A vascular ring: right aortic arch and descending aorta with left ductus arteriosus

A case is presented of vascular ring caused by right aortic arch with mirror-image branching and left ductus arteriosus. In this case, the descending aorta was located right of the tracheoesophagus and the left ductus arteriosus connected to the descending aorta far below the arch, producing compression of the esophagus only. Through median sternotomy, the ligation and division of the ductus was performed with concomitant repair of ventricular septal defect.

Clinical characteristics of congenital esophageal stenosis distal to associated esophageal atresia

BACKGROUND

Congenital esophageal stenosis (CES) has been reported to be a rare association in patients with esophageal atresia or tracheoesophageal fistula, or both (EA-TEF). This study investigates the clinical characteristics of this association with special reference to its treatment.

METHODS

A retrospective review of medical and radiographic records of 81 patients who underwent primary repair of EA-TEF was performed. An association of CES was diagnosed when they showed histologic evidence or persistent radiographic images of esophageal narrowing since the neonatal period.

RESULTS

Eleven of 81 EA-TEF patients (14%) were identified with CES. Their symptoms were difficulty in swallowing solid food, food impaction, emesis, stridor, repeated respiratory infection, and failure to thrive. Two patients had a recurrence of TEF. Three patients were diagnosed with CES in the neonatal period-2 at the time of primary repair of EA-TEF and 1 on the initial postoperative esophagram. The remaining 8 patients were diagnosed between the ages of 2 months and 3 years. Although esophageal dilatation was attempted in 9 patients, its effectiveness was temporary in all except 2 patients and esophageal laceration occurred in 4 patients. Surgical repair including myotomy and resection of the narrow segment was performed in 7 patients, in 6 of whom Nissen/Collis-Nissen fundoplication was added. A histologic examination was performed in 5 patients, revealing that their CES was due to fibro-muscular hypertrophy (2) or tracheobronchial remnants (3). The long-term outcome was satisfactory in all patients except one who showed wrap herniation.

CONCLUSIONS

The association between CES and EA-TEF is not rare. Esophageal dilatation was not universally effective and carried with it a considerable incidence of esophageal leakage. An antireflux operation concomitant with repair of CES may be useful to prevent postoperative gastroesophageal reflux in patients with a narrowing close to the esophagogastric junction.

Congenital esophageal stenosis: clinical and endoscopic features in adults

BACKGROUND

Congenital esophageal stenosis (CES) is an uncommon anomaly that reportedly rarely goes undiagnosed until adulthood. One variant of CES includes patients with multiple cartilaginous rings described usually in the mid-distal esophagus.

METHODS

Ten patients with CES seen over the past 7 years were interviewed and their clinical and endoscopic records reviewed.

RESULTS

Eight patients were male and age at time of diagnosis ranged from 21 to 75 years. Meat impaction was the presenting symptom in 8 patients and 3 patients reported a relapsing history. Intermittent solid food dysphagia over extended duration (10-40 years) was reported in all patients with an estimated onset of symptoms at a mean age of 27 years (11-52 years). Endoscopically, all patients had segmental esophageal stenosis (length 2-8 cm, mean = 4.7 cm) due to 'trachea-like' multiple submucosal rings. Pseudodiverticulosis and distal reflux esophagitis were evident in 1 patient. Nine of 10 patients had no macroscopic esophagitis. Dilatation was performed by balloon insufflation (18 mm in 5 patients, 15 mm in 3 patients, 12 mm followed by 15 mm in a patient with a tight stricture) and by Savary dilators in 1 patient, without any complications. No patient had recurrent meat impaction on follow-up (1-7 years, mean = 3 years) after education about the condition.

CONCLUSION

(1) We suspect CES is an under-recognized cause for intermittent, long-standing dysphagia in adults. (2) Food impaction is a frequent initial presentation. Recognition of CES is critical for appropriate patient education and planning.

Congenital esophageal stenosis in adults

OBJECTIVE

Congenital esophageal stenosis is thought to be a rare disease confined to infancy and childhood with only a few case reports in adults described.

METHODS

We report five patients between the ages of 19 and 46 yr who presented with this disorder over a 2-yr period.

RESULTS

Patients had been labeled with reflux strictures, webs, or as idiopathic in the past. All patients had chronic solid food dysphagia, some since early childhood. The location of the stricture varied, occurring in the mid or proximal esophagus in four, but throughout the esophagus in one. Radiographic and endoscopic appearance was a smooth concentric stricture or multiple rings, sometimes tracheal in appearance. Endosonography was performed in two patients, both of whom had focal circumferential hypoechoic wall thickening with disruption of the normal layer pattern corresponding to the areas of luminal narrowing. All patients dilated had good symptomatic response, with resolution of symptoms up to 6 months in follow-up.

CONCLUSIONS

We suggest that congenital esophageal stenosis does occur in adults and may be underrecognized. Its endosonographic appearance is described.

Congenital esophageal stenosis treated with endoscopic balloon dilation: report of one case

Congenital esophageal stenosis is a narrowing of esophageal lumen that is present at birth, and may be asymptomatic in the neonate. Stenosis of the lower esophagus is a very rare form of esophageal obstruction. Three types of congenital esophageal stenosis have been described: fibromuscular stenosis, membranous webs, and tracheobronchial remnants. Fibromuscular stenosis and membranous webs respond to dilation, but must be distinguished from strictures caused by peptic esophagitis. Tracheobronchial remnants generally require surgical therapy. We report a 5-year-old girl with congenital esophageal stenosis, who presented with persistent dysphagia and poor weight gain. An esophagogram showed stricture of lower esophagus with proximal dilatation above esophagogastric junction. She was successfully treated with endoscopic balloon dilation.

[Congenital oesophageal stenosis due to tracheobronchial remnants]

This paper presents the authors' experience with congenital oesophageal stenosis (= CES) in three patients who had CES due to tracheobronchial remnants. Difficulties with feeding started at 6-9 months of age, which corresponded with the introduction of solids. Contrast studies showed stenosis at the junction of the mid and distal thirds of the oesophagus. Limited resection of the oesophageal stenosis and primary anastomosis was performed in all three patients with good results. CES should be suspected if all other causes of oesophageal stenosis have been excluded by upper gastrointestinal examinations, endoscopy, oesophageal pH monitoring and oesophageal manometry.

Congenital esophageal stenosis

We report 6 new cases of congenital esophageal stenosis (CES) that presented to us with special diagnostic and management problems and review the literature on this subject. Gastroesophageal reflux and achalasia are important differential diagnoses of esophageal stenosis, they may be associated with CES making appropriate management even more difficult. Treatment is also controversial, ranging from simple dilatation to segmental resection. CES should be present in every pediatric surgeon's mind should dysphagia occur on the introduction of semisolid food or esophageal food impaction, with a segmental stenosis demonstrated at esophagogram even when more obvious diagnoses are evoked.

Tubular esophageal duplication associated with esophageal stenosis, pericardial aplasia, diaphragmatic hernia, ramification anomaly of lower lobe bronchus and partial pancreas anulare

Alimentary tract duplications are rare anomalies, which are often associated with other congenital malformations. We report on a newborn with the combination of tubular esophageal duplication, congenital esophageal stenosis, ramification anomaly of lower left lobe bronchus, complete pericardial aplasia and malrotation of the bowel with a partial pancreas anulare. The diagnoses are based on esophagogram, bronchogram, bronchoscopy, gastroscopy, explorative thoracotomy and laparotomy. The treatment was a resection of the duplication per thoracotomy, esophageal myotomy with fundoplicatio.

Esophageal stenosis in children

This article focuses on the special features of esophageal stenosis which pertain to children. In order to focus on stenoses intrinsic to the esophagus, esophageal stenosis due to extrinsic compression is excluded. While the causes of esophageal stenosis may be grouped as either congenital or acquired, congenital causes account for less than 5% of cases.

[Left aortic arch with right descending aorta and right ligamentum arteriosum in an infant]

A rare form of vascular ring, consisting of a left aortic arch, a right descending aorta and a right ligamentum arteriosum is reported in a symptomatic infant. The role of MRI in the surgical planning is emphasized.

Congenital esophageal stenosis owing to tracheobronchial remnants: a case report

A 3.5-year-old girl who had congenital esophageal stenosis caused by tracheobronchial remnants without esophageal atresia or tracheoesophageal fistula is presented. The diagnostic difficulties are discussed.

Congenital esophageal stenosis

Congenital esophageal stenosis caused by membranous webs occurred in three infants. There were no associated anomalies. First patient applied with respiratory symptoms while the second and third patients reported food impactions. Correct diagnosis was performed during intraoperative (first patient) and esophagoscopic examination (second and third patients). Resection and anastomosis were performed in the first patient and hydrostatic dilatations in the second and third patients. In three patients, symptoms were relieved following treatment. In this report, etiology, diagnostic aids and management of this rare pathology are discussed.

Esophageal atresia/tracheoesophageal fistula and associated congenital esophageal stenosis

BACKGROUND

The association of congenital stenosis of the distal esophagus (CES) in children with esophageal atresia/tracheoesophageal fistula complex (TEF) has been described but is thought to be rare. Most reports have been of individual or small numbers of cases.

OBJECTIVE

The objective of the study was to evaluate the incidence, clinical and radiographic features of CES associated with TEF, and to compare the clinical and radiographic features of CES with acquired anastomotic strictures in TEF patients.

MATERIALS AND METHODS

A retrospective review was undertaken of the records and radiographs of 225 infants with primary TEF repair over a 26-year period.

RESULTS

A total of 18 of 225 (8 %) cases of CES associated with TEF and 43 of 225 (19 %) cases of anastomotic strictures were identified. CES was typically a relatively long, smooth circumferential narrowing at the junction of the mid-esophagus and distal esophagus, with normal-caliber esophagus above and below; anastomotic strictures, in contrast, were focal. Diagnosis of CES was delayed in 10 cases and missed on one or more fluoroscopic studies in 14 children. Symptoms, including feeding and respiratory problems and foreign body impaction, were common in both CES and anastomotic strictures; repeated esophageal dilatations were usually necessary. Esophageal perforation complicated dilatation in 6 (33 %) young children with CES, but none of the children with anastomotic strictures (P < 0.001).

CONCLUSION

CES in combination with TEF is not rare and usually produces clinical symptoms. The diagnosis may be missed or delayed unless specifically evaluated surgically and radiologically. Esophageal dilatation in CES is potentially hazardous with a high risk of perforation, especially in young children.

[Reconstructive plastic surgery of the esophagus in children]

The article presents the authors' experiences with reconstructive-plastic operations of the esophagus in children. The esophagoplasty was performed in 60 patients with congenital and acquired diseases. Among the congenital diseases are esophageal atresia, short esophagus and Barrett's esophagus, the acquired diseases include postburn scarry injuries. The optimum method of creation of the artificial esophagus are described. Of great significance are thought to be angiosurgical and microsurgical methods of cutting out the intestinal transplants. Cases of free autotransplantation of the intestinal segments for the substitution of the injured esophagus are described. Positive results were obtained in most cases.

Iatrogenic esophageal perforation in children: patterns of injury, presentation, management, and outcome

Iatrogenic esophageal perforations in children are rare. To evaluate patterns of injury, clinical presentation, and treatment options for such patients, the authors reviewed the case records of 11 children who had sustained transmural injury to the esophagus during a dilatation procedure at their institution between 1967 and 1994. Strictures requiring dilatation were attributable to caustic ingestion in eight, esophageal atresia repair in two, and congenital stenosis in one. Eight were penetrating injuries, and three were disruptions. Two involved the cervical esophagus; and nine involved the thoracic esophagus. Pain, pyrexia, and tachycardia were early signs. Proximal thoracic perforations led to signs in the left chest region (effusion/pneumothorax); with distal perforation the signs were on the right side. Treatment along conventional lines (local drainage, gastrostomy, primary repair after early recognition, and antibiotic therapy) was successful, with two major complications, both empyemas. The most recent case, a disruption of a tracheoesophageal fistula stricture, was successfully treated with oral water irrigation and antibiotics only. Six had colonic interposition (all caustic ingestion), one required endoesophageal resection of a distal stricture, and four had resolution of the stricture, three without additional dilatation. The majority of children with iatrogenic injuries of the esophagus can be managed successfully by conservative measures and pleural drainage, with surgical procedures reserved for large disruptions of the esophagus, intraabdominal perforations, and cases that do not respond to appropriate conservative measures. Patients with caustic injury to the esophagus have a greater risk for the development of penetrating injury, and this may be one indicator of the severity of scarring. There are distinct clinical patterns of presentation, which depend on the level at which the esophagus is perforated. Dilatation disruption of a localized stricture has a good long-term prognosis for the esophagus and may even cure the stricture. The role of oral irrigation still must be fully evaluated where disruption has occurred as distinct from a penetrating injury.

Esophageal duplication cyst with esophageal web and tracheoesophageal fistula

The authors report the case of lower cervical/upper thoracic esophageal duplication associated with an obstructing esophageal web. This presented in the newborn period as an esophageal atresia. Initial resection of the web and closure of the fistula were performed. The duplication was excised electively at 2 months of age. Persistent symptomatic tracheomalacia required aortopexy, after which the child recovered uneventfully. There are only three other reports (four cases) in the literature of esophageal atresia (or variants) associated with esophageal duplication.

[X-ray diagnosis of rare esophageal diseases in children]

Clinical and X-ray studies of 300 children aged hours to 14 years who had abnormalities of the esophagus have revealed its atresia with or without tracheoesophageal fistulas in 77 subjects, that with congenital narrowings in 21. It was proved that some varieties of atresias might be roentgenologically detected and comprehensive studies should be carried out to determine fistulas in the completely patent esophagus. Despite the age, all children with esophageal atresia with a lower fistula were found to develop catarrhal and erosive esophagitis and "corrosive" pneumonia. Hamartia and recanalization impairments of the primary intestinal tube result in congenital esophageal narrowings leading not only to obstruction, but to aspiration obstructive changes in the lung.