Prognostic factors for mortality of oesophageal atresia patients: Waterston revived
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- Deurloo, J.A., de Vos, R., Ekkelkamp, S. et al. Eur J Pediatr (2004) 163: 624. doi:10.1007/s00431-004-1505-y
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This study shows that the effect of medical progress on mortality is considerable and that the three factors of the Waterston classification still had a high impact on mortality in the most recent years.
In 1962, Waterston et al.  proposed a prognostic classification for patients born with oesophageal atresia (OA) based on low birth weight, presence of pneumonia, and associated congenital malformations. Over the last decades, much progress has been made and several authors have questioned the validity of Waterston’s classification [1, 3, 4]. This study analyses the influence of several clinical characteristics on mortality of OA patients, and investigates the value of the Waterston classification within the past and current time frame.
We studied all patients who were treated at the Paediatric Surgical Centre of Amsterdam for OA and/or tracheo-oesophageal fistula between 1947 and 2000 (n=371) . Data were collected from patient charts, operative reports, and office notes, and were entered into a database. Medical progress was modelled by dividing the time interval arbitrarily into five time periods with approximately equal numbers of patients. Disease specific mortality was defined as mortality during the 1st year of life.
To determine the independent impact of factors on disease specific mortality over the total time period (1947–2000), a multivariate logistic regression model was performed. Effect sizes were expressed as odds ratios (OR’s) and their 95% confidence limits; an OR >1 refers to an increased risk for mortality. To study the five separate time periods (and specifically the most recent time period), separate models were made for each of these time periods.
To further decrease the mortality of OA patients in the future, we should focus on these prognostic factors found in the last time period. First, we feel it is important to make an early diagnosis and an early start with supportive, pre-operative care. Once the diagnosis has been established, keeping the proximal oesophageal sac empty with a double lumen Replogle tube will avoid aspiration and pre-operative pneumonia. Intensive collaboration between the paediatrician and the paediatric surgeon is of the utmost importance. Further reduction in the mortality of patients with a low birth weight (<1500 g) or with associated congenital malformations is more difficult.
In conclusion, despite the progress made in the last 50 years, the Waterston classification still has prognostic relevance.