The Management of Esophageal Strictures in Children

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1 Akram J. Jawad, FRCS(Ed); Asal Izzidien Al-Samarrai, FRCS,FACS; Abdullah Al-Rabeeah, MS,FRCS(C); Rashed Al-Rashed, FRCP(C) From the Divisions of Pediatric Surgery (Drs. Jawad, Al-Samarrai, Al-Rabeeah) and Gastroenterology (Dr. Al-Rashed), College of Medicine and King Khalid University Hospital, Riyadh. Address reprint requests and correspondence to Dr. Al-Samarrai: King Saud University, P.O. Box 2925, Riyadh 11461, Saudi Arabia. Accepted for publication 17 May During a 10-year period from 1982 to 1992, 36 children and infants were treated for esophageal stricture. The severity of the stricture was indicated by the degree of feeding intolerance manifested by delays in growth and development and confirmed by fluoroscopy and endoscopy. Their ages ranged from one month to seven years. During the first eight years, the initial treatment was the conventional use of Savory dilators. Balloon dilatation was applied in all patients with esophageal stricture during the last two years. According to the etiology of the stricture, patients were divided into three groups. Group A: (seven patients) due to peptic esophagitis following persistent gastroesophageal reflux (GER). Group B: (15 patients) following ingestion of corrosive material. All had severe strictures; two had stomach outlet obstruction in addition. Group C: (14 patients) following repair of esophageal atresia. There was no mortality; however, overall morbidity was 5.5%, as one patient had esophageal perforation during the initial esophageal dilatation and one patient developed anastomotic leak. Ann Saudi Med 1995;15(1): AJ Jawad, AI Al-Samarrai, A Al-Rabeeah, R Al-Rashed, The Management of Esophageal Strictures in Children. 1995; 15(1): Within the past century, rapid progress has been made in the prevention and nonoperative therapy of esophageal strictures in children. 1 "The use of steroids; insertion of intraluminal stent, bougienage, esophageal dilatation and balloon esophagoplasty" 1,13 are preferable forms of treatment, as the patient's own functional native esophagus is better than any other tube or conduit we can construct. Esophageal replacement procedure is indicated only after exhausting all available conservative measures. Material and Methods Between 1982 and 1992 a total of 36 children and infants were treated for esophageal strictures, the age range at the time of presentation being from one month to seven years with mean age of 48 months in group A, 36 months in group B and five months in group C. Twelve patients were boys and 24 were girls. In Group A (seven patients), the strictures were caused by gastroesophageal reflux (GER). In Group B (15 patients), the strictures were caused by ingestion of corrosive material and in group C (14 patients), the strictures followed anastomosis for esophageal atresia. In group A (19%) the main clinical symptoms were repeated vomiting, failure to thrive and repeated chest infection. The diagnosis was confirmed with Tc 99 radioactive milk scan which is a more sensitive method than ph monitoring and is more accurate than conventional contrast study, 2 which was used in our study in combination to achieve higher diagnostic value. 3 However, we agree this issue is still controversal. Conservative treatment consisted of Cimetidine, antacid, thick and frequent small feedings, nursing with elevation of the head, and chest physiotherapy for at least six weeks. Esophageal dilatation was carried out using Savory and balloon dilators (Table 1) followed by Nissen fundoplication in patients 5 and 7. In group B (42%) (Table 2), 11 of the 15 patients were referred after having received initial treatment elsewhere with a history of corrosive ingestion and well-established strictures. In 10 patients, the mid one-third of their esophagus was involved while in the remaining five, the upper one-third was involved. In two of these, the oropharynx was also affected. Two patients developed stomach outlet obstruction and required pyloroplasty. Eight patients had gastrostomy, followed in two cases by resection and esophageal circular myotomy with endto-end anastomosis. Four patients required esophageal replacement. One patient required local resection of the stricture and primary anastomosis. The remaining eight patients responded well to repeated dilatation. In group C: (39%) (Table 3) 14 patients developed anastomotic strictures out of 50 patients treated for esophageal atresia. Four patients required resection after failure of esophageal dilatation. The rest responded well to repeated esophageal dilatation.

2 No Age/ Months Sex Table 1. Group A: Gastroesophageal reflux: mean age (42 months). No. Esoph. Dil Per Times Site Conservative Treatment Surgery FU Results 1 24 F 6/24 mo Lower mo Good F 2/2 mo Lower mo Good 3 18 F 2/2 mo Lower mo Good 4 15 F 8/24 mo Lower mo Good 5 60 F 3/5 mo Lower + FP 34 mo Good 6 18 F 1/2 mo Lower mo Good 7 48 F 8/8 mo Lower + FP 30 mo Good Esoph. dil=esophageal dilatation; FU=Follow-up; FP=Fundoplication; mo=months; F=Female. Table 2. Group B: Corrosive: mean age (36 months). Results In group A (GER), all patients had excellent results with mean follow-up of 20 months. Group B (corrosive) patients showed good results with a mean follow-up period of 30 months. However, case 1 showed poor results in the immediate postoperative period with frequent aspiration; improvement in swallowing was noticed even for solid food six months after surgery. Group C (postanastomotic) all had good results with a mean follow-up of 25 months. Ten patients responded well to the dilatation. In four patients, the strictures were very severe. Balloon dilatation was not successful in two patients and the distal esophageal lumen could not be visualized in the others. Resection of the stenosis with esophageal anastomosis was required (Table 3).

3 Table 3. Group C: Anastomotic: mean age (5 months). No. Age Sex No. Dil Period Severity Surgical Rx Follow up Results 1 14 mo F mo severe resection + anastomosis 60 mo good 2 2 mo F 5 6 mo moderate - 42 mo good 3 1 mo F 2 2 mo moderate - 30 mo good 4 18 mo F 2 1 mo moderate - 36 mo good 5 16 mo F 2 1 mo moderate - 36 mo 6 1 mo F 2 3 mo moderate - 24 mo 7 12 mo M 3 6 mo moderate - 18 mo 8 1 mo M 3 3mo moderate - 12 mo good 9 6 mo M 5 4 mo severe resection + anastomosis 36 mo good 10 4 mo F 3 2 mo severe resection + anastomosis 29 mo good 11 4 mo F 1 1 mo severe resection + anastomosis 4 mo good 12 1 mo M 2 1 mo moderate - 9 mo good 13 2 mo M 2 2 mo moderate - 6 mo good 14 2 mo F 2 2 mo moderate - 8 mo good Discussion The most common cause of esophageal stricture in children is the accidental ingestion of strong corrosive substances. 4 Eighty percent of caustic ingestion occurs in children five years of age or younger, esophageal stricture occurring in up to 20% of cases. 5 Alkalis are the most destructive agents. They cause liquefaction necrosis, saponification of fat, dehydration of tissue and thrombosis of blood vessels, resulting in deep tissue injuries. Acids on the other hand cause coagulation necrosis with limited penetration, while bleach usually produces only a mild burn. 6,7 Boiling water can cause thermal injury with full thickness burn. Although esophageal lesions are found in only a minority of children who are suspected of having ingested a caustic agent, a prompt endoscopy by an experienced surgeon or pediatric gastroenterologist using flexible endoscope needs to be performed within the first 24 hours in all cases. The risk of aspiration either during the procedure or during recovery from anesthesia as well as the risk of perforation due to friability of the tissue involved should be considered in all cases. 8 However, this is necessary not only to confirm the diagnosis, but also to help determine the degree of esophageal burn. There is still no clinical standardized system of interpreting endoscopic findings for corrosive ingestion injuries. 7 All group B patients except four were referred with well-established esophageal strictures. Patient 2 presented initially to our Accident and Emergency after sulfuric acid ingestion. Emergency endoscopy showed a severely burned upper and middle third of the esophagus, with mild erythema of the prepyloric region. After three weeks of systemic antibiotics, steroids and total parenteral nutrition (TPN), repeat endoscopy revealed a moderately scarred mid one-third esophagus where conventional dilatation was started. Two weeks later, upper gastrointestinal tract (GIT) contrast study showed mild narrowing of the esophagus and stomach outlet obstruction which required pyloroplasty. In patient 5, contrast study showed mid one-third esophageal stricture and stomach outlet obstruction which also required pyloroplasty. Stomach burn has been reported at the gastroesophageal region, 7 prepyloric and pyloric regions. 3 Complete upper fiberoptic GIT endoscopy is recommended to predict the possible occurrence of this complication. The use of antibiotics is advised to reduce the potential complication of infection and more scar formation. However, there is a considerable controversy surrounding the use of steroids. Ferguson et al. believe the severity of injury appears to be determined within seconds of caustic ingestion and routine steroid administration has no apparent benefit. 9 Othersen et al. believe esophageal strictures often tend to be localized and amenable to treatment with the use of steroids. 1 Gandhi et al. advocate intraluminal injection of steroids and claim that complete remission of symptoms

4 has been achieved in all their patients. 10 Conventional esophageal dilatation may have satisfactory results; however, esophageal resection or replacement has become the standard therapy for severe esophageal stricture 10 since there is a vastly increased risk of esophageal carcinoma in the caustically injured esophagus. 11 Recently, considerable attention has been focused on the effect of GER. It is generally accepted that 60% to 80% of infants with GER improve spontaneously or with conventional medical therapy. 12 However, the incidence of esophageal stricture is 10% to 40%. 6 GER is a complex disease and may present with intractable vomiting, failure to thrive, recurrent pneumonia, asthma and bronchitis, and peptic esophagitis with or without stricture. Diagnosis is usually confirmed by upper GIT series (P<50%), radionuclear milk scan, endoscopy and biopsy 15 in addition to 24- hour ph esophageal monitoring. 14 The vast majority usually respond to medical treatment; however, for those patients older than one year of age, surgery is the treatment of choice, namely "Nissen fundoplication". 9 Anastomotic stricture following repair of tracheoesophageal atresia and tracheoesophageal fistula occurs in 30% to 50% of patients. 15 The stricture carries the risk of malnutrition and aspiration into the lungs. Repeated dilatation of postoperative stricture is often successful but occasionally it is necessary to resect the stricture. In our series, the stricture rate was 28% (14 cases of 50). In the management of well-established esophageal stricture, endoscopic assessment and trial of esophageal dilatation is essential since a functional native esophagus is the best conduit for feeding. Many authors recommend a six to 12 month period of conventional repeated esophageal dilatation. Recently, balloon dilatation has been claimed to be more effective than ante- or retrograde bougienage dilatation. Since the balloon applies a radially directed force, it stretches the stricture without the shearing component which may produce muscle avulsion. 1 Also, it can be done under sedation or general anesthesia. 15 In addition, it has a particular advantage in infancy and childhood over other forms of dilators, as it overcomes the size limitation of the dilators in relation to the throat capacity. We used "Aortic Valve Balloon Dilatation Catheter" from Mansfield Scientific Inc. up to size 18 mm, which otherwise would have been impossible with Savory or bougienage dilators (Figures 1A and 1B). In cases with severe esophageal stricture where conservative management is unsuccessful, esophageal resection or replacement is the standard therapy, 10 particularly in caustically injured esophagus because of the increased risk of development of esophageal carcinoma. 11 Figure 1A. Upper 1/3 corrosive stricture before balloon dilatation.

5 Figure 1B. Upper 1/3 corrosive stricture during balloon dilatation. Gastrostomy procedure is strongly advisable in severe esophageal stricture prior to the definitive procedure Depending on the length of the stricture, resection of the strictured esophagus and end-to-end anastomosis with or without circular myotomy 16,17 is the procedure of choice On the other hand, a long esophageal stricture will require a replacement procedure. Colonic interposition is the most popular technique. 4 However, gastric tube and mobilization of the whole stomach have been successfully used alternatives. 18 Colonic esophageal substitution in children is usually performed substernally. Rodgers (1981) reported the first pediatric experience of transmediastinal colonic esophageal replacement." Due to the anatomic relationship of the esophagus, local complications following this procedure are relatively common, i.e., pneumothorax (30%), transient pleural effusion and hemorrhage. Whole stomach interposition probably has fewer complications. A recent report utilizing both retrosternal and transthoracic colonic interposition in children has indicated 88% of patients had good results for up to 12 years of follow-up. 19 Gastric drainage procedure is advised as part of substitution esophageal procedures to prevent bleeding caused by stasis and gastrocolic ulceration. 18 Recently, Othersen et al. have advocated colic-esophageal patch procedure without esophageal resection and substitution. 1 In conclusion, there is no standard method to decide which patient will require conservative or operative treatment. It seems to be the length, the severity, and the response to conservative treatment rather than the etiology that will decide the choice of the treatment in individual cases. References 1. Othersen Jr, HB, Parker EF, Smith CD. The surgical management of esophageal stricture in children. Ann Surg 1988;207: Tolia V, Kuhns L, Kauffman RE. Comparison of simultaneous esophageal ph monitoring and scintigraphy in infants with gastroesophageal reflux. Am J Gastroenterol 1993;88C5: Laudizil Zaniol-P, Venuta A, Pantusal M, et al. Gastroesophageal reflux in children: a combined radiologic and scintigraphic study. Radiol Med Torino 1990;79: Moazam F, Talbert JL, Miller D, Mollitt DL. Caustic ingestion and its sequelae in children. S Med J 1987;80: Tunell WP. Corrosive structures of the esophagus. In: Welch KJ, Randolph JG, Ravtich MM, O'Neill JA, Rowe MI, eds. Pediatr Surg Year Book Med Publisher 1988; Kuhn JR, Tunell WP. The role of initial cine-esophagography in caustic esophageal injury. Am J Surg 1983;146: Estrera A, Taylor W, Mills LJ, Platt MR. Corrosive burns of the esophagus and stomach: a recommendation for an aggressive surgical approach.. Ann Thoracic Surg 1986;41: Wijburg FA, Heymans HSA, Urbanus NAM. Caustic esophageal lesions in childhood: prevention of structure formation. J Pediatr Surg 1989;24: Ferguson MK, Migliore MMD, Starzak VM, Little AG. Early evaluation and therapy for caustic esophageal injury. Ann J Surg

6 1989;157: Gandhi RP, Cooper A, Barlow BA. Successful management of esophageal strictures without resection or replacement. J Pediatr Surg 1989;24: Rodgers BM, Ryckman FC, Talbert JL. Blunt transmediastinal total esophagectomy with simultaneous substernal colon interposition for esophageal caustic structures in children. J Pediatr Surg 1981;16: Berlaztky Y, Cohen OM, Freund HR, Schiller, M. Surgical treatment of gastroesophageal reflux with esophageal strictures in infancy and childhood. Am J Surg 1982;143: Curci M, Dibbins A. Gastroesophageal reflux in children: an underrated disease. Am J Surg 1982;143: Leape LL, Bhan I, Ramenofsky ML. Esophageal biopsy in the diagnosis of reflux esophagitis. J Pediatr Surg 1981;16: Johnsen A, Jensen HI, Mauritzen K. Balloon dilatation of esophageal strictures in children. Pediatr Radiol 1986;16: Izzidien Al-Samarrai AY. Circular myotomy for esophageal stricture. J Pediatr Surg 1988;24: Izzidien Al-Samarrai AY. Circular myotomy for mid-esophageal stricture. Surgery in infancy and childhood. Z Kinderchirgie 1989;44: West KW, Vane DW, Grosfeld JL. Esophageal replacement in children: experience with thirty-one cases. Surg 1986;100: Stone MM, Mahour GH, Weizman JJ, Fonkalsrud EW, Takiff H. Esophageal replacement with colon interposition in children. Ann Surg 1986;203:

Colon Patch Esophagoplasty: A Clinical Study For Chemical Burn Esophageal Stricture

ISPUB.COM The Internet Journal of Surgery Volume 5 Number 1 Colon Patch Esophagoplasty: A Clinical Study For Chemical Burn Esophageal Stricture M Hourang, V Mehrabi Citation M Hourang, V Mehrabi. Colon