Successful management of an acquired gastric outlet obstruction with endoscopy guided balloon dilatation

Endoscopic Balloon Dilation of Gastric Stenosis secondary to Polyarteritis Nodosa and Arterial Thrombosis in an Adolescent

A 13-year-old female with polyarteritis nodosa underwent a partial gastrectomy for ischemic necrosis and gastric perforation following left gastric artery thrombosis. She later presented with vomiting, early satiety, weight loss, and severe malnutrition, when she was diagnosed with an occlusive gastric stricture. She successfully underwent repeated therapeutic endoscopic balloon dilations until the endpoint of 15-18 mm lumen was achieved without any complications, and her symptoms resolved.

Primary acquired cicatrizing gastric outlet obstruction in children

Background:

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Comparison of Symptom Control in Pediatric Gastroparesis Using Endoscopic Pyloric Botulinum Toxin Injection and Dilatation

OBJECTIVES

The objective of this study was to assess the tolerance and efficacy of endoscopic intrapyloric botulinum toxin injection compared with pyloric dilatation in children with gastroparesis.

METHODS

This was a retrospective descriptive multicentre study that included pediatric patients treated between 2010 and 2018 at 4 tertiary hospitals.

RESULTS

Data were collected for 24 patients. The median age at diagnosis was 2.5 years (range 0.5-4.7). A total of 46 endoscopic procedures were performed. The endoscopic procedure was multiple in 63% of patients. Among the interventions, 76% were successful and 15% were unsuccessful. The recurrence rate was 57% and the median time to recurrence was 3.7 months (0.1-73). The efficacy did not differ significantly between the 2 methods at the first intervention and as a second-line treatment. The recurrence rate also did not differ significantly between the 2 methods. No complications were reported. The median follow-up was 19.8 months (1.7-61.7).

CONCLUSIONS

In this retrospective multicentre study, endoscopic management of gastroparesis by balloon dilatation or botulinum toxin was safe in children and seemed to be partially efficient within the first months. Symptoms recurred frequently and required repetition of the interventions.

Successful combination of endoscopic pyloromyotomy and balloon dilatation for hypertrophic pyloric stenosis in an older child: A novel procedure

Background

Hypertrophic pyloric stenosis (HPS) is a rare cause of gastric outlet obstruction beyond infancy. Ramstedt pyloromyotomy remains the gold standard treatment for HPS. This type of HPS can be managed successfully with pyloromyotomy under laparoscopic or open procedures. Endoscopic pyloric balloon dilation (EPBD) has not been recommended in the treatment of HPS, and there are only a small number of reported cases who had had successful endoscopic pyloromyotomy (EP) for HPS only in infants.

Case presentation

The patient was suspected of having HPS when the patient was 1 year old after infancy. However, his parents thought that the vomiting and poor sucking were caused by Down syndrome-associated muscular hypotonia. Since then, no additional tests have been performed at their request. At 6 years of age, he was readmitted to our department because of persistent vomiting and failure to thrive, and HPS was diagnosed again. However, it was unknown whether the HPS had been persisting since infancy or was acquired. The first EPBD was slightly effective but did not remain effective for a long time. When the second EPBD was performed in combination with EP, the amount and frequency of vomiting were reduced dramatically.

Conclusions

The combination of EP and EPBD procedure may represent a safe, effective, and minimally invasive option for selected HPS patients in whom laparotomy would pose a significant risk or who do not respond to conventional medical treatment. To our knowledge, this is the first report to describe combination treatment with EP and EPBD in an older child with HPS.

Update on endoscopic management of gastric outlet obstruction in children

Endoscopic balloon dilatation (EBD) and surgical intervention are two most common and effective treatments for gastric outlet obstruction. Correction of gastric outlet obstruction without the need for surgery is an issue that has been tried to be resolved in these decades; this management has developed with EBD, advanced treatments like local steroid injection, electrocauterization, and stent have been added recently. The most common causes of pediatric gastric outlet obstruction are idiopathic hypertrophic pyloric stenosis, peptic ulcer disease followed by the ingestion of caustic substances, stenosis secondary to surgical anastomosis; antral web, duplication cyst, ectopic pancreas, and other rare conditions. A complete clinical, radiological and endoscopic evaluation of the patient is required to make the diagnosis, with complimentary histopathologic studies. EBD are used in exceptional cases, some with advantages over surgical intervention depending on each patient in particular and on the characteristics and etiology of the gastric outlet obstruction. Local steroid injection and electrocauterization can augment the effect of EBD. The future of endoscopic treatment seems to be aimed at the use of endoscopic electrocauterization and balloon dilatations.

Caustic oesophagitis in children: prevalence, the corrosive agents involved, and management from primary care through to surgery

PURPOSE OF REVIEW

Caustic substance ingestion (CSI) remains a major health issue, particularly in developing countries, where laws are not effectively enforced. This review offers a thorough analysis of the current epidemiology, clinical features, management, treatment, and long-term complications of CSI in children.

RECENT FINDINGS

Strong alkalis sold in liquid and granular forms, particularly crystalline grease cleaners (concentrated sodium hydroxide), are the principal causes of severe oesophageal damage. Currently, early endoscopy to assess the gastro-oesophageal mucosa is not considered necessary for all CSI cases. Oesophageal stricture is a major complication developing after CSI, and should be diagnosed and treated earlier, 10-14 days after CSI via commencement of a dilation program. Fluoroscopically guided oesophageal balloon dilatation seems to be safe, with a low frequency of complications and a high success rate. However, it should commence earlier than is currently the case, and should be performed gently, using balloons of gradually increasing diameter. If dilation fails after a few months, oesophageal replacement surgery should be performed.

SUMMARY

Unfortunately, neither dilatation treatment nor oesophageal bypass surgery can prevent the development of oesophageal carcinoma, the incidence of which is high after CSI. The continuing unacceptably high incidence of CSI accidents would be reduced if corrosive materials were sold in their original childproof containers, highlighting the need for preventive and adult education programmes.

Therapy of caustic ingestion: new treatment considerations

PURPOSE OF REVIEW

This review will focus on therapeutic considerations and recent advances in treatment of caustic ingestion injuries.

RECENT FINDINGS

A retrospective study suggests that it may be safe to advance the endoscope beyond the first circumferential burn to allow for a more complete assessment of extent of injury. A randomized controlled prospective study suggested that a 3-day course of high-dose methylprednisolone might reduce the occurrence of esophageal stricture formation. Balloon dilatation has been shown to be as effective as other bougienage techniques with lower risk of perforations. Recent studies indicate that esophageal dilatation can be safely performed as early as 5-15 days after initial ingestion and may decrease risk for long-term stricture formation. The use of adjunctive treatment, such as topical mitomycin C and esophageal stents, shows promise in reducing the reoccurrence of stricture formation after dilatation.

SUMMARY

Caustic ingestion remains a significant problem in children, despite continued efforts to educate the public about ways to avoid this preventable accident. Because there are few good quality therapeutic trials in children, many of the current recommendations regarding treatment are based on expert opinion. Large, prospective, multicenter, controlled treatment trials are needed to identify the best protocols to prevent serious complications.

Caustic injury of the oesophagus

Caustic ingestion continues to be a significant problem world-wide especially in developing countries and particularly in the under 6 years age group. The presence or absence of symptoms or oral lesions does not reliably predict the existence or severity of oesophageal lesions. Upper endoscopy remains the mainstay diagnostic modality for evaluation to define the extent and severity of the injury. The best predictor of morbidity and mortality is the extent of injury as assessed during initial evaluation. Early management strategies for caustic ingestion are well defined. Controversy still surrounds the use of steroids, antibiotics, antacid therapy in the acute phase, and the use of oesophageal stents and the frequency, timing and method of dilatation in the prevention and management of oesophageal strictures. There is a pressing need for non-invasive diagnostic modalities and effective therapeutic options to evaluate and treat the complications associated with caustic ingestion. Indications for definitive surgery or bypass and the type of procedure to use are also subject to ongoing debate.

Paediatric GI emergencies

Paediatric GI emergencies constitute a wide range of gut pathologies ranging from those that are common, easily diagnosed and treated to conditions that are rarer, often more severe and challenging to manage. Among a myriad of ordinary clinical symptoms and signs physicians have to identify the child with a serious, life-threatening pathology and initiate the appropriate diagnostic and therapeutic pathway. The aim of the review is to present and discuss a selection of key paediatric GI emergencies that provide challenges in diagnosis and treatment. These conditions are classified by their presentation or pathogenesis and include inflammatory conditions, those presenting with GI obstruction or haemorrhage and the ingestion of foreign bodies or caustic substances. The most recent advances regarding the management of these entities are discussed along with key areas of clinical practice and future research.

Management of pyloric stricture in children: endoscopic balloon dilatation and surgery

BACKGROUND

Surgical correction is the most preferred treatment modality in pyloric stricture (PS). Recently a few studies reported the experience of balloon dilation in children with PS. This study was designed to present our experiences of the management of the patients with PS with balloon dilation and corrective surgery.

METHODS

The records of 14 patients who were treated with the diagnosis of PS between August 2003 and August 2011 were reviewed retrospectively.

RESULTS

There were nine boys and five girls (mean age, 3.4 ± 1.7 years). The history of caustic ingestion was detected in eight patients; six of them were admitted on the day of ingestion. Two patients were admitted with nonbilious vomiting more than 2 weeks after ingestion. Four patients did not have a remarkable medical history, including caustic ingestion. They admitted with the complaint of nonbilious vomiting. PS was detected during endoscopy in two patients who had a diagnosis of peptic ulcer disease. PS was shown by barium meal study in all patients. Endoscopy was performed in all patients. Endoscopic balloon dilation was tried in 12 patients. Overall eight patients required surgical procedures for PS. The complaints were resolved by endoscopic balloon dilation of pylorus in the remaining six patients.

CONCLUSIONS

Although endoscopic balloon dilatation for benign PS in adults is a generally accepted method of treatment, there is less experience with endoscopic balloon dilatation for PS in children. PS due to benign disorders can be effectively and successfully treated through endoscopic balloon dilatation in suitable patients. In patients with successful pyloric balloon dilatation, surgery can be avoided.

Caustic ingestion in children

Caustic ingestion continues to be a significant problem worldwide especially in developing countries. In 2008 over 200,000 exposures to caustic substances were reported to the National Poison Data System. The presence or absence of symptoms or oral lesions does not predict the existence or severity of lesions. The best predictor of morbidity and mortality is the extent of injury as assessed during initial evaluation. Upper endoscopy remains the mainstay diagnostic modality for the evaluation of patients with caustic ingestion. There is a pressing need for noninvasive diagnostic modalities and effective therapeutic options to evaluate and treat the complications associated with caustic ingestion.

Idiopathic non-hypertrophic pyloric stenosis in an infant successfully treated via endoscopic approach

Non-peptic, non-hypertrophic pyloric stenosis has rarely been reported in pediatric literature. Endoscopic pyloric balloon dilation has been shown to be a safe procedure in treating gastric outlet obstruction in older children and adults. Partial gastric outlet obstruction (GOO) was diagnosed in an infant by history and confirmed by an upper gastrointestinal series (UGI). Abdominal ultrasonography and computed tomography scan excluded idiopathic hypertrophic pyloric stenosis, abdominal tumors, gastrointestinal and hepato-biliary-pancreatic anomalies. Endoscopic findings showed a pinhole-sized pylorus and did not indicate peptic ulcer disease, Helicobacter pylori infection, antral web, or evidence of allergic and inflammatory bowel diseases. Three sessions of a step-wise endoscopic pyloric balloon dilation were conducted under general anesthesia and a fluoroscopy at two week intervals using catheter balloons (Boston Scientific Microvasive^®, MA, USA) of increasing diameters. Repeat UGI after the first session revealed normal gastrointestinal transit and no intestinal obstruction. The patient tolerated solid food without any gastrointestinal symptoms since the first session. The endoscope was able to be passed through the pylorus after the last session. Although the etiology of GOO in this infant is unclear (proposed mechanisms are herein discussed), endoscopic pyloric balloon dilation was a safe procedure for treating this young infant with non-peptic, non-hypertrophic pyloric stenosis and should be considered as an initial approach before pyloroplasty in such presentations.

Nonsurgical management of severe esophageal and gastric injury following alkali ingestion

The ingestion of caustic substances may result in significant gastrointestinal injury. Endoscopy can play a major role in the initial evaluation and subsequent therapy of such injuries. The case of a 50-year-old man who ingested an alkaline floor stripper is described, including the endoscopic management of esophageal and pyloric strictures, with good functional results. The role of endoscopy, steroids and acid suppression in the management of such patients is also explored.

Recurrent pyloric stenosis: to dilate or operate? A preliminary report

PURPOSE

Idiopathic hypertrophic pyloric stenosis is a common surgical problem in infants, and pyloromyotomy is almost always successful in alleviating the obstruction. There are few reports in the literature that discuss recurrent pyloric stenosis as opposed to incomplete pyloromyotomy. We report 2 such babies with different cures.

METHODS

The health records department files were electronically searched for the number of infants at our children's hospital with hypertrophic pyloric stenosis seen over the past 30 years (1973-2003), and the recurrences were reviewed.

RESULTS

Recurrent pyloric stenosis was encountered in 2 cases (<0.07%). Balloon dilatation was first tried in both cases and was successful in 1 case; redo pyloromyotomy was required for the second case.

CONCLUSION

Recurrent pyloric stenosis is rare. Fluoroscopic balloon dilatation of the pylorus warrants further study as the first choice for curing this problem, and if unsuccessful, redo pyloromyotomy.

Stapled gastroplasty for antral stricture after repair of neonatal gastric rupture: report of a case

The patient was the second of twin girls born at 32 weeks' gestation, weighing 1736 g. Abdominal distention was noted the day after birth, and abdominal x-ray showed free air in the abdomen. An emergent laparotomy with debridement and primary closure were performed for spontaneous gastric rupture. From the age of 8 months, the infant sometimes vomited after meals and was unable to gain weight. She was diagnosed, by upper gastrointestinal series and gastroscopy, with antral stricture with a normal prepyloric area and pylorus. The presence of an antral web, ulcers, or ectopic pancreatic tissue was excluded. There was sufficient distance between the stricture area and the pylorus. Stapled gastroplasty using an Endopath linear cutter stapler and a Proximate linear stapler was performed safely and quickly without injury to the normal pylorus or branches of the vagal nerve at the lesser curvature. The child's postoperative course was uneventful.

Gastric outlet obstruction secondary to acid ingestion in children

BACKGROUND/PURPOSE

Gastric outlet obstruction (GOO) is a well-known complication of acid ingestion. However, most reports deal with adults. In this report, the authors present their experience with the treatment of acid-induced GOO in children.

METHODS

The records of patients admitted for unintentional ingestion of corrosive agents between 1980 and 2002 were reviewed retrospectively. Data concerning age at ingestion, type of ingested substance, time between ingestion and the first signs of GOO, weight loss, treatment, complications, duration of hospital stay, and long-term follow-up were reviewed.

RESULTS

GOO was not observed in any of the children admitted for alkaline ingestion, whereas GOO developed in 8 of 98 children (8.2%) in a mean period of 26.7 +/- 10 days after the ingestion of acid substances. Presenting symptoms were frequent nonbilious vomiting and marked weight loss. All had pyloric obstructions in the upper gastrointestinal series and required surgical intervention. Gastrojejunostomy was the operation of choice for all patients. Oral feedings were started on the third postoperative day. The complications were wound infection in 1 and upper gastrointestinal bleeding in another in the early postoperative period. Mean follow-up is 8.33 +/- 4.45 (4.8-18.7) years. No late complications such as marginal ulcus or stricture at the anastomosis site were observed in the series.

CONCLUSIONS

Treatment of GOO with gastrojejunostomy gives good long-term results in children. This procedure is safe and causes minimal morbidity particularly in patients without extensive gastric damage.

Balloon catheter dilatation for hypertrophic pyloric stenosis

Balloon dilating catheters (BDC) have provided a non-operative means of managing obstructive lesions within the gastrointestinal tract. Its potential utility in infants with hypertrophic pyloric stenosis (HPS) was studied. Six patients with HPS underwent balloon catheter dilatation of the pylorus under the direct observation of the surgeon. The pylorus was exposed using a standard right upper quadrant incision. The BDC was passed transorally into the stomach and manipulated into the pyloric canal by the surgeon. The balloon was inflated with saline to a maximum pressure of 50 psi for 2 minutes. Four patients were dilated with a 10-mm diameter balloon catheter, and in two patients, a 15-mm balloon was used. Success was defined as the complete and longitudinal disruption of the seromuscular ring without violation of mucosal integrity. Using this criterion, none had successful pyloric dilatation. No disruption occurred in three patients, partial disruption in two. These patients subsequently underwent a Ramstedt pyloromyotomy. Complete disruption was observed in one; however, a breach of the mucosa was evident. This was repaired without incident. All seromuscular breaks occurred at the point of vascular entry along the lesser curve, presumably the weakest point of the ring. Pyloric dilatation using BDC does not reliably disrupt the muscular ring. This preliminary report recognizes that major refinements must occur before this method will supplant the time-honored surgical pyloromyotomy for HPS.

Long-term follow-up in patients who have undergone balloon dilation for gastric outlet obstruction

Although balloon dilation for gastric outlet obstruction has supplanted vagotomy plus drainage or resective therapy in some institutions, there are no long-term data which demonstrate what percentage of patients ultimately requires surgical intervention. Of 23 evaluable patients treated with hydrostatic balloon dilation in our institution, 70% were asymptomatic at a mean follow-up of 2.5 years. Five patients required surgery--one for acute perforation and the other four for symptoms of continued obstruction, despite one to three additional attempts at dilation. Only three of seven patients with previous gastric resection had a satisfactory long-term result. Whereas endoscopic therapy initially cost one tenth to one fifth that of surgical intervention, such figures do not factor for loss of productivity, on the one hand, or potential need for chronic H2 blockade, on the other. Despite instruction to the contrary, only 6 of 15 (40%) active patients continue acid-suppressive therapy. We conclude that balloon dilation remains a viable alternative for selected patients with gastric outlet obstruction.