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Global Journal of Surgery 2012, 3: 15
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Review Article
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Does anti-reflux surgery prevent Reflux Induced Mucosal Abnormalities (RIMA) in children born with Esophageal Atresia/Tracheo Esophageal Fistula (EA/TEF)? - A review of current practice
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Sathyaprasad Burjonrappa
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Division of Pediatric Surgery, Maimonides Medical Center, 921 49th Street, Brooklyn, NY 11219, USA
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Abstract |
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Objectives: EA/TEF patients are prone to developing reflux and in a small proportion of cases this reflux is complicated by development of RIMA. We wanted to compare the incidence of RIMA (esophagitis and metaplasia) in a subset of patients who had undergone Nissen fundoplication to those who hadn’t to prove our hypothesis that anti-reflux surgery prevents development of RIMA. Secondly we wanted to see if there was any reversal in RIMA to normal mucosa after a Nissen fundoplication. Experimental: Fifty one patients (28 male) in an EA/TEF clinic at a tertiary centre were the subjects of the study. Floppy Nissen, Collis Nissen or Toupet fundoplication was performed in patients with severe symptoms recalcitrant to conservative management. They were followed in a multi disciplinary clinic with regular endoscopy and pH monitoring. Incidence of RIMA was compared in the group with and without fundoplication. Evolution of RIMA in patients who had undergone a fundoplication was evaluated by ongoing screening endoscopy. Results: Fifty one patients (28 male) underwent esophageal atresia correction in the study period (1990-2009). Thirty seven patients (72.5%) had reflux proved either by pH studies or endoscopy. Seventeen patients (46%) underwent anti-reflux surgery. 12 of 15 patients with RIMA had metaplasia (11 gastric and 1 intestinal metaplasia) while the other three had mild esophagitis. Two patients with normal pH probe studies had RIMA on endoscopic biopsies. The mean age of children who developed metaplasia was around 13 years. Six of 12 had anti-reflux surgery (1 Collis, 1 Toupet, 4 Nissen) done at a median age of 3 months and this did not prevent development of metaplasia later. Two patients had the procedure redone with no improvement in the metaplastic changes. The other six were managed by maximal medical treatment only with resolution of esophagitis and metaplasia in one. Of the patients with uncomplicated reflux the median age to fundoplication was 17 months and the mean age at follow-up was 6.5 years. Conclusions: While anti-reflux surgery may symptomatically benefit some infants with EA/TEF, pathological changes may persist and progress in the esophageal mucosa. Severe reflux, with mucosal injury at a young age seems to carry a higher risk of RIMA. The median age to development of metaplasia is in the early teen years and careful follow up of this group is indicated by endoscopy.
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Keywords |
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Esophageal Atresia; Tracheo Esophageal Fistula; Barrett’s; Dysplasia
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