Reflux esophageal stricture--a review of 30 years' experience in children

Inflammatory Causes of Dysphagia in Children

Gastroesophageal reflux (GER) and eosinophilic esophagitis (EoE) are the most common inflammatory causes of pediatric dysphagia, but several other less prevalent conditions should be considered. These conditions can affect one or several aspects of the swallowing process. In some inflammatory conditions dysphagia may be an early symptom. Esophagoscopy and instrumental swallow studies are often needed to determine the underlying diagnosis and best treatment plan. In some inflammatory conditions dysphagia can portend a worse outcome and need for more aggressive treatment of the underlying condition. Consultations with speech language pathology, gastroenterology, dietetics, allergy/immunology and/or rheumatology are often needed to optimize management.

Esophageal dilation with EsoFLIP is faster than CRE balloon dilation combined with EndoFLIP in children

BACKGROUND

Controlled radial expansion (CRE) balloon dilators are traditionally used to dilate esophageal strictures during an esophagogastroduodenoscopy (EGD). EndoFLIP is a diagnostic tool used during an EGD to measure important parameters of the gastrointestinal lumen, capable of assessing treatment before and after dilation. EsoFLIP is a related device that combines a balloon dilator with high-resolution impedance planimetry to provide some of the luminal parameters in real time during dilation. We sought to compare procedure time, fluoroscopy time, and safety profile of esophageal dilation using either CRE balloon dilation combined with EndoFLIP (E + CRE) versus EsoFLIP alone.

METHODS

A single-center retrospective review was performed to identify patients ≤ 21 years of age who underwent an EGD with biopsy and esophageal stricture dilation using E + CRE or EsoFLIP between October 2017 and May 2022.

RESULTS

Twenty-nine EGDs with esophageal stricture dilation were performed in 23 patients (19 E + CRE and 10 EsoFLIP). The two groups did not differ in age, gender, race, chief complaint, type of esophageal stricture, or history of prior gastrointestinal procedures (all p > 0.05). The most common medical history in the E + CRE and EsoFLIP groups were eosinophilic esophagitis and epidermolysis bullosa, respectively. Median procedures times were shorter in the EsoFLIP cohort compared to E + CRE balloon dilation (40.5 min [IQR 23-57 min] for the EsoFLIP group; 64 min [IQR 51-77 min] for the E + CRE group; p < 0.01). Median fluoroscopy times were also shorter for patients who underwent EsoFLIP (0.16 min [IQR 0-0.30 min] for EsoFLIP dilation; 0.30 min [IQR 0.23-0.55] for the E + CRE group; p = 0.003). There were no complications or unplanned hospitalizations in either group.

CONCLUSION

EsoFLIP dilation of esophageal strictures was faster and required less fluoroscopy than CRE balloon dilation combined with EndoFLIP in children, while being equally as safe. Prospective studies are needed to further compare the two modalities.

Paediatric gastrointestinal endoscopy in the Asian-Pacific region: Recent advances in diagnostic and therapeutic techniques

There has been a rapid expansion in the knowledge of paediatric gastroenterology over the recent decade, with a fast-growing repertoire of diagnostic techniques and management strategies for a wide spectrum of childhood gastrointestinal (GI) diseases. Paediatric GI endoscopy is a core competency every paediatric gastroenterologist should possess, and represents one of the most common procedures performed in children for both diagnostic and therapeutic purposes. Yet there remains a dearth of literature on the utility and outcomes of paediatric GI endoscopy in the Asia-Pacific region. Data on the diagnostic value of paediatric GI endoscopy would be an important aspect of discussion, with the emergence of inflammatory bowel disease (IBD) and eosinophilic GI disease as increasingly common endoscopic diagnoses. Time-based trends in paediatric GI endoscopy do point towards more IBD and gastroesophageal reflux disease-related complications being diagnosed, with a declining incidence of GI bleeding. However, the real-world diagnostic value of endoscopy in Asia must be contextualised to the region-specific prevalence of paediatric GI diseases. Helicobacter pylori infection, particularly that of multidrug-resistant strains, remains a highly prevalent problem in specific regions. Paediatric functional GI disorders still account for the majority of childhood GI complaints in most centres, hence the diagnostic yield of endoscopy should be critically evaluated in the absence of alarm symptoms. GI therapeutic endoscopy is also occasionally required for children with ingested foreign bodies, intestinal polyposis or oesophageal strictures requiring dilation. Endoscopic haemostasis is a potentially life-saving skill in cases of massive GI bleeding typically from varices or peptic ulcers. Advanced endoscopic techniques such as capsule endoscopy and balloon-assisted enteroscopy have found traction, particularly in East Asian centres, as invaluable diagnostic and therapeutic tools in the management of IBD, obscure GI bleeding and intestinal polyposis. State of the art endoscopic diagnostics and therapeutics, including the use of artificial intelligence-aided endoscopy algorithms, real-time confocal laser endomicroscopy and peroral endoscopic myotomy, are expected to gain more utility in paediatrics. As paediatric gastroenterology matures as a subspecialty in Asia, it is essential current paediatric endoscopists and future trainees adhere to minimum practice standards, and keep abreast of the evolving trends in the diagnostic and therapeutic value of endoscopy. This review discusses the available published literature on the utility of paediatric GI endoscopy in Asia Pacific, with the relevant clinical outcomes.

Surgical Management of Acute Life-Threatening Events affecting Esophageal Atresia and/or Tracheoesophageal Fistula Patients

BACKGROUND

Following surgical correction, many patients with esophageal atresia with or without tracheoesophageal fistula (EA/TEF) present to the emergency department (ED) with acute airway complications. We sought to determine the incidence and risk factors for severe acute life-threatening events (ALTEs) in pediatric patients with repaired congenital EA/TEF and the outcomes of operative interventions.

METHODS

A retrospective cohort chart review was performed on patients with EA/TEF with surgical repair and follow-up at a single centre from 2000 to 2018. Primary outcomes included 5-year ED visits and/or hospitalizations for ALTEs. Demographic, operative, and outcome data were collected. Chi-square tests and univariate analyses were performed.

RESULTS

In total, 266 EA/TEF patients met inclusion criteria. Of these, 59 (22.2%) had experienced ALTEs. Patients with low birth weight, low gestational age, documented tracheomalacia, and clinically significant esophageal strictures were more likely to experience ALTEs (p < 0.05). ALTEs occurred prior to 1 year of age in 76.3% (45/59) of patients with a median age at presentation of 8 months (range 0-51 months). Recurrence of ALTEs after esophageal dilatation was 45.5% (10/22), mostly due to stricture recurrence. Patients experiencing ALTEs received anti-reflux procedures (8/59, 13.6%), airway pexy procedures (7/59, 11.9%), or both (5/59, 8.5%) within a median age of 6 months of life. The resolution and recurrence of ALTEs after operative interventions are described.

CONCLUSION

Significant respiratory morbidity is common among patients with EA/TEF. Understanding the multifactorial etiology and operative management of ALTEs have an important role in their resolution.

TYPE OF STUDY

Original Research, Clinical Research.

LEVEL OF EVIDENCE

Level III Retrospective Comparative Study.

Clinical outcome of endoscopic balloon dilatations employed in benign paediatric oesophageal pathologies

Background

Oesophageal dilatations can be done either by bougies or balloons for differing aetiologies in children. We investigated the efficacy and safety of endoscopic balloon dilatations (EBDs) employed by a single surgeon.

Patients and Methods

Relevant data over 12 years were retrospectively evaluated with an ethical committee approval.

Results

Ninety-seven children underwent 514 EBD with a median EBD of 3 (1-50). The primary diagnoses were oesophageal atresia (OA) in 51 children, corrosive ingestion in 21, peptic strictures in 13, achalasia in 8 and congenital oesophageal stenosis in 4. The balloon size varied between 3 and 30 mm. The EBD was successfully ended in 72 patients and unsuccessful in six patients. Six children are still under EBD and 13 are lost to follow-up. The overall success rate was 92%. The age at the time of first dilatation was the youngest in OA group followed by corrosive strictures. The balloon sizes differed regarding the age of the patients with larger balloons used as the patient age increased. The sizes of the balloons used at the first and the last EBD differed among diagnostic groups. The total number of dilatations or the time interval between the first and the last EBD dilatation did not show a statistically significant difference among groups. The anatomical type of OA or the height of corrosive stricture revealed no significant difference in any of the above parameters. A transmural oesophageal perforation occurred during 2 (0.4%) EBD sessions.

Conclusions

EBD is an effective mean in relieving paediatric oesophageal pathologies with a variety of aetiologies and has a low complication rate.

Endoscopic Treatment for Pediatric Esophageal Stenosis Induced by Chemical Burn, Congenitally, or After Surgical Repair of Esophageal Atresia

OBJECTIVES

To evaluate the safety and efficacy of endoscopic treatment for congenital pediatric esophageal stenosis or pediatric stenosis that develops after a chemical burn or surgical repair of esophageal atresia.

METHODS

We retrospectively reviewed the medical records of 15 pediatric patients who underwent endoscopic treatments (dilation and/or stenting and/or incision) for congenital esophageal stenosis or esophageal stenosis that developed after a chemical burn or surgical repair of esophageal atresia, between January 2010 and January 2019. The patients were periodically followed-up to assess the safety and efficacy of treatment by comparing the diameter of stricture and dysphagia score before and after procedures, and complications or recurrence.

RESULTS

All children successfully underwent the procedures. Fourteen of the 15 patients received endoscopic balloon dilation (EBD) as the first step of treatment, but EBD alone only resolved the symptoms in two patients. The remaining patients received other comprehensive treatments, such as EBD with endoscopic incision (EI), EBD with stent replacement, or a combination of EBD, stent replacement, and EI. Eleven (11/15, 73.3%) patients experienced symptomatic relief after endoscopic treatment, and recurrence was noted in four patients on 3-36 months after the final endoscopic treatment. All four patients underwent esophageal surgery to relieve their symptoms. Until October 2021, all patients experienced symptom relief, and their dysphagia scores decreased from 3-4 to 0-1 during the follow-up period of 8-121 months. The average diameter of stenosis was increased from 0.34 cm (range 0.2-0.7 cm) to 1.03 cm (range 0.8-1.2 cm). No severe complications occurred during endoscopic treatment and follow-up.

CONCLUSIONS

Endoscopic treatment is safe and effective for pediatric esophageal stenosis that is congenital or induced by chemical burns or surgical repair of esophageal atresia. Comparative large-scale studies are required to confirm our findings.

EFFICACY OF ENDOSCOPIC BALLOON DILATION IN IRANIAN PEDIATRIC PATIENTS WITH ESOPHAGEAL STRICTURE

BACKGROUND

Esophageal stenosis (ES) in children is a fixed intrinsic narrowing of the esophagus due to numerous aetiologies.

OBJECTIVE

This study aimed to determine the clinical and nutritional impacts of endoscopic balloon dilation (EBD) in Iranian children with an esophageal stricture.

METHODS

This retrospective study, pediatric patients (aged <18 years) who underwent EBD for esophageal stricture from April 2015 until March 2020 in Abuzar Children's Hospital (Ahvaz, Iran) were enrolled in the study. Outcome parameters were the frequency of dilations, nutritional status, complications, and clinical success rates. EBD was used in children with radiologic evidence of esophageal stenosis. The nutritional status was evaluated by weight-for-age (z-score). Clinical success was considered as no necessity of EBD for a minimum of one year and/or increasing interval among dilation and the frequency of EBD was less than four times per year.

RESULTS

A total of 53 cases (mean age, 4.72±3.38 years) were enrolled. There were 25 (47.2%) females and 28 (52.8%) males. During follow-up, a total of 331 EBD sessions were performed, with an average of 6.24 sessions per patient. There was one case of perforation and one case of mediastinitis, while there was no other complication or mortality. The clinical success rate of EBD therapy was 62.3% (33/53). The mean standard deviation z-score weight-for-age of patients before and after endoscopic dilation was 2.78 (2.41) and 1.18 (1.87), respectively. The t-test showed a significant difference between the weights-for-age (z-score) before and after endoscopic dilation. The majority of the patients had raised weight-for-age (z-score) after EBD treatment.

CONCLUSION

EBD attained a good clinical success rate and nutritional improvement in children with an esophageal stricture.

Acquired noncaustic esophageal strictures in children

BACKGROUND

Esophageal stricture (ES) is an uncommon clinic entity in pediatrics that may be congenital or acquired in childhood. Acquired noncaustic ES is very rare, and clinical features of affected patients are unknown.

PURPOSE

We aimed to evaluate the clinical findings, and outcomes of patients with acquired noncaustic ES to aid physicians in the early referral of patients to gastroenterologists.

METHODS

The medical data of patients with acquired noncaustic ES who were followed in our gastroenterology clinic between January 2009 and December 2019 were reviewed.

RESULTS

Acquired noncaustic ES was found in 12 of the 4,950 patients (0.24%) who underwent endoscopy during the study period. The main symptoms were dysphagia (58.3%), vomiting (33.3%), and chronic anemia (8.3%). Chronic malnutrition and underweight were found in 66.6% of the patients. The most common etiological factors were radiotherapy, peptic reflux, and achalasia (16.6%, each), while chemotherapy, squamous-cell carcinoma (SC) of the esophagus, eosinophilic esophagitis (EoE), esophageal web, epidermolysis bullosa, and esophageal diverticulum (8.2%, each) were the other etiological factors. Patients with EoE underwent endoscopic bougie dilation in addition to steroid use and elimination diet. Patients with epidermolysis bullosa and esophageal web underwent bougie dilation. Patients with peptic reflux-related ES were initially put on antireflux therapy, but during follow-up, one patient required esophageal replacement with colonic interposition. Patients with radiotherapy-related ES recovered with medical therapy. The patient with initially underwent surgical gastrostomy and tumoral mass excision. The patient then received chemotherapy and radiotherapy and underwent jejunal interposition. Patients with achalasia underwent surgical esophagomyotomy.

CONCLUSION

The presence of solid dysphagia, malnutrition, and an associated disease may alert physicians to the presence of ES.

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.

Endoscopic postdilatation application of Mitomycin C in children with resistant esophageal strictures

BACKGROUND

The esophagus is the most common part of gastrointestinal (GI) tract at the risk of stricture. Benign disorders are the leading causes of narrowing. Caustic ingestion is the most common cause of esophageal stricture in children, especially in developing countries. Clinical responses to the topical application of Mitomycin C in various medical procedures have been reported.

PURPOSE

The study aimed to evaluate the methodology, efficacy, and side effects of Mitomycin C in the treatment of esophageal strictures.

METHODS

This study included 30 children with resistant esophageal strictures. Upper GI endoscopy was performed up to the area of stricture, esophageal dilatation was done, endoscopy was repeated, and Mitomycin C was applied topically under direct endoscopic vision. The effect of the procedure was followed over a period of 3-5 years.

RESULTS

The response to Mitomycin C was excellent (clinically and endoscopically) in 28 patients (93.3%) and good (endoscopically only) in 2 patients (6.7%). No side effects of topical Mitomycin C in children with esophageal strictures were reported in this study.

CONCLUSION

Esophageal dilatation followed by local Mitomycin C application may be a useful strategy for treating resistant esophageal strictures.

Predictors of multiple readmissions or death in the first year after Nissen fundoplication in children

PURPOSE

Nissen fundoplication (NF) is commonly performed in children with gastro-esophageal reflux disease (GERD). Patients undergoing NF often have co-morbidities. Reported outcomes of NF vary considerably. This study investigated which factors might predict multiple readmissions or death in the first year following NF at our institution.

METHODS

A retrospective chart review of 187 children who underwent NF at our institution between January 2004 and December 2015 was undertaken. Underlying medical conditions, age, weight, presence of malnutrition, length of hospital stay prior to surgery and type of surgery were recorded. Patients who had more than one admission in the first post-operative year were compared to those who had one or none, and patients who died within the first post-operative year were compared to those who did not.

RESULTS

Risk factors for multiple readmissions were underlying cardiac disease (p = 0.011), esophageal atresia (EA) (p = 0.011), and esophageal stricture (p = 0.0002). Risk factors for death included younger age (p = 0.028), need for gastrostomy tube (GT) (p = 0.01) and prolonged pre-operative hospital admission (p = 0.0003).

CONCLUSION

This study identified multiple factors associated with readmission and death in the first year after NF. These findings will help with the counseling patients and caregivers regarding expectations following NF.

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.

Management of Benign Esophageal Strictures in Children

Esophageal strictures are seldom in children. In many countries, accidental ingestion of corrosives is a major cause of risk for stricture formation. Therefore, their management is a challenge. Safety and long-term efficacy of esophageal dilation for benign esophageal strictures has been confirmed in children. Because most children with structures are toddlers or younger, balloon dilatation is often preferred over bouginage. There is increasing evidence that short duration administration of high doses steroids may be of benefit in some specific situation (IIb esophagitis according to Zargar classification). Mytomycin-C application needs to be further evaluated. Stenting was reported to be successful in some refractory cases.

Paediatric Gastrointestinal Endoscopy: European Society for Paediatric Gastroenterology Hepatology and Nutrition and European Society of Gastrointestinal Endoscopy Guidelines

This guideline refers to infants, children, and adolescents ages 0 to 18 years. The areas covered include indications for diagnostic and therapeutic esophagogastroduodenoscopy and ileocolonoscopy; endoscopy for foreign body ingestion; corrosive ingestion and stricture/stenosis endoscopic management; upper and lower gastrointestinal bleeding; endoscopic retrograde cholangiopancreatography; and endoscopic ultrasonography. Percutaneous endoscopic gastrostomy and endoscopy specific to inflammatory bowel disease has been dealt with in other guidelines and are therefore not mentioned in this guideline. Training and ongoing skill maintenance are to be dealt with in an imminent sister publication to this.

Savary Dilation Is Safe and Effective Treatment for Esophageal Narrowing Related to Pediatric Eosinophilic Esophagitis

OBJECTIVES

Data on management of esophageal narrowing related to eosinophilic esophagitis (EoE) in children are scanty. The aim of the present study is to assess the safety and effectiveness of esophageal dilation in pediatric EoE from the largest case series to date.

METHODS

Children diagnosed with EoE during 2004 to 2015 were reviewed for the presence of esophageal narrowing. Esophageal narrowing was categorized as short segment narrow caliber, long segment narrow caliber, and single short stricture. The characteristics of the narrowed esophagus, therapeutic approach, clinical outcome, and complications were reviewed.

RESULTS

Of the 50 EoE cases diagnosed during the study period, 11 cases (9 boys; median age 9 years, range 4-12) were identified with esophageal narrowing (22%). Six had short segment narrow caliber esophagus and 5 had long segment narrow caliber esophagus (median length of the narrowing was 4 cm, range 3-20 cm). Three cases with narrow caliber esophagus also had esophageal stricture 2 to 3 cm below the upper esophageal sphincter. Nineteen dilation sessions were performed in 10 cases using Savary dilator. Esophageal size improved from median 7 mm to median 13.4 mm. Good response was obtained in all cases. Following the dilation procedure, longitudinal esophageal mucosal tear occurred in all cases without esophageal perforation or chest pain.

CONCLUSIONS

Esophageal dilation using Savary dilator is safe and highly effective in the management of esophageal narrowing related to EoE in children. Dilation alone does not improve the inflammatory process, and hence a combination with dietary or medical intervention is required.

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 therapy of oesophageal strictures in children - a multicentre study

INTRODUCTION

Oesophageal strictures are rare in children but may require endoscopic dilation.

AIM

To gather information on centres performing endoscopic oesophageal dilation in Poland.

MATERIAL AND METHODS

The data were obtained from questionnaires concerning the relevant data mailed to 22 paediatric endoscopy centres. Completed questionnaires were received from 11 centres.

RESULTS

In 2010 the 11 Polish paediatric endoscopy centres performed a total of 10,650 endoscopic procedures. This included 347 oesophageal dilations in 106 paediatric patients aged from 1 month to 18 years. The numbers of patients treated at individual centres ranged from 2 to 40. The indications for oesophageal dilation were as follows: postoperative strictures in 68 children, oesophageal burns in 17 children, postinflammatory strictures in 14 children, achalasia in 4 children, and strictures caused by a foreign body in 3 children. Rigid guidewire dilators were used in the majority of procedures (271), rigid dilators without a guidewire in 32 procedures, and balloon dilators in 45 procedures. A total of 203 procedures were conducted under fluoroscopic guidance, and 144 without the use of fluoroscopy. The number of dilating sessions performed in individual children varied from 1 to 6 and more.

CONCLUSIONS

Oesophageal dilation constituted a minor proportion of all paediatric endoscopic procedures. The majority of children requiring dilation were patients up to 3 years of age with postoperative oesophageal strictures. In the majority of the centres rigid guidewire dilators were used, and in one third of the procedures these dilators were introduced without fluoroscopic guidance.

Macrophage Phenotype Is Associated With the Regenerative Response in Experimental Replacement of the Porcine Esophagus

A porcine model for bridging circumferential defects in the intrathoracic esophagus has been developed in order to improve the treatment of children born with long-gap esophageal atresia. The aim of this study was to identify factors beneficial for tissue regeneration in the bridging area in this model and to describe the histological progression 20 days after replacement with a silicone-stented Biodesign mesh. Resection of 3 cm of intrathoracic esophagus and replacement with a bridging graft was performed in six newly weaned piglets. They were fed through a gastrostomy for 10 days, and then had probe formula orally for another 10 days prior to sacrifice. Two out of six piglets had stent loss prior to sacrifice. In the four piglets with the stent in place, a tissue tube, with visible muscle in the wall, was seen at sacrifice. Histology showed that the wall of the healing area was well organized with layers of inflammatory cells, in-growing vessels, and smooth muscle cells. CD163+ macrophages was seen toward the esophageal lumen. In the animals where the stent was lost, the bridging area was narrow, and histology showed a less organized structure in the bridging area without the presence of CD163+ macrophages. This study indicates that regenerative healing was seen in the porcine esophagus 20 days after replacement of a part of the intrathoracic esophagus with a silicone-stented Biodesign mesh, if the bridging graft is retained. If the graft is lost, the inflammatory pattern changes with invasion of proinflammatory, M1 macrophages in the entire wall, which seems to redirect the healing process toward scar formation.

Disease associations in eosinophilic oesophagitis and oesophageal eosinophilia

Eosinophilic infiltration into oesophageal tissue, typical of eosinophilic oesophagitis (EoE), has been described in several other conditions, including infections, hypersensitivity, and other autoimmune disorders. Since its description, EoE has been associated with an increasing number of diseases also characterized by tissue infiltration, including eosinophilic gastroenteritis and Crohn's disease. While an association between EoE and coeliac disease was previously reported, it is not supported by recent research. In contrast, EoE seems to be common in patients with a history of congenital oesophageal atresia, leading to hypotheses linking both disorders. The prevalence of EoE has also been shown to be eight times higher in patients with connective tissue disorders (CTDs), which has led to the proposal of an EoE-CTD phenotype, although this requires further assessment. This paper reviews the evidence of EoE's associations with several disorders, defining the common bases from an epidemiological, clinical, molecular and genetic perspective whenever possible.

Revisional surgery for recurrent tracheoesophageal fistula and anastomotic complications after repair of esophageal atresia in 258 infants

AIM

We assessed the occurrence and outcome of major reoperations following repair of esophageal atresia with or without tracheoesophageal fistula (TOF). Major outcome measures were survival, preservation of native esophagus, and long-term esophageal function.

METHODS

Hospital charts of 258 consecutive patients treated for esophageal atresia from 1980 to 2013 were reviewed.

RESULTS

Forty-two (16%) patients required a total of 57 reoperations after primary repair (n=37) or esophageal reconstruction (n=5). The indications were anastomotic leakage (n=17), anastomotic rupture after endoscopic dilatation (n=5), recurrent tracheoesophageal fistula (TOF) (n=12), undiagnosed proximal TOF (n=3), recalcitrant anastomotic stricture (n=11, primary anastomosis 9, reconstruction 2), undetected proximal fistula (n=3), and inadvertently perforated jejunal graft (n=1). Anastomotic leakage and rupture after dilatation were treated with rethoracotomy and suture and recurrent or undetected TOF by open repair. Strictures not manageable with repeated dilatations were resected and esophageal ends reanastomosed (n=10) or bridged with jejunum graft (n=1). Five (12%) patients required further reoperations, two after recurrent TEF (reocclusion n=1, reconstruction with gastric tube n=1), two after stricture operations (re-resection n=1, resuture after leakage n=1), and one after recurrent dilatation-related rupture. Mortality was 4/42 (10%). Two patients died of recurred leakage or TOF and two of unrelated cause. Of 38 survivors, 35 retained their native or initially reconstructed esophagus, and 3 had secondary reconstruction. After a median follow-up of 23 (range 0.6-32) years, 35 (95%) patients have acceptable esophageal function. Three patients remained dependent on gastrostomy feedings.

CONCLUSION

Anastomotic and TOF complications required a substantial number of reoperations, including esophageal reconstructions. Over 90% of the patients survived with a functioning native or reconstructed esophagus.

Outcomes at one-year post anastomosis from a national cohort of infants with oesophageal atresia

BACKGROUND AND AIMS

We aimed to provide a contemporaneous assessment of outcomes at one-year post oesophageal atresia/tracheoesophageal fistula (OA-TOF) repair, focussing particularly on post-operative complications. It is generally accepted that oesophageal stricture is the most common complication and causes significant morbidity. We also aimed to assess the efficacy of prophylactic anti-reflux medication (PARM) in reducing stricture formation.

METHOD

A prospective, multi-centre cohort study of all infants live-born with oesophageal atresia in the United Kingdom and Ireland in 2008/9 was performed, recording clinical management and outcomes at one year. The effect of PARM on stricture formation in infants with the type-c anomaly was assessed using logistic regression analysis.

RESULTS

151 infants were live-born with oesophageal atresia in the defined reporting period, 126 of whom had the type-c anomaly. One-year follow-up information was returned for 105 infants (70%); the mortality rate was 8.6% (95% CI 4.7-14.3%). Post-operative complications included anastomotic leak (5.4%), recurrent fistula (3.3%) and oesophageal stricture (39%). Seventy-six (60%) of those with type-c anomaly were alive at one-year with returned follow-up, 57(75%) of whom had received PARM. Of these, 24 (42%) developed a stricture, compared to 4 (21%) of those who had not received PARM (adjusted odds ratio 2.60, 95% CI 0.71-9.46, p = 0.147).

CONCLUSIONS

This study provides a benchmark for current outcomes and complication rates following OA-TOF repair, with oesophageal stricture causing significant morbidity. The use of PARM appeared ineffective in preventing strictures. This study creates enough doubt about the efficacy of PARM in preventing stricture formation to warrant further investigation of its use with a randomised controlled trial.

Modifications in endoscopic practice for pediatric patients

We recommend that endoscopy in children be performed by pediatric-trained endoscopists whenever possible. We recommend that adult-trained endoscopists coordinate their services with pediatricians and pediatric specialists when they are needed to perform endoscopic procedures in children. We recommend that endoscopy be performed within 24 hours in symptomatic pediatric patients with known or suspected ingestion of caustic substances. We recommend emergent foreign-body removal of esophageal button batteries, as well as 2 or more rare-earth neodymium magnets. We recommend that procedural and resuscitative equipment appropriate for pediatric use should be readily available during endoscopic procedures. We recommend that personnel trained specifically in pediatric life support and airway management be readily available during sedated procedures in children. We recommend the use of endoscopes smaller than 6 mm in diameter in infants and children weighing less than 10 kg. We recommend the use of standard adult duodenoscopes for performing ERCP in children who weigh at least 10 kg. We recommend the placement of 12F or 16F percutaneous endoscopic gastrostomy tubes in children who weigh less than 50 kg.

Esophageal endoscopic dilations

OBJECTIVE

Esophageal strictures in children are serious and require specialized care. Peptic stricture is most common in our context, whereas caustic and congenital strictures are rare. The present study reports our experience in esophageal endoscopic dilation while specifying the causes of esophageal strictures as well as their response to endoscopic treatment.

METHODS

This is a case study during a period of 7 years, in which 60 cases of esophageal stricture were treated with endoscopic dilation by Savary-Gilliard bougies. Our patients were divided into 3 groups: group A for peptic strictures (52 patients), group B for caustic strictures (4 patients), and group C for strictures subsequent to esophageal atresia surgery (4 patients). The age of patients was between 10 months and 17 years. Dysphagia was the main symptom and was the major reason for consultation. Two hundred forty-seven dilation sessions were performed, with an average of 4 sessions per patient ranging from 1 to 15 sessions. The maximum score was observed in group B (50%). Expansion was performed under deep sedation.

RESULTS

We had 2 esophageal perforations: 1 in group A and 1 in group B. A good response was obtained in group A (70%) and B (50%). The patients in group C still required repeated sessions.

CONCLUSIONS

Esophagus endoscopic dilation is an effective technique, especially in peptic stricture, with no need of surgery in some cases. In addition, perforation was rare in this group.