Fluoroscopically guided large balloon dilatation for treating congenital esophageal stenosis in children

Fluoroscopy-guided balloon dilatation of benign esophageal strictures in children: 11-year experience

BACKGROUND

The esophageal stricture is an important clinical problem in children, and the treatment is difficult.

OBJECTIVE

To evaluate the results of fluoroscopy-guided balloon dilatation of benign pediatric esophageal strictures and to suggest a safety range for balloon diameters.

MATERIALS AND METHODS

We retrospectively reviewed the medical records of children who underwent fluoroscopy-guided esophageal balloon dilatation for treatment of benign esophageal stricture from February 2008 to July 2019. We recorded the demographic data of the children, technical details of each procedure, balloon diameter, number of repeated procedures, clinical and technical success rates, complications and follow-up period. Technical success was defined as the disappearance of the waist formation on the balloon catheter, and clinical success was defined as no need for re-dilation or other treatment methods during the 1-year follow-up after the procedure. These children were divided into groups and evaluated according to esophageal stricture etiology.

RESULTS

Technically successful procedures included 375 balloon dilatations in 116 patients (67 boys; age range: 1 month to 18 years; mean age: 4.3 ± 4.8 standard deviation [SD] years at the initial dilatation). The follow-up period was 1-138 months (median: 41 months; mean: 44 months) since the last dilatation. In this study, the clinical success rate was 34% per procedure (120 of 353 procedures) and 85% per patients (91 of 107 patients). The total complication rate per procedure was 0.5%, and the perforation rate was 0.25% per session.

CONCLUSION

Fluoroscopy-guided esophageal balloon dilatation is an effective and reliable method for treating benign esophageal strictures in children.

Management and clinical outcomes of congenital esophageal stenosis in pediatric patients: Experience of a tertiary referral center

PURPOSE

This study aimed to retrospectively investigate congenital esophageal stenosis (CES) cases managed at our institution using a non-aggressive strategy based on a step-up approach from esophageal balloon dilatations to surgery.

METHODS

Patients' charts with CES managed in a tertiary pediatric surgery department were retrospectively evaluated. Demographic characteristics, clinical features, pH-monitoring, imaging, and esophagoscopy results were recorded together with their treatments and outcomes.

RESULTS

Nineteen patients, confirmed with radiologic and endoscopic investigations, were managed. Complete symptom resolution was achieved in 14 patients by a median of five (2-15) recurrent esophageal balloon dilatations lasting for 7.5 (2-108) months. Two more patients, after 7 and 15 dilatations, had mild dysphagia, not interfering with their daily living. One patient, in whom the initial dilatation attempt with 3 atm was unsuccessful, and two patients with persistent symptoms and growth retardation despite ongoing dilatation treatment, underwent surgery. After 48 (12-132) months of follow-up, 17 patients were symptom-free.

CONCLUSION

Conservative treatment with esophageal balloon dilatations is an efficient and reliable modality that can be used as a first-line treatment in CES. Surgical treatment option should be used when dilatation attempt is unsuccessful, or symptoms and growth retardation persist despite dilatation treatment.

Characteristics and treatment of congenital esophageal stenosis: A retrospective collaborative study from three Japanese children's hospitals

BACKGROUND/PURPOSE

There is no consensus on treatment strategy of congenital esophageal stenosis (CES). This study aimed to assess appropriateness of the treatment we have provided to patients with CES over the past four decades.

METHODS

We carried out a retrospective chart review of 83 CES patients treated at three children's hospitals between 1973 and 2015. Each patient underwent an initial treatment with either surgery or a series of dilation that was followed by surgery if dilation failed to improve esophageal transit. Demographic data, course of treatment, outcomes, and complications were analyzed.

RESULTS

During this initial treatment, 19 and 64 patients underwent surgery and dilation, respectively. Out of the 64 patients who underwent dilations as an initial treatment, 26 patients eventually required surgery. Out of all patients who required surgery (19 initial treatments + 26 failed dilations), 29 had tracheobronchial remnants and 16 had fibromuscular hypertrophy. Six patients experienced esophageal perforation during dilation and ten experienced anastomotic leakage after surgery. No patients had swallowing difficulties at the latest follow up, 141(9-324) months.

CONCLUSIONS

Dilation is recommended as an initial therapy, especially if histological diagnosis of CES is uncertain. Persistent swallowing difficulties after 2 series of dilation may be an indication for surgery.

LEVELS OF EVIDENCE

level IV.

Laparoscopic-Assisted Longitudinal Incision and Transverse Anastomosis: A Novel Surgical Approach for Treatment of Esophageal Stenosis Caused by Tracheobronchial Remnants

Purpose: To review the treatment of lower congenital esophageal stenosis caused by tracheobronchial remnants (TBR) and to introduce a novel technical approach through laparoscopic surgery. Methods: Patients with TBR who underwent surgery in our single-center from January 2016 to December 2019 were enrolled. Resection of cartilage with stenotic esophageal segment and end-to-end anastomosis was the traditional surgery. Since 2018, longitudinal incision with partial resection of cartilage loop in the anterior esophageal wall and the transverse suture was conducted endoscopically. We reviewed the treatment, followed-up with these patients, and discussed the new procedure's preponderance. Main Results: Thirteen patients underwent surgery and were followed-up for 0.5-45 months (M = 13) after surgery. Twelve patients showed good physical development with a regular diet. One patient, who was 2 weeks after the surgery, was fed by a soft diet and regularly followed-up at our clinic. In 13 cases, five patients underwent traditional laparotomy with pyloroplasty. Two patients who went through anastomotic leakage were cured by drainage and conservative treatments. Anastomotic stricture that occurred in two cases was improved by one-time of dilation. The administration time of parenteral nutrition (PN) was 9.0 ± 1.4 days. The length of hospitalization was 36.6 ± 5.2 days. Eight cases underwent the new surgical approach through laparoscopy or thoracoscopy. Pyloroplasty was avoided since the vagal close to the posterior wall of the esophagus was protected. Gastric motility disorder did not occur as expected. No leakage occurred postoperatively. The anastomotic stricture was found in six cases and improved after one to five times of dilations. The length of hospitalization dropped to 18.6 ± 6.9 days significantly (P < .001). Conclusions: Longitudinal incision and transverse anastomosis of the anterior wall of the esophagus with partial resection of cartilage without pyloroplasty through endoscopy is a novel practical surgical approach to treat patients with TBR.

Complications of esophageal strictures dilatation in children. A tertiary-center experience

OBJECTIVES

To report the results of endoscopic dilatation of esophageal strictures in children, its complications, and their management. The outcomes of esophageal dilatation differ according to the underlying etiology.

METHODS

The study included 46 patients who underwent esophageal dilatation between 2014-2019. All patients underwent a contrast study of the esophagus before endoscopic dilation to determine the location, number, and length of the narrowing. In addition, the type of dilators (balloon versus semi-rigid dilators), the number of dilatation sessions, the interval between them, and the duration of follow-up were also documented. The median age was 2.47 years, and 26 patients were females. Dysphagia was the main presenting symptom, and the leading cause of stricture was esophageal atresia.

RESULTS

The main treatment modality was endoscopic balloon dilatation (n=29, 63%). The esophageal diameter was significantly increased after dilation (9 [7-11] versus 12 [10-12.8]) mm; p less than 0.001). Topical mitomycin-C was used as adjuvant therapy in 3 patients (6.5%). Esophageal perforation was reported in 2 cases (4.3%). Patients needed a median of 3 dilatation sessions, 25-75th percentiles: 1-5, and the median duration between the first and last dilatation was 2.18 years 25-75th percentiles: 0.5-4.21.

CONCLUSION

Esophageal dilatation is effective for the management of children with esophageal stricture; however, repeated dilatation is frequent, especially in patients with corrosive strictures. Complications are not common, and open surgery is not frequently required.

Congenital esophageal stenosis: a rare malformation of the foregut

Congenital esophageal stenosis (CES) is a type of esophageal stenosis, and three histological subtypes (tracheobronchial remnants, fibromuscular thickening or fibromuscular stenosis, and membranous webbing or esophageal membrane) are described. Symptoms of CES usually appears with the introduction of the semisolid alimentation. Dysphagia is the most common symptom, but esophageal food impaction, respiratory distress or failure to thrive can be clinical manifestations of CES. Wide spectrum of differential diagnoses leads to delayed definitive diagnosis and appropriate treatment. Depends on hystological subtype of CES, some treatment procedures (dilation or segmental esophageal resection) are recommended, but individually approach is still important in terms of frequency and type of dilation procedures or type of the surgical treatment. Dysphagia can persist after the treatment and a long follow-up period is recommended. In 33% of patients with CES, a different malformations in the digestive system, but also in the other systems, are described.

Clinical and nutritional outcome of pediatric esophageal stenosis with endoscopic balloon dilatation

AIM

The present study evaluates the long-term clinical and nutritional effect to endoscopic balloon dilatation (EBD) in pediatric esophageal stricture.

METHODS

This was a 15-year retrospective study involving pediatric patients with esophageal stricture treated with EBD. Outcome parameters included the number of dilatations, procedural success rates, nutritional status, and complications. EBD was performed in patients with a dysphagia score greater than 2. The nutritional status was assessed by weight-for-age z-score. Clinical success was defined as no requirement for EBD for at least 1 year and/or increasing interval between dilatation and the numbers of EBD was fewer than 4 times per year.

RESULTS

A total of 50 cases (mean age, 4.41 ± 4.9 years) were enrolled. During a mean follow-up of 3.2 ± 1.9 years, a total of 268 EBD sessions were performed, with an average of 5.36 sessions per patient (range, 1-33). Patients who had short segment stricture (<2 cm) were prone to achieve clinical success after EBD (p = 0.0094). Procedural perforation rate is 2.6% (7/268); subsequent tracheoesophageal fistula occurred in two patients. The clinical success rate of EBD therapy was 72% (36/50). All had increments of weight-for-age z-score after EBD therapy, and the increment was significantly greater in those patients with short segment stricture or stricture in the middle esophagus at 12 months (p = 0.01 and 0.008, respectively).

CONCLUSIONS

EBD has good long-term clinical success and nutritional promotion in pediatric patients with esophageal stricture, especially in short segment stricture or stricture in the middle esophagus.

Efficacy and safety of endoscopic dilatation in the management of esophageal strictures in children

Objectives:

To determine the outcomes of endoscopic dilatation of esophageal strictures in children.

Methods:

Children younger than 18 years of age diagnosed with esophageal strictures over a period of 7 years (June 2010 to June 2017) were reviewed and analyzed retrospectively. The study took place at King Khalid University Hospital, Riyadh, Saudi Arabia. The patients’ clinical characteristics, endoscopic findings, and details of the strictures, treatment, and outcomes were documented.

Results:

Forty-three children with esophageal strictures were identified (median age, 8.1 years; range, 2-17 years; 23 [53.5%] boys). The median age at presentation was 2 years (range, 1-16 years), and the median follow-up period was 3 years (range, one month-17 years). Tracheoesophageal fistula (n=14, 32.6%), gastroesophageal reflux disease (n=10, 23.3%) and eosinophilic esophagitis (n=8, 18.6%) were the leading causes of esophageal strictures. Forty-three patients underwent 180 dilatation sessions; the median number of dilatation sessions per patient was 3 (range, 1-48), and the median interval between sessions was 8 weeks (range, 1-24 weeks). Among 180 dilatation sessions, 3 events (1.7%) of esophageal perforation were observed. The outcomes varied depending on the primary cause of the stricture; complete response was achieved the best in eosinophilic esophagitis-related strictures (87.5%), followed by anastomotic strictures post tracheoesophageal fistula repair (71.4%) and gastroesophageal reflux disease-related strictures (70%).

Conclusion:

Endoscopic dilatation is a safe and effective intervention in the management of esophageal strictures in children, with minimal complications when conducted by experts.

Complications in pediatric endoscopy

The experience of the "endoscopic community" in pediatric patients is limited, but during recent years increased skills of the endoscopists and technological improvements lead to a standardization of pediatric endoscopy and the development of specialized pediatric endoscopy unit. Adverse events related to diagnostic and therapeutic endoscopy in children are usually rare. Diagnosis, prevention and treatment of complications in pediatric endoscopy is crucial when dealing with benign diseases in children. The complication rate of diagnostic EGD and colonoscopy in children are extremely low. Therapeutic procedures have obviously an increased rate of adverse events. Esophageal dilations are the most common indication for endoscopic therapy in children and can lead to perforations which requires prompt diagnosis and management. Complications of ERCP in pediatric age are similar to those reported in adults. The experience in pediatric emergency endoscopy (mainly foreign body removal) is consolidated and related adverse events extremely rare. Sedation of children during endoscopy maybe needs further evaluation and standardization, to reduce the rate of specific complications.

Steroid pulse therapy prevents restenosis following balloon dilatation for esophageal stricture

PURPOSE

This study aimed to evaluate the effectiveness of intravenous steroid pulse therapy following balloon dilatation for esophageal stenosis and stricture in children.

METHODS

The study enrolled six children, including three with congenital esophageal stenosis and three with anastomotic strictures after surgery for esophageal atresia, all of whom were treated by balloon dilatation combined with high-dose intravenous methylprednisolone pulse therapy. Methylprednisolone was injected intravenously at a dose of 20 mg/kg/day for 2 days, starting from the day of dilatation, followed by 10 mg/kg/day for 2 days, for a total of 4 days.

RESULTS

Esophageal stricture recurred in all three patients with congenital esophageal stenosis despite repeated balloon dilatation without methylprednisolone. However, the symptoms of dysphagia improved and did not recur after systemic steroid pulse therapy following balloon dilatation. Symptoms also resolved in all three patients with anastomotic strictures following balloon dilatation with systemic steroid pulse therapy. All six patients remained asymptomatic after 6-21 months follow-up, with no complications.

CONCLUSION

Intravenous methylprednisolone pulse therapy following balloon dilatation is safe and effective for the treatment of esophageal stenosis and strictures in children.

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.