Gastroesephageal reflux and related motility disorders after esophageal atresia : a clinical study

The most common congenital malformation of the esophagus is esophageal atresia (EA) with or without tracheoesophageal fistula (TEF). Successful repair of EA does not ensure normal esophageal function. Disturbed esophageal motility and gastroesophageal reflux (GER) are often detected after repair of EA. GER can cause feeding problems, esophagitis, recurrent strictures, aspiration and respiratory complications. The aims of this thesis were to study the incidence of GER after EA, the long-term complications, especially regarding GER and related gastrointestinal motility disorders in patients with repaired EA. Esophageal pH monitoring was performed in 12 infants after EA repair. Patients with a reflux index (R.l.) >5% at I month of age developed symptoms of GER, such as vomiting, failure to thrive or respiratory symptoms. Patients with R.l. <5% at I month, did not show symptoms of GER during the first year of life.

The mortality after EA (110 patients) was 12%. Early mortality (within 6 months) was caused mainly by prematurity and associated malformations, whereas late mortality was associated with symptoms related to GER, mainly pulmonary. Decreased lung function was found in patients aged 8-21 years with repaired EA. Impairment of lung function was mainly seen in the patients who had had severe respiratory symptoms during the first years of life. The maximal working capacity did not differ between patients with or without respiratory complications. Capillary blood gases were normal. Esophageal dysmotility was noted in all patients (by radiography and manometry), both symptomatic and asymptomatic patients. Symptoms of regurgitation occurred in half of the patients.

Gastric scintigraphy showed impaired gastric emptying of solids in children with repaired EA, compared to healthy control children. Delayed gastric emptying was observed mainly in patients with reflux symptoms and abdominal complaints. Gastric emptying has not before been studied by scintigraphy in healthy children. Videomanometry of the pharynx and upper esophagus in adults with repaired EA showed a disturbance of coordination in swallowing. The time interval between contraction of the pharynx constrictor (PCI) and relaxation of the upper esophageal sphincter (UES) was significantly shorter in patients than in healthy controls. This disturbance of coordination entails an increased risk of aspiration.

In conclusion, these studies emphasize the importance of GER after EA repair. GER seems to be an important factor in mortality as well as in the long-term complications, such as decreased lung function. These findings suggest the need for early diagnosis and aggressive treatment of GER. Motility disturbances a~er EA are seen in the pharynx, esophagus and the gastric emptying pattern, indicating that these disturbances are mainly congenital rather than caused by the surgical repair.