Authors: Areej Mohammed Alzamil , Walaa Alrasheed , Yasir Ghareeb Alrashdan , Raif Nassir , Abdulwahab Aljubab

Abstract

Background: Esophageal atresia (EA), frequently associated with tracheoesophageal fistula (TEF), is the most common congenital anomaly of the esophagus. Although survival after surgical repair has improved substantially, gastroesophageal reflux disease (GERD) remains a frequent postoperative complication. Proton pump inhibitors (PPIs) are commonly prescribed to reduce GERD-related complications, including anastomotic stricture; however, evidence supporting their effectiveness is conflicting. This study evaluated the association between postoperative PPI use and outcomes, including esophageal stricture formation, in children undergoing EA repair at a tertiary center.

Methodology: This retrospective cohort study included patients with EA managed at King Fahad Medical City, Riyadh, Saudi Arabia, between January 1, 2010, and December 30, 2021. Patients treated initially at another institution, those who died before or after repair because of unrelated comorbidities, patients with long-gap EA or complex surgical procedures, and those with type E TEF were excluded. Demographic, clinical, operative, postoperative, and follow-up data were abstracted from medical records. Categorical variables were compared using Fisher’s exact test. A two-sided p value <0.05 was considered statistically significant.

Results: Thirty-three patients were included; 20 (60.6%) were male, and 30 (90.9%) had type C EA. Primary one-stage repair was performed in 31 patients (93.9%), and open repair in 30 (90.9%). Esophageal strictures developed in 11 patients (33.3%). Among patients with strictures, 10 underwent endoscopic dilatation, and six required one to three dilatation sessions. Anti-reflux surgery was performed in two patients with strictures. Strictures were more frequent in patients with type A or B EA than in those with type C EA (3/3 vs. 8/30; p = 0.037). A two-stage repair was also associated with stricture formation (2/2 vs. 9/31 after one-stage repair; p = 0.039). We did not detect a significant association between postoperative PPI use and stricture formation (p = 0.706), and PPI-treatment duration was not significantly associated with study outcomes.

Conclusions: In this single-center retrospective cohort, we did not detect an association between routine postoperative PPI therapy and a lower incidence of esophageal stricture after EA repair; given the small sample size, this may reflect limited statistical power rather than a true absence of effect. Stricture formation appeared more strongly associated with anatomic complexity and staged repair. Larger prospective studies with objective GERD assessment are needed to define which patients benefit from acid-suppressive therapy after EA repair.

Keywords: Esophageal atresia, tracheoesophageal fistula, proton pump inhibitors, gastroesophageal reflux disease, anastomotic stricture, pediatric surgery.