QUAD #26 - Use of Ultrashort Echo-Time MRI to Measure Tracheomalacia in Neonates with Esophageal Atresia with Dr. Douglas von Allmen

GlobalCAST-MD, along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe. Hello, pediatric surgery family. I've lived you leave from Cincinnati Children's Hospital Medical Center. In October 2022, Cincinnati Children's hosted the Quad Conference, which is a combination of four conferences, the International Organization for Esophageal Etergia, the Aerodigestus Society Conference, the Cincinnati Children's Airway course, and the Cincinnati Children's Pediatric Dispager Series. Today, Dr. Doug Bon Alman, a pediatric ENT surgeon at Cincinnati Children, will tell us about a new imaging technique, the ultra short Echo Time MRI, to measure tracheomalacia in neonates with esophageal atregia. Our evaluation of tracheomalacia can be tricky and that we're doing this under artificial conditions. Tracheomalacia is weakening of the airway wall, which collapses the airway in lumen during respiration. The gold standard to diagnose tracheomalacia is bronchoscopy. Even the gold standard of flexible bronchoscopy, we have variations in sedation, the vigor at which they're breathing, which can affect the static imaging. Ultra short Echo Time in the gene uses motion tracking to evaluate tracheomalacia. It is less invasive and doesn't use ionizing radiation. We can do this in neonates without any sedation. You can see here, we get really good resolution that allows us to create models like virtual bronchoscopy or this 3D modeling. There's been lots of theories about why tracheomalacia develops in patients with TEF, tracheosophageal fistula, and esophageal atregia or EA, which is a congenital condition where the esophagus ends in a pouch instead of connecting to the stomach. Faulty division of the foregut suggests changes in the posterior membrane of the trachea that may make it more susceptible to being malacic. Dr. von Amin chose to use this new imaging to evaluate TEF and EA patients. Our long gap isophageal atregia patients going to have more severe tracheomalacia. Their results show that long gap isophageal atregia patients have more tracheomalacia than short gap isophageal atregia patients. We divided the trachea overall in the thirds, to look at what was going on in different of the airway, and then we created a really simple measure of esentricity of the airway. Tracheal esentricity refers to how off-center the trachea's position is from where it should be. Smaller value represents a more esentric airway, which you can see here. The period of expiration is a period when you see the most collapse during tracheomalacia. We took the minimum value during the period of expiration and used that minimum value in each third of the trachea. They did a retrospective research study, including 26 patients with esophageal atregia. All these patients had preoperative studies prior to their TEF, EA repair, and we had a subset of patients that also had post-op imaging after their repair and ligation. They looked through the patients' data to compare short versus long gap esophageal atregia. They defined a short gap as those with two centimeters or less between the proximal and distal pouch. Everybody else was considered a long gap. Most of these patients had a distal tracheosophageal fistula. The majority of the patients had a short gap esophageal atregia. I think the portion of these patients required at least one steroid or one pneumonia course per year afterwards. When comparing the short gap to the long gap, they found that along all levels of the trachea, the long gap esophageal atregia patients had a more eccentric trachea. When we looked at our bronchoscopy results of these patients, there wasn't a lot of difference in terms of the patients that had significant collapse greater than 75%. Then they looked at the patients who had imaging before and after the TEF and EA repair. In the upper third of the trachea, the esentricity was significantly improved after the repair. In the distal trachea, the esentricity got significantly worse after repair. Or as the middle portion of the trachea remained unchanged. That's probably because there is a dilated esophageal pouch. And once you decompress that, it also relieves the compression on the upper trachea. Changes in the lower trachea, we suspect that's due to mobilization of that distal segment, ligation of the TEF. Next, they looked at the patients' respiratory-related readmissions after their NICU stay. Despite having a significantly longer NICU stay for the long gap esophageal trachea, they were more likely to have respiratory-related admissions. Their results show that long gap esophageal atregia patients have a higher risk of significant trachea malacia. They had a more eccentric or flattened airway along the length of the airway. After repair, the esentricity worsened in the distal third of the trachea. This would suggest that the distal third is an important segment to consider, even if it doesn't look severe when you do your first-pronged cost-copy. In summary, ultra-shorter ECHOTIME MRI effectively evaluates the severity of trachea malacia without intubation, sedation, or radiation in neonates. Patients with esophageal atregia and tracheosophageal fistula commonly have trachea malacia, but more research needs to be done to understand this correlation. Long gap esophageal atregia patients have more severe trachea malacia and higher respiratory re-admission. Trachea malacia worsens in the distal trachea after repair, requiring focused post-operative monitoring. Don't forget to subscribe to the StayCurrent MD YouTube channel. Follow our social media channels and download the StayCurrent MD app for tons of content in pediatric surgery. Global cast MD. Along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe.