Stefanie P Lazow1, Offir Ben-Ishay2, Vamsi K Aribindi3, Steven J Staffa4, Francesca R Pluchinotta5, Samuel C Schecter6, Ryan P Cauley1, Wayne Tworetzky5, Hanmin Lee6, Anita J Moon-Grady7, Terry L Buchmiller8. 1. Department of Surgery, Boston Children's Hospital/Harvard Medical School, Boston, MA. 2. Department of Surgery, Boston Children's Hospital/Harvard Medical School, Boston, MA; Advanced Fetal Care Center, Boston Children's Hospital, Boston, MA. 3. Department of Surgery, University of California at San Francisco, San Francisco, CA. 4. Department of Anesthesiology, Critical Care and Pain Medicine Research, Boston Children's Hospital/Harvard Medical School, Boston, MA. 5. Advanced Fetal Care Center, Boston Children's Hospital, Boston, MA; Department of Cardiology, Boston Children's Hospital/ Harvard Medical School, Boston, MA. 6. Department of Surgery, University of California at San Francisco, San Francisco, CA; Fetal Treatment Center, UCSF Benioff Children's Hospital, University of California at San Francisco, San Francisco, MA. 7. Department of Pediatrics, Division of Cardiology, UCSF Benioff Children's Hospital, University of California at San Francisco, San Francisco, CA; Fetal Treatment Center, UCSF Benioff Children's Hospital, University of California at San Francisco, San Francisco, MA. 8. Department of Surgery, Boston Children's Hospital/Harvard Medical School, Boston, MA; Advanced Fetal Care Center, Boston Children's Hospital, Boston, MA. Electronic address: terry.buchmiller@childrens.harvard.edu.
Abstract
BACKGROUND/ PURPOSE: The Spitz classification for esophageal atresia with/without tracheoesophageal fistula (EA/TEF) predicts mortality. This study evaluates the contemporary relevance of the Spitz classification and investigates predictors of morbidity. METHODS: EA/TEF patients born between 1995 and 2018 at two centers were retrospectively reviewed. Clinical variables including sex, prenatal diagnosis, birth weight, prematurity, major congenital heart disease (MCHD), and pre-operative mechanical ventilation (POMV) were collected. Index admission composite morbidity was considered positive if: length-of-stay >90th percentile (139 days), ventilation days >90th percentile (24 days), and/or gastrostomy was used for long-term feeding. Multivariable regression determined predictors of index admission mortality and composite morbidity. A composite morbidity predictive algorithm was created. ROC curves evaluated model discrimination. RESULTS: Of 253 patients, 13 (5.1%) experienced index admission mortality. Of the patients not suffering mortality, 74 (31.6%) experienced composite morbidity. Only MCHD predicted mortality (p = 0.001); birth weight did not (p = 0.173). There was no difference between the Spitz classification and MCHD alone in predicting mortality risk (p = 0.198); both demonstrated very good discrimination. Prenatal diagnosis, POMV, prematurity, and male sex predicted composite morbidity risk (p < 0.001; p = 0.008; p = 0.009; p = 0.05). An algorithm incorporating these predictors demonstrated good discrimination (AUC = 0.784; 95% CI: 0.724, 0.844). CONCLUSIONS: The Spitz classification maintains contemporary relevance for mortality risk, though birth weight can be de-emphasized. A new morbidity risk algorithm is proposed for early postnatal counseling. TYPE OF STUDY: Prognosis study. LEVEL OF EVIDENCE: Level IV.
BACKGROUND/ PURPOSE: The Spitz classification for esophageal atresia with/without tracheoesophageal fistula (EA/TEF) predicts mortality. This study evaluates the contemporary relevance of the Spitz classification and investigates predictors of morbidity. METHODS: EA/TEFpatients born between 1995 and 2018 at two centers were retrospectively reviewed. Clinical variables including sex, prenatal diagnosis, birth weight, prematurity, major congenital heart disease (MCHD), and pre-operative mechanical ventilation (POMV) were collected. Index admission composite morbidity was considered positive if: length-of-stay >90th percentile (139 days), ventilation days >90th percentile (24 days), and/or gastrostomy was used for long-term feeding. Multivariable regression determined predictors of index admission mortality and composite morbidity. A composite morbidity predictive algorithm was created. ROC curves evaluated model discrimination. RESULTS: Of 253 patients, 13 (5.1%) experienced index admission mortality. Of the patients not suffering mortality, 74 (31.6%) experienced composite morbidity. Only MCHD predicted mortality (p = 0.001); birth weight did not (p = 0.173). There was no difference between the Spitz classification and MCHD alone in predicting mortality risk (p = 0.198); both demonstrated very good discrimination. Prenatal diagnosis, POMV, prematurity, and male sex predicted composite morbidity risk (p < 0.001; p = 0.008; p = 0.009; p = 0.05). An algorithm incorporating these predictors demonstrated good discrimination (AUC = 0.784; 95% CI: 0.724, 0.844). CONCLUSIONS: The Spitz classification maintains contemporary relevance for mortality risk, though birth weight can be de-emphasized. A new morbidity risk algorithm is proposed for early postnatal counseling. TYPE OF STUDY: Prognosis study. LEVEL OF EVIDENCE: Level IV.