DOZ047.114: Fundoplications in patients born with esophageal atresia: preoperative workup and evaluation of postoperative symptoms

Abstract

Abstract Background The consensus esophageal atresia (EA) guideline recommends performing contrast esophagogram, esophagogastroduodenoscopy with biopsies and pH(+ /-impedance) measurement prior to fundoplication to assess upper gastrointestinal anatomy, severity of gastroesophageal reflux disease (GERD), and exclude eosinophilic esophagitis (EoE).(Krishnan et al. JPGN 2016) Our aim was to evaluate which of these investigations were performed prior to fundoplication and which in case of postoperative symptoms. Methods In this multicenter international retrospective cohort study, all EA patients who underwent fundoplication between 2006 and 2017 were included. Results Forty EA patients (52% male, median age 2.3 years [0.08–17 years], 82.5% type C) were included in three centers worldwide; 32(80%) underwent complete and 8 (20%) partial fundoplication. Preoperative investigations included contrast esophagogram (n = 35, 88%), esophagogastroduodenoscopy (n = 33, 83%), and pH(+/-impedance) measurement (n = 11, 28%). Only six patients (15%) underwent all three recommended preoperative investigations. Esophagogastroduodenoscopy prefundoplication revealed abnormalities in 33%, including esophageal strictures in 18%, EoE in 6%, hiatal hernia in 6%, and intestinal metaplasia in 3%. Patients with EoE underwent partial fundoplication; no associations between diagnostic testing outcomes and type of fundoplication were found. Nearly all patients had symptoms postfundoplication (n = 34, 85%). Symptoms included dysphagia (53%), gagging (33%), oral food aversion (23%), bloating (8%), and/or dumping (3%). Recurrent GERD symptoms were present in 34 patients (85%). Twenty-one patients (53%) had pH(+/-impedance) tests performed, which were abnormal in 14 patients (67%). Thirty-five patients (88%) also had EGD performed, which showed abnormalities in 5 patients (13%), of which 3 patients (8%) had strictures on EGD. One of these patients with postoperative strictures had EoE (3%). Abnormalities of 2 other patients on EGD were not further specified. Conclusion Preoperative diagnostic workup for fundoplication in EA patients varies greatly. Although the majority of patients had some preoperative evaluation, only 15% underwent all gastrointestinal diagnostic tests that are currently advocated by the consensus EA guidelines. Postoperatively, most patients (85%) had symptoms for which testing was indicated. A large percentage still had evidence of GERD. More research is needed to tailor (surgical) management of GERD in EA patients, develop a postoperative testing paradigm, and evaluate the efficacy and safety of fundoplication in this specific patient group.