Indwelling esophageal balloon catheter for benign esophageal stenosis in infants and children. Surg Endosc. 2014;28:1126-1130. [PMID: 24202711 DOI: 10.1007/s00464-013-3288-6]

Surgical esophageal diseases in children

Pediatric age esophageal diseases are rare and complex clinical conditions. Treatment options should be individually determined for the patient. The advances in the follow-up and treatment process is the most important reason for the increase in survival time, particularly for congenital pediatric surgical diseases. This study aimed to evaluate the general characteristics of pediatric surgical esophageal diseases in light of the literature.

ERNICA Consensus Conference on the Management of Patients with Long-Gap Esophageal Atresia: Perioperative, Surgical, and Long-Term Management

INTRODUCTION

 Evidence supporting best practice for long-gap esophageal atresia is limited. The European Reference Network for Rare Inherited Congenital Anomalies (ERNICA) organized a consensus conference on the management of patients with long-gap esophageal atresia based on expert opinion referring to the latest literature aiming to provide clear and uniform statements in this respect.

MATERIALS AND METHODS

 Twenty-four ERNICA representatives from nine European countries participated. The conference was prepared by item generation, item prioritization by online survey, formulation of a final list containing items on perioperative, surgical, and long-term management, and literature review. The 2-day conference was held in Berlin in November 2019. Anonymous voting was conducted via an internet-based system using a 1 to 9 scale. Consensus was defined as ≥75% of those voting scoring 6 to 9.

RESULTS

 Ninety-seven items were generated. Complete consensus (100%) was achieved on 56 items (58%), e.g., avoidance of a cervical esophagostomy, promotion of sham feeding, details of delayed anastomosis, thoracoscopic pouch mobilization and placement of traction sutures as novel technique, replacement techniques, and follow-up. Consensus ≥75% was achieved on 90 items (93%), e.g., definition of long gap, routine pyloroplasty in gastric transposition, and avoidance of preoperative bougienage to enable delayed anastomosis. Nineteen items (20%), e.g., methods of gap measurement were discussed controversially (range 1-9).

CONCLUSION

 This is the first consensus conference on the perioperative, surgical, and long-term management of patients with long-gap esophageal atresia. Substantial statements regarding esophageal reconstruction or replacement and follow-up were formulated which may contribute to improve patient care.

An international survey on anastomotic stricture management after esophageal atresia repair: considerations and advisory statements

Background

Endoscopic dilatation is the first-line treatment of stricture formation after esophageal atresia (EA) repair. However, there is no consensus on how to perform these dilatation procedures which may lead to a large variation between centers, countries and doctor’s experience. This is the first cross-sectional study to provide an overview on differences in endoscopic dilatation treatment of pediatric anastomotic strictures worldwide.

Methods

An online questionnaire was sent to members of five pediatric medical networks, experienced in treating anastomotic strictures in children with EA. The main outcome was the difference in endoscopic dilatation procedures in various centers worldwide, including technical details, dilatation approach (routine or only in symptomatic patients), and adjuvant treatment options. Descriptive statistics were performed with SPSS.

Results

Responses from 115 centers from 32 countries worldwide were analyzed. The preferred approach was balloon dilatation (68%) with a guidewire (66%), performed by a pediatric gastroenterologist (n = 103) or pediatric surgeon (n = 48) in symptomatic patients (68%). In most centers, hydrostatic pressure was used for balloon dilatation. The insufflation duration was standardized in 59 centers with a median duration of 60 (range 5–300) seconds. The preferred first-line adjunctive treatments in case of recurrent strictures were intralesional steroids and topical mitomycin C, in respectively 47% and 31% of the centers.

Conclusions

We found a large variation in stricture management in children with EA, which confirms the current lack of consensus. International networks for rare diseases are required for harmonizing and comparing the procedures, for which we give several suggestions.

Electronic supplementary material

The online version of this article (10.1007/s00464-020-07844-6) contains supplementary material, which is available to authorized users.

Oesophageal atresia

Oesophageal atresia (EA) is a congenital abnormality of the oesophagus that is caused by incomplete embryonic compartmentalization of the foregut. EA commonly occurs with a tracheo-oesophageal fistula (TEF). Associated birth defects or anomalies, such as VACTERL association, trisomy 18 or 21 and CHARGE syndrome, occur in the majority of patients born with EA. Although several studies have revealed signalling pathways and genes potentially involved in the development of EA, our understanding of the pathophysiology of EA lags behind the improvements in surgical and clinical care of patients born with this anomaly. EA is treated surgically to restore the oesophageal interruption and, if present, ligate and divide the TEF. Survival is now ~90% in those born with EA with severe associated anomalies and even higher in those born with EA alone. Despite these achievements, long-term gastrointestinal and respiratory complications and comorbidities in patients born with EA are common and lead to decreased quality of life. Oesophageal motility disorders are probably ubiquitous in patients after undergoing EA repair and often underlie these complications and comorbidities. The implementation of several new diagnostic and screening tools in clinical care, including high-resolution impedance manometry, pH-multichannel intraluminal impedance testing and disease-specific quality of life questionnaires now provide better insight into these problems and may contribute to better long-term outcomes in the future.

Endoscopic dilation in pediatric esophageal strictures: a literature review

BACKGROUND

Esophageal strictures in pediatric age are a quite common condition due to different etiologies. Esophageal strictures can be divided in congenital, acquired and functional. Clinical manifestations are similar and when symptoms arise, endoscopic dilation is the treatment of choice. Our aim was to consider the efficacy of this technique in pediatric population, through a wide review of the literature.

METHOD

A search on PubMed/Medline was performed using "esophageal strictures", "endoscopic dilations" and "children" as key words. Medline, Scopus, PubMed publisher and Google Scholar were searched as well. As inclusion criteria, we selected clinical studies describing dilations applied to all type of esophageal strictures in children. Papers referred to single etiology strictures dilations or to adult population only were excluded, as well as literature-review articles.

RESULTS

We found 17 studies from 1989 to 2018. Overall, 738 patients in pediatric age underwent dilation for esophageal strictures with fixed diameter push-type dilators (bougie dilators) and/or radial expanding balloon dilators. Severe complications were observed in 33/738 patients (4,5%) and perforation was the most frequent (29/33). Conversion to surgery occurred only in 16 patients (2,2%).

CONCLUSIONS

Endoscopic dilation is the first-choice treatment of esophageal strictures, it can be considered a safe procedure in pediatric age. Both, fixed diameter push-type dilators and radial expanding balloon dilators, showed positive outcomes in term of clinical results and cases converted to surgery. However, it's essential to perform these procedure in specialized Centers by an experienced team, in order to reduce complications.

Esophageal Atresia and Upper Airway Pathology

Esophageal atresia is an anomaly with frequently occurring sequelae requiring lifelong management and follow-up. Because of the complex issues that can be encountered, patients with esophageal atresia preferably should be managed in centers of expertise that have the ability to deal with all types of anomalies and sequelae and can perform rigorous lifelong follow-up. Tracheomalacia is an often-occurring concurrent anomaly that may cause acute life-threatening events and may warrant immediate management. In the past, major thoracotomies were necessary to carry out the aortopexy. Nowadays, aortopexy and posterior tracheopexy can both be performed thoracoscopically with quick recovery.

Long-Term Management Challenges in Esophageal Atresia

OPINION STATEMENT

Esophageal atresia is a rare congenital anomaly, but improved surgical and critical care has resulted in survival rates exceeding 90%. Long-term survival is associated with numerous management challenges including chronic motility disorders, dysphagia, strictures, reflux, esophagitis and attendant complications, tracheomalacia and chronic restrictive lung disease, and recurrent pulmonary infections. No guidelines for adolescents and younger or older adults exist for the treatment and monitoring of this specialized patient population. As such, patients with esophageal atresia can experience life-long sequelae of their disease and are best served by intentional transition to adult care for surveillance and monitoring, specifically for chronic lung disease, reflux, and its complications. This is best accomplished in a multidisciplinary fashion at experienced esophageal and lung centers.

Esophageal replacement in children: Challenges and long-term outcomes

Replacement of a nonexistent or damaged esophagus continues to pose a significant challenge to pediatric surgeons. Various esophageal replacement grafts and techniques have not produced consistently good outcomes to emulate normal esophagus. Therefore, many techniques are still being practiced and recommended with no clear consensus. We present a concise literature review of the currently used techniques and with discussions on the advantages and anticipated morbidity. There are no randomized controlled pediatric studies to compare different types of esophageal replacements. Management and graft choice are based on geographical and personal predilections rather than on any discernible objective data. The biggest series with long-term outcome are reported for gastric transposition and colonic replacement. Comparison of different studies shows no significant difference in early (graft necrosis and anastomotic leaks) or late complications (strictures, poor feeding, gastro-esophageal reflux, tortuosity of the graft, and Barrett's esophagus). The biggest series seem to have lower complications than small series reflecting the decennials experience in their respective centers. Long-term follow-up is recommended following esophageal replacement for the development of late strictures, excessive tortuosity, and Barrett's changes within the graft. Once child overcomes initial morbidity and establishes oral feeding, long-term consequences and complications of pediatric esophageal replacement should be monitored and managed in adult life.

Endoscopic management of esophageal stenosis in children: New and traditional treatments

Post-esophageal atresia anastomotic strictures and post-corrosive esophagitis are the most frequent types of cicatricial esophageal stricture. Congenital esophageal stenosis has been reported to be a rare but typical disease in children; other pediatric conditions are peptic, eosinophilic esophagitis and dystrophic recessive epidermolysis bullosa strictures. The conservative treatment of esophageal stenosis and strictures (ES) rather than surgery is a well-known strategy for children. Before planning esophageal dilation, the esophageal morphology should be assessed in detail for its length, aspect, number and level, and different conservative strategies should be chosen accordingly. Endoscopic dilators and techniques that involve different adjuvant treatment strategies have been reported and depend on the stricture’s etiology, the availability of different tools and the operator’s experience and preferences. Balloon and semirigid dilators are the most frequently used tools. No high-quality studies have reported on the differences in the efficacies and rates of complications associated with these two types of dilators. There is no consensus in the literature regarding the frequency of dilations or the diameter that should be achieved. The use of adjuvant treatments has been reported in cases of recalcitrant stenosis or strictures with evidence of dysphagic symptoms. Corticosteroids (either systemically or locally injected), the local application of mitomycin C, diathermy and laser ES sectioning have been reported. Some authors have suggested that stenting can reduce both the number of dilations and the treatment length. In many cases, this strategy is effective when either metallic or plastic stents are utilized. Treatment complications, such esophageal perforations, can be conservatively managed, considering surgery only in cases with severe pleural cavity involvement. In cases of stricture relapse, even if such relapses occur following the execution of well-conducted conservative strategies, surgical stricture resection and anastomosis or esophageal substitution are the only remaining options.