How should esophagitis in esophageal atresia patients be recognized and treated?

Presenting one of Apse's November articles of interest. Today we are joined by Dr. Robert Rika from the Naval Medical Center at Portsmouth, representing Apse's Outcomes Committee. So, Dr. Rika, before we dive into what exactly you chose, tell us what knowledge gap it fills. So the group in November chose this article, which is looking at esophagitis in pediatric esophageal atresia, and we feel that this was important because this is a bit of a knowledge gap on multiple fronts, what's the occurrence of esophagitis, what is the best management strategy and and really do we need to follow these children long term and what is the best management strategy from that standpoint? That's why we felt that this was an important opportunity to talk about this article. Todd, what do you know about esophagitis in esophageal atresia patients? We talk about, do patients need PPIs or some sort of prophylaxis after surgery, when and should they be getting an Nissen? Should they be followed prolonged for Barretts? Those are the controversies that go along with it. Can you give us the cliff notes on Nisuda at all's esophagitis and pediatric esophageal atresia? Acid may not always be the issue. Sure. So this article starts to look at what are the risk factors for developing esophagitis through a cohort of children that were followed from a single institution that over a two-year period underwent endoscopic surveillance as well as biopsy to look at the prevalence of esophagitis. And then what mitigation strategies were in place. So many of these children were on acid suppressive therapy and despite the acid suppressive therapy, about half of those children still had esophagitis present on biopsy. So even if the child's asymptomatic at the time, we still know that they may be developing esophagitis. Are these children at risk for developing Barrett's esophagitis, adenocarcinoma later in life? These children still need surveillance and annual follow up with some sort of endoscopy and subsequently biopsy. They also started to look, looking about a quarter of these children had fundoplication and many of those children despite their fundoplication, still had evidence of esophagitis. And I think that goes to the multifactorial nature of the esophagitis that we're seeing in these children. As you put that all together, especially, I'm a community surgeon, um and trying to see what do I need to do for my children. Well, I need to make sure that I'm still following up with these children annually throughout adolescence. I think the other part of this as we look to evaluate children with esophageal atresia who have esophagitis is understanding what the underlying mechanism is, to start to treat their other underlying conditions, whether it's eosinophilic esophagitis, whether it's a dysmotility issue. I'm glad the problem is at least being recognized more now. I think that's the biggest thing. A lot of us in pediatric surgery, we do the esophageal atresia repair and we pat ourselves on the back and we say, you know, that's it. And I think the the trend change, the paradigm shift should be that these are long-term chronic patients, just like an anorectal malformation or something like that. Thank you Dr. Rika for bringing this article and we appreciate it. No, great. Thank you for the opportunity. This is outstanding. So the takeaways from this article with Dr. Rika are, so acid suppressive medications do seem to reduce the risk of esophagitis, but there are a couple of important caveats to that. Increasing the dose doesn't decrease esophagitis, and even with these meds and surgery, some children still develop esophagitis. Therefore, we need to continue surveillance beyond the current recommendations of three biopsies at some point during childhood. We also need more research into other therapies when acid isn't the cause of the esophagitis.