Initial Esophageal Anastomosis Diameter Predicts Treatment Outcomes in Esophageal Atresia Patients With a High Risk for Stricture Development

Abstract

Background and Aims: Children with esophageal atresia (EA) who undergo surgical repair are at risk for anastomotic stricture, which may need multiple dilations or surgical resection if the stricture proves refractory to endoscopic therapy. To date, no studies have assessed the predictive value of anastomotic diameter on long-term treatment outcomes. Our aim was to evaluate the relationship between anastomotic diameter in the early postoperative period and need for frequent dilations and stricture resection within 1 year of surgical repair.Methods: A retrospective chart review was performed of patients who had EA repair or stricture resection (SR). Medical records were reviewed to evaluate the diameter of the anastomosis at the first endoscopy after surgery, number and timing of dilations needed to treat the anastomotic stricture, and need for stricture resection. A generalized estimating equations (GEE) modeling with a logit link and binomial family was done to analyze the relationship between initial endoscopic anastomosis diameter and the outcome of needing a stricture resection. Median regression was implemented to estimate the association between number of dilations needed based on initial diameter.Results: A total of 121 patients (56 females) with a history of EA (64% long-gap EA) were identified who either underwent Foker repair at 46% or stricture resection with end-to-end esophageal anastomosis at 54%. The first endoscopy occurred a median of 22 days after surgery. Among all cases, a narrower anastomoses were more likely to need stricture resection with an OR of 12.9 (95% CI, 3.52, 47; p < 0.001) in patients with an initial diameter of <3 mm. The number of dilations that patients underwent also decreased as anastomotic diameter increased. This observation showed a significant difference when comparing all diameter categories when looking at all surgeries taken as a whole (p < 0.008).Conclusion: Initial anastomotic diameter as assessed via endoscopy performed after high-risk EA repair predicts which patients will require more esophageal dilations as well as the likelihood for stricture resection. This data may serve to stratify patients into different endoscopic treatment plans.

Measurement of Stricture Dimensions Using a Visual Comparative Estimation Method With Biopsy Forceps During Endoscopy

“…Similarly, selecting an appropriate stent diameter is critical to balance the need to produce adequate radial force to generate a beneficial effect at the stricture and to reduce chance of stent migration, while also avoiding overly large diameters that may cause major complications from excessive pressure (eg, hemorrhage, perforation, fistula) (8). Assessment of stricture diameter to the single millimeter level in children at high risk for stricture formation after esophageal surgery has been shown to be predictive of outcomes, with children who have smaller stricture diameters at initial-look endoscopy having nearly 13-fold greater odds of failing endoscopic stricture treatment altogether and needing surgical revision (3). While we observed a strong to very strong degree of concordance between visual estimates and radiographic measurements across all stricture diameters, our observed higher concordance of visual estimates and radiograph measurements at small to mid-sized esophageal stricture diameters likely reflects greater ease of visually estimating stricture size when it falls within or close to the dimensions of the biopsy forceps (which can be 1.8–7 mm, depending on standard vs pediatric capacity and closed vs open configuration).…”

“…E stimation of the dimensions of endoscopic findings such as polyp dimensions or stricture diameter is largely subjective and at risk for error (1,2). Accurate assessment of stricture dimensions has the benefits of allowing the endoscopic to choose safe and appropriately sized therapeutic interventions for stricture (eg, dilator size, stent dimensions), reliably tracking response to endoscopic therapies at subsequent procedures, and potentially even predicting outcomes of response to endoscopic therapy (3). Here we describe a comparative estimation method of stricture dimension measurement using the commonly available biopsy forceps tool as a visual reference, and compare the performance of this method to the standard radiographic means of dimension assessment.…”