Acid Suppression Duration Does Not Alter Anastomotic Stricture Rates After Esophageal Atresia with Distal Tracheoesophageal Fistula Repair: A Prospective Multi-institutional Cohort Study

Saturday, October 9, 2021

9:39 AM – 9:47 AM CDT

Background: Anastomotic stricture is the most common complication after surgical repair of esophageal atresia (EA). Acid suppression is commonly administered post-operatively to prevent stricture formation despite inconclusive evidence to support this practice. We explore the association between the duration of acid suppression administration and post-operative strictures in patients undergoing Type C EA/TEF (tracheoesophageal fistula) repair.

Methods: A prospective cohort study of infants undergoing primary repair of Type C EA/TEF from 2016 to 2020 across 11 centers was conducted. We performed landmark analysis at hospital discharge (DC), 3-, 6-, and 9-months post-operatively with multivariate Cox regression to explore if initial duration of continuous acid suppression was associated with post-operative stricture formation. The following variables were included in our multivariate analysis based on “a priori” knowledge; surgical approach (thoracoscopic vs thoracotomy), long esophageal gap length (greater than or equal to 3 vertebral bodies), use of a transanastomotic tube and an anastomotic leak (within 30 days of surgery). Acid suppression was defined as the use of a proton pump inhibitor or H2 blocker.

Results: Acid suppression data was available on 156 patients after EA/TEF repair. Overall, 79 (51%) strictures requiring dilation developed and 60 (75%) of these strictures occurred within the first 3 months. Acid suppression was used during follow up in 141 patients (90%). On univariate analysis, the duration of acid suppression was not associated with a reduction in initial stricture formation at DC, 3-, 6- and 9-months respectively (p= 0.19-0.95). On multivariate Cox regression, use of a transanastomotic tube (Hazard Ratio (HR) 2.21 (95% CI 1.24,3.95), p<0.01) and a thoracoscopic approach (HR 2.07 (95% CI 1.07-3.98), p=0.03) were significantly associated with post-operative stricture formation at DC. At 3-months, only use of a transanastomotic tube remained significant (HR 5.31, (95% CI 1.65-17.16), p<0.01). At all four measured time points, there was no association between acid suppression duration and stricture formation (p=0.12-0.99).

Conclusion: Anastomotic strictures are common, and the majority occur within the first 90 days after EA/TEF repair. We found no association between the duration of post-operative acid suppression and the formation of an anastomotic stricture at hospital DC, 3-, 6- and 9- months post-operatively. Transanastomotic tube use increased the risk of anastomotic strictures at hospital discharge and 3 months post-operatively.

Presenting Author(s)

Alexis N. Bowder, MD, MPH
Resident/Research Fellow
Department of Pediatric Surgery, Medical College of Wisconsin
Milwaukee, Wisconsin
Disclosure: No Financial Relationships Disclosed

Co-Author(s)

CB
Christina M. Bence, MD
Research Fellow
Division of Pediatric Surgery, Department of Surgery, Medical College of Wisconsin
Milwaukee, Wisconsin
Disclosure: No Financial Relationships Disclosed
Samir K. Gadepalli, MD, MBA
Pediatric Surgeon
Section of Pediatric Surgery, Department of Surgery, University of Michigan
Ann Arbor, Michigan
Disclosure: No Financial Relationships Disclosed
BR
Beth A. Rymeski, DO
Assistant Professor
Cincinnati Children's Hospital
Cincinnati, Ohio
Disclosure: No Financial Relationships Disclosed
TS
Thomas T. Sato, MD
Pediatric Surgeon
Children’s Hospital of Wisconsin
Milwaukee, Wisconsin
Disclosure: No Financial Relationships Disclosed
PM
Peter C. Minneci, MD, MHSc
Pediatric Surgeon
Center for Surgical Outcomes Research, Abigail Wexner Research Institute at Nationwide Children’s Hospital, The Ohio State University College of Medicine and 5Department of Pediatric Surgery, Nationwide Children’s Hospital
Columbus, Ohio
Disclosure: No Financial Relationships Disclosed
CD
Cynthia D. Downard, MD, MMSc
Pediatric Surgeon
Department of Surgery, Division of Pediatric Surgery, University of Louisville School of Medicine
Louisville, Kentucky
Disclosure: No Financial Relationships Disclosed
TM
Troy A. Markel, MD
Pediatric Surgeon
Division of Pediatric Surgery, Department of Surgery, Indiana University School of Medicine
Indianapolis, Indiana
Disclosure: No Financial Relationships Disclosed
CC
Cathleen M. Courtney, MD
Pediatric Surgeon
Division of Pediatric Surgery, Department of Surgery, Washington University School of Medicine
St. Louis, Missouri
Disclosure: No Financial Relationships Disclosed
KD
Katherine J. Deans, MD, MHSc
Pediatric Surgeon
Center for Surgical Outcomes Research, Abigail Wexner Research Institute and Department of Surgery,Nationwide Children's Hospital
Columbus, Ohio
Disclosure: No Financial Relationships Disclosed
Jason D. Fraser, MD
Pediatric Surgeon
Division of Pediatric Surgery, Department of Surgery, Children’s Mercy Hospital
Univerisity of Missouri-Kansas City, Children's Mercy Kansas City
Kansas City, Missouri
Disclosure: No Financial Relationships Disclosed
RK
Rashmi D. Kabre, MD
Pediatric Surgeon
Division of Pediatric Surgery, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine
Chicago, Illinois
Disclosure: No Financial Relationships Disclosed
JK
Johnathan E. Kohler, MD
Pediatric Surgeon
Division of Pediatric Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health
Madison, Wisconsin
Disclosure: No Financial Relationships Disclosed
ML
Matthew P. Landman, MD, MPH
Pediatric Surgeon
Division of Pediatric Surgery, Department of Surgery, Indiana University School of Medicine,
Indianapolis, Indiana
Disclosure: No Financial Relationships Disclosed
JA
Jordan C. Apfeld, MD
Research Fellow
Center for Surgical Outcomes Research, Abigail Wexner Research Institute and Department of Surgery, Nationwide Children’s Hospital,
Columbus, Ohio
Disclosure: No Financial Relationships Disclosed
CL
Charles M. Leys, MD, MSC
Pediatric Surgeon
Division of Pediatric Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health
Madison, Wisconsin
Disclosure: No Financial Relationships Disclosed
GM
Grace Mak, MD
Pediatric Surgeon
Division of Pediatric Surgery, Department of Surgery, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine
Chicago, Illinois
Disclosure: No Financial Relationships Disclosed
Jacqueline Saito, MD, MSCI, MBA
Pediatric Surgeon
Division of Pediatric Surgery, Department of Surgery, Washington University School of Medicine
Washington University School of Medicine
St. Louis, Missouri
Disclosure: No Financial Relationships Disclosed
Shawn D. St. Peter, MD
Pediatric Surgeon
Division of Pediatric Surgery, Department of Surgery, Children’s Mercy Hospital,
Kansas City, Missouri
Disclosure: No Financial Relationships Disclosed

Senior Author(s)

Dave R. Lal, MD, MPH
Pediatric Surgeon
Division of Pediatric Surgery, Department of Surgery, Medical College of Wisconsin
Medical College of Wisconsin/Children's Wisconsin
MILWAUKEE, Wisconsin
Disclosure: No Financial Relationships Disclosed