After repair of tracheo-oesophageal atresiaBMJ 2012; 344 doi: https://doi.org/10.1136/bmj.e3517 (Published 15 June 2012) Cite this as: BMJ 2012;344:e3517
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We read with interest Love and Morice’s article  on tracheo-oesophageal fistula repair and sequelae related to chronic “TOF cough”. As clinicians from varying paediatric specialities, we also recognise significant long-term symptoms for some of our patients that have undergone oesophageal atresia repair as neonates. The apparent deficiencies in care noted from the patients’ perspective highlight the importance of multi-disciplinary follow-up throughout childhood as many symptoms might otherwise go unrecognised and untreated . Many tertiary paediatric institutions recognise this need and provide specialised clinics for a variety of childhood conditions, including transition clinics into the adult sector.
We agree with Professor Morice’s suggestions for assessment and treatment of gastro-oesophageal reflux, although the long term consequences of untreated, unrecognised gastro-oesophageal reflux (in addition of problematic cough) are worthy of further mention. Assessment of long-term outcomes have demonstrated more significant complications than previously appreciated, including reflux oesophagitis, Barrett’s oesophagus and oesophageal squamous cell carcinoma .
We concur that tracheomalacia is also a longstanding problem for many children, but Professor Morice makes no mention of the role of brochoscopy, either rigid or flexible, in the management of ongoing cough for these children and adults. A well-recognised complication of surgery is the persistence of a tracheal pouch with pooling of secretions leading to significant cough, aspiration, pulmonary soiling and acute life-threatening events[4-7]. Tracheal pouches arise after surgery due to the oblique submucosal course of the fistula. Although the surgeon divides and closes the fistula flush with the outer aspect of the trachealis muscle in the neonatal period, a small “blind” submucosal pouch can enlarge over time with growth of the patient. Pouches are reported to occur in 7-8% of patients following TOF repair  although the incidence of symptomatic pouches remains unknown. We, along with others, [4-7] have observed and reported improved airway symptoms with the division of these pouches.
We understand that this information may have been omitted due to editorial limitations but would like to remind clinicians of the importance of these potentially treatable conditions.
W. Andrew Clement Paediatric Otolaryngologist,
Haytham Kubba Paediatric Otolaryngologist,
Jonathan Coutts Neonatologist,
Gregor Walker Paediatric Surgeon
Phil Hammond Paediatric Surgeon
Royal Hospital for Sick Children,
1. After repair of tracheo-oesophageal atresia. Love C, Morice AH. BMJ. 2012 Jun 15;344:e3517.
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8. P. Holinger, W.T. Brown, D.G. Maurizi, Endoscopic aspects of post-surgical management of congenital esophageal atresia and tracheoesophageal fistula, J. Thorac. Cardiovasc. Surg. 49 (1) (1965) 22—32.
Competing interests: No competing interests