Postsurgical Perforation of the Esophagus Can Be Treated Using a Fully Covered Stent in Children

Endoscopic Management of Congenital Esophageal Defects and Associated Comorbidities

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.

Esophageal Stents for the Management of Benign Esophageal Strictures in Children and Adolescents: A Systematic Review of Observational Studies

Little is known about the efficacy and safety of esophageal stents for the management of esophageal strictures in children and adolescents. A systematic review was performed to assess the efficacy and safety of esophageal stents for the management of benign esophageal strictures in children and adolescents. Observational studies related to the examination of esophageal stents in pediatrics were extracted using the original databases by December 2021. We found 18 retrospective and prospective studies with a total of 340 children and adolescents. Overall, our findings show that different therapeutic modalities based on esophageal stents were offered to children and adolescents for various indications, in which most studies reported successful cases, although ineffective claims cannot be ignored. Fully covered self-expandable metal stent, self-expandable metal stent, and silastic esophageal stent were the stent types most used, although different materials and prototypes were reported as well. The number of stents used per patient and the duration of the stenting therapy varied widely (ranging from 1 to 584 days). Such treatments were not standardized because of different factors, such as different tolerance to complications in subjects aged 1 month and 16 years, frequent stent migration requiring removal followed or not by its replacement, different guides provided by each stent manufacturer, and successful healing of esophageal lesions. Different esophageal stents may be a reasonable therapeutic approach for the management of benign esophageal strictures in children and adolescents. We believe that esophagus-sparing methods like stents represent a promising alternative or adjunctive treatment to be considered in pediatrics.

Therapeutic Upper Gastrointestinal Endoscopy in Pediatric Gastroenterology

This paper seeks to give a broad overview of pediatric upper gastrointestinal (GI) pathologies that we are now able to treat endoscopically, acquired or congenital, and we hope this delivers the reader an impression of what is increasingly available to pediatric endoscopists and their patients.

Self-expanding esophageal stents for the management of benign refractory esophageal strictures in children: A systematic review and review of outcomes at a single center

BACKGROUND

This study aimed to evaluate our outcomes and complication rate following placement of self-expanding esophageal stents in children for the management of refractory esophageal strictures and comparing these to the existing literature.

METHODS

Outcomes following placement of stents in consecutive patients under 18 years at a single center from 2003 to 2018 were reviewed. A PRISMA-guided systematic review was conducted identifying studies with 5 or more children evaluating self-expanding stents published from 1975 to 2018. Endpoints for both the retrospective and systematic reviews were the requirement for further intervention and stent-associated complications.

RESULTS

25 patients received 65 stents. There were 12 caustic injury-related strictures (48%), 9 anastomotic strictures (36%), and 4 esophagitis-related strictures (16%). Four patients were lost to follow-up. 19/21 patients (90%) required further intervention, and 8/21 (38%) had esophageal replacement. Nine studies, all case series, were included in the systematic review. 97 patients received 160 stents for esophageal strictures and/or perforation. 36 out of 69 patients (52%) with strictures required no further treatment post-stenting, and 22/29 (76%) of esophageal perforations closed with stenting.

CONCLUSIONS

Esophageal stents may have a role as a bridge to definitive surgery and for the management of esophageal leaks, but complete stricture resolution post-stenting is unlikely.

TYPE OF STUDY

Treatment Study (Case Series with no Comparison Group) LEVEL OF EVIDENCE: Level IV.

Pediatric Endoscopy, Update 2020

Optimal management of pediatric endoscopy requires a multidisciplinary approach. In most hospitals, endoscopy in pediatric patients is performed by conventional gastroenterologists and only a few centers have specialized pediatric gastroenterologists. This is due to the fact that the number of pediatric gastroenterologists is limited and not all of them are experienced in endoscopic techniques. However, there are also some pediatric centers offering a high-quality and high-volume endoscopy service provided by very experienced pediatric gastroenterologists. Up to now, the literature on pediatric endoscopy is rather sparse. In this article, we describe current knowledge and practice of endoscopic procedures in pediatric patients, which should be relevant for both the adult and pediatric gastroenterologists.

Efficacy and risk profile of self-expandable stents in the management of pediatric esophageal pathology

PURPOSE

The purpose of this study was to evaluate the efficacy and risk profile of esophageal stents in the management of complicated pediatric esophageal disease.

METHODS

An IRB-approved, single-center, retrospective review was performed on all pediatric patients (n = 13) who underwent esophageal stent placement (2005-2017). Demographic, perioperative, and outcome data were analyzed (p < 0.05).

RESULTS

Forty-one stents were placed due to recalcitrant strictures (n = 36), perforations (n = 2), and/or fistulae (n = 3). Median age at initial stent placement was 23.8 months (range, 50 days to 16 years), and median stent duration was 36 days (range, 3-335). The recurrence rate for strictures after initial stent removal was 100%. Four (31%) children subsequently underwent definitive operative repair. There were 5 deaths, including 2 related to stent placement. Seventy-one percent of stents were associated with an adverse event, most commonly intraluminal migration (56%). Younger children experienced an increased risk for airway compression and retching (p = 0.010).

CONCLUSION

These data suggest that stents are associated with high complication rates and are not effective as definitive therapy for recalcitrant strictures in children. Although there may be a temporizing role for stents in selected patients, further refinements in stent technologies are needed to help manage this difficult patient population.

LEVEL OF EVIDENCE

Level IV.

Endoscopic Esophageal Vacuum Therapy: A Novel Therapy for Esophageal Perforations in Pediatric Patients

BACKGROUND

Esophageal perforation is a potentially life-threatening problem if not quickly diagnosed and treated appropriately. Negative-pressure wound therapy, commercially known as V.A.C. therapy, was developed in the early 1990s and is now standard of care for chronic surface wounds, ulcers, and burns. Adapting vacuum sponge therapy for use intraluminally for perforations of the esophagus was first reported in 2008. We report the first pediatric experience on a customized esophageal vacuum-assisted closure (EVAC) device for closure of esophageal perforations.

AIM

To evaluate the technical feasibility, safety, and efficacy of EVAC in a pediatric population with esophageal perforations and compare efficacy to a cohort of patients who underwent stenting for esophageal perforation.

METHODS

We performed an institutional review board-approved retrospective chart review on all patients who underwent EVAC for esophageal perforations (October 2013-September 2017) and who underwent externally removable stent placement for esophageal perforation (January 2010-December 2017) at our institution. Our primary aim was to evaluate technical feasibility, efficacy, and safety in the treatment of pediatric esophageal perforations. A secondary aim was to compare the efficacy of EVAC to esophageal stenting in healing esophageal perforations in our pediatric population.

RESULTS

A total of 17 patients with esophageal atresia underwent therapy for esophageal perforation. Eight sponges were placed for surgical perforation and 9 were placed after endoscopic therapy perforation. The median age of patients was 24 months with the youngest patient being 3 months of age. The success rate of EVAC to seal all esophageal perforations was 88% (15/17). The success rate was similar in both subgroups: surgical anastomotic leaks at 88% (7/8) and endoscopic therapy leaks at 89% (8/9). There were no technical failures with placement. The stent group had a total of 24 patients: 19 were placed secondary to perforations from endoscopic therapy and 5 were placed secondary to surgical anastomotic perforations. The success rate of stents to seal all esophageal perforations was 63% (15/24). The success rate in the subgroups was 74% (14/19) for endoscopic therapy leaks and 20% (1/5) for surgical anastomotic leaks. In comparing success of EVAC and stent therapy, we found a statistically significant difference in favor of EVAC in healing surgical anastomotic perforations (P = 0.032). There was, however, no statistical difference in healing endoscopic therapy perforations (P = 0.360).

CONCLUSIONS

EVAC is a novel, promising technique for the treatment of esophageal perforations in a pediatric population. This treatment is comparable to esophageal stenting in iatrogenic endoscopic therapy perforations and superior to stenting surgical perforations. Further prospective studies are needed to compare the effectiveness of EVAC to esophageal stenting. Improvement in device design and customization could further improve success and ease of placement.

Neonatal and pediatric esophageal perforation

Esophageal perforation (EP) is a rare complication that is often iatrogenic in origin. In contrast with adult patients in whom surgical closure of the defect is preferred, nonoperative treatment has become a common therapeutic approach for EP in neonates and children. Principles of management pediatric EP includes rapid diagnosis, appropriate hemodynamic monitoring and support, antibiotic therapy, total parenteral nutrition, control of extraluminal contamination, and restoration of luminal integrity either through time or operative approaches.

Diagnosis and treatment of congenital esophageal atresia with tracheoesophageal fistula

Esophageal atresia with or without tracheoesophageal fistula (EA/TEF) is a congenital life-threatening malformation which requires surgical repair, but it is still a challenge for patients and surgeons because of EA itself, possible combined severe deformities, and surgical risk. Thanks to the development and improvement of diagnostic and therapeutic methods and techniques, especially the progress achieved in preoperative EA diagnosis, successful surgery for long-gap EA/TEF, and the application of thoracoscopic technology, the survival rate after surgery has reached 95%. However, the possible postoperative complications and its managements should not be ignored.

Complications in pediatric endoscopy

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