Factors affecting the outcome of endoscopic dilatation in refractory post-corrosive oesophageal stricture in Egyptian children: a single-centre study

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

Background

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

Patients and Methods

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

Results

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

Conclusions

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

Colon patch esophagoplasty for esophageal strictures refractory to multi-modal treatment revisited

INTRODUCTION/PURPOSE

Esophageal strictures due to caustic ingestion (CI) may require repeat esophageal dilations and dilation adjuvants, including local anti-fibrinogenic injection therapy, stent placement, and radial stricture incisions. Refractory strictures require surgical intervention. Pedicled colon patch esophagoplasty (CPE) may avoid the morbidity associated with total esophageal replacement, although reports of its use are limited. Indications and outcomes for CPE in patients undergoing repeat esophageal stricture dilations following caustic ingestion are described according to our local experience and literature reports.

MATERIALS AND METHODS

A retrospective review of indications for surgical management of esophageal strictures to tertiary pediatric surgical services between 2015 and 2020 focused on patients undergoing CPE. English-language literature (PubMed, Google Scholar, and Scopus) describing CPE was also reviewed.

RESULTS

Eight (12%) out of 65 patients with esophageal strictures requiring 7 or more esophageal dilations with poor response underwent surgical stricture management over a 6 year period, which included stricture resection and re-anastomosis in 2 patients, total esophageal replacement with colon graft in 2 patients, gastric pull-up in 1 patient, and CPE in 3 patients. The patients undergoing CPE were aged 3-8 years and had 17 to more than 25 dilations following caustic ingestion over a 2-5 year period. One patient had a 4 cm stricture; the other 2 had strictures 7 cm in length. A transverse colon patch based on the middle and left colic vessels was utilized in all three, with the vascular pedicle placed retrogastrically via the esophageal hiatus and the patch inlay esophagoplasty concluded via right thoracotomy. Post-operative contrast studies showed near-normal anatomy, and the patients could tolerate full oral diets. During a 9-36 month follow-up period, only 2 patients required dilations of a proximal anastomotic stricture at 1 and 5 months postoperatively. One patient required additional proximal stricturoplasty with advancement of the original graft across the stricture via a cervical surgical approach.

CONCLUSION

Colon patch esophagoplasty to restore esophageal luminal continuity and allow a normal diet should be considered for refractory esophageal strictures. CPE had excellent functional outcomes in our 3 patients and should be considered in selected cases instead of total esophageal replacement.

Acquired Esophageal Strictures in Children: Morphometric and Immunohistochemical Analyses

BACKGROUND

Esophageal strictures (ES) in children are not well characterized pathologically. We report unique histopathologic analyses of resected acquired ES and control esophagi (CE).

METHODS

Muscle layer thicknesses were measured in intact well-oriented areas; inflammatory cells were counted in the most inflamed high power field (hpf). Sections were stained with relevant antibodies. Results were expressed as median, lower and upper quartiles. Wilcoxon Rank Sums non-parametric test was used to compare groups; P ≤ 0.05 was considered significant.

RESULTS

All ES (N = 10) showed focal replacement of lamina propria, muscularis mucosa and submucosa by actin+ fibers emanating from muscularis propria. Compared to CE (N = 8), ES displayed significantly thickened muscularis mucosa and propria, and increased mast cells (tryptase- and chymase-positive), and eosinophils in muscle layers (all P ≤ 0.01). Matrix proteins periostin and fibronectin were identified in the muscle layers of CE, and in the extracellular matrix in areas of disrupted architecture in ES.

CONCLUSIONS

Compared to CE, acquired ES in children show significant structural alterations, including obliterative muscularization, inflammatory cell mural infiltrates, and extracellular matrix protein deposits. Therapies targeting connective tissue expansion, mast cells, eosinophils and inflammation may be beneficial to treat ES.

New therapies for esophageal strictures in children

PURPOSE OF REVIEW

The present review aims at describing recent advances in therapeutic strategies for the treatment of benign esophageal strictures in children. We discuss current knowledge and practice on esophageal dilations, which are still the mainstream of treatment. We present new evidence about adjuvant treatments for recurrent and refractory strictures, including endoscopic incisional therapy, esophageal stenting, intralesional or topical mytomicin C and intralesional, systemic or topical steroids.

RECENT FINDINGS

Current evidence on esophageal dilations is not sufficient to establish superiority of one of the available techniques, especially the use of balloon or bougie dilators, but a prospective international cohort study on anastomotic stricture in esophageal atresia is underway to address this issue. Recurrent and refractory strictures still represent a challenge, since none of the adjuvant pharmacological and mechanical interventions has shown to be enough feasible, effective and safe to revolutionize clinical practice.

SUMMARY

In the last couple of years, several encouraging results have been published on management of esophageal strictures in children. Further research is needed, hopefully directed toward secure, easily reproducible and minimally invasive measures.