bluuebunny/crossref_metadata_2025 huggingface dataset:
DOZ047.13: Prophylactic endoscopic esophageal vacuum (EVAC) therapy of high-risk esophageal anastomoses in pediatric surgical patients
Authors: Yasuda J L , Svetanoff W J , Staffa S J , Ngo P D , Clark S J , Smithers C J , Manfredi M A
Published: June 2019

Esophageal anastomotic leak (EAL) is a potentially severe complication of surgical procedures of the esophagus. Vacuum-assisted closure (VAC) therapy is increasingly used in the treatment of EAL, with observational studies suggesting it is a highly effective method for esophageal defect closure.1–3 It was hypothesized that prophylactic esophageal VAC (EVAC) placement at the time of new anastomosis creation may improve blood flow and healing, potentially leading to fewer EALs.

Methods

Between July 2015 and November 2018, patients who underwent surgery that resulted in a new esophageal anastomosis and were deemed to be high risk for anastomotic complications had a prophylactic EVAC placed at the time of surgery. Retrospective review of similar surgical procedures without prophylactic EVAC placement from January 2014 to November 2018 was performed for comparison.

Results

Thirteen pediatric patients had prophylactic EVAC placement at the time of esophageal repair. Procedures prompting EVAC placement included primary repair of long-gap esophageal atresia (LGEA) by the Foker technique (N = 7), stricture resection after repaired LGEA (N = 3) or type C esophageal atresia (N = 1), and stricture resection after delayed identification of a retained esophageal foreign body (N = 2). Three of 13 patients who had prophylactic EVAC placement (23.1%) experienced EAL in the post-operative period. Two patients were found to have technical failure of their EVAC leading to absence of suction, and one patient experienced delayed EAL 12 days after removal of the EVAC. In comparison, post-surgical EAL occurred in 13 of 58 patients who had the Foker procedure for LGEA and in 8 of 31 patients who had esophageal stricture resection without prophylactic EVAC placement. The rates of EAL in the prophylactic EVAC group were not significantly different from rates of EAL in either the post-surgical Foker (23.1% vs 22.4%, P = 0.999), post-stricture resection (23.1% vs 25.8%, P = 0.999), or combined post-Foker and stricture resection (23.1% vs 23.6%, P = 0.999) groups by Fisher's exact test.

Conclusions

Prophylactic EVAC placement does not carry increased risk of EAL compared to standard post-surgical care; however, further device refinement is needed to reduce technical failure.
DOZ047.14: Endoscopic incisional therapy and other novel strategies for treatment of congenital esophageal stenosis
Authors: Yasuda J L , Staffa S J , Clark S J , Ngo P D , Jennings R W , Manfredi M A
Published: June 2019

Management of congenital esophageal stenosis (CES) often involves dilation with reversion to myotomy or stricture resection in refractory cases.1,2 However, surgery often fails to produce durable response, with anastomotic strictures requiring ongoing dilation and stenotic symptoms plaguing more than half of the patients in published series.3

Methods

In this study, the medical records of all patients with CES treated by our tertiary care center who had at least one endoscopy between July 2007 and October 2018 were retrospectively reviewed. Success was defined as full when the diet included all age-appropriate textures with dysphagia once per month or less, or partial when the diet included most textures with dysphagia at most 1–2 times per week.

Results

Thirty patients with CES had at least one endoscopic intervention. All patients had balloon dilation(s) and at least one other therapy such as endoscopic incisional therapy (EIT), steroid injection, or stenting. Esophageal vacuum-assisted closure (EVAC) was used for treatment or prevention of esophageal leak. Of patients who had EIT at their CES (N = 18), 14 (77.8%) achieved full (N = 13) or partial (N = 1) success with endoscopic therapy alone; 3 (16.7%) required surgery to achieve full (N = 3) success; 1 nonsurgical patient does not yet eat by mouth due to oral aversion. Of patients who did not undergo EIT at their CES (N = 12), 5 (41.7%) achieved full success with endoscopic therapy alone; 7 (58.3%) required surgery (2 full success, 4 partial success, and 1 does not eat by mouth due to airway comorbidities). The rate of surgical intervention was significantly lower in the group that received EIT (Fisher's exact test, P = 0.045). Twenty-five endoscopies (8.9%) were associated with complications, including esophageal leak (N = 21) or stent migration (N = 4). Of endoscopies with a complication, 16 (64%) involved EIT. Odds of complications after therapeutic endoscopies involving EIT were significantly higher than those without EIT (odds ratio 6.15; 95% CI (2.44, 15.52); P < 0.001). The rates of esophageal leak significantly decreased over time as the use of EVAC increased (P = 0.003).

Conclusion

EIT shows promise as an alternative to surgery in CES; however, further study is needed. Complementary endoscopic techniques such as injection, stenting, and EIT broaden the toolbox of the treating physician and may allow for avoidance of surgery in CES.
DOZ047.19: Outcomes in the management of long-gap esophageal atresia: is the Foker technique superior?
Authors: Wiseman A , Krishnan J , Wanaguru D , Langusch C , Varjavandi V , Jiwane A , Dilley A , Adams S , Henry G , Currie B , Krishnan U
Published: June 2019

Background

Long-gap esophageal atresia (LGEA) has traditionally been managed by delayed anastamosis. However, over the last 10 years the Foker technique of esophageal growth elongation has been used. There is limited data evaluating outcomes using both techniques.

Aims

The aim of this study was to compare the outcomes in LGEA repair using the traditional delayed repair technique versus the Foker technique.

Methods

A retrospective chart review was done of LGEA patients at Sydney Children's Hospital between 1997 and 2016, comparing the Foker technique with the delayed repair technique.

Results

There were 9 children repaired using the Foker technique, and 10 by delayed repair. There were 7 patients with Type A, 1 with Type B, and 1 with Type C in the Foker group and in the delayed repair cohort, 5 were Type A, 2 Type B, 2 Type C, and 1 Type D esophageal atresia/tracheoesophageal fistula. There were 4 males in the Foker group and 5 in the non-Foker group. Median time to join was 59 days (15–117 days) for Foker repair and 173 days (16–433 days) for delayed repair. There was no significant difference in the incidence of post-operative leak, incidence of strictures needing dilation, presence of reflux symptoms, presence of reflux esophagitis on endoscopy, proton pump inhibitor use, need for fundoplication, incidence of cyanotic spells, occurrence of recurrent fistula, and symptoms of dysphagia when comparing both groups. Data on time to oral feeds and incidence of malnutrition was incomplete. Details are shown in Table 1.

Conclusions

Although the time to anastamosis was shorter in the Foker group and the incidence of post-operative leak, strictures needing dilation, need for fundoplication, and dysphagia were lower in the Foker group, the difference was not significant probably secondary to the small sample size. These results require validation in larger cohorts.
DOZ047.20: Growth, feeding difficulties, and developmental scores in children born with esophageal atresia: a single-center study
Authors: Grech A , Kwan M , Hatton L , Robinson P , Karpelowsky J , Collin M , Tzannes G , North H , Fitzgerald D A
Published: June 2019

Background

Children with repaired tracheoesophageal fistula/oesophageal atresia (TOF/OA) often have ongoing feeding difficulties and poor growth related to esophageal dysmotility, strictures, gastroesophageal reflux, aspiration, and respiratory infections. The impact of neurocognitive development on feeding in this cohort is less well studied.

Objective

The objective of this study was to investigate the growth, parent-reported feeding difficulties, and developmental scores of children with TOF/OA at The Children's Hospital at Westmead in Sydney, Australia.

Methods

The validated Montreal Children's Hospital Feeding Scale (MCH-FS) was completed by parents of patients aged 6 months to 6 years at a multidisciplinary aerodigestive clinic between February 2016 and October 2018. Growth, developmental outcomes (using the Bayley Scales of Infant and Toddler Development [BAYLEY-III]), demographic information, OA subtype, and associated comorbidities were reviewed.

Results

Forty-three caregivers completed the MCH-FS at least once, with questionnaires returned up to five times, totaling 101 reviews. The mean age was 4 years (± 1.9) and 53% were female. Thirty percent of patients were born prematurely and 30% had VACTERL association. Mean [± SD] growth z-scores were below WHO/CDC means for weight (−0.86 ± 1.37), length/height (−0.70 ± 1.2), and weight-for-length/BMI (−0.35 ± 1.15). BAYLEY-III scores were available for 27 children at 13 (± 1) months. Mean scores for four domains were within ‘average’ range (8–12): cognition (11 ± 2), receptive language (8 ± 3), expressive language (8 ± 2), and fine motor skills (9 ± 2). The mean gross motor score was below average (7 ± 3). Parent-reported feeding difficulties were moderate. When first completed, cumulative MCH-FS scores indicated 44% of patients had severe feeding difficulties, 40% moderate, and 14% mild. Sixty percent of patients required referral to a speech pathologist. However, most parents did not feel that these feeding difficulties influenced the relationship with their child or their family (88% and 84%, respectively).

Conclusions

The majority of patients in the cohort experienced significant feeding difficulties and some below average developmental scores, underscoring the need for multidiscplinary support for children born with TOF/OA. Further work in correlating growth, developmental, and feeding outcomes within subjects will assist in identifying early risk factors that may highlight infants most predisposed to these challenges, and who may benefit from early intervention.
DOZ047.21: Esophageal atresia and long-term quality of life in Italian population: a pilot study
Authors: Parracciani M , Tona C , Gamba P , Dall’Oglio L , Conforti A , Cheli S
Published: June 2019

Introduction

In Italy, long-term outcomes of esophageal atresia (EA) are poorly understood. The Italian Association ‘Family with Esophageal Atresia’ (F.AT.E.) and Tages Onlus, and some Italian pediatric centers of reference for AE, collaborated to define the first work about long-term outcomes and quality of life (QoL) in a cohort of Italian adults and young adults born with AE. As a rare disease, given the specificity of the reference population and the absence of similar research, this study was in any case designed to be a pilot study.

Methods

To date, 65 adults born with EA have participated in completing the questionnaire. Two survey formats were created: (i) a standard paper questionnaire and (ii) an online platform. The questionnaire included the following tools: (i) socio-personal data; (ii) QoL questionnaire (SF-36); (iii) a sub-battery of short questionnaires to investigate psychological adaptation to chronic diseases (HADS, IES-R, Brief-COPE); (iv) a questionnaire linked to the specific perception of social support (MOS-SSQ); and (v) four open questions developed to investigate the subjective experience of QoL and long-term morbidity. The use of quantitative and qualitative data (Mixed Methods) will allow us to deeply investigate the experience and perceptions related to the QoL.

Results

Our results indicated that AE type C is the most frequent, and the renal ones are the most common malformations associated with AE. According to the dysphagia score, more than half are suffering states of dysphagia. A significant negative statistical association emerges between the presence of dysphagia and perception of social support (MOSS-SSS). Gastroesophageal reflux symptoms are reported by more than half, in association with antireflux medications. At last, it emerges that the main psychological factors accused are sleep disorders and obsessive-compulsiveness symptoms.

Conclusions

Despite this study confirming that the frequency of respiratory, gastrointestinal, and musculoskeletal symptoms affects the QoL, it appears generally good. The information provided by this study could be an incentive to implement and improve long-term follow-up programs and to involve more specialist adult doctors in the care of these patients.
DOZ047.35: Early parental adjustment in esophageal atresia and other rare abdominothoracic malformations
Authors: Ribeiro M-H , Hanafi M , Michaud L , Blanc S , Lapillonne A , Mur S , Gelas T , Kermorvant E , Gottrand F , Guerrien A , Coulon N
Published: June 2019

Parents of a child with a congenital malformation including esophageal atresia (OA), congenital diaphragmatic hernia (CDH), or intestinal atresia (IA) have to face various potentially stressful situations and exercise their role in a highly medicalized context. Yet no study has so far sought to identify the factors that facilitate or make difficult their adjustment of the first months.

This study aimed to propose a grounded theory to account for the dynamics of parental adjustment for the period from the announcement of the diagnosis to the age of one year of the child with a rare abdominothoracic malformation requiring neonatal surgery. Participants were recruited to form a reasoned sample of 30 parents of children aged from 12 to 36 months with an OA, a CDH, or an IA. To date, 22 parents (17 mothers and 5 fathers) have been included. Semistructured individual interviews were conducted in which four main themes were discussed: the medical and hospital care of the child, the daily life with the child at home, the consequences of the illness on family life, and personal experience.

Preliminary results show that the child's condition impact parental adjustment and family functioning. Parents reported high level of distress and fatigue during the first year of their child. The highly medicalized context makes it more difficult for parents to practice their parental role and bring them to expense energy to implement normalization strategies in their parental practices.

Interestingly, the relationship with doctors and medical staff has been widely discussed by parents. Most of them felt a lack of information about their child's condition, or felt that the information was not authentic. Some of them felt that doctors were trying to protect them by omitting certain events that they ended up learning by the medical staff. All parents pointed the availability, the quality of the educational relationship, the emotional and informational support from the medical staff allowing them to feel more effective and to reduce their negative feelings.

Results of our study will be used to design appropriate psychoeducational interventions in order to improve support for families.
DOZ047.37: 5-year follow-up after 17 laparoscopic transhiatal esophagectomy and gastric pull-up (TEGPUL)
Authors: Perera A P , Pasten A
Published: June 2019

Background

Survival in patients with EA.

Materials and Methods

Between 2011 and 2015, we performed 17 transhiatal esophagectomy and gastric pull-up (TEGPUL) in 8 girls and 9 boys, with a mean age 34 months (range: 8–99 months). All born with EA 65% (11) were acquired long-gap (EA type III, those where a primary anastomosis was initially achieved and then lost because of complications and redo surgeries) and 35% (6) congenital long-gap (EA types I and II). Immediate, mediate, and late complications were recorded. They were contacted by email, Facebook, instagram, and WhatsApp. WHO charts were used for nutritional diagnosis.

Results

Mean operating time 5.5 hours (3.5–8 hours), mean days of mechanical ventilation 4.5 (2–8 days), mean days of hospitalization 18 (9–40 days), mean time of oral feeding 12.5 days (3–30 days). We contacted 92% of the living patients. Immediate complications (first 14 postoperative days): 3 (18%) reoperative surgery (2 acute gastric obstruction and 1 incidental colon perforation); 3 (18%) patients had perioperative cardiac arrest (2 in-OR and 1 out-OR) all left but one, with neurological sequelae, died on the 12th postoperative day; 8 patients (47%) had a leak of the esophagogastric anastomosis, all health spontaneously in an average of 15 days and high blood pressure in 10 (59%) patients, unknown etiology. Mediate complications (from 15 postoperative days to 3 months): gastric emptying delay 3 (18%), GER 5 (29%), and recurrent lower respiratory infections 9 (53%). Late complications (from 3 months to 5 years): malnutrition 2 (18%), risk of malnutrition 3 (27%), diaphragmatic hernia 1 (9%), upper gastrointestinal bleeding 1 (9%). Postoperative parents satisfaction 100%.

Conclusion

TEGPUL is a safe and reproducible esophageal replacement technique in patients with long-gap EA, but have a long learning curve. However, more long-term and larger follow-up studies are needed, for which we recommend grouping these patients in a national reference center.
DOZ047.47: Flourish device for treatment of esophageal atresia
Authors: Slater Bethany J , Zaritzky Mario
Published: June 2019

Esophageal atresia (EA) is usually repaired soon after birth. However, there are conditions in which early repair is not possible including prematurity, a large distance between the ends, failed attempt at primary anastomosis, and postoperative complications. Cases in which the ends of the esophagus are not able to be brought together without significant tension, or long-gap esophageal atresia (LGEA), remain a challenge to manage. A variety of techniques have been used to establish esophageal continuity consisting of extensive mobilization, myotomies, esophageal flaps, and traction of the segments.

The use of magnets is a nonsurgical alternative for esophageal anastomosis. There have been a few series demonstrating initial success and accomplishment of magnamosis in EA patients. A prospective, single-arm, observational study is currently enrolling patients to evaluate the safety and benefit of the Flourish Device (Cook Medical), a catheter-based, magnetic device used to lengthen the atretic esophageal ends and create an anastomosis. The primary outcomes include stricture requiring dilation or surgery, anastomotic leaks or other adverse events with follow-up for two years.

The distance of the esophageal gap is measured with metal probes. All patients require a mature gastrostomy and atretic segments < 4 cm apart. The proximal catheter has a suction port and the distal portion has a channel for feeds. Placement is done under fluoroscopy with anesthesia or sedation. Daily chest radiographs are obtained until union of the magnets occur. Successful anastomosis is identified by saliva in the gastrostomy catheter, feeds in the esophageal catheter, or with a contrast study. One day after confirmation, the magnets may be removed.

When the catheters are aligned, the magnets attract. Once the magnets have connected, the tissue between them sloughs off while the outer rim heals establishing the anastomosis. The Flourish device may be particularly useful in patients in whom additional operations are not ideal such as those with congenital anomalies or who have undergone previous operations or complications.
DOZ047.57: Eosinophilic esophagitis in an infant with repaired esophageal atresia and tracheoesophageal fistula
Authors: Mustafa A , AlKhabaz A , Mallik A A , Kumar S
Published: June 2019

Esophageal atresia (EA) with or without tracheoesophageal fistula (TEF) requires early surgical intervention in life, following which symptoms related to esophageal dysmotility, gastroesophageal reflux, and strictures may develop. Eosinophilic esophagitis (EoE) is an immune-mediated disorder presents with vomiting and dysphagia. The appearance of exudates, rings, and furrows during endoscopy and the presence of >15 eosinophils/HPF in biopsy confirm the diagnosis. Treatment options include elimination diet, proton pump inhibitors (PPI), and topical steroids.

We report a full-term male who had EA and TEF repaired in the second day of life. At 11 months of age, he developed progressive vomiting, contrast study showed esophageal dysmotility with slow emptying and no stricture. The initial endoscopy showed a mild nonobstructive narrowing 5 cm above the gastroesophageal junction, below which the mucosa was erythematous, biopsies showed >25 eosinophils/HPF. Started treatment with PPI and endoscopy repeated three months later showed same endoscopic features and biopsies showed >45 eosinophils/HPF. Allergy testing was positive for milk, wheat, oat, and rice. Topical steroids and elimination diet were added to PPI. At 32 months of age, the child was asymptomatic, not on elimination diet and treatment was stopped. Repeat endoscopy showed longitudinal furrows and erosions of the lower esophagus, no stricture, and biopsies showed >15 eosinophils/HPF. Steroids, PPI, and elimination diet were all resumed.

Despite moderate esophagitis due to EoE and poor compliance to treatment, our patient shows normal growth, development, and symptoms resolution. Asymptomatic children with repaired EA and treated EoE may require close follow-up and repeat endoscopy.
DOZ047.58: The familial occurrence of congenital esophageal atresia with or without a fistula is an extremely rare pathology
Authors: Smigiel R , Dzielendziak A , Toczewski K , Rozensztrauch A , Bloch M , Patkowski D
Published: June 2019

We report on two siblings (boy and girl), which were treated for congenital esophageal atresia with the fistula, at the Department of Pediatric Surgery and Urology in Wroclaw, at an interval of two years. These children have two healthy siblings. Both newborns were born on time (38 and 42 week of pregnancy). Prenatally hydramnios was observed in younger child.

They were postnatally diagnosed with congenital esophageal atresia with a distal fistula. Newborns were operated on the second day of life. Bronchoscopy and right-sided thoracoscopy were performed. Both patients had a short-gap esophageal atresia with a distal fistula. The fistula was proximally closed with sutures and divided distally. Subsequently, the one-layered esophageal anastomosis was performed. There were no early postoperative complications. Both patients underwent two esophageal dilatations. Siblings are tolerating oral feeding. Occasionally, parents observe choking in the older child. Patients remain under the constant care of a pediatric surgery clinic.

Moreover, children were evaluated by clinical geneticist and exome sequencing (WES) study on the base of DNA isolated from lymphocytes and esophageal tissues were performed in both siblings.
DOZ047.67: Comparison of mesenchymal stem cells from pediatric normal and esophageal atresia patients for use in regenerative medicine
Authors: Jensen T , Wanczyk H , Thaker S , Mitchell A , Sharma I , Finck C
Published: June 2019

Esophageal atresia (EA) is a congenital defect in which the esophagus is not fully connected. Current treatments to bring together long gaps between the esophagus have very high complication rates and the replacement tissue does not possess the correct structure or physiologic properties. Tissue engineering and regenerative medicine have been suggested as a new patient-specific treatment for EA utilizing the patient's own cells and a tubular scaffold. Our group recently published on the successful regeneration of an esophagus using a retrievable scaffold seeded with adipose derived mesenchymal stem cells (AD-MSC) in a porcine model of esophageal loss. The goal of this study is to evaluate phenotypic differences between AD-MSCs from normal (N-AD-MSC) and EA patients (EA-AD-MSC) to determine if EA-AD-MSC could be used for autologous tissue engineering approaches. Subcutaneous fat was obtained from pediatric patients undergoing surgery (IRB#). The cells from all patients expressed mesenchymal stem cell markers CD90, CD105, CD73, CD44 and did not express hematopoietic markers CD45, CD34 and HLA-DR by flow cytometry. Growth kinetics revealed similar population doubling times and morphology was similar between the two groups. Some of the EA-AD-MSC demonstrated upregulated expression of ATNX1, BMI1, FOXF1, GLI2, GLI3, MYC, HOXC4 and NOG, known genotypic abnormalities in EA patients. None of the N-AD-MSCs had upregulated expression of these genes. Furthermore N-AD-MSCs and EA-AD-MSCs underwent osteogenic and adipogenic differentiation with positive staining for Oil Red O and Alizarian Red after 2 weeks in culture. The integrin profiles of these cells were also similar across all patients as demonstrated by flow cytometry. In conclusion, in vitro, the EA-AD-MSCs behaved similarly to N-AD-MSCs in growth kinetics, mesenchymal phenotype and differentiation ability. Genotypically there were some differences and how this will impact the growth of these cells on scaffolds is currently being investigated.
DOZ047.69: Tracking outcomes of tracheoesophageal fistula and esophageal atresia in pediatric population
Authors: Sharma I , Thaker S , Jensen T , Finck C
Published: June 2019

Purpose

The purpose of this study is to conduct a retrospective chart review of patients with a rare congenital deformity, tracheoesophageal fistula, and esophageal atresia treated at a small, freestanding Children's Hospital. The goal is to identify important variables to inform clinical pathways and prospective database creation. Current national surgical quality databases do not track tracheoesophageal fistula/esophageal atresia (TEF/EA)-specific data points such as TEF-type and incidence of postoperative complications such as gastroesophageal reflux disease (GERD) and esophageal stricture.

Methods

Patients diagnosed with esophageal atresia and trachesophageal fistula between January 2005 and January 2019 were identified using the appropriate ICD 9 or ICD 10 codes. Data for 35 variables including patient demographics and type of esophageal atresia were abstracted. SPSS 16.0 software was used for descriptive statistics.

Results

A total of 43 patients were identified, 64.3% female and 35.7% male. 77.5% were type C, 12.5% type A, 7.5% type H, and 2.5% type D. 15% were long-gap type. 53.8% had postoperative esophageal strictures, and 66.7% had postoperative gastroesophageal reflux disease. Of those who had strictures, 77.2% of patients required at least three postoperative dilations for stricture, with an overall mean six dilations. 26.2% of patients had tracheomalacia; of these, two patients underwent thoracoscopic aortopexy. Four patients were not included in subgroup analysis: two patients had missing variables, one patient passed away before surgical intervention, and one patient has not yet undergone surgical intervention for EA/TEF.

Conclusions

We conclude that, although a rare congenital anomaly, a database dedicated to tracheoesophageal fistula and esophageal atresia at a pediatric hospital can aid in reviewing trends in outcomes and inform standardization of management.
DOZ047.76: Eosinophilic esophagitis and esophageal atresia. Is there an association?
Authors: García L , Giné C , Laín A , Martín M , Molino J A , Bordón E , Alvarez M , Segarra O , López M
Published: June 2019

Aim of the Study

Eosinophilic esophagitis (EoE) is a recently diagnosed entity and seems to be more prevalent in patients with esophageal atresia (EA). It can mimic dysphagia and gastroesophageal reflux (GER) symptoms frequently observed in EA, but treatment is different.

Methods

Retrospective review (2002–2019) of patients with EA who underwent esophagogastroduodenoscopy (EGD) and esophageal biopsy was performed. EGD was performed in symptomatic patients and in all patients at 12–15 years. Diagnostic criteria for EoE included >15 eosinophils for a high-power field in the esophageal mucosa.

Main Results

From a total of 110 patients with EA, 27 lost follow-up. In the remaining 83, 56 patients (67, 5%) underwent EGD because of dysphagia or gastroesophageal reflux (GER) studies. Esophageal biopsies were performed in 35 patients and the diagnostic criteria for EoE were achieved in 5 (14,3%). The mean age at diagnosis of EoE was 10 + 2 years and the indication for EGD was GER symptoms (3) or dysphagia (2). In one case an antireflux surgery was previously performed but symptoms slightly persisted, while in 4 cases contrast studies and pH-metry showed no or minimal GER. EGD demonstrated light distal esophagitis in 2 cases, white exudates in 2, and was completely normal in the remaining one. On follow-up, 4 patients remain asymptomatic with proton pump inhibitor medication, and periodic EGD shows macroscopic improvement with a decreased eosinophilic peak on esophageal biopsies.

Conclusions

Patients with EA seem to have a higher risk of developing EoE at early puberty. EGD on follow-up should be focused not only on studying GER or Barrett, but also on actively search for EoE with an esophageal biopsy, even when the macroscopic appearance is normal.
DOZ047.77: Extraluminal airway stabilization for localized tracheomalacia: a case report
Authors: Laín A , Pumarola F , Giné C , García L , Barila P , López M
Published: June 2019

Aim

In the last years several treatments for tracheomalacia have been reported. However, management of this entity is still a complex matter. This study presents a case diagnosed of severe proximal tracheomalacia managed by external tracheal resorbable plates.

Case Report

A seven-year-old child was tracheostomized in the neonatal period in relation to severe generalized tracheomalacia in association with swallowing incoordination and recurrent respiratory infections. Data to point out of his personal history were prematurity, a mosaic type genetic anomaly, cognitive and development impairment, and bilateral hypoacusia.

After improvement of the neurological status and his feeding and swallow problems he was evaluated by the Airway Unit of our centre. Dynamic transnasal flexible laryngotracheobronchoscopy showed severe tracheomalacia. The collapse was 100% in the proximal airway (from the subglotis to the middle part of the trachea) and decannulation was not possible. Given the extent, localization, and proximity of the tracheomalacia to the vocal cords a surgical approach with external bioresorbable plates was indicated. By a transcervical approach, dissection of the larynx and cervical trachea was carried out. Two 2.5 cm multiperforated plates of ‘poly [L-lactide-co-glycolide] copolymer’ were modeled and fixed to the anteromedial laryngotracheal surface. Direct intraoperative endoscopy defined the proper location to fix the plates and showed significant improvement of the collapse thanks to the rigidification of the airway. Three weeks after the procedure endoscopic control was realized and the patient was successfully decannulated. He remains asymptomatic with a 6 months follow-up. No complications were reported.

Conclusion

Extraluminal stabilization with resorbable plates can be a safe and effective option for selected patients with localized tracheomalacias. It represents a valid alternative for the management of this complex entity.
DOZ047.79: Bronchoscopic treatment of plastic bronchitis in children
Authors: Erdas M Y , Valiyev N , Cerit K K , Gokdemir Y , Kiyan G
Published: June 2019

Purpose

Plastic bronchitis or cast bronchitis is a rare condition characterized by the formation of large gelatinous or rigid airway casts. Classification of plastic bronchitis is done by disease association and cast histology. This rare condition can cause airway obstruction and there is no standardized treatment. Here are presented two cases with plastic bronchitis treated by bronchoscopic removal of casts in our clinic.

Patients

Case 1: A 9-year-old boy presented with wheezing, cough, and respiratory distress. He expectorated the cast spontaneously and the cast was misdiagnosed as germinative membrane of a hydatid cyst at the previous center. Total collapse of the left hemithorax was seen on chest X-ray. Any underlying disease was not detected. The plastic-like solid structure was detected and easily extracted from the bronchial tree. Pathology results of the casts were eosinophilic mucoid casts. The patient experienced three bronchoscopic removals and had no recurrence thereafter for two years.

Case 2: A 7-year-old girl presented with persistent cough and respiratory distress. The patient was referred to our center with the diagnosis of foreign body aspiration. Total collapse of the right middle and lower segment and partial collapse of the upper segment were seen on chest X-ray. Previously, she was diagnosed with reactive airway disease. The plastic-like semisolid structure was detected during bronchoscopy its extraction from the bronchial tree was not easy but was possible. Pathology results were eosinophilic mucoid and fibrinotic casts. This patient still needs bronchoscopy for cast removal after 12 bronchoscopic removals but her symptoms and bronchoscopy findings have regressed with time.

Conclusion

Bronchoscopic extraction of casts provides fast improvement of patients’ symptoms and postoperative chest X-rays, but recurrence of cast formation is common. Nevertheless, it is the mostly chosen therapy in the literature. Further researches in this area are required.
DOZ047.84: Use of a decannulation protocol in the pediatric population: decrease in the day of use
Authors: Urquizo M , Canepari A , Ricciardelli M , Sanchez M
Published: June 2019

Objective

This study aimed to compare days of use of a tracheostomy cannula in two groups of patients: one group used a guided decannulation protocol carried out by an interdisciplinary team and the other group did not apply any protocol.

Design and Population

A comparative retrospective cohort study of 40 patients was carried out, of whom 20 were decannulated without a protocol (WOP) between 2008 and 2011 and in the other 20 patients, the decannulation protocol (WP) was applied by an interdisciplinary team between 2015 and 2017.

Method

In 2015 a guided decannulation evaluation protocol was implemented in patients successfully weaned from prolonged mechanical ventilation that consisted of three parts: (1) daily evaluation tracheotomy requirement; (2) measuring subglottic pressure, decreasing the internal diameter of the cannula and usage of phonation valve; and (3) endoscopic evaluation, occlusion test according to age, and decannulation. The main variable was days of use of tracheostomy cannula in both groups, from the day of the surgery to the day of decannulation.

Results

In the cohort WOP of the 38 tracheotomized children, 20 achieved decannulation. In the group WP, the first 20 children who reached decannulation were consecutively enrolled, out of a total of 24 tracheotomized patients in that period. The median age was 58 months, with IQR (21.5–138); the diagnoses of admissions for both groups were of respiratory cause 20% CI 95% (10–35), cardiovascular 15% CI 95% (7–30), neurological 17.5% CI 95% (8–33), and other 47.5% CI 95% (32–63). The surgical procedure of tracheostomy, 52.5% were percutaneous with 95% CI (37-68) while 47.5% were surgical with 95% CI (32–63). The median use of the tracheostomy cannula was 46 days with an IQR (29–144). When analyzing the days of cannulation in both cohorts, a median of 94 days WP and CI 95% (51–261) in the group WOP and a median of 33 days WP and CI 95.5% (23–44) were found, obtaining a value of Wilcoxon–Mann–Whitney p 0.0012.

Conclusions

The use of a decannulation protocol applied by an interdisciplinary work team showed a significant decrease in days of use of tracheostomy cannulas in pediatric patients unrelated from the respiratory assistance.
DOZ047.90: An interesting and extremely rare case report of PCD and HLHS
Authors: Jaiswal A , Andrew N
Published: June 2019

An antenatally diagnosed hypoplastic left heart syndrome boy from Kuwait was transferred in utero for postnatal surgical management. He was born to a nonconsanguineously married couple by spontaneous delivery at 33 + 5 weeks of gestation with a birth weight of 2.4 kg. He was on prostaglandin infusion after birth and shortly underwent bilateral pulmonary artery banding with gore-tex shunts (aorta to pulmonary artery shunts) to let him grow and get over his prematurity for his cardiac surgical palliative procedures. He had some right upper lobe collapse, which was treated with physiotherapy and suctioning to proceed for his first stage cardiac surgical repair (Norwood I). Following this, he had a rough course owing to his cardiac condition but was extubated without many problems in due course. He was persistently tachypnoeic, had two episodes of acute decompensations during his stay due to his lung segment collapse needing invasive ventilation, and was very fragile, needing careful management. He needed noninvasive positive pressure ventilation at other times even when stable, to keep his airways from collapsing. He underwent a bronchoscopy and CT scan when stable enough to do it that showed a normal airway but with thick, tenacious, and clear secretions on bronchoscopy while a CT showed some areas of atelectasis and pulmonary interstitial emphysema. He was investigated for cystic fibrosis and primary ciliary dyskinesia as other causes that could lead to persistent and recurrent atelectasis were ruled out and his acute episodes dealt with appropriately. His genetic testing results have confirmed the clinical diagnosis of primary ciliary dyskinesia and he is being discussed for further management from a multidisciplinary point of view.
DOZ047.91: Bronchoscopic treatment of recurrent tracheoesophageal fistula: is it an effective option?
Authors: Valiyev N , Cerit K K , Erdas M Y , Ergenekon A P , Kiyan G
Published: June 2019

Purpose

Despite technical and surgical improvements, treatment of recurrent tracheoesophageal fistula (rTEF) still remains a challenging problem in pediatric patients. Bronchoscopic closure of rTEF using different agents is described with different success rates in the literature. This study aimed to report results of patients with rTEF treated with chemocauterization using trichloroacetic acid (TCA) and with laser cauterization (LC) followed by fibrin glue (FG) application.

Methods

Nine patients with rTEF were included in the study from 2014 to 2018. Four patients underwent fistula closure with LC followed by FG application, while another four patients had chemocauterization with TCA. In one case both agents were used. Patients were checked for the success of the treatment by bronchoscopy. All patients had the diagnosis of rTEF. Seven patients had EA with distal TEF and the remaining two patients had H-type TEF as primary pathologies. FG application was performed by LC followed by injection of FG into the fistula. Application of the TCA was made by a TCA-soaked sponge for 30 seconds and 3 times each trial.

Results

Nine children of the age range 4 months to 5 years (mean 1.5 year) were treated endoscopically. Follow-up ranged between 3 months and 5 years (mean 28 months). Among the nine patients only in one patient with only laser coagulation with FG application the treatment was successful. In the remaining eight patients all attempts failed. All these patients underwent open surgical closure of the fistula. There were no acute or late complications related to either endoscopic method.

Conclusion

The results of this study suggest that endoscopic occlusion of recurrent TEF has a low success rate. Surgical closure is still a standard method with a high success rate. Even though endoscopic options are less invasive, they prolong the period of aspiration and may cause increased pulmonary problems.
DOZ047.93: Thoracoscopic multistage repair of long-gap esophageal atresia using internal traction suture technique—evolution of the method
Authors: Patkowski D , Gerus S , Rasiewicz M
Published: June 2019

Treatment of long-gap esophageal atresia poses a great challenge for a surgeon. A new multistage thoracoscopic repair of long-gap esophageal atresia using internal traction technique was developed that evolved with time and growing experience. The goal of this study is to present the changes in the strategy and important technical aspects of the operative method based on a retrospective analysis of performed surgeries.

Methods and Materials

Thirty-five cases of newborns with long-gap esophageal atresia (type A-26 cases and B-9 cases exclusively) were operated thoracoscopically between 2008 and 2019 using internal traction technique in different pediatric surgery centers (Poland–28, Czech–1, Ukraine–1, Switzerland–2, Egypt–2, Russia–1). The idea of the internal traction technique was to place the suture between thoracoscopically mobilized esophageal pouches and keep a static tension between them for a period of time. Patients were operated on as early as it was possible after birth.

Results

Of the 35 newborns operated on using internal traction 2 patients died before the final stage from not surgically-related causes. Two patients had complications that required neck fistula and had later Collis–Nissen and colon interposition, respectively. One case is awaiting the final procedure. For 31 cases the final esophageal anastomosis was completed in two stages–16 cases, three stages–9, four stages–2, five stages–2, and six stages–1. At the beginning the time between stages was planned for 4 weeks (for some cases it was even longer) and it was shortened for the last three cases to 5 days. It allowed avoiding gastrostomy in two cases. The internal traction was modified from using two traction loops to one traction loop with two slipping knots on each branch of the loop. The clips were applied transversely through the tip of each pouch and part of the traction loop to prevent disruption and pouch perforation. It also allowed increasing of the created static traction force.

Conclusion

Results of the study may indicate that in a majority of long-gap esophageal atresia it is possible to preserve the native esophagus by a thoracoscopic approach using an internal traction suture technique. Shortened time between stages allowed completion of the final esophageal anastomosis with gastrostomy avoidance.
DOZ047.97: Anastomotic strictures in patients with oesophageal atresia systematically treated with PPI: prospective cohort study over 10 years
Authors: Grunder F R , Petit L M , Ezri J , Jantchou P , Aspirot A , Faure C
Published: June 2019

Objectives and Study

Clinical course in oesophageal atresia (OA) patients is frequently complicated by gastroesophageal reflux disease, which is thought to be a risk factor for formation of anastomotic strictures. It is currently recommended that OA patients be treated systematically with proton pump inhibitors (PPI) after surgical repair. However, it is not clear if PPI treatment does really prevent the formation of anastomotic strictures and reduce the incidence of histological complications during long-term follow up. This study aimed to describe the outcomes of a cohort of OA patients with or without tracheoesophageal fistula (TOF) systematically treated with PPI since the neonatal period.

Method

Prospective longitudinal cohort study over 11 years of 73 children with OA-TOF, systematically treated with PPI, was carried out. Descriptive data is presented as median (interquartiles) for continuous variables and as frequency (%) for categorical variables. Pearson's χ2 test, Fisher's exact test, and Wilcoxon rank sum test were used for univariate analysis. SAS software, version 9.3 (SAS Institute, Cary, NC) was used; P-values < 0.05 were considered statistically significant.

Results

Seventy-three patients (41 males) were included in the final analysis. The median age at study completion was 4.87 years (3.64, 7.97; range 1–11.4). According to Gross classification, 64 patients (88%) had OA type C, 8 (11%) had type A, and 1 (1%) had type D; long-gap OA was present in 16 patients (22%). Thoracotomy was performed in 56 patients and thoracoscopy in 17. Anastomotic strictures and recurrent strictures were diagnosed in 32 (44%) and 17 patients (23%), respectively. In all but one case, strictures occurred when the child was on PPI. Anastomotic strictures occurred significantly more frequently in long-gap OA, in patients with anastomotic leak after surgical repair and longer hospital stay (P = 0.02, 0.002, and 0.02 respectively). Histological complications, especially gastric metaplasia, appeared more frequently in OA patients with anastomotic strictures (P = 0.01).

Conclusion

Forty-two percent of patients developed anastomotic strictures on PPI treatment, therefrom 55% patients with recurrent anastomotic strictures, indicating that acid gastroesophageal reflux seems not to be the major trigger factor for developing anastomotic strictures. A more selective prescription of PPI should be discussed.
Transfer 2.0: Applying the Concept of Transfer from Track-Two Workshops to Inclusive Peace Negotiations
Authors: Cuhadar Esra , Paffenholz Thania
Published: June 2019

This article argues that the scholarly study of “transfer” from track-two workshops to track-one negotiations is highly applicable to the study of transfer from other modalities of participation to track-one in inclusive peace negotiations. During the last decade, other approaches to make negotiations more inclusive have also been increasingly employed, such as national dialogue conferences, variety of consultation mechanisms, or a diverse set of peace commissions. In this paper, we aim to expand the conceptualization of transfer beyond ICR workshops and discuss how the knowledge accumulated concerning transfer in the ICR literature during the last decades can be applied to understand and evaluate transfer from other inclusion modalities used in peace negotiations today. We therefore make a distinction between the first generation of transfer (1.0) developed by the ICR workshops scholars and practitioners and the transfer process from other modalities used in inclusive negotiations (2.0). To apply the lessons learned from transfer 1.0 to 2.0, we start with an overview of the concept as developed in track-two literature. We then suggest a conceptualization of transfer 2.0, based on insights from how it has unfolded in five of the seven inclusion modalities examined in our comparative case study. We discuss the similarities and differences between transfer 1.0 and 2.0 and how transfer 2.0 can be studied, including and beyond track-two initiatives. We conclude by suggesting a number of directions for future research on transfer 2.0 that are relevant to several inclusion modalities.