Congenital esophageal stenosis due to tracheobronchial cartilage

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.

Isolated congenital esophageal stenosis

The incidence of congenital esophageal stenosis (CES) is approximately 1 in 25,000 to 50,000 live births. There is associated esophageal atresia in one third of cases; the remainder are classified as isolated CES. Histologically, the anomaly may include tracheobronchial remnants, a membranous diaphragm, or diffuse fibrosis of the muscularis and submucosa. The authors report their experience with three patients who had isolated CES. The patients were free of symptoms for the first 6 months of life. All had difficulty with feeding from 6 to 12 months of age, which corresponded with the introduction of solids. Most solid feedings were regurgitated. Evaluation consisted of cine-esophagogram, pH monitoring, manometry, and endoscopy, with biopsies to exclude the diagnosis of gastroesophageal reflux. All patients underwent hydrostatic dilatation, but the benefit was only transient. The patients were referred for surgical correction when symptoms recurred. Limited resection of the esophageal stenosis with primary anastomosis was performed on all three patients via a left thoracotomy. The stenoses were located in the distal third of esophagus, near the junction with the middle third. Pathological examination showed tracheobronchial remnants in one patient and fibrotic muscle in the other two. The average age at the time of surgery was 19 months. The hospital stay averaged 8 days. The contrast study 1 week postthoracotomy showed esophageal patency in all patients, with no leakage. All were discharged from the hospital, tolerating solid food. CES should be sought for in patients who present with dysphagia to solid food that begins after the first 6 months of life.(ABSTRACT TRUNCATED AT 250 WORDS)

Congenital esophageal stenosis due to tracheobronchial remnants: a rare but important association with esophageal atresia

Congenital esophageal stenosis caused by tracheobronchial remnants occurred in eight children, six of whom had associated esophageal atresia and/or tracheoesophageal fistula. Symptoms usually began in early infancy but delayed diagnosis was a common feature. The mean lag period between presentation and definitive operation was 4.6 years (range, 1 month to 16 years). Errors in diagnosis were common. Six were initially diagnosed as having inflammatory strictures secondary to reflux esophagitis. Seven children were subjected to repeated esophagoscopy and bouginage of the "stricture" (mean no. = 3.4), with invariable failure to ameliorate dysphagia. Antireflux procedures were performed in three patients. In all children, symptoms were dramatically relieved following resection of the stenotic segment or esophageal replacement. Although a rare entity, congenital esophageal stenosis due to tracheobronchial remnants should be considered a possibility in patients with esophageal stricture, presumed to be inflammatory in nature, which fails to respond to standard therapy.