Congenital esophageal stenosis diagnosed in an infant at 9 month of age

Esophageal stenosis is a relatively uncommon condition in pediatrics and requires an accurate diagnostic approach. Here we report the case of a 9-month old female infant who presented intermittent vomiting, dysphagia and refusal of solid foods starting after weaning. She was treated for gastroesophageal reflux. At first, radiological investigation suggested achalasia, while esophagoscopy revelaed a severe congenital esophageal stenosis at the distal third of the esophagus. She underwent four endoscopic balloon dilatations that then allowed her to swallow solid food with intermittent mild dysphagia. After 17 months of esomeprazole treatment off therapy impedance-pH monitoring was normal. At 29 months of follow-up the child is asymptomatic and eats without problems.Infants with dysphagia and refusal of solid foods may have undiagnosed medical conditions that need treatment. Many disorders can cause esophageal luminal stricture; in the pediatric age the most common are peptic or congenital. Careful assessment with endoscopy is needed to diagnose these conditions early and referral to a pediatric gastroenterologic unit may be necessary.

[Congenital esophageal stenosis: a case report]

Congenital esophageal stenosis, a rare disease of unknown cause which reports have increased in the last few years, requires a high index of suspicion for its diagnosis and treatment. It can be classified in three types based on the etiology of the stenosis: tracheobronchial rest, fibromuscular hypertrophy and membranous diaphragm. Symptoms may vary depending on location and severity of the stenosis. Treatment options are based on clinical suspicion of the histologic type and they can be balloon dilation or surgical resection of the stenotic segment. The definitive diagnosis is the histological study.

[Congenital esophageal stenosis owing to ectopic tracheobronchial remnants: report of four cases and review of the literature]

OBJECTIVE

Congenital esophageal stenosis owing to tracheobronchial remnants (TBR) is a rare condition. This study was conducted to understand the clinical features of TBR.

METHOD

The data of the four cases with TBR admitted to our hospital and 76 patients identified from the literature were reviewed. The clinical manifestation, X-ray, endoscopy, biopsy and treatment were studied retrospectively.

RESULT

Of the total of 80 cases, 45 were male, 33 were female, and for 2 cases the gender was unknown. Symptoms of dysphagia and regurgitation developed at the age of 1-day to 12-month. Definitive treatment was carried out at the age of 1-month to 16-year. Twenty-seven patients had associated anomalies with esophageal atresia being the most prevalent. X-ray esophagography showed segmental stenosis at the distal third of the esophagus in all patients except three. An abrupt narrow segment at the lower esophagus with marked proximal dilatation was found in 32 cases. Esophagography of 12 cases showed distal esophageal stenosis with tapered narrowing. Esophagography of 20 cases showed flask-shaped shadow of distal esophageal stenosis and one patient showed linear projection of barium at the level of stenosis. Endoscopy found almost complete obstruction of the lower esophageal lumen without signs of the esophagitis or reflux. Esophagoscopic dilatation of the stenosis was attempted in 24 cases, but was ineffective, and 3 patients suffered esophageal perforation. Seventy-nine patients underwent resection of the stenotic segment. Histologic examination of the resected specimen showed cartilage, mucus glands, resembling bronchal tissue. Post-operative complication included anastomotic stenosis, anastomotic leakage, hiatal hernia, and gastroesophageal reflux.

CONCLUSION

TBR should be suspected in patients who present with a typical history of dysphagia after ingestion of solid food. Esophagography and esophagoscopy are the essential means for diagnosis. TBR should be different from achalasia and should be diagnosed by biopsy. Operation is the only choice of treatment.

Congenital distal esophageal obstruction caused by intraluminal mucosal web

Here, we report a case with intraluminal membrane (web) located in the lower esophagus causing complete obstruction. Esophagogram revealed complete obstruction near the esophagogastric junction. Surgical excision of the esophageal membrane was performed. To our knowledge, only a few cases with membranous esophageal atresia have been reported. It must be remembered in neonates who cannot tolerate feeding.

[Dysphagia after introduction of solid food: typical presentation of congenital oesophageal stenosis]

BACKGROUND

Congenital oesophageal stenosis is a rare cause of food passage symptoms in infants. It has a typical presentation with symptoms of dysphagia of solid food, starting at the time of introducing supplementary feeding.

CASE DESCRIPTION

We present a 6-month-old girl, who started spitting and coughing and had a slower growth rate after the introduction of solid food. Using upper gastrointestinal tract radiography, oesophagogastroscopy and histopathological examination, a congenital oesophageal stenosis due to tracheobronchial remnants was demonstrated. The stenosis was surgically removed. This case description is typical for congenital oesophageal stenosis.

CONCLUSION

Early recognition of the typical presentation of congenital oesophageal stenosis can prevent unnecessary investigation and delay in treatment. Surgical resection of the stenotic oesophageal segment usually results in full recovery.

Surgical correction of an aberrant right subclavian artery in a dog

A diagnosis of an aberrant right subclavian artery was made in a 3-month-old Boston terrier. Surgical correction was performed after confirming adequate collateral circulation. Reports of surgical correction and evaluation of the perioperative thoracic limb blood pressure are rare in dogs.

Endoscopic management of congenital esophageal stenosis

BACKGROUND/PURPOSE

Congenital esophageal stenosis (CES) is a rare malformation. Endoscopic dilations represent a therapeutic option. This study retrospectively evaluated the efficacy and safety of a conservative treatment of CES.

PATIENTS AND METHODS

Patients diagnosed with CES since 1980 by a barium study or endoscopy were reviewed. Endoscopic ultrasonography (Olympus UM-3R-20-MHz radial miniprobe, Olympus Corporation, Tokyo, Japan), available from 2001, allowed for the differential diagnosis of tracheobronchial remnants (TBR) and fibromuscular hypertrophy (FMH) CES. All children underwent conservative treatment by endoscopic dilations (hydrostatic and Savary).

RESULTS

Forty-seven patients (20 men) had CES. Fifteen were associated with esophageal atresia; and 8, with Down syndrome. Mean age at the diagnosis was 28.3 months (range, 1 day to 146 months). Symptoms were solid food refusal, regurgitation, vomiting, and dysphagia. Congenital esophageal stenosis was located in the distal esophagus. Endoscopic ultrasonography demonstrated TBR and FMH in 6 patients. One hundred forty-eight dilations in 47 patients were performed. The stenosis healed in 45 (95.7%). Complications were 5 (10.6%) esophageal perforations, hydrostatic (3/32, or 9.3%), and Savary (2/116, or 1.7%). At follow-up, 1 patient with FMH CES and 1 patient with TBR CES required operation for persistent dysphagia.

CONCLUSIONS

The conservative treatment yielded positive outcomes in CES. Endoscopic ultrasonography allows for a correct diagnosis of TBR/FMH CES. A surgical approach should be reserved for CES not responsive to dilations.

[A case of congenital esophageal stenosis that remained untreated until adulthood and was improved by endoscopic balloon dilatation]

A 20-year-old man had suffered from dysphagia since primary school. Upper gastrointestinal and endoscopy examinations revealed severe circumferential stenosis of the upper intra-thoracic esophagus. Secondary stenosis due to factors such as inflammation did not appear present, so congenital esophageal stenosis (CES) was diagnosed. Dysphagia improved after two endoscopic balloon dilatations. Almost all cases of CES are treated in baby-hood, and individuals who remain untreated until adulthood are rare. Check ups and diagnoses should be made taking CES into consideration, even in adults.

Congenital esophageal stenosis and antral web. A new association and management challenge

Congenital esophageal stenosis is a rare condition that may be associated with other anomalies. Antral web is also a rare congenital condition. Association of both conditions is extremely rare. We present this rare association in preterm baby in whom initially misdiagnosis of esophageal atresia and trachea-esophageal fistula then followed by a dilemma in differentials diagnosis to explain the uneventful postoperative recovery. The aim of this report is to highlight the diagnostic and therapeutic difficulty of this rare condition.

Congenital esophageal stenosis because of tracheobronchial remnant and treated by circular myectomy: a case report

Congenital esophageal stenosis (CES) is a rare anomaly, and appropriate management is not well established. We performed myectomy of the esophageal wall in a child with critical esophageal stenosis caused by tracheobronchial remnant (TBR). An 18-month-old boy was admitted to our hospital having frequent vomiting and failure to thrive. Esophagography and esophagoscopy showed abrupt stenosis at the lower esophageal wall. Balloon dilatation was performed but was ineffective. Surgery was performed under a diagnosis of CES because of TBR. Cartilage was palpable in the stenotic esophageal wall, and extirpation of the muscular layer of the stenotic portion was performed, leaving the mucosal layer intact. The muscular layer was closed loosely using interrupted 5-0 absorbable sutures to match the oral and anal sides together. Postoperatively, the esophageal passage was improved to the point that the patient was able to take solid foods without vomiting. This successful outcome suggests that circular myectomy of the TBR is worth recommending as a surgical procedure for short segment and stenosis of patients with CES because of TBR.

Esophageal obstruction-prenatal detection rate and outcome

OBJECTIVE

Prenatal diagnosis of esophageal obstruction is believed to improve the outcome for the affected newborn. However, the prenatal detection rate is only 10-40%, the diagnosis is usually not made before the third trimester and the false-positive rate has been high. This study investigated the prenatal detection rate and time of prenatal diagnosis at our center and its influence on outcome. In addition, incidence, detection rate and accuracy of the diagnosis in a large non-selected population were determined.

METHODS

All cases diagnosed pre- or postnatally with esophageal obstruction and examined prenatally by ultrasound at the National Center for Fetal Medicine in Norway during 1987-2004 were evaluated.

RESULTS

Of 48 cases with esophageal obstruction, 21 (44%) were diagnosed prenatally (median, 32 + 0 weeks). All 21 had a small or empty stomach, 20/21 (95%) had polyhydramnios and 9/21 (43%) had a visible esophageal pouch. Associated anomalies were present in 38/48 cases (79%). The karyotype was abnormal in 11/48 cases (23%). Ten (21%) pregnancies with lethal fetal conditions were terminated. Two fetuses died in utero. Ten infants with associated anomalies died within 3 months after birth. The 26/48 (54%) survivors included 16/21 cases with a prenatal diagnosis of esophageal obstruction and 9/10 cases with isolated esophageal obstruction.

CONCLUSIONS

The clinical signs of polyhydramnios were the most important factors for prenatal detection of esophageal obstruction. Consequently, the time of diagnosis was late and the detection rate was low (44%). An increased awareness of the possibility of esophageal obstruction, leading to targeted examinations whenever the suspicion is raised during pregnancy, might improve the prenatal detection rate and thereby provide a possibility to improve the outcome. Of the cases with isolated esophageal obstruction, 90% survived, irrespective of prenatal diagnosis.

Congenital esophageal stenosis associated with esophageal atresia: new concepts

Congenital esophageal stenosis (CES) is suspected by a fixed intrinsic narrowing of the esophagus that affects the normal swallowing mechanism. The diagnosis is only confirmed by histopathologic picture, which may show fibromuscular disease (FMD) or tracheobronchial remnants (TBR). The latter involves ciliated pseudo stratified columnar epithelium, seromucous glands or cartilage each alone or in combination. The aim of this study is to document the usefulness of histologic picture of surgical specimens obtained from the lower esophageal pouch (LEP) during primary repair in detecting cases of CES associated with esophageal atresia (EA) with or without tracheoesophageal fistula (TEF). Over an 8-year period, 57 consecutive cases operated upon for EA with or without TEF were subjected for histologic examination of surgical specimens obtained from the tip of the LEP. Cases that histologically showed FMD or TBR were included. The usefulness of this histologic picture as a diagnostic and therapeutic aid is assessed. Methods of treatment and outcome were also reviewed. Eight patients out of 57 (14%) had a histologic picture suggestive of CES, two with FMD, four with TBR without cartilage and two with cartilage. Out of 57 patients, 23 developed strictures, six of them had positive biopsies suggestive of CES. One patient with TBR without cartilage did not have stricture. Another case of pure atresia had LEP resection and gastric pull up showed cartilage involving the whole lower esophagus. Excluding the case of pure EA with gastric pull up, all patients suffered from feeding problems and recurrent aspiration. Fluoroscopic barium studies showed late onset minor dysmotility in five patients and late onset major dysmotility in two. All cases studied showed significant gastro-esophageal reflux (GER). Stricture was seen at the anastomotic site extending distally in the two fibromuscular cases and one case with cartilage, at the anastomotic site in three cases with TBR without cartilage. Anti reflux surgical procedures were performed in four patients without benefit in two patients with major dysmotility. Dilatation was successful in the three patients with TBR without cartilage. One patient with cartilage had resection of the anastomotic site and required frequent dilatations and is now doing well. A case of FMD did not improve after frequent dilatations and myotomy together with Nissen's fundoplication and required resection while the other case of FMD responded partially to dilatations. Cartilage in cases of CES requires surgical resection. Those with TBR without cartilage may not develop stricture. If stricture develops, it responds well to dilatation and patients have good clinical outcomes. Unlike isolated CES, GER is a significant feature in CES with EA. Anti reflux procedures should be avoided before definitive surgery for the stricture and if necessary a partial wrap with gastrostomy is recommended. CES should be considered in the etiology of anastomotic stricture. Taking a surgical specimen routinely from the tip of the LEP during primary esophageal repair for histologic studies is highly recommended.

Congenital anomalies of the esophagus

Normal anatomy, embryology, and congenital anomalies of the esophagus are discussed in this article. The classification, epidemiology, embryology, diagnosis, and management, including outcome following repair of esophageal atresia with or without an associated tracheoesophageal fistula, are described. The diagnosis and management of less common anomalies, such as congenital esophageal stenosis and congenital esophageal duplication, are outlined.

"Total Gastric Dissociation (TGD)" in difficult clinical situations

BACKGROUND

Since the first report by Bianchi in 1997, TOGD has been found to be safe and effective in patients with gastro-oesophageal reflux (GOR) with neurological impairment. This paper explores the versatility of total gastric dissociation (TGD) in difficult clinical situations.

METHODS

The medical records of 11 neurologically normal children treated with TGD and gastrostomy after failure of conventional procedures between 1999 and 2004 were reviewed with respect to demographic data, initial diagnosis, previous operations, postoperative complications, feeding pattern, and follow-up.

RESULTS

There were 7 males and 4 females. The mean age at operation was 52.7 months (24 to 72 m). The indications were severe colo-oesophageal reflux in 3; 1 post-fundoplication necrotic stomach; 1 gastric remnant after subtotal gastrectomy for bleeding; 1 microgastria; 2 with severe oesophageal obstruction following repeated failed repair of congenital stenosis of the oesophagus and after fundoplication; 1 congenital short oesophagus with left-sided congenital diaphragmatic hernia; and 2 with severe dysfunctional oesophagus following repair of congenital tracheo-oesophageal cleft. Full oral or gastrostomy feeding was established by the 5th postoperative day. The average follow-up was 47.2 months (24-72 months). There were 4 late deaths in the group: 2 with respiratory failure, 1 with sepsis secondary to peritonitis (small bowel herniation into the thorax) and 1 with pneumococcal infection. Seven patients are alive and thriving with markedly reduced episodes of chest infections and hospitalizations.

CONCLUSIONS

In this study TGD presented with no peri-operative morbidity and mortality and had good long-term results. The procedure offers a safe alternative for neurologically normal children after the failure of conventional surgical procedures.

Thoracoscopic approach for congenital esophageal stenosis

Congenital esophageal stenosis (CES) is an infrequent entity; however, many cases have been reported during the last years. Its incidence falls between 1 per 25,000 and 1 per 50,000 live births and is associated with other congenital malformations in 17% to 33% of cases (mainly esophageal atresia). Congenital esophageal stenosis is defined as an intrinsic alteration of the esophageal wall given by the presence of ectopic tracheobronchial tissue, membranous diaphragm, muscular hypertrophy, or diffuse fibrosis of the submucosa, among other causes. The therapeutic options include endoscopic dilation and resection plus anastomosis (by either laparotomy or thoracotomy, depending on the level of the stenosis). We present the case of a 1-month-old baby boy with a CES located in the distal esophagus that is associated with anophthalmia and micropenis. We treated the lesion by means of a thoracoscopic resection of the affected segment and an esophageal end-to-end anastomosis. The patient's long-term outcome was uneventful. As far as we know, this is the first report on thoracoscopic resolution of a CES.

Dysphagia in the young male: the ringed esophagus

The endoscopic view of the multi-ringed esophagus readily explains why the term "tracheal esophagus" is applicable. This entity may be undiagnosed until dysphagia and impactions secondary to strictures occur in the young male. Several factors point to a congenital rather than an acquired disorder. Treatment consists of slow, progressive dilatations that are repeated for recurrent dysphagia.

Sténose congénitale de l'œsophage par hétérotopie trachéobronchique : à propos de 2 cas et revue de littérature

Congenital esophageal stenosis due to tracheobronchial remnants is a rare malformation whose diagnosis may be difficult. It is characterised by the abnormal presence of congenital tissue of tracheal origin in the esophageal wall, which is responsible for the narrowing of the esophagus. We report 2 cases whose treatment was surgical after failure of esophageal dilations. The presence of tracheal-bronchial tissue was confirmed by histological examination of the operative piece. Outcome was favourable and the final result was excellent. Recently, endoscopic ultrasonography has been proved useful in the diagnosis of congenital esophageal stenosis due to tracheobronchial remnants by showing the presence of cartilage, which explains the failure of dilation. The high rate of perforation in these cases is due to brutal fragmentation of the cartilaginous rings. Surgical resection of esophageal stenosis with the tracheobronchial tissue appears the only treatment susceptible to completely suppress the stenosis and its consequences.

Congenital segmental fibromuscular hypertrophy of the esophagus and esophageal atresia: an uncommon case

Although a rare entity, congenital esophageal stenosis due to segmental hypertrophy of the muscularis and submucosal layers with diffuse fibrosis should be considered a possibility in patients with esophageal stricture associated to congenital esophageal atresia. The efficacy of dilatation seems to be limited, and may even result in severe complications such as an esophageal rupture. Surgical repair for congenital esophageal stenosis is the authors' preferred treatment, although initial dilatation may be effective for some patients.