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Yasuda JL, Manfredi MA. Endoscopic Management of Congenital Esophageal Defects and Associated Comorbidities. Gastrointest Endosc Clin N Am 2023; 33:341-361. [PMID: 36948750 DOI: 10.1016/j.giec.2022.11.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/24/2023]
Abstract
The endoscopist plays a critical role in the management of patients with congenital esophageal defects. This review focuses on esophageal atresia and congenital esophageal strictures and, in particular, the endoscopic management of comorbidities related to these conditions, including anastomotic strictures, tracheoesophageal fistulas, esophageal perforations, and esophagitis surveillance. Practical aspects of endoscopic techniques for stricture management are reviewed including dilation, intralesional steroid injection, stenting, and endoscopic incisional therapy. Endoscopic surveillance for mucosal pathology is essential in this population, as patients are at high risk of esophagitis and its late complications such as Barrett's esophagus.
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Affiliation(s)
- Jessica L Yasuda
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Michael A Manfredi
- Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA 19104, USA.
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2
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Abstract
Esophageal dilations in children are performed by several pediatric and adult professionals. We aim to summarize improvements in safety and new technology used for the treatment of complex and refractory strictures, including triamcinolone injection, endoscopic electro-incisional therapy, topical mitomycin-C application, stent placement, functional lumen imaging probe assisted dilation, and endoscopic vacuum-assisted closure in the pediatric population.
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3
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Kahriman G, Hosgecin C, Herdem N, Dogan A, Altay D, Pehlivan SS. Fluoroscopy-guided balloon dilatation of benign esophageal strictures in children: 11-year experience. Pediatr Radiol 2022; 52:977-984. [PMID: 35098336 DOI: 10.1007/s00247-021-05253-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 08/10/2021] [Accepted: 11/30/2021] [Indexed: 11/24/2022]
Abstract
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.
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Affiliation(s)
- Guven Kahriman
- Department of Radiology, Erciyes University, Gevher Nesibe Hospital, 38039, Kayseri, Turkey
| | - Cenk Hosgecin
- Radiology Section, Dr. Ersin Arslan Research and Education Hospital, Gaziantep, Turkey
| | - Nevzat Herdem
- Department of Radiology, Erciyes University, Gevher Nesibe Hospital, 38039, Kayseri, Turkey.
| | - Aytac Dogan
- Radiology Section, Oltu State Hospital, Erzurum, Turkey
| | - Derya Altay
- Department of Pediatric Gastroenterology, Erciyes University, Gevher Nesibe Hospital, Kayseri, Turkey
| | - Sibel Seckin Pehlivan
- Department of Anesthesia and Reanimation, Erciyes University, Gevher Nesibe Hospital, Kayseri, Turkey
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4
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Loff S, Diez O, Ho W, Kalle TV, Hetjens S, Boettcher M. Esophageal Diameter as a Function of Weight in Neonates, Children and Adolescents: Reference Values for Dilatation of Esophageal Stenoses. Front Pediatr 2022; 10:822271. [PMID: 35295699 PMCID: PMC8918730 DOI: 10.3389/fped.2022.822271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Accepted: 01/24/2022] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Esophageal stenoses are frequent complications after esophageal atresia surgery as well as after acid, alkali and battery ingestion. Worldwide, repeated balloon dilatations are the most frequently performed procedures for these stenoses. In most cases the stenoses can be dilated sufficiently to allow adequate enteral nutrition. Until recently, age dependent esophageal lumen size has not been established; which was aim of the current study. METHODS All children in whom an esophageal contrast imaging was performed between 1/2011 and 5/2021 were included. The width was measured by two investigators at two measuring points in two planes, the diameter was calculated and plotted against the respective weight of the child. Bland-Altmann plots have confirmed the validity of the measurements of both investigators. RESULTS Esophagus diameter was measured in more than 100 children. The resulting curves show a very good correlation with weight (upper measuring point: r = 0.86743, p < 0.0001; lower measuring point: r = 0.80593, p < 0.0001). CONCLUSION These results are the first to define the esophageal diameter in children. The results of this study may guide physicians performing esophageal interventions including dilatations in future.
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Affiliation(s)
- Steffan Loff
- Kinderchirurgische Klinik, Olgahospital, Klinikum Stuttgart, Stuttgart, Germany
| | - Oliver Diez
- Kinderchirurgische Klinik, Olgahospital, Klinikum Stuttgart, Stuttgart, Germany
| | - Wei Ho
- Kinderchirurgische Klinik, Olgahospital, Klinikum Stuttgart, Stuttgart, Germany
| | - Thekla V Kalle
- Radiologisches Institut, Olgahospital, Klinikum Stuttgart, Stuttgart, Germany
| | - Svetlana Hetjens
- Medizinische Statistik, Biomathematik und Informationsverarbeitung Universitätsmedizin Mannheim, Mannheim, Germany
| | - Michael Boettcher
- Department of Pediatric Surgery, University Medical Center Mannheim, Heidelberg University, Mannheim, Germany
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5
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Zhou B, Peng H, Han L, Liang C, Lv L, Wang X, Liu D, Tan Y. Endoscopic Treatment for Pediatric Esophageal Stenosis Induced by Chemical Burn, Congenitally, or After Surgical Repair of Esophageal Atresia. Front Pediatr 2022; 10:814901. [PMID: 35281238 PMCID: PMC8914068 DOI: 10.3389/fped.2022.814901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Accepted: 01/31/2022] [Indexed: 11/29/2022] Open
Abstract
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.
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Affiliation(s)
- Bingyi Zhou
- Department of Gastroenterology, The Second Xiangya Hospital, Central South University, Changsha, China.,Research Center of Digestive Disease, Central South University, Changsha, China
| | - Hailing Peng
- Department of Gastroenterology, The Second Xiangya Hospital, Central South University, Changsha, China.,Research Center of Digestive Disease, Central South University, Changsha, China
| | - Liu Han
- Department of Gastroenterology, The Second Xiangya Hospital, Central South University, Changsha, China.,Research Center of Digestive Disease, Central South University, Changsha, China
| | - Chengbai Liang
- Department of Gastroenterology, The Second Xiangya Hospital, Central South University, Changsha, China.,Research Center of Digestive Disease, Central South University, Changsha, China
| | - Liang Lv
- Department of Gastroenterology, The Second Xiangya Hospital, Central South University, Changsha, China.,Research Center of Digestive Disease, Central South University, Changsha, China
| | - Xuehong Wang
- Department of Gastroenterology, The Second Xiangya Hospital, Central South University, Changsha, China.,Research Center of Digestive Disease, Central South University, Changsha, China
| | - Deliang Liu
- Department of Gastroenterology, The Second Xiangya Hospital, Central South University, Changsha, China.,Research Center of Digestive Disease, Central South University, Changsha, China
| | - Yuyong Tan
- Department of Gastroenterology, The Second Xiangya Hospital, Central South University, Changsha, China.,Research Center of Digestive Disease, Central South University, Changsha, China
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6
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Rothe K. [Current Treatment of Oesophageal Atresia]. Zentralbl Chir 2021; 147:83-89. [PMID: 34872134 DOI: 10.1055/a-1657-0661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Oesophageal atresia is a rare congenital malformation occurring in 1 : 3000/1 : 4000 neonates. Surgical correction is always required. Perioperative management concepts depend on the type of malformation. Postoperative results are closely related to postsurgical complications. Interdisciplinary management should extend from prenatal diagnosis, birth and perinatal care to neonatal intensive care and paediatric surgical therapy with specialised pediatric anaesthesia. Other areas that should be available are logopedia, paediatric gastroenterology and paediatric pulmonology. Long-term care should include systematic aftercare and transition programs to adult medicine.
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Affiliation(s)
- Karin Rothe
- Klinik für Kinderchirurgie, Charite Universitatsmedizin Berlin, Berlin, Deutschland
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Flor MM, Ribeiro IB, DE Moura DTH, Marques SB, Bernardo WM, DE Moura EGH. EFFICACY OF ENDOSCOPIC TOPICAL MITOMYCIN C APPLICATION IN CAUSTIC ESOPHAGEAL STRICTURES IN THE PEDIATRIC POPULATION: A SYSTEMATIC REVIEW AND META-ANALYSIS OF RANDOMIZED CONTROLLED TRIALS. ARQUIVOS DE GASTROENTEROLOGIA 2021; 58:253-261. [PMID: 34231663 DOI: 10.1590/s0004-2803.202100000-38] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 02/02/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND Caustic ingestion and development of esophageal strictures are recognized major public health problems in childhood. Different therapeutic methods have been proposed in the management of such strictures. OBJECTIVE To evaluate efficacy and risk of endoscopic topical application of mitomycin C in the treatment of caustic esophageal strictures. METHODS We searched MEDLINE, EMBASE, Central Cochrane, and LILACS databases. The outcomes evaluated were dysphagia resolution rate, number of dilations performed in resolved cases, and the number of dilations performed in all patients. RESULTS Three randomized clinical trials were included for final analysis with a total of 190 patients. Topical mitomycin C application group showed a significant increase in dysphagia resolution rate, corresponding to a 42% higher dysphagia resolution as compared to endoscopic dilation alone, with statistical significance between the two groups (RD: 0.42 - [CI: 0.29-0.56]; P-value <0.00001). The mean number of dilations performed in resolved cases were significantly less in the topical mitomycin C application group, compared to endoscopic dilations alone, with statistical significance between the two groups (MD: 2.84 [CI: 1.98-3.69]; P-value <0.00001). When comparing the number of dilations in all patients, there was no statistical difference between the two groups (MD: 1.46 [CI: -1.53-4.44]; P-value =0.34). CONCLUSION Application of topical mitomycin C with endoscopic dilations in caustic esophageal strictures was more effective in dysphagia resolution than endoscopic therapy alone in the pediatric population. Moreover, topical mitomycin C application also reduced the number of dilation sessions needed to alleviate dysphagia without rising morbidity.
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Affiliation(s)
- Marcelo Mochate Flor
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - HC/FMUSP, Unidade de endoscopia gastrointestinal, São Paulo, SP, Brasil
| | - Igor Braga Ribeiro
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - HC/FMUSP, Unidade de endoscopia gastrointestinal, São Paulo, SP, Brasil
| | - Diogo Turiani Hourneaux DE Moura
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - HC/FMUSP, Unidade de endoscopia gastrointestinal, São Paulo, SP, Brasil
| | - Sérgio Barbosa Marques
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - HC/FMUSP, Unidade de endoscopia gastrointestinal, São Paulo, SP, Brasil
| | - Wanderley Marques Bernardo
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - HC/FMUSP, Unidade de endoscopia gastrointestinal, São Paulo, SP, Brasil
| | - Eduardo Guimarães Hourneaux DE Moura
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - HC/FMUSP, Unidade de endoscopia gastrointestinal, São Paulo, SP, Brasil
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8
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Luu K, Tellez PA, Chadha NK. The effectiveness of Mitomycin C in Otolaryngology procedures: A systematic review. Clin Otolaryngol 2021; 47:1-13. [PMID: 34310062 DOI: 10.1111/coa.13839] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 05/10/2021] [Accepted: 07/11/2021] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Many studies have evaluated the effectiveness of topical intraoperative mitomycin (MCC) usage in a wide range of Otolaryngologic procedures with variable conclusions on effectiveness. This systematic review aims to provide a qualitative estimation of mitomycin C's treatment effectiveness in maintaining or preventing stenosis after surgical interventions. DESIGN AND MAIN OUTCOME MEASURES Following the PRISMA guideline, a comprehensive systematic search of MEDLINE, EMBASE, and CINAHL databases was performed including hand-searching and cross-reference checking. The search was limited to humans, sample size greater than two, and study designs including a comparative arm. RESULTS 571 unique abstracts and 109 full articles were reviewed. 77 studies were included in the final analysis. The available evidence ranged from case series to randomized control studies. Meta-analysis was deemed inappropriate due to heterogeneity of study design. 38 studies assessed the effective of MCC in dacryocystorhinostomy, which is reported in a separate meta-analysis. All other studies were categorized into otolaryngologic site and pathology including: choanal atresia (n=5), endoscopic sinus surgery (n=12), airway procedures (n=9), esophageal procedures (n=8), and other (n=2). CONCLUSIONS The published literature on the effectiveness of MMC was mixed, but suggested topical MMC improved surgical outcomes in many Otolaryngologic procedures compared to controls. This was the first review to assemble literature on MMC usage for different surgical procedures. Comprehensive interpretation of the data was limited due to heterogeneity in primary outcome, procedure type, and study quality. High quality prospective and randomized controlled studies are required to further confirm the positive effect of MMC use on surgical outcomes.
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Affiliation(s)
- Kimberly Luu
- University of California San Francisco, Division of Otolaryngology, San Francisco, CA
| | - Paula A Tellez
- Hospital Universitario San Ignacio, Division of Otolaryngology, Bogota, Colombia
| | - Neil K Chadha
- Division of Pediatric Otolaryngology-Head and Neck Surgery, BC Children's Hospital, University of British Columbia, Vancouver, BC, Canada
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9
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Zhou XB, Xu SW, Ye LP, Mao XL, Chen YH, Wu JF, Cai Y, Wang Y, Wang L, Li SW. Progress of esophageal stricture prevention after endoscopic submucosal dissection by regenerative medicine and tissue engineering. Regen Ther 2021; 17:51-60. [PMID: 33997185 PMCID: PMC8100352 DOI: 10.1016/j.reth.2021.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 11/17/2020] [Accepted: 01/11/2021] [Indexed: 01/10/2023] Open
Abstract
Endoscopic submucosal dissection (ESD) has been widely accepted as an effective treatment for early esophageal cancer. However, post-ESD esophageal stricture remains a thorny issue. We herein review many strategies for preventing post-ESD esophageal stricture, as well as discuss their strengths and weaknesses. These strategies include pharmacological prophylaxis, esophageal stent and tissue engineering and regenerative medicine treatment. In this review, we summarize these studies and discuss the underlying progress and future directions of tissue engineering and regenerative medicine treatment.
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Key Words
- 5-FU, 5-Fluorouracil
- ADSC, Autologous adipose-derived stem cells
- ASGS, autologous skin graft surgery
- ChST15, carbohydrate sulfotransferase 15
- EBD, endoscopic balloon dilation
- ECM, extracellular matrix
- ESD, endoscopic submucosal dissection
- Endoscopic submucosal dissection
- Esophageal stricture
- FCMS, fully covered metal stent
- OMECs, oral mucosal epithelial cell sheets
- PGAs, polyglycolic acid sheet
- PIPAAm, poly(N-isopropylacrylamide)
- Regenerative medicine
- SESCNs, superficial esophageal squamous cell neoplasms
- SIS, small intestinal submucosa
- SeMS, self-expandable metal stents
- TA, triamcinolone acetonide
- TS-PGA, triamcinolone-soaked polyglycolic acid sheet
- Tissue engineering
- Tβ4, Thymosin β4
- ccESTD, complete circular endoscopic submucosal tunnel dissection
- siRNA, small interfering RNA
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Affiliation(s)
- Xian-Bin Zhou
- Department of Gastroenterology, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, LinHai, Zhejiang, China
| | - Shi-Wen Xu
- Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Li-Ping Ye
- Department of Gastroenterology, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, LinHai, Zhejiang, China
| | - Xin-Li Mao
- Department of Gastroenterology, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, LinHai, Zhejiang, China
| | - Ya-Hong Chen
- Health Management Center, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Linhai, Zhejiang, China
| | - Jian-Fen Wu
- Department of Gastroenterology, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, LinHai, Zhejiang, China
| | - Yue Cai
- Department of Gastroenterology, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, LinHai, Zhejiang, China
| | - Yi Wang
- Department of Gastroenterology, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, LinHai, Zhejiang, China
| | - Li Wang
- College of Basic Medicine, Inner Mongolia Medical University, Hohhot, Inner Mongolia, China
| | - Shao-Wei Li
- Department of Gastroenterology, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, LinHai, Zhejiang, China
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Dingemann C, Eaton S, Aksnes G, Bagolan P, Cross KM, De Coppi P, Fruithof J, Gamba P, Husby S, Koivusalo A, Rasmussen L, Sfeir R, Slater G, Svensson JF, Van der Zee DC, Wessel LM, Widenmann-Grolig A, Wijnen R, Ure BM. ERNICA Consensus Conference on the Management of Patients with Esophageal Atresia and Tracheoesophageal Fistula: Follow-up and Framework. Eur J Pediatr Surg 2020; 30:475-482. [PMID: 31777030 DOI: 10.1055/s-0039-3400284] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
INTRODUCTION Improvements in care of patients with esophageal atresia (EA) and tracheoesophageal fistula (TEF) have shifted the focus from mortality to morbidity and quality-of-life. Long-term follow-up is essential, but evidence is limited and standardized protocols are scarce. Nineteen representatives of the European Reference Network for Rare Inherited Congenital Anomalies (ERNICA) from nine European countries conducted a consensus conference on the surgical management of EA/TEF. MATERIALS AND METHODS The conference was prepared by item generation (including items of surgical relevance from the European Society for Pediatric Gastroenterology Hepatology and Nutrition (ESPGHAN)-The North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) guidelines on follow-up after EA repair), item prioritization, formulation of a final list containing the domains Follow-up and Framework, and literature review. Anonymous voting was conducted via an internet-based system. Consensus was defined as ≥75% of those voting with scores of 6 to 9. RESULTS Twenty-five items were generated in the domain Follow-up of which 17 (68%) matched with corresponding ESPGHAN-NASPGHAN statements. Complete consensus (100%) was achieved on seven items (28%), such as the necessity of an interdisciplinary follow-up program. Consensus ≥75% was achieved on 18 items (72%), such as potential indications for fundoplication. There was an 82% concordance with the ESPGHAN-NASPGHAN recommendations. Four items were generated in the domain Framework, and complete consensus was achieved on all these items. CONCLUSION Participants of the first ERNICA conference reached significant consensus on the follow-up of patients with EA/TEF who undergo primary anastomosis. Fundamental statements regarding centralization, multidisciplinary approach, and involvement of patient organizations were formulated. These consensus statements will provide the cornerstone for uniform treatment protocols and resultant optimized patient care.
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Affiliation(s)
- Carmen Dingemann
- Department of Pediatric Surgery, Hannover Medical School, Hannover, Germany
| | - Simon Eaton
- Department of Paediatric Surgery & Metabolic Biochemistry, UCL Great Ormond Street Institute of Child Health, University College London Institute of Child Health, London, United Kingdom
| | - Gunnar Aksnes
- Department of Pediatric Surgery, Oslo University Hospital, Oslo, Norway
| | - Pietro Bagolan
- Department of Medical and Surgical Neonatology, Bambino Gesù Children's Hospital-Research Institute, Rome, Italy
| | - Kate M Cross
- Specialist Neonatal and Paediatric Surgery, Great Ormond Street Hospital for Children, London, United Kingdom
| | - Paolo De Coppi
- Specialist Neonatal and Paediatric Surgery, Great Ormond Street Hospital for Children, London, United Kingdom.,Department of Paediatric Surgery & Metabolic Biochemistry, UCL Great Ormond Street Institute of Child Health Library, London, United Kingdom
| | - JoAnne Fruithof
- Esophageal Atresia and Tracheo-Esophageal Fistula Support Federation & - VOKS, Lichtenvoorde, The Netherlands
| | | | - Steffen Husby
- Department of Pediatric Gastroenterology, Hans Christian Andersen Children's Hospital, Odense University Hospital, Odense, Denmark
| | - Antti Koivusalo
- Department of Pediatric Surgery, University of Helsinki, Helsinki, Finland
| | - Lars Rasmussen
- Department of Pediatric Surgery, Odense University Hospital, Odense, Denmark
| | - Rony Sfeir
- Department of Pediatric Surgery CRACMO, Centre Hospitalier Régional Universitaire de Lille, Lille, France
| | - Graham Slater
- Esophageal Atresia and Tracheo-Esophageal Fistula Support Federation & - TOFS, Nottingham, United Kingdom
| | - Jan F Svensson
- Department of Pediatric Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - David C Van der Zee
- Department of Pediatric Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Lucas M Wessel
- Department of Pediatric Surgery, University of Mannheim, Medical Faculty of Heidelberg, Mannheim, Germany
| | - Anke Widenmann-Grolig
- Esophageal Atresia and Tracheo-Esophageal Fistula Support Federation & - KEKS, Stuttgart, Germany
| | - Rene Wijnen
- Department of Pediatric Surgery, Erasmus MC Rotterdam, Rotterdam, The Netherlands
| | - Benno M Ure
- Department of Pediatric Surgery, Hannover Medical School, Hannover, Germany
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11
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An international survey on anastomotic stricture management after esophageal atresia repair: considerations and advisory statements. Surg Endosc 2020; 35:3653-3661. [PMID: 32748272 PMCID: PMC8195894 DOI: 10.1007/s00464-020-07844-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 07/24/2020] [Indexed: 11/11/2022]
Abstract
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.
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12
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Efficacy and Safety of the Local Application of Mitomycin C to Recurrent Esophageal Strictures in Children. J Pediatr Gastroenterol Nutr 2019; 69:528-532. [PMID: 31436711 DOI: 10.1097/mpg.0000000000002445] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Research on long-term use of mitomycin C (MC) for recurrent esophageal stenoses is limited. We assessed the long-term efficacy and safety of local application of MC for recurrent esophageal stenoses in children. METHODS This was a retrospective study of 39 patients (17 girls) with a median age of 19.5 months (range: 2.4-196.0) at the time of MC application. The etiologies of stenosis were esophageal atresia (n = 25), caustic ingestion (n = 9), congenital esophageal stenosis (n = 3), and other causes (n = 2). Stenosis was single in 35 (90%) patients and multiple in 4 (10%). Before MC, patients underwent multiple repeated dilations (median: 3 dilations per child [range: 2-26]) over a median period of 7 months (range: 2.6-49.3). Treatment success was defined a priori as a reduction in the number of dilations over the same period from before to after the application of MC. RESULTS For 26 (67%) patients, the application of MC was considered a success: 102 versus 17 dilatations (P < 0.0001). Sixteen (41%) patients never required additional dilation during the follow-up after MC application (median: 3.1 years [range: 0.6-8.5]). No complication related to MC was observed. Biopsies at the site of MC application were performed at maximal follow-up in 16 patients and revealed no dysplasia. Three factors were associated with success of MC: single stenosis, short stenosis, and esophageal atresia type III. CONCLUSIONS This study is the largest series reported showing that topical application of MC is an efficient and safe treatment for recurrent esophageal stenosis in children.
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Patel PA, Minhas K, Ang J, Stuart S, De Coppi P, Gnannt R. Non-vascular interventional radiology in the paediatric alimentary tract. Eur J Radiol 2019; 112:72-81. [PMID: 30777223 DOI: 10.1016/j.ejrad.2018.12.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Revised: 12/03/2018] [Accepted: 12/12/2018] [Indexed: 11/17/2022]
Abstract
Paediatric interventional radiology is an evolving speciality which is able to offer numerous minimally invasive treatments for gastrointestinal tract pathologies. Here we describe interventions performed by paediatric interventional radiologists on the alimentary tract from the mouth to the rectum. The interventions include sclerotherapy, stricture management by dilation, stenting and adjunctive therapies such as Mitomycin C administration and enteral access for feeding, motility assessment and administration of enemas.
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Affiliation(s)
- Premal A Patel
- Interventional Radiology, Radiology Department, Great Ormond Street Hospital, Great Ormond Street, London, WC1N 3JH, United Kingdom.
| | - Kishore Minhas
- Interventional Radiology, Radiology Department, Great Ormond Street Hospital, Great Ormond Street, London, WC1N 3JH, United Kingdom
| | - Jestine Ang
- Interventional Radiology, Radiology Department, Great Ormond Street Hospital, Great Ormond Street, London, WC1N 3JH, United Kingdom
| | - Sam Stuart
- Interventional Radiology, Radiology Department, Great Ormond Street Hospital, Great Ormond Street, London, WC1N 3JH, United Kingdom
| | - Paolo De Coppi
- Specialist Neonatal and Paediatric Surgery Department, Great Ormond Street Hospital, Great Ormond Street, London, WC1N 3JH, United Kingdom
| | - Ralph Gnannt
- Bilddiagnostik, Paediatric Interventional Radiology, University Children's Hospital, Steinwiesstrasse 75, CH-8032, Zürich, Switzerland
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Endoscopic Electrocautery Incisional Therapy as a Treatment for Refractory Benign Pediatric Esophageal Strictures. J Pediatr Gastroenterol Nutr 2018; 67:464-468. [PMID: 29697549 DOI: 10.1097/mpg.0000000000002008] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND AND AIM Refractory esophageal strictures are rare conditions in pediatrics, and are often due to anastomotic, congenital, or caustic strictures. Traditional treatment options include serial dilation and surgical stricture resection; endoscopic intralesional steroid injections, mitomycin C, and externally removable stents combined with dilation have had variable success rates. Although not as widely used, endoscopic electrocautery incisional therapy (EIT) has been reported as an alternative treatment for refractory strictures in a small number of adult series. The aim of the study was to evaluate the safety and efficacy of EIT in a pediatric population with refractory esophageal strictures. METHODS A retrospective chart review was conducted on all patients who underwent EIT for esophageal strictures (May 2011-September 2017) at our tertiary-care referral center. A total of 57 patients underwent EIT. Procedural success was defined as no stricture resection, appropriate diameter for age, and fewer than 7 dilations within 24 months of first EIT session. This corresponded to the 90th percentile of the observed number of dilations in the data. All patients included in the study had at least 2-year follow-up. RESULTS A total of 133 EIT sessions on 58 distinct anastomotic strictures were performed on 57 patients (24 girls). The youngest patient to have EIT was 3 months old and 4.8 kg. There were 36 strictures that met the criteria for refractory stricture and 22 non-refractory (NR) strictures. The median number of dilations before EIT therapy was 8 (interquartile range [IQR]: 6-10) in the refractory group and 3 (IQR: 0-3) in the NR group. In the refractory group, 61% of the patients met the criteria for treatment success. The median number of dilations within 2 years of EIT in the refractory group was 2 (IQR: 0-4). In the NR group, 100% of the patients met criteria for success. The median number of dilations within 2 years of EIT in the NR was 1 (IQR: 0-2). The overall adverse event rate was 5.3% (7/133), with 3 major (2.3%) and 4 minor events (3%). CONCLUSIONS EIT shows promise as an adjunct treatment option for pediatric refractory esophageal strictures and may be considered before surgical resection even in severe cases. The complication rate, albeit low, is significant, and EIT should only be considered by experienced endoscopists in close consultation with surgery. Further prospective longitudinal studies are needed to validate this treatment.
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Topical Mitomycin C Application Is Effective Even in Esophageal Strictures Resistant to Dilatation Therapy in Children. Surg Laparosc Endosc Percutan Tech 2018; 27:e96-e100. [PMID: 28902039 DOI: 10.1097/sle.0000000000000462] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE Several treatment techniques may be used in the treatment of esophageal strictures. The purpose of this study was to present the effects of topical mitomycin C (TMC) as an useful adjunct to dilatation therapy in esophageal strictures. MATERIALS AND METHODS A retrospective analysis of patients who underwent TMC between February 2015 and July 2016 was performed. Dysphagia score, periodic dilatation index, and number of dilatations were compared before and after intervention to investigate the efficacy of TMC. RESULTS TMC was performed on 20 patients with a median age of 3.5 years (2 to 17 y). The diagnosis was corrosive esophageal strictures in 14 patients, anastomotic strictures in 5 patients, and congenital esophageal stricture in 1 patient. The length of the stricture was long in 10 patients (50%). The median dysphagia score decreased from 2 (1 to 3) to 0 (0 to 2) after application (P<0.001). The median number of dilatation sessions decreased from 5 (1 to 41) to 1 (0 to 11) after intervention (P<0.001). The median periodic dilatation index decreased from 1 (0.66 to 1.34) to 0 (0 to 1.33) after TMC (P<0.001). Regular esophageal dilatation was not necessary in 16 patients after application (80%). The length of the stricture did not affect the efficacy of TMC. The success of treatment was lower in patients with a long treatment period before TMC (>3 y) (50%). No complications were seen in a median follow-up period of 16 months (7 to 22 mo). CONCLUSIONS TMC application has a significant positive effect as an adjunct to dilatation therapy in most of the patients with different types of esophageal strictures. It should be performed as a safe and efficient treatment option even in patients who were resistant to dilatation therapy.
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Prospective study of the effect of topical application of Mitomycin C in refractory pediatric caustic esophageal strictures. Surg Endosc 2018; 32:4932-4938. [DOI: 10.1007/s00464-018-6253-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2017] [Accepted: 05/29/2018] [Indexed: 12/31/2022]
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Vergouwe FWT, Gottrand M, Wijnhoven BPL, IJsselstijn H, Piessen G, Bruno MJ, Wijnen RMH, Spaander MCW. Four cancer cases after esophageal atresia repair: Time to start screening the upper gastrointestinal tract. World J Gastroenterol 2018; 24:1056-1062. [PMID: 29531469 PMCID: PMC5840470 DOI: 10.3748/wjg.v24.i9.1056] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Revised: 01/25/2018] [Accepted: 01/25/2018] [Indexed: 02/06/2023] Open
Abstract
Esophageal atresia (EA) is one of the most common congenital digestive malformations and requires surgical correction early in life. Dedicated centers have reported survival rates up to 95%. The most frequent comorbidities after EA repair are dysphagia (72%) and gastroesophageal reflux (GER) (67%). Chronic GER after EA repair might lead to mucosal damage, esophageal stricturing, Barrett’s esophagus and eventually esophageal adenocarcinoma. Several long-term follow-up studies found an increased risk of Barrett’s esophagus and esophageal carcinoma in EA patients, both at a relatively young age. Given these findings, the recent ESPGHAN-NASPGHAN guideline recommends routine endoscopy in adults born with EA. We report a series of four EA patients who developed a carcinoma of the gastrointestinal tract: three esophageal carcinoma and one colorectal carcinoma in a colonic interposition. These cases emphasize the importance of lifelong screening of the upper gastrointestinal tract in EA patients.
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Affiliation(s)
- Floor WT Vergouwe
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam 3000 CA, Netherlands
- Department of Pediatric Surgery, Erasmus MC University Medical Center - Sophia Children's Hospital, Rotterdam 3000 CB, Netherlands
| | - Madeleine Gottrand
- Department of Pediatrics, Jeanne de Flandre Children’s Hospital - Univ. Lille, CHU Lille, Lille 59000, France
| | - Bas PL Wijnhoven
- Department of Surgery, Erasmus MC University Medical Center, Rotterdam 3000 CA, Netherlands
| | - Hanneke IJsselstijn
- Department of Pediatric Surgery, Erasmus MC University Medical Center - Sophia Children's Hospital, Rotterdam 3000 CB, Netherlands
| | - Guillaume Piessen
- Department of Digestive and Oncological Surgery, Claude Huriez Hospital - Univ. Lille, CHU Lille, Lille 59000, France
| | - Marco J Bruno
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam 3000 CA, Netherlands
| | - René MH Wijnen
- Department of Pediatric Surgery, Erasmus MC University Medical Center - Sophia Children's Hospital, Rotterdam 3000 CB, Netherlands
| | - Manon CW Spaander
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam 3000 CA, Netherlands
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Abstract
PURPOSE OF REVIEW Guidelines were recently published highlighting why esophageal atresia (EA) patients are prone to complication risks, and the need for long-term follow-up. In this review, we will focus on how to investigate and treat potential complications, as well as the pros and cons of different investigative and treatment modalities, and what areas continue to need further research. RECENT FINDINGS EA patients are at high risk for gastroesophageal reflux and esophageal strictures, and the sequela that result. Extraintestinal manifestations of gastroesophageal reflux disease (GERD) can appear similar to other pathologic diagnoses commonly found in EA patients, such as congenital stricture, eosinophilic esophagitis, esophageal dysmotility, tracheomalacia, recurrent fistula, aspiration, etc. Therefore, it is important to have a standardized way to monitor for these issues. pH impedance allows for detection of nonacid reflux and the height of reflux, which are important in correlating symptoms with reflux episodes. A multidisciplinary approach is beneficial in evaluating and monitoring EA patients in the long term.
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Tambucci R, Angelino G, De Angelis P, Torroni F, Caldaro T, Balassone V, Contini AC, Romeo E, Rea F, Faraci S, Federici di Abriola G, Dall'Oglio L. Anastomotic Strictures after Esophageal Atresia Repair: Incidence, Investigations, and Management, Including Treatment of Refractory and Recurrent Strictures. Front Pediatr 2017; 5:120. [PMID: 28611969 PMCID: PMC5447026 DOI: 10.3389/fped.2017.00120] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Accepted: 05/04/2017] [Indexed: 01/10/2023] Open
Abstract
Improved surgical techniques, as well as preoperative and postoperative care, have dramatically changed survival of children with esophageal atresia (EA) over the last decades. Nowadays, we are increasingly seeing EA patients experiencing significant short- and long-term gastrointestinal morbidities. Anastomotic stricture (AS) is the most common complication following operative repair. An esophageal stricture is defined as an intrinsic luminal narrowing in a clinically symptomatic patient, but no symptoms are sensitive or specific enough to diagnose an AS. This review aims to provide a comprehensive view of AS in EA children. Given the lack of evidence-based data, we critically analyzed significant studies on children and adults, including comments on benign strictures with other etiologies. Despite there is no consensus about the goal of the luminal diameter based on the patient's age, esophageal contrast study, and/or endoscopy are recommended to assess the degree of the narrowing. A high variability in incidence of ASs is reported in literature, depending on different definitions of AS and on a great number of pre-, intra-, and postoperative risk factor influencing the anastomosis outcome. The presence of a long gap between the two esophageal ends, with consequent anastomotic tension, is determinant for stricture formation and its response to treatment. The cornerstone of treatment is endoscopic dilation, whose primary aims are to achieve symptom relief, allow age-appropriate capacity for oral feeding, and reduce the risk of pulmonary aspiration. No clear advantage of either balloon or bougie dilator has been demonstrated; therefore, the choice is based on operator experience and comfort with the equipment. Retrospective evidences suggest that selective dilatations (performed only in symptomatic patients) results in significantly less number of dilatation sessions than routine dilations (performed to prevent symptoms) with equal long-term outcomes. The response to dilation treatment is variable, and some patients may experience recurrent and refractory ASs. Adjunctive treatments have been used, including local injection of steroids, topical application of mitomycin C, and esophageal stenting, but long-term studies are needed to prove their efficacy and safety. Stricture resection or esophageal replacement with an interposition graft remains options for AS refractory to conservative treatments.
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Affiliation(s)
- Renato Tambucci
- Digestive Endoscopy and Surgery Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy.,University of L'Aquila, L'Aquila, Italy
| | - Giulia Angelino
- Digestive Endoscopy and Surgery Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Paola De Angelis
- Digestive Endoscopy and Surgery Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Filippo Torroni
- Digestive Endoscopy and Surgery Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Tamara Caldaro
- Digestive Endoscopy and Surgery Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Valerio Balassone
- Digestive Endoscopy and Surgery Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Anna Chiara Contini
- Digestive Endoscopy and Surgery Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Erminia Romeo
- Digestive Endoscopy and Surgery Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Francesca Rea
- Digestive Endoscopy and Surgery Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Simona Faraci
- Digestive Endoscopy and Surgery Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | | | - Luigi Dall'Oglio
- Digestive Endoscopy and Surgery Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
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Paediatric Gastrointestinal Endoscopy: European Society for Paediatric Gastroenterology Hepatology and Nutrition and European Society of Gastrointestinal Endoscopy Guidelines. J Pediatr Gastroenterol Nutr 2017; 64:133-153. [PMID: 27622898 DOI: 10.1097/mpg.0000000000001408] [Citation(s) in RCA: 140] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
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.
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Abstract
Neonatal surgery is recognized as an independent discipline in general surgery, requiring the expertise of pediatric surgeons to optimize outcomes in infants with surgical conditions. Survival following neonatal surgery has improved dramatically in the past 60 years. Improvements in pediatric surgical outcomes are in part attributable to improved understanding of neonatal physiology, specialized pediatric anesthesia, neonatal critical care including sophisticated cardiopulmonary support, utilization of parenteral nutrition and adjustments in fluid management, refinement of surgical technique, and advances in surgical technology including minimally invasive options. Nevertheless, short and long-term complications following neonatal surgery continue to have profound and sometimes lasting effects on individual patients, families, and society.
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Affiliation(s)
- Mauricio A Escobar
- Pediatric Surgery, Mary Bridge Children׳s Hospital, PO Box 5299, MS: 311-W3-SUR, 311 South, Tacoma, Washington 98415-0299.
| | - Michael G Caty
- Section of Pediatric Surgery, Department of Surgery, Yale-New Haven Children׳s Hospital, New Haven, Connecticut
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Wessel LM, Fuchs J, Rolle U. The Surgical Correction of Congenital Deformities: The Treatment of Diaphragmatic Hernia, Esophageal Atresia and Small Bowel Atresia. DEUTSCHES ARZTEBLATT INTERNATIONAL 2016; 112:357-64. [PMID: 26051693 DOI: 10.3238/arztebl.2015.0357] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/13/2014] [Revised: 03/03/2015] [Accepted: 03/03/2015] [Indexed: 12/27/2022]
Abstract
BACKGROUND More than half of all congenital deformities can be detected in utero. The initial surgical correction is of paramount importance for the achievement of good long-term results with low surgical morbidity and mortality. METHODS Selective literature review and expert opinion. RESULTS Congenital deformities are rare, and no controlled trials have been performed to determine their optimal treatment. In this article, we present the prenatal assessment, treatment, and long-term results of selected types of congenital deformity. Congenital diaphragmatic hernia (CDH) affects one in 3500 live-born infants, while esophageal atresia affects one in 3000 and small-bowel atresia one in 5000 to 10,000. If a congenital deformity is detected and its prognosis can be reliably inferred from a prenatal assessment, the child should be delivered at a specialized center (level 1 perinatal center). The associated survival rates are 60-80% after treatment for CDH and well over 90% after treatment for esophageal or small-bowel atresia. Despite improvements in surgical correction over the years, complications and comorbidities still affect 20-40% of the treated children. These are not limited to surgical complications in the narrow sense, such as recurrence, postoperative adhesions and obstruction, stenoses, strictures, and recurrent fistulae, but also include pulmonary problems (chronic lung disease, obstructive and restrictive pulmonary dysfunction), gastrointestinal problems (dysphagia, gastro-esophageal reflux, impaired intestinal motility), and failure to thrive. Moreover, the affected children can develop emotional and behavioral disturbances. Minimally invasive surgery in experienced hands yields results as good as those of conventional surgery, as long as proper selection criteria are observed. CONCLUSION Congenital deformities should be treated in recognized centers with highly experienced interdisciplinary teams. As no randomized trials of surgery for congenital deformities are available, longitudinal studies and registries will be very important in the future.
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Affiliation(s)
- Lucas M Wessel
- Department of Pediatric Surgery, University Hospital Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Department of Pediatric Surgery and Pediatric Urology, University Children's Hospital Tübingen, Department of Pediatric Surgery and Pediatric Urology, University Hospital Frankfurt, Campus Niederrad,Frankfurt am Main
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ESPGHAN-NASPGHAN Guidelines for the Evaluation and Treatment of Gastrointestinal and Nutritional Complications in Children With Esophageal Atresia-Tracheoesophageal Fistula. J Pediatr Gastroenterol Nutr 2016; 63:550-570. [PMID: 27579697 DOI: 10.1097/mpg.0000000000001401] [Citation(s) in RCA: 210] [Impact Index Per Article: 26.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Esophageal atresia (EA) is one of the most common congenital digestive anomalies. With improvements in surgical techniques and intensive care treatments, the focus of care of these patients has shifted from mortality to morbidity and quality-of-life issues. These children face gastrointestinal (GI) problems not only in early childhood but also through adolescence and adulthood. There is, however, currently a lack of a systematic approach to the care of these patients. The GI working group of International Network on Esophageal Atresia comprises members from ESPGHAN/NASPGHAN and was charged with the task of developing uniform evidence-based guidelines for the management of GI complications in children with EA. METHODS Thirty-six clinical questions addressing the diagnosis, treatment, and prognosis of the common GI complications in patients with EA were formulated. Questions on the diagnosis, and treatment of gastroesophageal reflux, management of "cyanotic spells," etiology, investigation and management of dysphagia, feeding difficulties, anastomotic strictures, congenital esophageal stenosis in EA patients were addressed. The importance of excluding eosinophilic esophagitis and associated GI anomalies in symptomatic patients with EA is discussed as is the quality of life of these patients and the importance of a systematic transition of care to adulthood. A systematic literature search was performed from inception to March 2014 using Embase, MEDLINE, the Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Clinical Trials, and PsychInfo databases. The approach of the Grading of Recommendations Assessment, Development and Evaluation was applied to evaluate outcomes. During 2 consensus meetings, all recommendations were discussed and finalized. The group members voted on each recommendation, using the nominal voting technique. Expert opinion was used where no randomized controlled trials were available to support the recommendation.
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Deng HY, Wang WP, Lin YD, Chen LQ. Can mitomycin facilitate endoscopic dilatation treatment of benign oesophageal stricture? Interact Cardiovasc Thorac Surg 2016; 24:112-114. [DOI: 10.1093/icvts/ivw318] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2016] [Revised: 07/28/2016] [Accepted: 08/25/2016] [Indexed: 11/14/2022] Open
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Bartel MJ, Seeger K, Jeffers K, Clayton D, Wallace MB, Raimondo M, Woodward TA. Topical Mitomycin C application in the treatment of refractory benign esophageal strictures in adults and comprehensive literature review. Dig Liver Dis 2016; 48:1058-65. [PMID: 27443493 DOI: 10.1016/j.dld.2016.06.024] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Revised: 06/08/2016] [Accepted: 06/20/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND Recurrent complex esophageal strictures remain difficult to manage. AIMS To determine the efficacy of topical Mitomycin C application for recurrent benign esophageal strictures. METHODS All patients who underwent balloon dilation followed by topical Mitomycin C application for recurrent benign esophageal strictures were included. Primary outcome was number of dilations and change of dysphagia score. RESULTS Nine patients with anastomotic (3), radiation-induced (3), caustic (2), and combined anastomotic and radiation-induced (1) strictures were included. Strictures had a mean length of 13.75mm, diameter of 8.0mm, and were dilated 10.7 times over a median of 8 months (1.5 dilations per month). Following Mitomycin C application, the need for further dilation decreased to 0.39 dilations per month over a median of 10 months; however, dysphagia scores improved not significantly from 3.2 to 2.6 (mean). CONCLUSION In this pilot study, topical Mitomycin C in conjunction with dilation decreased the frequency of esophageal dilations for recurrent benign esophageal strictures.
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Affiliation(s)
- Michael J Bartel
- Gastroentrology and Hepatology, Mayo Clinic, Jacksonville, FL, USA
| | - Kristina Seeger
- General Internal Medicine, Mayo Clinic, Jacksonville, FL, USA
| | - Kayin Jeffers
- General Internal Medicine, Mayo Clinic, Jacksonville, FL, USA
| | | | | | - Massimo Raimondo
- Gastroentrology and Hepatology, Mayo Clinic, Jacksonville, FL, USA
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Dall’Oglio L, Caldaro T, Foschia F, Faraci S, Federici di Abriola G, Rea F, Romeo E, Torroni F, Angelino G, De Angelis P. Endoscopic management of esophageal stenosis in children: New and traditional treatments. World J Gastrointest Endosc 2016; 8:212-219. [PMID: 26962403 PMCID: PMC4766254 DOI: 10.4253/wjge.v8.i4.212] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2015] [Revised: 10/14/2015] [Accepted: 12/18/2015] [Indexed: 02/05/2023] Open
Abstract
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.
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Manfredi MA. Endoscopic Management of Anastomotic Esophageal Strictures Secondary to Esophageal Atresia. Gastrointest Endosc Clin N Am 2016; 26:201-19. [PMID: 26616905 DOI: 10.1016/j.giec.2015.09.002] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The reported incidence of anastomotic stricture after esophageal atresia repair has varied in case series from as low as 9% to as high as 80%. The cornerstone of esophageal stricture treatment is dilation with either balloon or bougie. The goal of esophageal dilation is to increase the luminal diameter of the esophagus while also improving dysphagia symptoms. Once a stricture becomes refractory to esophageal dilation, there are several treatment therapies available as adjuncts to dilation therapy. These therapies include intralesional steroid injection, mitomycin C, esophageal stent placement, and endoscopic incisional therapy.
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Affiliation(s)
- Michael A Manfredi
- Esophageal and Airway Atresia Treatment Center, Boston Children's Hospital, Boston, MA 02132, USA; Pediatrics Harvard Medical School, Boston, MA 02115, USA.
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Endoscopic Incision for the Treatment of Refractory Esophageal Anastomotic Strictures in Children. J Pediatr Gastroenterol Nutr 2015; 61:319-22. [PMID: 25844710 DOI: 10.1097/mpg.0000000000000801] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVES The aim of the present study was to assess the safety and efficacy of endoscopic incision (EI) for the treatment of refractory anastomotic esophageal strictures in pediatric patients. METHODS We retrospectively reviewed the medical records of pediatric patients with refractory anastomotic strictures after surgical repair of esophageal atresia who underwent ≥3 sessions of endoscopic treatments (dilation and/or stenting). They were treated with EI alone or together with esophageal stenting. Efficacy and safety were evaluated during periodical follow-up. RESULTS All of the 7 children received the procedure successfully with the operation time of 15 to 60 minutes. Four of them received EI alone, whereas the other 3 received EI with esophageal stenting (EIES). The symptoms remitted in all of the patients, and the dysphagia score decreased from 3-4 to 0-1 during follow-up from 1 to 21 months. The average diameter of stricture was enlarged from 3 mm (range 2-5 mm) to 10.6 mm (range 8-12 mm). One patient suffered from chest pain, which resolved within 3 days. Patient 1 had recurrence 11 months after EIES, and patient 6 had recurrence 3 months after EI. They all underwent an additional EI to maintain patency. No severe complications were observed during operation and periodical follow-up. CONCLUSIONS EI is safe and appears effective for refractory esophageal anastomotic strictures in children in the short term. Large comparative studies are warranted to further confirm our findings. The long-term follow-up is necessary for assessing the long-term efficacy of the new technique.
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Zhang Y, Wang X, Liu L, Chen JP, Fan ZN. Intramuscular injection of mitomycin C combined with endoscopic dilation for benign esophageal strictures. J Dig Dis 2015; 16:370-6. [PMID: 25944169 DOI: 10.1111/1751-2980.12255] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate the safety and efficacy of intramuscular injection of either mitomycin C or dexamethasone with endoscopic dilation for benign esophageal strictures after esophageal surgery or endoscopic submucosal dissection. METHODS Patients with benign esophageal strictures were retrospectively enrolled in this study and divided into three groups: mitomycin C group (mitomycin C injection with endoscopic dilation, dexamethasone group (dexamethasone injection and dilation) and dilation group (physiological saline injection and dilation). The patients' characteristics, locations of lesions, number of previous dilations, esophageal diameters after dilation, grades of dysphagia before and after the procedure and dysphagia-free period during the follow-up period were recorded. RESULTS Altogether 74 patients including 25 in the mitomycin C group, 25 in the dexamethasone group and 24 in the dilation group were enrolled. The diameter of the esophagus before the procedure was 3.32 ± 0.90 mm, 3.92 ± 1.55 mm and 3.70 ± 1.30 mm, respectively, while that was increased to 12.77 ± 1.62 mm, 12.14 ± 1.28 mm and 12.73 ± 1.42 mm after endoscopic dilation in the mitomycin C, dexamethasone and conventional dilation groups. The dysphagia-free period was 4.88 ± 1.66 months in the mitomycin C group, 4.02 ± 1.77 months in the dexamethasone group and 2.41 ± 1.26 months in the dilation group (P < 0.05). CONCLUSION Intramuscular injection of mitomycin C or dexamethasone may prolong the dysphagia-free period and decrease the frequency of repeat dilations compared with conventional endoscopic dilations in patients with benign esophageal strictures.
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Affiliation(s)
- Yin Zhang
- Department of Digestive Disease, The First People's Hospital of Changzhou, Changzhou, Jiangsu Province, China.,Department of Digestive Endoscopy and Medical Center for Digestive Diseases, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Xiang Wang
- Department of Digestive Endoscopy, The First Affiliated Hospital with Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Li Liu
- Department of Digestive Endoscopy, The First Affiliated Hospital with Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Jian Ping Chen
- Department of Digestive Disease, The First People's Hospital of Changzhou, Changzhou, Jiangsu Province, China
| | - Zhi Ning Fan
- Department of Digestive Endoscopy, The First Affiliated Hospital with Nanjing Medical University, Nanjing, Jiangsu Province, China
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