Surgical treatment of esophageal stricture secondary to gastroesophageal reflux

High dose intravenous methylprednisolone resolves esophageal stricture resistant to balloon dilatation with intralesional injection of dexamethasone

One of the most serious problems in patients with long-gap esophageal atresia or corrosive esophagitis is esophageal stricture, which may require esophageal resection and replacement. We describe two cases with persistent esophageal stricture successfully managed by high dose intravenous methylprednisolone following balloon dilatation. High-dose methylprednisolone with gradual tapering (daily 25, 15, 10, 5, 2 mg/kg for 4 days each) plus cimetidine and ampicillin for 1 week was intravenously administrated immediately after balloon dilatation of the esophageal stenosis. This was followed by oral prednisolone (daily 2, 1, 0.5 mg/kg for 1 week each) for persistent esophageal stricture. High dose intravenous methylprednisolone therapy was given to two patients. One patient was a 5-year-old boy with long-gap esophageal atresia who had undergone repair of the esophagus resulting in severe anastomotic stenosis of 3 cm in length. The other case was a 10-year-old boy with corrosive stenosis caused by alkali ingestion. Both patients had been requiring balloon dilatation of the esophagus with intralesional injection of dexamethasone every 3 weeks for more than 1 year to tolerate oral feeding. After the high-dose methylprednisolone protocol was initiated, the symptoms of dysphagia or choking dramatically improved in both patients, and they remained symptom-free for 8 and 7 months. There were complications of moon faces that resolved concomitantly with the withdrawal of oral prednisolone in both cases. High dose intravenous methylprednisolone in addition to intralesional injection of dexamethasone following balloon dilation is an effective therapeutic strategy for persistent esophageal strictures.

Gastroesophageal reflux strictures in children, management and outcome

Esophageal reflux (GER) strictures are frequently diagnosed late and require a prolonged management programme depending on the severity of the stricture. Management protocols include medical therapy, bouginage, fundoplication, stricture resection and even interposition grafting. Our preferred method is to delay the anti-reflux surgery until the esophagitis is medically controlled, adequate enteral intake with weight gain is achieved and the oesophageal narrowing adequately dilated. We review the results of the approach over a 27-year period (1977-2004).

METHOD

Thirty-one children were treated (mean age at diagnosis 35 months). Diagnosis of GERD was made on barium meal and confirmed by pH studies, gastroesophageal scintigraphy and oesophagoscopy. Stenosed site, its length and nature (i.e. response to dilatation) were documented. Dilatations were carried by prograde, balloon and string-guided techniques. Three fundoplication techniques were used (Boix-Ochoa, Toupet and Nissen).

RESULTS

Twenty-two strictures were in the lower third, seven in the mid-third and two in the upper third of the oesophagus. Thirteen (42%) had associated hiatus hernia (HH). Twenty (64%) had a stricture length>3 cm. Twelve strictures were so severe (tight) as to require gastrostomy and string-guided dilatation. An average 5.5 dilatations were required prior to surgery. Only six children did not require post-surgery dilatation. Twelve required more than five post-operative dilatations. Reasons for stricture persistence were identified as failed reflux surgery in seven, candida oesophagitis in two, HIV infection in one and severity of fibrosis in three (two requiring stricture resection). At average follow-up of 5 years, all patients have restored growth without further symptoms.

CONCLUSION

Strictures are a major complication of GER requiring prolonged and intensive management in most cases. Reasons for persistence of stricture after anti-reflux surgery can be identified and require early intervention. Long-term follow-up is essential but results have been good in our hands.

Gastric smooth muscle contractility changes in the esophageal atresia rat model: an in vitro study

PURPOSE

The aim of the study was to investigate the gastric smooth muscle reactivity in the Adriamycin-induced esophageal atresia (EA) rat model.

METHODS

The fetuses were divided into 3 groups. The control group was exposed to saline. The second group was comprised of fetuses that were exposed to Adriamycin but did not have EA (Adriamycin-no-EA group). The third group was comprised of fetuses that were exposed to Adriamycin and had EA (Adriamycin-EA group). Gastric fundus strips were studied in vitro for their contractile response to receptor activation in the 3 groups.

RESULTS

Contractile responses of gastric smooth muscle to carbachol and KCl were increased in the Adriamycin-EA group compared with the Adriamycin-no-EA group. Also serotonin-induced contractile response in the Adriamycin-EA group decreased compared with the Adriamycin-no-EA group. Relaxation of gastric smooth muscle strips to isoproterenol was comparably unaffected in the Adriamycin-EA and Adriamycin-no-EA groups. Likewise, no change in the response to agonist studies was observed between the control and Adriamycin-no-EA groups. The relaxant response to papaverine was not different in the 3 groups.

CONCLUSIONS

This study found changes of receptor-dependent and receptor-independent contraction of the gastric fundus smooth muscle in the fetuses with EA. Therefore, impaired contractile responses may be, at least in part, a contributing factor in the abnormal gastric motility seen in EA.

Current surgical considerations in gastroesophageal reflux disease in infancy and childhood

An understanding of gastroesophageal reflux disease in infants and children by the clinician requires a working knowledge of 18- to 24-hour esophageal pH monitoring and the motility disorders of the esophagus and stomach that may be associated with gastroesophageal reflux disease. The results of surgical therapy for childhood gastroesophageal reflux disease cannot be assessed accurately without this knowledge. Antireflux operations can be tailored to the child's situation, which includes a combination of clinical symptoms and findings on objective tests for reflux and associated alimentary-tract motility disorders. The presence of severe complications from gastroesophageal reflux disease in "asymptomatic" infants and children is a troublesome and not yet fully defined problem. Special areas include the documentation of gastroesophageal reflux disease as a cause of SIDS, the increased reporting of Barrett's esophagus and adenocarcinoma of the esophagus in childhood, and the effect of associated alimentary-tract motility disorders in children with CNS disease who have gastroesophageal reflux disease requiring surgical intervention.

Reflux strictures of the esophagus in children

Although the therapeutic approach to gastroesophageal reflux in children is well established, there are differences of opinion regarding the management of esophageal strictures, viz bougienage with medical therapy, fundoplication without dilatation, preoperative dilatation followed by fundoplication with intraoperative and postoperative dilatation, or resection and interposition. Sixteen consecutive children (mean age, 30.2 months) with reflux strictures were evaluated, constituting 12% of children operated on for gastroesophageal reflux. The strictures became clinically apparent 22.4 months (mean) from the onset of symptoms and were diagnosed by contrast studies and endoscopy. At first endoscopy all the patients had well-established fibrotic strictures. The strictures were mostly situated in the middle or lower esophagus and 7 were longer than 3 cm in length. All 16 were treated with antacids, H2-receptor blockers (Cimetidine), prokinetic agents, and intense nutritional resuscitation, together with preoperative stricture dilatations (average, 3.6 times). This was followed by fundoplication when nutritional parameters had been restored, esophagitis improved, and the strictures dilated to adequate size. Seven children required concomitant gastrostomies for prograde esophageal dilatations. Twelve children needed postoperative esophageal dilatations. The results were satisfactory in 14 (88%). Two required endoesophageal resection for localized unyielding strictures. One child responded only after failed reflux surgery was corrected at a second procedure. During an average follow-up of 8.2 years (range, 3 to 11) there has been no stricture recurrence and growth velocity was restored in all. We conclude that our preferred method is preoperative in-hospital management of gastroesophageal reflux with maximum nutritional support and careful evaluation of the degree and extent of esophagitis and fibrous scarring.(ABSTRACT TRUNCATED AT 250 WORDS)

Persistence of Barrett's esophagus in children after antireflux surgery: influence on follow-up care

Adenocarcinoma arising in Barrett's esophagus has recently been described in two children aged 11 and 14 years. The long-term follow-up of Barrett's esophagus in children is not well described. We evaluated 16 cases of Barrett's esophagus in children treated at this institution during the last 16 years. Ages ranged from 1.2 to 16 years (mean, 10.3 years). There were 11 boys and 5 girls. Barrett's esophagus was documented by endoscopy in 14 instances and at autopsy in 2 patients with secretory diarrhea and tetralogy of Fallot who died of sepsis. Two children had cancer (neuroblastoma, leukemia) and died of their malignant disease. Five patients had cerebral palsy, 1 esophageal atresia, 1 Fanconi's anemia, and 5 were otherwise normal children. Six were treated medically. Eight patients underwent Nissen fundoplication for complications of gastroesophageal reflux (GER). Five patients were available for follow-up endoscopy (mean, 2 years; range, 1.1 to 5.4 years). Endoscopy was performed on a yearly basis, obtaining biopsy specimens from multiple levels of the esophagus. Four children had satisfactory clinical response to an antireflux procedure including the resolution of a stricture in one case. However, in all 5 cases persistent metaplastic epithelium was documented and showed no evidence of regression. Although there has been speculation that Barrett's esophagus in children may be more likely to revert to normal squamous epithelium than in the adult, there has been only one case of regression in 180 cases of Barrett's esophagus occurring in children described in 37 reports in the literature.(ABSTRACT TRUNCATED AT 250 WORDS)

Oesophageal stenosis distal to oesophageal atresia

Oesophageal atresia with or without tracheo-oesophageal fistula is often associated with a functionally abnormal distal oesophagus. The association of oesophageal atresia and a distal oesophageal stenosis is less well recognized and is usually regarded as a rarity. We describe four cases of oesophageal stenosis distal to oesophageal atresia and review the literature relating to this condition.

Surgical treatment of reflux stricture of the esophagus

Ten children, aged 7 months to 15 years, with peptic esophageal stricture, were treated surgically. In four of the children, the stricture had occurred after esophageal anastomosis. Peptic stricture was diagnosed by esophagography, pH monitoring, manometry, and esophagoscopy. Barrett's esophagus was found in two children. Nine children underwent transabdominal Nissen fundoplication initially. In the first child of this series, a tight anastomotic stricture had been excised 2 weeks before fundoplication. Seven children became complaint-free within 2 or 3 months after fundoplication without any dilatation, and two children with anastomotic stricture improved after 1 or 2 postoperative dilatations. The condition of one boy, with a 6-year history of tight stricture, did not improve with repeat Nissen and subsequent dilatations. Histological examination showed proliferation of smooth muscle cells in the submucosa. A conservative surgical approach is effective for the management of peptic esophageal stricture in children, and direct surgical intervention for stricture should be attempted only in cases of stricture resistant to antireflux surgery with a long history of reflux.

Successful management of esophageal strictures without resection or replacement

Esophageal resection or replacement has become the standard therapy for severe esophageal strictures chiefly because less aggressive methods generally have failed. We hereby report our experience with 12 consecutive infants and children who have been managed successfully by means of Stamm gastrostomy and string-guided esophageal dilatation, coupled with endoscopically guided four-quadrant intralesional steroid injection, protected by Nissen fundoplication when gastroesophageal reflux has been demonstrated. In six patients, the stricture(s) were caused by ingestion of lye. In five, they were associated with repair of esophageal atresia. In one, the etiology was never determined. The strictures averaged 3.5 cm in length (range, 1 to 10 cm); the severity of the lesions was indicated by the fact that, in all instances, patients were completely intolerant of solids, and was confirmed fluoroscopically by demonstration of significant luminal narrowing. A mean of 4.3 steroid injections (range, 1 to 8) was required to obtain complete remission of symptoms; there have been no complications except in one lye ingestion patient who developed a tiny perforation following the initial dilatation, which responded to antibiotics alone. All patients remain symptom-free; the mean length of follow-up is 6.2 years (range, 1 to 11 years). We conclude that string-guided esophageal dilatation, when coupled with endoscopically guided steroid injection, is a safe and reliable method for treatment of severe esophageal strictures, which should obviate the need for esophageal resection or replacement in most patients. Moreover, even if treatment should ultimately fail, a procedure of lesser magnitude than esophageal replacement will likely be possible.(ABSTRACT TRUNCATED AT 250 WORDS)

Evaluation of lower esophageal sphincter function in infants and children following esophageal surgery

Esophageal manometry was performed before and after the operations for esophageal disorders in children to evaluate lower esophageal sphincter (LES) function and motility of the esophagocardiac region in each disease. Patients who underwent radical operations for gross C-type esophageal atresia (EA) and those with hiatal hernias considered to have gastroesophageal reflux (GER) showed reduction in LESP and LESL and eosphagocardiac motor abnormalities. Lower esophageal sphincter pressure and length, and motility of the esophagocardiac region improved in six patients who underwent an antireflux operation. Abnormal esophageal waves in EA patients persisted even after improvements in LES function by the antireflux operation and were considered to be a congenital problem, as the literature suggests. Effects of surgical intervention on the esophagus on the LES function were studied. Lower esophageal sphincter and esophagocardiac function were preserved, and GER did not develop after Livaditis' procedure for EA or esophageal transection and sectioning the esophageal branch of the vagus nerve for esophageal varices. Anatomic abnormalities that lead to LES dysfunction are considered to cause GER.

Disorders of the esophageal motor activity in atresia of the esophagus

Esophageal dysfunction has been reported after successful repair of esophageal atresia but its nature has not been clearly defined. We studied esophageal motility in 20 newborns with esophageal atresia by recording intraluminal pressure of both proximal and distal segments. The investigation was made by pressure monitoring of the upper pouch via the mouth and of the distal segment via the gastrostomy. In all cases we found motility disorders. Two patients (12.5%) showed incomplete relaxation of the upper esophageal sphincter. The resting pressure of the esophageal body in both segments was constantly positive in all cases. Lower esophageal sphincter (LES) function was normal in all but two patients (16.7%) in whom the LES pressure was reduced and one case (8.4%) with incomplete relaxation of the LES. These studies suggest that motility disorders are also present in esophageal atresia before surgery.

Results and complications of surgery for gastro-oesophageal reflux

One hundred and six children undergoing antireflux surgery were studied; 41 were severely mentally retarded and 29 had reflux strictures. Although the eventual rate of success was 92%, 20 patients developed complications that required a second operation. Prolapse of the fundoplication into the mediastinum was the commonest complication (in seven patients), followed by intestinal obstruction (in five), and intractable fibrous oesophageal strictures (in five). The incidence of postoperative complications was highest in patients with mental retardation or oesophageal strictures. Referral of these patients for operation was invariably delayed, and earlier referral may have avoided many of the complications.

Measurement of esophageal reflux by scintigraphy

Gastroesophageal reflux and clearance of the refluxed material can be measured by plotting a time-activity curve from an esophageal area of interest after 1 mCi of 99mTc sulfur colloid is placed in the stomach. Control subjects do not have peaks exceeding a value twice that of the baseline count levels. Reflux patients exceed this value, either spontaneously or after Valsalva maneuvers. This technique has a sensitivity which is greater than that of barium and equal to the sensitivity of a pH probe in patients with both moderate and severe reflux. Scintigraphic reflux was shown in 62% of moderate refluxes and 85% of those with severe reflux as defined clinically. Clearing of the refluxed material occurs rapidly in most patients if measured by this scintigraphic technique. This test can be performed rapidly with minimal radiation exposure and is noninvasive.

Follow-up studies on patients undergoing Nissen fundoplication utilizing intraoperative manometry

Intraoperative esophageal manometry has been developed for use in children as a guide to optimizing the surgical results of Nissen fundoplication. Eighty-two Nissen fundoplication operations were performed using intraoperative manometry. Follow-up manometry was performed within 6 wk postoperatively in 45 patients and later than 6 wk postoperatively in 33 patients. The mean preoperative lower esophageal sphincter pressure (LESP) was 13 mm Hg. The mean postoperative LESP was 42 mm Hg. LESP was found to drop in the early postoperative period nearly 40%. There was minimal further decline in LESP between the early and late follow-up determinations. Lower esophageal sphincter length (LESL) was measured both pre- and postoperatively in 56 patients with an average increase of 1.4 cm. There was a very mild decline in LESL in the late follow-up period. The clinical course of these patients was correlated with manometric findings. The routine use of gastrostomy has been found to be unnecessary.

Surgical management of reflux strictures of the esophagus in childhood

The etiology of gastroesophageal reflux (GER) in infancy is related to developmental factors, and there is a high incidence of associated conditions such as neurologic syndromes and esophageal atresia (60%). This is different from the situation in adults. Experience with 18 consecutive children with peptic esophageal strictures is reviewed to determine if conservative surgical management is effective. Eighteen children 14 months to 13 years (mean 6.3 years) of age took an average of 3.5 years from the time of onset of symptoms of GER to develop tight strictures diagnosed by esophagography and esophagoscopy. The incidence of stricture in patients with GER was approximately 15%. Preoperative dilation or direct surgical management prior to correction of reflux is ineffective. All 18 children were managed by intraoperative dilatation, Nissen fundoplication, and guided dilatation after operation. More aggressive surgical procedures were not required nor were associated operations such as pyloroplasty; they are rarely necessary. An average three-year follow-up indicates that this conservative surgical approach is effective in the management of peptic esophageal strictures in childhood with relief of symptoms and gratifying improvement in growth.