and results from the in 62 consecutive patients operated for esophageal atresia.

Postoperative complications and status at follow up

Number (%)

Postoperative complications:

 

Stricture

45 (73)

Leakage

8 (13)

Status at follow-up

 

Gastro-esophageal reflux disease (GERD)

Pneumonia

19 (31)

25 (40)

Asthma

5 (8)

Asthmatic bronchitis

17 (27)

From questionnaire

 

Dyspepsia

22 (35)

RAP

13 (21)

Medicine prescribed within the last 6 months

 

PPI

19 (31)

Asthma medicine

16 (26)

Antibiotics

6 (10)


Table II: The frequency of recurrent abdominal pain and dyspepsia  in patients operated for esophageal atresia and in the control group.

Group

RAP

Dyspepsia

Control group

N=846

12%

5%

Oesophageal atresia

N=62

21%

35%

P-value

0.07

<0.0001


Table III: The number of patients with the different conditions, the prescription of medicine in relation to leakage or stricture in 62 patients operated for esophageal atresia. Figures in bracket are in %. (* p<0.05)

Condition

No stricture

N=17

Stricture

N=45

No Leak

N=54

Leak

N=8

GERD

4 (24)

15 (33)

17 (31)

2(25)

Pneumonia

7 (41)

18 (40)

21 (39)

4 (50)

Asthma

2 (12)

3 (7)

5 (9)

0

Asthmatic bronchitis

2 (12)

15 (33)

15 (28)

2 (25)

Dyspepsia

7 (41)

15 (33)

15 (28)

2 (25)

RAP

4 (24)

9 (20)

11 (20)

2 (25)

Prescription of medicine:

 

 

 

 

PPI

5 (29)

14 (23)

14 (26)

5 (63)*

Asthma medicine

7 (41)

9 (15)

14 (26)

2 (25)

Antibiotics

1 (6)

5 (8)

5 (9)

1 (13)


Comments

The present study showed, that there was no significant correlation between anastomotic leakage or stricture and that the development of late sequelae such as GERD, pneumonia, asthma, asthmatic bronchitis, dyspepsia and RAP in children operated for EA. However, there was a significant correlation between the history of anastomotic leakage and the prescription of PPI. This might explain the tendency to a higher percentage of children with dyspepsia and pneumonia in the group of children with anastomotic leakage. The difference was not significant, but the relative low number of patients with anastomotic leakage could be a confounding factor.

The frequency of GER/GERD is difficult to compare to other studies because of differences in definition and differences in patient population [1,4,5,8,10,13]. Several factors such as the gap between esophageal endings and the type of EA may influence the frequency. In our study only patients with a primary repair for a tracheo-oesophageal fistula was included. In the study by Little et al. [6] including a similar type of EA, the frequency of GERD was 48%, 25% and 31% at 5 years, 5-10 years and >10 years follow-up, respectively. In that study GERD was not defined clearly. In the study by Koivusalo et al. [4] an overall incidence of significant GER was found in 45.9% defined as reflux-surgery, biopsy verified moderate esophagitis or an increased reflux index at 24-hour pH monitoring. Gastro-esophageal reflux symptoms were reported in 55% of the patients >15 years at follow-up by Chetcuti et al [1]. Konkin et al [5] found GER in 31% of the cases. In our study the frequency of GERD was 31% based on the results of endoscopic finding in patients referred for endoscopy or 24 hour pH monitoring during the follow-up period. This figure therefore has to be considered as a minimum. However, it is striking that the majority of the patients with abnormal endoscopy had normal histological findings.

According to the literature16-28% of the patients with GER had antireflux surgery [4,5,6,8,10,13]. Only one patient in our study underwent fundoplication. However, this might reflect differences in the indications for surgical treatment for GERD. Seventy-three % of the patients in the present study underwent subsequent balloon dilatation of the anastomotic stricture. This is somewhat higher than the frequency of 52% reported by Konkin et al [5] and a frequency of 37% by Spitz et al [10]. An explanation may be difference in the definition of stricture. In the present study it was defined as at least one performed esophageal dilatation.

Sixty five % of the children who underwent dilatation had more than one, which is also a high figure compared to the literature (24-26%) [5,6]. Despite the high figure we found no correlation between the development of stricture and late sequelae. Thirteen per cent of the patients had anastomotic leakage. This is consistent with the findings by Konkin et al [5] were 8 % had leakage and Yanchar et al [13] with a reported incidence on 17 %. The present study showed that 40% of the patients had been treated for pneumonia the first year of life. This is consistent with the literature where Chetcuti et al [1] found an incidence of 31% within the first 5 years of life, and Little et al [6] reported an incidence on 29% patients with respiratory infections. On contrary Konkin et al [5] reported a frequency of only 6% for pneumonia. In a large series of 334 patients half of the patients had been hospitalized for respiratory diseases during 1-37 years of follow-up [1].

In the background population, Dahl-Larsen et al [2] found that dyspepsia occurred in 5% of the children compared to 35% in the EA group, and this difference was significant. This result is important and warrants further and systematic investigations on gastro-esophageal function in patients operated for EA. The difference in the frequency of RAP was not significant. Dyspepsia was reported in 5% of the school children compared to 35% in the EA group (P<0.0001) (Table II).

The Rome II criteria for children [7] were used in the present study in order to make a comparison with the background population. The study group in the background population included children in the age of 9-13 years compared to 6-16 years in the patients operated for EA. The geographic and demographic characteristic in the catchment area for the treatment of EA at our institution was similar to the background population. The study from the background population was performed in 2003 and in 2006 in the patients with EA. Furthermore, the study in the background population showed no changes compared to a study performed several years previously. In conclusion, this study found no significant correlation between early postoperative complications as anastomotic leakage and stricture and late complication as GERD, pneumonia, asthma and asthmatic bronchitis. However, there was significant correlation between anastomotic leakage and the use of PPI. Dyspepsia was significantly more frequent in patients operated for EA compared to a background population. Further extensive physiological studies are needed to explain the reason.

 

 

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