Reply

Abstract

We agree that it is difficult to translate the results of the study into future practice. Although it seems obvious to recommend endoscopic screening through adulthood in this patient group, there are several arguments against this recommendation. The intended effect of screening would be early detection of intestinal metaplasia, in order to start treatment early and to prevent the development of esophageal malignancy. To do so, we should first be informed about the incidence of intestinal metaplasia after repair of esophageal atresia (EA) and make an estimate of the effect of upper gastrointestinal (UGI) endoscopy and histological evaluation on improved survival. Second, it is not clear at what age UGI endoscopy should be performed. Because the incidence of intestinal metaplasia seems nil in patients less than 20 years of age, one may want to advocate performance of endoscopy at 10-year intervals starting at age 20 years. We also have to take into account the duration of the preclinical detectable phase, the effect of false-positive test results, and the side effects of treatment. So far, there is no evidence in the literature that the incidence of esophageal malignancies is increased in this patient group that may not yet be old enough to develop malignancies. Not only the efficacy of screening, but also its cost-effectiveness and aspects concerning the implementation of a screening program, should be taken into consideration. Before healthy ex-patients can be asked to undergo a repeated invasive investigation, which turns them into patients again, its efficacy must at least be likely. To establish this efficacy, further studies will be necessary to collect more data on long-term follow-up after this congenital anomaly. Because our study population was operated upon in the early period of correction, there are relatively few premature patients or patients with more complex anomalies like long-gap EA. It is possible that further study with a more complex population might result in higher numbers of patients with gastroesophageal reflux or Barrett’s esophagus. For this reason, we are performing a similar study in a younger group of patients, which has more premature patients and patients with more complex anomalies like long-gap EA.