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The Prenatal Detection of Distal Tracheoesophageal Fistulas in Fetuses Diagnosed with Esophageal Atresia

  • Author Footnotes
    ∗ Tal Weissbach and Anya Kushnir should be considered joint first authors.
    Tal WEISSBACH
    Correspondence
    Corresponding author: Tal Weissbach, MD, Phone: +972-54-6250-299
    Footnotes
    ∗ Tal Weissbach and Anya Kushnir should be considered joint first authors.
    Affiliations
    The Institute of Obstetrical and Gynecological Imaging, Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer

    Sheba Medical Center, Tel Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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  • Author Footnotes
    ∗ Tal Weissbach and Anya Kushnir should be considered joint first authors.
    Anya KUSHNIR
    Footnotes
    ∗ Tal Weissbach and Anya Kushnir should be considered joint first authors.
    Affiliations
    Department of Obstetrics and Gynecology, Tel Aviv, Israel

    Sheba Medical Center, Tel Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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  • Shayan YOUSEFI
    Affiliations
    Department of Obstetrics and Gynecology, Tel Aviv, Israel

    Sheba Medical Center, Tel Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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  • Abeer MASSARWA
    Affiliations
    The Institute of Obstetrical and Gynecological Imaging, Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer

    Sheba Medical Center, Tel Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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  • Leah LEIBOVITCH
    Affiliations
    Department of Neonatology, Tel Aviv, Israel

    Sheba Medical Center, Tel Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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  • Denise-Dana FRANK
    Affiliations
    Department of Pathology, Tel Aviv, Israel

    Sheba Medical Center, Tel Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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  • Debora KIDRON
    Affiliations
    Department of Pathology, Tel Aviv, Israel

    Sheba Medical Center, Tel Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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  • Reuven ACHIRON
    Affiliations
    The Institute of Obstetrical and Gynecological Imaging, Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer

    Sheba Medical Center, Tel Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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  • Raanan MEYER
    Affiliations
    Department of Obstetrics and Gynecology, Tel Aviv, Israel

    Sheba Medical Center, Tel Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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  • Boaz WEISZ
    Affiliations
    The Institute of Obstetrical and Gynecological Imaging, Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer

    Sheba Medical Center, Tel Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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  • Shali MAZAKI TOVI
    Affiliations
    Department of Obstetrics and Gynecology, Tel Aviv, Israel

    Sheba Medical Center, Tel Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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  • Eran KASSIF
    Affiliations
    The Institute of Obstetrical and Gynecological Imaging, Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer

    Sheba Medical Center, Tel Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
    Search for articles by this author
  • Author Footnotes
    ∗ Tal Weissbach and Anya Kushnir should be considered joint first authors.
Published:August 04, 2022DOI:https://doi.org/10.1016/j.ajog.2022.06.065
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      Abstract

      Objective

      Esophageal atresia is a major anomaly of varying severity. The complexity of surgical correction depends on the presence of a distal fistula. The aim of this study was to determine the feasibility and accuracy of prenatal ultrasound detection of the distal fistula in fetuses diagnosed with esophageal atresia.

      Methods

      This was an observational study conducted at a single tertiary care center between 2019-2021. Included were pregnant patients carrying a fetus prenatally diagnosed with esophageal atresia which was confirmed postnatally during corrective surgery or at post-mortem autopsy. During the scan, the performing investigator determined the presence or absence of a distal fistula by scanning the location of the lower esophagus during fetal breathing. If the lower esophagus was observed distending with amniotic fluid during breathing, this was determined 'fistula present', the remaining cases were determined 'fistula absent'. Test feasibility and performance indices, including sensitivity, specificity, positive and negative predictive value were calculated. The offline clips and images were reviewed by two investigators for the assessment of inter-operator agreement, using Cohen's Kappa formula.

      Results

      Included were 16 fetuses with esophageal atresia scanned between 2019 and 2021. All fetuses were successfully scanned with sufficient resolution of the area of interest, during at least 3 cycles of breathing. It took a median of 8.5 minutes to determine the presence or absence of a DF. The feasibility of the test was 100% (16/16). The test's sensitivity, specificity, positive and negative predictive values 80% (95th CI 55%-100%), 100% (95th CI 60%-100%), 100% (95th CI 65%-100%) and 75% (95th CI 45%-100%), respectively. The Cohen's Kappa for inter-operator agreement was calculated 1, p<0.001, corresponding to 'perfect' level of agreement.

      Conclusion

      Distal fistulas in esophageal atresia can be demonstrated prenatally by targeted scanning using appropriate technique. The method provided is feasible, reproducible and has excellent performance indices. This novel technique and observations may improve the prenatal diagnosis and counselling of esophageal atresia.

      Keywords

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