H-type tracheo-oesophageal fistula with congenital oesophageal stenosis

H-type tracheo-oesophageal fistula (H-TOF) and congenital oesophageal stenosis (COS) are both rare anomalies. Only six cases of H-TOF in association with COS have been described in the literature. Characteristically, diagnosis is delayed, often well beyond the neonatal period. We report a patient who was accurately diagnosed on day 12 of life, and outline several of the key clinical dilemmas encountered in managing a neonate with this combination of rare congenital anomalies.

[Congenital hiatus hernia associated with reflux esophageal stenosis]

A small group of three patients presented in our study represents extraordinary and very complicated problem of congenital hiatus hernia in infant period from 6th to 9th month of life, associated with gastroesophageal reflux and consecutive esophageal stenosis. There are two very rare and delicate entities within differential diagnosis, in the domain of the same pathology: congenitally short esophagus and congenital esophageal stenosis; with completely different surgical options for their treatment. That is why an optimal diagnostics and an adequate operative technique are extremely important for the treatment of hiatus hernia. The uppergastrointestinal barium radiography is definitely the method of diagnosing hiatus hernia, which provides typical, almost pathognomonic image of hiatus hernia accompanied by the esophageal stenosis. Nissen fundoplication is the technique of choice for its surgical treatment, with gastrostomy for probable postoperative esophageal dilatation. The results are more than satisfying: early peroral feeding, with spontaneous resolving of esophageal stenosis, which significantly diminishes the need for esophageal bougienage.

Circular myectomy for the treatment of congenital esophageal stenosis owing to tracheobronchial remnant

The management of the congenital esophageal stenosis is not well established. The authors present an infant with critical esophageal stenosis owing to tracheobronchial remnant. This lesion was managed successfully by circular myectomy of the esophageal wall without resection. An 1-year-old girl was referred for recurrent vomiting and dysphagia. An esophagogram showed an abrupt stenosis, and endoscopic ultrasonography showed cartilaginous tracheobronchial remnants within the esophageal wall. The extirpation of muscular layer, which contained cartilage, was attempted. Circular muscular layer was resected in 1 cm width leaving mucosal layer intact. Muscular layer was closed horizontally with absorbable sutures. The patient is free from the symptoms and eats normally 1 year after surgery. In case of short segmental stenosis owing to tracheobronchial remnant, this may be the preferred approach.

Congenital esophageal stenosis owing to ectopic tracheobronchial remnants

BACKGROUND/PURPOSE

Congenital esophageal stenosis owing to tracheobronchial remnants (TBR) is a rare condition. Inappropriate treatment often is carried out before the correct diagnosis is established. For a better understanding and management of this disease, patients with TBR treated at our hospital and collected from the literature are reviewed to evaluate the course of onset, associated anomalies, methods of diagnosis and treatment, and outcomes.

METHODS

Three patients treated at our hospital and 59 patients identified from the literature were included in the study. Gender, age at onset of symptoms, age at definitive treatment, esophagographic findings, pathology, methods of treatment, and outcomes of the 62 patients were recorded and analyzed.

RESULTS

Boys slightly predominated (33:28, 1 unknown gender). Symptoms of dysphagia and regurgitation developed at the mean age of 3.2 +/- 4.5 months. Definitive treatment was carried out at the mean age of 2.6 +/- 3.0 years with a time lag of 2.0 +/- 2.5 years from the onset of symptoms. Twenty-five patients had associated anomalies with esophageal atresia being the most prevalent. Esophagography showed segmental stenosis over the distal third of the esophagus in all patients except one. The esophagographic findings could be classified into 3 types: type Ia, 10 cases; Ib, 15 cases; type II, 14 cases; type III, 3 cases. A nonyielding esophageal stenosis without inflammation was the characteristic esophagoscopic finding. Esophagoscopic dilatation of the stenosis was attempted in 26 patients, but all failed, and 2 patients suffered esophageal perforation. Surgical resection was mandatory for all patients to restore their esophageal continuity. Postoperative complications included anastomotic stenosis, anastomotic leakage, hiatal hernia, and gastroesophageal reflux.

CONCLUSIONS

TBR should be suspected in patients who present with a typical history of dysphagia after ingestion of solid food and have characteristic esophagographic and esophagoscopic findings. It has a strong tendency to occur with esophageal atresia. Esophagoscopic dilatation is ineffective and may render the patient at risk for esophageal perforation. Operation is the treatment of choice and carries little morbidity and mortality.

Congenital esophageal stenosis: a case report and review of the literature

A child with congenital esophageal stenosis (CES) demonstrates the need for accuracy in the diagnosis and management of this rare problem. Other etiologies of dysphagia must be looked into, but when the expected results are not realized CES should be considered. A range of diagnoses and diagnostic studies may help to get children with dysphagia the treatment that they need to resolve their symptoms.

Congenital esophageal stenosis

Congenital esophageal stenosis CES is an uncommon anomaly that rarely goes undiagnosed until adulthood. We report 2 cases of CES. The first was a one-month-old baby boy who was referred for work up of swallowing disorder and recurrent pneumonias. The diagnosis was confirmed by a continuous fluoroscopic esophagogram, and endoscopic exploration. Simple dilatation resolved his symptoms completely. The second was an 18-month-old boy, who was referred with a feeding gastrostomy due to complete esophageal obstruction. Resection and end-to-end anastomosis was performed with uneventful postoperative course.

Superimposed spontaneous esophageal perforation in congenital esophageal stenosis

Congenital esophageal stenosis (CES) is a very rare embryologic anomaly of tracheoesophageal development that requires lifelong management, usually with frequent esophageal dilations and dietary precautions. We present a patient with spontaneous thoracic esopahgeal perforation in a setting of CES. The patient, a 27-year-old male, recovered uneventfully following open primary esophageal closure. A brief but comprehensive discussion of CES follows the case report.

Esophageal motor function in congenital esophageal stenosis

BACKGROUND/PURPOSE

Congenital esophageal stenosis (CES) is a rare condition that is associated with various foregut symptoms. The aim of the current study was to investigate esophageal motor function in pediatric patients with isolated CES.

METHODS

Four boys with CES (age, 3 weeks to 4 years old) were studied before treatment. The initial symptoms were dysphagia or stridor. The CES was caused by fibromuscular stenosis (FMS) in 2, tracheobronchial remnants (TBR) in 1, and membranous diaphragm (MD) in 1. An esophagram, endoscopy, 24-hour esophageal pH monitoring, and manometry were conducted.

RESULTS

The esophagram showed the stasis of contrast medium proximally to the distal esophageal narrowing in FMS/TBR patients. Endoscopic esophagitis was not found in any patients. Three patients were documented with pathologic esophageal acid exposure by 24-hour esophageal pH monitoring. Manometry showed that esophageal contractions predominantly were synchronous in FMS/TBR patients but were peristaltic in an MD patient. Basal lower esophageal sphincter (LES) pressure was at least 20 mm Hg in all. Swallow-induced LES relaxations were incomplete in FMS/TBR patients.

CONCLUSIONS

The presence of gastroesophageal reflux and impaired esophageal motility are common in patients with CES.

Adult case of squamous cell carcinoma arising on congenital esophageal stenosis due to fibromuscular hypertrophy

This study relates to an adult case of squamous cell carcinoma arising on congenital esophageal stenosis. The patient was a 65-year-old man who had suffered from dysphagia and vomiting since birth and was diagnosed as having congenital esophageal stenosis. The patient had not received any treatment because his symptoms were mild. The patients suffered from severe dysphagia since he was 20 years old and had received balloon therapies several times; however, the effects were transient. After admission to our hospital, he underwent a transhiatal esophagectomy without thoracotomy. Histopathological examination of the resected specimen revealed a thick muscular mucosae associated with hypertrophic fibromuscular components and poorly to moderately differentiated squamous cell carcinoma in the region of stenosis. This case report is the first of a patient with squamous cell carcinoma arising on congenital esophageal stenosis.

Clinical characteristics and management of congenital esophageal stenosis: a report on 14 cases

PURPOSE

The aim of this study was to review 14 patients with congenital esophageal stenosis (CES) from diagnostic and therapeutic points of view.

METHODS

From 1976 to 1999, 14 patients with CES were treated at the authors' hospital. In each diagnostic examination, an esophagogram, 24-hour pH monitoring, a manometric study, and an endoscopy were performed. The medical, radiologic, and operative reports of these patients were reviewed.

RESULTS

Esophagogram results showed an abrupt stenosis in 5 patients and a tapered stenosis in 9. After 24-hour pH monitoring and an endoscopy, we were able to rule out the possibility of gastroesophageal reflux with esophagitis in most of the patients. Of the 11 patients who initially underwent bougienage or balloon dilatation, 8 of them had recurrent stenosis. Eleven patients required surgical treatment, including the 8 who had recurrent stenosis after undergoing dilatation. Nine of the patients underwent a resection of the stenotic segment and esophago-esophagostomy. An antireflux procedure was performed on 2 patients. Another patient had an esophageal rupture, which required a jejunal interposition. A histopathologic study showed that tracheobronchial remnants were present in 6 patients, and fibromuscular thickening was found in 4 patients.

CONCLUSIONS

The efficacy of dilatation seems to be limited and may even result in severe complications such as an esophageal rupture. In this study, most patients ultimately required surgical treatment. Surgical repair for CES is the authors' preferred treatment, although initial dilatation may be effective for some patients.

Congenital oesophageal stenosis: an atypical presentation in a young woman

Congenital oesophageal stenosis is a very rare disease that commonly occurs in infancy with male predominance. This report describes a highly unusual case of congenital oesophageal stenosis extended throughout the length of the oesophagus, without webs or tracheobronchial remnants in the oesophageal wall, with normal oesophageal motility and normal endosonography in an adult female.

Usefulness of endoscopic ultrasonography in the diagnosis of congenital esophageal stenosis

BACKGROUND/PURPOSE

Endoscopic ultrasonography (EUS) is considered a potentially useful tool to investigate structural abnormalities of the esophagus in pediatric patients, as in adults. The aim of this study was to evaluate the usefulness of EUS for the diagnosis of congenital esophageal stenosis.

METHODS

High-frequency catheter probe EUS was performed under general anesthesia in 2 patients who had congenital esophageal stenosis.

RESULTS

A 4-year-old boy with anorectal anomaly showed tapered narrowing in the distal esophagus, which was not ameliorated with balloon dilatation. High-frequency catheter probe EUS showed hypertrophy of the muscular layer in the esophageal wall at the narrowed portion, but no images suggested the presence of tracheobronchial remnants. The histologic diagnosis of fibromuscular hypertrophy was confirmed at esophagoplasty. A 5-month-old boy with Gross C-type esophageal atresia and symptomatic gastroesophageal reflux showed tapered narrowing in the middle esophagus on esophagography. The symptoms of stenosis were not ameliorated by balloon dilatation performed 4 times. High-frequency catheter probe EUS showed hyperechoic lesions suggesting cartilage at the esophageal narrowing. The diagnosis of tracheobronchial remnants was confirmed by the finding of 2 pieces of cartilage in the specimen obtained at the time of esophageal resection.

CONCLUSION

EUS can be applied to show structural abnormalities of the esophageal wall even in pediatric patients with congenital esophageal stenosis and is useful for planning the therapeutic strategy.

Imaging and intervention in the gastrointestinal tract in children

Vascular and interventional techniques have become an integral component of modern pediatric healthcare. Minimally invasive procedures of the gastrointestinal tract now comprise a large part of any active pediatric interventional practice. Magnetic resonance cholangiopancreatography offers a reliable, non-invasive means to evaluate patients with possible pancreatic or biliary pathology. This article reviews treatment of esophageal strictures and placement of gastronomy and gastrojejunostomy tubes and discusses new developments. Placement of percutaneous cecostomy tubes is a relatively new procedure that creatively uses the techniques developed for placement of percutaneous gastronomy tubes. This procedure offers significant benefits and lasting positive lifestyle changes for patients suffering from fecal incontinence. Liver biopsy in high-risk patients can be performed safely using measures designed to significantly decrease the risk of post-biopsy hemorrhage, such as track embolization or the transjugular approach.

Management of congenital esophageal stenosis

BACKGROUND/PURPOSE

The authors report the incidence, diagnosis, and treatment methods of congenital esophageal stenosis (CES) at their institution.

METHODS

A retrospective analysis of 123 patients with tracheoesophageal anomalies in a pediatric hospital between 1980 and 1999 was performed. Charts were reviewed for patient demographics, presence of true CES, associated congenital anomalies, method of diagnosis, methods of treatment, and histopathology.

RESULTS

Six of the 123 patients (4.9%) had true CES (one patient had 2 separate stenoses). Two patients had isolated CES, one patient had CES with isolated tracheoesophageal fistula (TEF), one patient had CES with isolated esophageal atresia (EA), and 2 patients had CES with EA/TEF. Diagnoses were made with an upper gastrointestinal (GI) contrast study in 5 patients, and one patient had one of 2 stenoses diagnosed by prenatal ultrasound and the other diagnosed intraoperatively. Four of the 7 stenoses were treated with surgical resection, and the remainder was treated with esophageal dilatation. Histopathology from the 4 resected stenoses showed tracheobronchial remnants in 3 specimens and submucosal thickening in 1 specimen.

CONCLUSIONS

Although isolated CES is rare (2 of 123 = 1.6%), CES associated with other tracheoesophageal anomalies has a higher incidence (4 of 123 = 3.25%). Patients with this lesion should be treated first with dilatation. If ineffective, resection is required.

Endosonographic evaluation in two children with esophageal stenosis

The authors report the successful use of endoscopic ultrasonography (EUS) for finding the etiology and subsequent treatment strategy for esophageal stenosis in 2 children. In case 1, EUS showed anterior wall thickening and multiple low echoic regions in the mp layer. These regions were believed to be cartilage. Esophageal resection therefore was performed. In case 2, EUS showed disruption of the sm and mp layers at the stenosis, leading us to speculate that the stenosis was caused by gastroesophageal reflux. After balloon dilatation, he underwent antireflux surgery of Nissen's fundoplication. EUS was useful for determining the etiology of esophageal stenosis and, thus, the appropriate treatment strategy.

[Occurrence of congenital esophageal defects in the Czech Republic 1961-2000--incidence, prenatal diagnosis and prevalence according on maternal age]

OBJECTIVE

To present incidences of the oesophageal atresia or stenosis and their maternal age distribution. To analyse maternal age as a possible risk factor for the defects studied.

DESIGN

Retrospective epidemiological study.

SETTING

Institute for Care of Mother and Child, Prague, Czech Republic.

METHODS

Retrospective epidemiological study of oesophageal atresia and stenosis using data from the population based register of congenital malformations in the Czech Republic over the 1961-2000 period. The main source of data for this paper is the database of congenital anomalies at the Institute for Care of Mother and Child in Prague (the 1961-1990 period) and the data analysed by the Institute of Health Information and Statistics (the 1987-2000 period).

RESULTS

Out of the total number of 5,589,888 births in the Czech Republic in 1961-2000 period, 804 cases of oesophageal atresia and stenosis were registered. Mean incidence of oesophageal atresia and stenosis in the period under the study was 1.51 per 10,000 livebirths. In the 1991-2000 period an increase of incidences of this congenital anomaly was revealed in the Czech Republic. By application of the two-sided 95% CI, statistically significant correlation was found in women of 39 years of age and older.

CONCLUSIONS

Statistically significant increase of risk (for age as a risk factor) was found in maternal age groups of 39 years of age and over.

Balloon catheter dilatation in children with congenital and acquired esophageal anomalies

BACKGROUND/PURPOSE

Esophageal stricture requiring dilatation often is the sequelae in children with a history of congenital or acquired esophageal anomalies. Balloon catheter dilatation (BCD) for esophageal stricture is well established in adults, yet its role in children is less well described. The authors report their initial experience using BCD in children with esophageal stricture, assessing outcome.

METHODS

Between January 1994, and December 1998, 20 children (age range, 17 days to 12 years) underwent BCD for esophageal strictures and were divided into 2 etiology groups (A and B). (A, n = 10) included congenital anomalies (esophageal atresia, 10), and (B, n = 10) included acquired anomalies (caustic ingestion, 7; tight fundoplication, 2; peptic stricture, 1). BCD was performed in all cases under conscious sedation with a balloon catheter (6 to 25 mm) with fluoroscopy. Outcome parameters included number of dilatations; complications, ie, perforation; and success or failure of procedure. Success was defined as increasing intervals of age-appropriate food tolerance between dilatations, and failure was defined as abandonment of dilatation in favor of surgical intervention. Follow-up for A and B ranged from 6 to 42 months.

RESULTS

Seventeen of 20 (85.0%) underwent successful BCD. In A, 10 of 10 (100%) had complete resolution of symptoms with follow-up ranging from 6 to 42 months versus 7 of 10 (70.0%) in B with follow-up of 6.5 to 36 months. In A, number of dilatations ranged from 1 to 4 over an average period of 2 months. In B, number of dilatations ranged from 3 to 40 over periods ranging from 2 to 30 months. All 3 failures occurred in children with caustic ingestion, with 1 child suffering perforation requiring urgent surgical intervention.

CONCLUSIONS

Balloon catheter dilatation can be applied safely and effectively to children in whom esophageal strictures develop after repair of esophageal atresia. However, its use in children with acquired esophageal anomalies, notably caustic injury, is associated with higher complication and failure rates, necessitating greater caution and lower expectations.

Congenital esophageal stenosis: Therapeutic strategy based on etiology

BACKGROUND/PURPOSE

The diagnosis and treatment of congenital esophageal stenosis (CES) can be a vexing clinical problem. This study aims at determining the ideal therapeutic strategy for the management of CES.

METHODS

Medical records of patients with CES were reviewed retrospectively with regard to diagnostic method, therapy, and outcome.

RESULTS

During the last 29 years, 36 patients, aged 1 month to 9 years, were found to have CES. Diagnosis was made by fluoroscopy, esophagoscopy, endoscopic ultrasonography (EUS), and pathologic examination. Of the 36 patients, 15 had tracheobronchial remnants (TBR), 13 had fibromuscular stenosis (FMS), 5 had membranous stenosis (MS), and 3 had multiple stenoses (MPS). EUS was diagnostic in distinguishing TBR from FMS. All patients with TBR underwent operative repair in which 13 patients had resection and anastomosis with or without preoperative dilation. The 14th patient had enucleation and the 15th underwent myotomy. Postoperative dilation was needed 2.2 times for 2.1 months on average in this group of patients. Ten patients with FMS were treated by dilation only (a mean of 4.7 dilations was required for a duration of 2.6 years), whereas 3 patients underwent open surgical intervention. Most patients with MS or MPS were treated by dilation (with or without endoscopic resection of the membranes), whereas 2 patients had surgical intervention. All patients in this study are doing well after a mean follow-up period of 5.3 years (range, 0.5 to 25 years) without any further operative interventions.

CONCLUSIONS

If the etiologic diagnosis of CES is unclear, EUS is useful in distinguishing TBR from FMS. This distinction is critical, because patients with TBR should undergo surgical resection, whereas most cases of FMS, MS, and MPS can be treated with esophageal dilation alone.

Vascular anomalies and tracheoesophageal compression: a single institution's 25-year experience

BACKGROUND

Vascular rings are uncommon anomalies in which preferred strategies for diagnosis and treatment may vary among institutions. In this report, we offer a description of our approach and a review of our 25-year experience.

METHODS

A retrospective review was conducted of all pediatric patients with symptomatic tracheoesophageal compression secondary to anomalies of the aortic arch and great vessels diagnosed from 1974 to 2000.

RESULTS

Thirty-one patients (38%) of eighty-two patients (mean age, 1.7 years), were identified with double aortic arch, 22 patients (27%) with right arch left ligamentum, and 20 patients (24%) with innominate artery compression. Our diagnostic approach emphasized barium esophagram, along with echocardiography. This regimen was found to be reliable for all cases except those with innominate artery compression for which bronchoscopy was preferred, and except those with pulmonary artery sling for which computed tomography or magnetic resonance imaging, in addition to bronchoscopy, were preferred. Left thoracotomy was the most common operative approach (70 of 82; 85%). Ten patients (12%) had associated heart anomalies, and 6 (7%) patients underwent repair. Complications occurred in 9 (11%) patients and led to death in 3 (4%) patients.

CONCLUSIONS

In our practice, barium swallow and echocardiography are sufficient in diagnosing and planning the operative strategy in the majority of cases, with notable exceptions. Definitive intraoperative delineation of arch anatomy minimizes the risk of misdiagnosis or inadequate treatment.

[Prenatal diagnosis and management in VACTERL association]

In terms of the VACTERL-Association we are dealing with a non-random association of malformations following a defect during mesodermal development of embryogenesis due to a variety of causes. We report on three cases with VACTERL-type malformations diagnosed by prenatal ultrasound presenting cardial defects, renal abnormalities, single umbilical arteries and esophageal stenosis. We present sonographical, clinical and autopsy findings and discuss the pathogenesis of VACTERL-Association as a defect of mesenchymal development in early embryogenesis.

Congenital esophageal stenosis in adults: clinical and radiographic findings in seven patients

OBJECTIVE

The purpose of this study was to determine the clinical and radiographic findings in seven adults with congenital esophageal stenosis.

CONCLUSION

In young or middle-aged individuals, particularly men with long-standing dysphagia, an upper or mid esophageal stricture with multiple ringlike constrictions is a characteristic appearance of congenital esophageal stenosis on double-contrast esophagography.

Congenital esophageal stenosis: report of three cases, literature review, and a proposed classification

The aim of this paper is to report three cases of congenital esophageal stenosis (CES) of different anatomical varieties: (1) stenosis due to tracheobronchial remnants (TBR) involving the lower third of the esophagus; (2) fibromuscular stenosis (FMS) of the middle third; and (3) a membranous diaphragm (MD) involving the lower third. The first two patients were treated by segmental resection of the esophagus and end-to-end anastomosis with dramatic relief of symptoms. The third responded to dilatation. CES is a rare lesion, and about 500 cases are reported in the literature. CES due to TBR and fibromuscular hypertrophy is considered a segmental stenosis, as it involves a length of the esophageal wall, whereas the MD consists of mucosal folds and does not involve its muscular layer. The clinical presentation is varied, and a high index of suspicion is essential to arrive at an early diagnosis. Management depends on the type and severity of the stenosis. Stenosis due to TBR requires segmental resection. FMS may respond to dilatation, but severe degrees of stenosis require segmental excision. MDs usually respond to dilatation or may require endoscopic excision. Segmental stenosis can occur as an isolated lesion or in association with esophageal atresia or stenosis due to a MD. Based on this observation, a classification of CES is proposed.