Management of Esophagitis Following Repair of Esophageal Atresia

Study Overview
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Brief Summary
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The goal of this study is to prospectively evaluate the impact of antacid therapy on esophagitis in children with repaired esophageal atresia. Recent clinical guidelines have attempted to define a systematic approach to the management of these patients with regards to minimizing and treating esophagitis (Krishnan et al 2016), however the quality of evidence supporting many of the recommendations are based on expert opinion or on limited, retrospective studies. Risk factors for esophagitis and optimal length of antacid therapy are not well defined. Through this study, we aim to identify risk factors for the presence of esophagitis in patients with repaired esophageal atresia. We hypothesize that antacid therapy improves esophagitis severity in children following esophageal repair.

Detailed Description
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A. Specific Aims/Objectives The goal of this study is to prospectively evaluate the impact of antacid therapy on esophagitis in children with repaired esophageal atresia. Recent clinical guidelines have attempted to define a systematic approach to the management of these patients with regards to minimizing and treating esophagitis (Krishnan et al 2016), however the quality of evidence supporting many of the recommendations are based on expert opinion or on limited, retrospective studies. Risk factors for esophagitis and optimal length of antacid therapy are not well defined. Through this study, we aim to identify risk factors for the presence of esophagitis in patients with repaired esophageal atresia. We hypothesize that antacid therapy improves esophagitis severity in children following esophageal repair. B. Background and Significance Esophageal atresia is one of the most common congenital gastrointestinal anomalies and affects 1 in 2500 to 1 in 4000 live births (Pinheiro et al 2012; Krishnan et al 2016). Recent ESPGHAN-NASPGHAN guidelines have attempted to define a systematic approach to the post-operative management of these patients with regards to minimizing and treating esophagitis, anastomotic strictures, and feeding difficulties (Krishnan et al 2016), however the quality of evidence supporting many of the recommendations are based on expert opinion or on limited, retrospective studies. For example, there are no controlled studies describing benefit of systematic acid suppression on outcomes such as esophagitis or associated long-term sequelae such as esophageal stricture. While esophagitis in these patients has been presumed to be related to high rates of acid reflux, it is unclear that antacid therapy leads to reduced rates of esophagitis or its complications. A recent meta-analysis of four observational studies suggests that antacid therapy with PPI is not associated with lower rates of esophageal strictures (Miyake et al 2018). Boston Children's Hospital Esophageal and Airway Treatment Center has one of the largest cohorts of children with esophageal atresia in the United States with the opportunity to study the impact of antacid therapy in management of esophagitis in repaired esophageal atresia. C. Design and Methods Prospective analysis of inpatient and ambulatory pediatric patients and their medical records at Boston Children's Hospital who have undergone primary anastomosis repair of esophageal atresia beginning upon IRB approval. For the remainder of the protocol, year-1 refers to the initial set of testing/procedures/clinic visits occurring during the study period. Year-2 refers to the second set of routine testing/procedures/clinic visits occurring approximately one year after the year-1 time point. Inclusion Criteria: All repaired esophageal atresia patients with primary esophageal anastomosis are eligible to enroll at the time of their routine year-1 surveillance endoscopy / pH-impedance studies: For patients with histology showing no or mild esophagitis, no erosive esophagitis, and reflux index <3% on pH-metry, antacid therapy will be discontinued. For patients with histology showing moderate or severe esophagitis and/or erosive esophagitis and/or reflux index > 3% on pH-metry, antacid therapy with PPI will be initiated. For patients already taking PPI at therapeutic dosing, an H2 blocker will be added. Data collection will include: Clinical history including age at enrollment, gender, esophageal atresia type, date of esophageal atresia repair, associated anomalies, history of prematurity, history of anastomotic leak, history of prior esophageal dilations, history of gastrostomy tube placement, history of fundoplication, hiatal hernia Medication history Symptom questionnaire at enrollment and at 1 year post-enrollment pH-Impedance data (including reflux index, retrograde bolus movements, mean acid clearance time, mean bolus clearance time, and proximal events) at enrollment and at 1 year post-enrollment Endoscopic findings as well as data from interventions (e.g. dilations, injections) at enrollment and at 1 year post-enrollment Histology from esophageal biopsies Outcome data including primary outcome histologic esophagitis severity and secondary outcomes including presence of Barrett's esophagus, erosive esophagitis on endoscopy, and rates of BRUEs, respiratory infections, hospitalizations, and need for dilations

Official Title
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Management of Esophagitis Following Repair of Esophageal Atresia

Conditions
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Esophageal Atresia, Esophagitis

Intervention / Treatment
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* Drug: Antacids


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: All repaired esophageal atresia patients with primary esophageal anastomosis treated at Boston Children's Hospital are eligible to enroll before or at year-1 surveillance endoscopy Exclusion Criteria: Patients with jejunal or colonic interpositions

Ages Eligible for Study
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Minimum Age: 30 Days
Maximum Age: 17 Years

Sexes Eligible for Study
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All

Study Plan
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How is the study designed?
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Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| No/Mild Esophagitis<br>All repaired esophageal atresia patients at Boston Children's Hospital with primary esophageal anastomosis undergoing routine year-1 surveillance endoscopy / pH-impedance studies found to have no or mild histologic esophagitis, no erosive esophagitis, and reflux index <3% on pH-metry. Antacid therapy will be discontinued. | |
| Moderate/Severe Esophagitis<br>All repaired esophageal atresia patients at Boston Children's Hospital with primary esophageal anastomosis undergoing routine year-1 surveillance endoscopy / pH-impedance studies found to have moderate or severe histologic esophagitis, and/or erosive esophagitis, and/or reflux index > 3% on pH-metry. Antacid therapy with PPI (omeprazole 1mg/kg/dose BID) will be initiated. For patients already taking PPI at therapeutic dosing, an H2 blocker (ranitidine 3mg/kg/dose BID) will be added. | Drug: Antacids<br>* Omeprazole 1 mg/kg/dose BID or Omeprazole 1mg/kg/dose BID plus Ranitidine 3 mg/kg/dose BID<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Esophagitis | Histologic esophagitis score graded as none, mild, moderate or severe | 2 years | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Esophagitis (macroscopic) | Erosive esophagitis score graded according to LA classification | 2 years | 
| Barrett's esophagus | Presence of intestinal metaplasia (Barrett's esophagus) on esophageal biopsies | 2 years | 
| Hospitalizations | Need for intercurrent hospitalization for any reason | 2 years | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Esophageal Atresia, Esophagitis, GER, Gastroesopheal reflux, PPI