With the improvement in survival rates among patients with esophageal atresia, there has been a significant focus on their early morbidities. Anastomotic stricture, gastro-esophageal reflux disease (GERD), and respiratory anomalies are recognized as significant contributors to these early morbidities. Symptoms and signs arising from these complications often overlap, making management challenging. Thorough esophagograms and endoscopies play a crucial role in identifying the underlying causes.
Early symptoms associated with anastomotic strictures, such as feed regurgitation, choking, coughing during feeding, and recurrent pneumonia episodes, are often attributed to GERD, respiratory anomalies, or esophageal motility disorders. Many studies report anastomotic strictures only when patients develop dysphagia, experience impaction of foreign bodies or food material, or exhibit significant feed regurgitation. However, delaying diagnosis until these symptoms appear in infants can lead to life-threatening complications. Dysphagia in infants consuming milk feed may emerge as a late symptom, usually associated with a tight stricture. Strictures presenting beyond infancy may be linked to the introduction of solid foods.
Efforts have been made to define anastomotic strictures and identify patients at risk of narrowing. Despite extensive literature, there is no consensus on the definition of anastomotic stricture. Many authors have attempted to objectively define anastomotic stricture on esophagogram by calculating the ratio of stricture diameter either with maximum upper or lower esophageal dilatation or with the mean of the maximum diameter of both upper and lower pouches.[2, 3] However, none of these definitions have gained wide acceptance, as studies on anastomotic strictures have not uniformly used a stricture index. Most authors label anastomotic stricture only when patients exhibit obstructive symptoms. Factors such as long gaps between esophageal pouches, tension on the anastomosis, and GERD have been correlated with an increased risk of stricture formation. GERD itself can potentially cause anastomotic stricture. Screening for GERD is commonly performed in follow-up cases despite the universal use of anti-reflux medications. Anastomotic stricture rates remain high in many large series and are among the leading causes of morbidity.
Contrast swallow and esophagoscopy play roles in promptly diagnosing esophageal stricture, but routine screening isn't universally embraced due to concerns about radiation exposure. Landisch et al., in their study, concluded that a second esophagogram at a median age of 38 days enhanced predictability in diagnosing stricture [3]. Shawyer et al. in an extensive literature review, found that 80% of surgeons obtained a second esophagogram and 12% performed esophagoscopy before 6 months of age [4]. Pereira et al conducted a second esophagogram within the first 60 days post-surgery, with a median of 35 days, revealing anastomotic strictures in 67.7% of patients [5]. The median age for esophageal dilatation in their study was 40 days. Parolini et al. conducted routine endoscopy at the first month post-surgery and proposed a Stricture Index based on endoscopic measurements [6].
In our study, we employed a second esophagogram and esophagoscopy to diagnose anastomotic strictures promptly. We believe that most strictures form during the healing process, around 3–6 months; hence, we conducted these studies between 2–4 months of age. Studies by Michaud et al. revealed that a significant proportion of patients had anastomotic strictures during infancy [7]. We diagnosed significant narrowing of the anastomosis in 10 patients during esophagogram. All these patients were confirmed to have anastomotic strictures during esophagoscopy. Additionally, one patient who did not exhibit a stricture in the esophagogram was diagnosed with anastomotic stricture during esophagoscopy. In our experience, early screening for anastomotic stricture not only facilitates the process of anastomotic dilatation but also potentially reduces episodes of aspiration pneumonia resulting from feed retention at the anastomotic site. In our patients, symptoms of cough and choking improved after anastomotic dilatations in all patients with anastomotic stricture. In the evidence-based care recommendations for respiratory complications by Koumbourlis et al, a workup to rule out anastomotic stricture is recommended in all patients with a wet cough or aspirations [8].
Early endoscopy in patients with anastomotic strictures facilitated safe and adequate dilatation of the anastomosis. Esophageal dilatations performed during outpatient follow-ups are often done with infant feeding tubes (IFT). The maximum dilatation achieved with the biggest IFT will not exceed 3mm, while the smallest bougie dilator allows dilation of 5mm caliber. All patients in the study were serially dilated under endoscopic guidance with Savary-Gillard wire-guided bougies numbered 6, 9, and 11.
In conclusion, our study underscores the importance of early detection and intervention in cases of anastomotic narrowing among patients diagnosed with Type 3 esophageal atresia. Timely diagnosis not only facilitates prompt treatment but also holds the potential to significantly improve the long-term morbidity outcomes for these individuals.