Clinical and nutritional outcome of pediatric esophageal stenosis with endoscopic balloon dilatation

Outcomes of pneumatic dilation in pediatric caustic esophageal strictures: a descriptive and analytic study from a developing country

OBJECTIVES

Corrosive substance ingestion in children represents a significant public health issue due to its long-term health sequelae. Esophageal stricture, main complication of this dangerous condition, is treated by pneumatic dilation and eventually by esophageal replacement. We aimed, through this study, to report the outcomes of esophageal pneumatic dilation complicating corrosive substance ingestion in children in a developing country.

METHODS

This cross-sectional study was performed on the population of pediatric patients with caustic esophageal stenosis between January 2005 and December 2020. All patients underwent pneumatic balloon dilation. A logistic regression model was built to predict the probability of the occurrence of the event (success/failure) of the dilation. The ROC curve is used to evaluate the performance of the logistic regression model to discriminate between positive and negative values of the dependent variable.

RESULTS

The success rate of pneumatic balloon dilation was 80.4%. The median duration of overall management was 11 months. The severity of caustic stricture observed during endoscopy was significantly linked to worse outcomes (p = 0.001). Multivariate analysis indicated that the severity of stenosis and the number of dilation sessions were independent risk factors for failure of dilation. ROC curve analysis showed that the area under the curve was 71.7%. A Cut-Off point value of 7 provided the best sensitivity and specificity.

CONCLUSION

Pneumatic balloon dilation has been proven to be efficacious in infants with caustic esophageal stricture. Pediatric surgeons should take into account factors to promptly switch to replacement surgery and avoid unnecessary and time-consuming serial dilations.

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.

Postoperative Complications of Esophageal Atresia and Role of Endoscopic Balloon Dilatation in Anastomotic Strictures

PURPOSE

Esophageal atresia (EA) with or without tracheoesophageal fistula (TEF) is a congenital anomaly that can cause frequent digestive and nutritional problems, even after repair. The most common complication is anastomotic stricture, for which reoperation or balloon dilatation is performed. This study aimed to evaluate the postoperative complications of EA and the role of endoscopic balloon dilatation (EBD) in cases of anastomotic stricture.

METHODS

We retrospectively analyzed patients diagnosed with EA with or without TEF between January 2000 and February 2021. Patients' baseline characteristics, associated anomalies, and postoperative complications were reviewed.

RESULTS

Among 26 patients, 14 (53.8%) were male, 12 (46.2%) had coexisting anomalies, and the median follow-up was 6.1 years (range, 1.2-15.7 years). In univariate analysis, prematurity, low birth weight, and long-gap EA were associated with postoperative complications in 12 (46.2%) patients. Among the 10 (38.5%) patients with anastomotic stricture, nine (90.0%) required EBD. Regarding the first EBD, it was performed at a median of 3.3 months (range, 1.2-7.6 months) post-repair, while the average patient weight was 4.6 kg. The mean diameter ranged from 3.3 to 9.1 mm without major complications. In univariate analysis, long-gap EA alone was significantly associated with EBD.

CONCLUSION

Approximately half of the patients experienced complications after EA repair. In particular, patients with a long-gap EA had a significantly increased risk of complications, such as anastomotic strictures. EBD can be safely used, even in infants.

Fluoroscopy-guided balloon dilatation of benign esophageal strictures in children: 11-year experience

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.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Efficacy and Safety of Endoscopic Esophageal Dilatation in Pediatric Patients with Esophageal Strictures

Materials and Methods

In this retrospective cross-sectional single center study, records of patients with esophageal strictures presented to the pediatric department, Salmaniya Medical Complex, Bahrain, in the period between 1995 and 2019 were reviewed. Demographic data, indications of endoscopic dilatations, the procedure success rate, and possible complications were assessed.

Results

Forty-six children were found to have esophageal strictures. Twenty-five (54.3%) patients were males. Most patients presented during infancy (86.5%, 32/37 patients). Twenty-six (56.5%) patients required 88 dilatation sessions, while the remaining 20 (43.5%) patients did not require dilatations. The median number of dilatation sessions per patient was three (interquartile range = 2-5). Savary-Gilliard bougienages were the main dilators used (80.8%, 21/26 patients). Anastomotic stricture (post esophageal atresia/tracheoesophageal fistula repair) was the main cause of esophageal strictures and was found in 35 (76.1%) patients. Patients with nonanastomotic strictures had more frequent dilatations compared to those with anastomotic strictures (P = 0.007). The procedure success rate was 98.8%. Yet, it was operator dependent (P = 0.047). Complete response to dilatation was found in 18 (69.2%) patients, satisfactory in seven (26.9%), and an inadequate response in one (3.9%). Those with satisfactory responses still require ongoing dilatations based on their symptoms and radiological and endoscopic findings. No perforation or mortality was reported. Patients with dilatations had more recurrent hospitalization (P < 0.0001), more dysphagia (P = 0.001), but shorter hospital stay (P = 0.046) compared to those without dilatations. Surgical intervention was required in one patient with caustic strictures. The median follow-up period was six years (interquartile range = 2.25-9.0).

Conclusions

Endoscopic esophageal dilatation in children with esophageal strictures is effective and safe. Yet, it was operator dependent. Nonanastomotic strictures require more dilatations compared to anastomotic strictures. Findings of this study are comparable to those reported worldwide.

The Outcome of Pediatric Esophageal Strictures Managed with Endoscopic Balloon Dilation in Saudi Arabia

Background: Esophageal strictures can affect nutrition of infants and children impairing their weight gain. To our knowledge, this is the first article evaluating and comparing between the two methods of dilation in terms of outcome and one of few, if any, to assess both weight and height to evaluate the nutritional outcomes following dilation. To determine the safety, efficacy, and long-term effects of endoscopic dilation in managing pediatric esophageal strictures by assessing the clinical and nutritional outcomes. Methods: A retrospective study of 137 patients with esophageal strictures who underwent either endoscopic balloon dilatation or Savary dilatation, or both. Outcome parameters measured include the number of dilatations, nutritional status, and if symptoms had been relieved. Results: The most frequent cause of esophageal strictures was post-tracheoesophageal fistula repair (n = 51, 37.2%), and the majority were lower third strictures (n = 47, 34.3%). However, 8 cases (5.8%) had failed the dilation procedure. Savary dilatation had the highest number of complications. Overall, success rate was 79.6%. Higher success rate was for cases dilated by endoscopic balloon dilation (EBD) (n = 47, 90.4%). There was a statistically significant correlation between the success rate and the method of dilatation (P = .042). Statistically significant increment of weight was recorded for lower strictures (P = .001). Conclusion: EBD was associated with the highest success rate. Endoscopic dilatations are safe and efficient in managing pediatric esophageal strictures with improvement in both clinical and nutritional outcomes.

Balloon dilatation for paediatric airway stenosis: Evidence from the UK Airway Intervention Registry

Objectives

To assess the safety and efficacy in routine clinical practice of balloon dilatation procedures in the treatment of paediatric airway stenosis.

Design

Observational data collection in prospective online research database.

Setting

Acute NHS Trusts with ENT department undertaking complex paediatric airway work.

Participants

Children (<18) undergoing balloon dilatation treatment for airway stenosis.

Main outcome measures

Airway diameter, complications, hospital resource usage.

Results

Fifty‐nine patients had 133 balloon procedures during 128 visits to 10 hospitals. Sixty‐nine (52%) of balloon procedures were conducted with a tracheostomy. Intra‐operative Cotton‐Myer grade decreased in 43 (57%). The mean pre‐balloon subglottic diameter was 4.2 [95% CI: 3.8 to 4.5] mm, and its rate of increase was 0.8 [0.5 to 1.2] mm per year modelled on 30 patients' long‐term data. As the primary treatment of stenosis, the procedural success rate of balloon dilatation (n = 52) was 65% (22% with tracheostomy, 88% without tracheostomy), and 71% as an adjunct to open reconstructive surgery (n = 7). In the 64 hospital visits where a balloon procedure was conducted with a tracheostomy in place, only one in‐hospital complication (lower respiratory tract infection) occurred. For those without a tracheostomy in place, in‐hospital complications occurred in seven of 64 balloon hospital visits, all related to ongoing or worsening stenosis. Six out‐of‐hospital complications were deemed related to ongoing or worsening stenosis following the procedure, and two complications were a combination of lower respiratory infection and ongoing or worsening stenosis.

Conclusions

Balloon dilation increases the size of the airway intraoperatively and is associated with long‐term increase in airway diameter. Safety outcomes mostly relate to ongoing or worsening stenosis and are more common in patients without a tracheostomy.