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Management of Esophageal Strictures in Children
Norberto Rodriguez-Baez1, John M. Andersen
1Department of Gastroenterology and Nutrition, University of Texas Southwestern Medical School, 1935 Motor Street, Dallas, TX 75235, USA.
Insights
Esophageal stricture treatment involves aggressive dilatation, with triamcinolone injections reducing scar tissue and repeat procedures. Different dilators suit various stricture types, but surgery may be needed if dilatation fails.
Area of Science:
- Gastroenterology
- Surgical Innovation
- Pharmacological Intervention
Background:
- Esophageal strictures are commonly treated with dilatation, which can cause trauma and lead to restenosis.
- Various etiologies contribute to esophageal strictures, necessitating aggressive management.
- Recurrent stricturing after dilatation poses a significant clinical challenge.
Purpose of the Study:
- To evaluate the efficacy of intralesional triamcinolone in reducing scar formation and restenosis after esophageal dilatation.
- To compare the effectiveness of balloon dilators versus Savary-Gilliard dilators for different stricture types.
- To outline a comprehensive strategy for managing esophageal strictures, including medical and surgical interventions.
Main Methods:
- The study reviews current practices in esophageal stricture management, focusing on dilatation techniques and adjunct therapies.
- It discusses the application of local triamcinolone injection at the time of dilatation.
- Comparison of balloon and Savary-Gilliard dilators based on stricture characteristics and clinical outcomes is presented.
Main Results:
- Intralesional triamcinolone infiltration may significantly reduce scar formation and the need for repeat dilatations, particularly for short strictures.
- Balloon dilators are suitable for minimizing trauma and treating short strictures.
- Savary-Gilliard dilators are preferred for resistant, long, or complex strictures, offering controlled, graded dilatation.
Conclusions:
- Aggressive esophageal dilatation is crucial for managing strictures, regardless of cause or length.
- Adjunctive therapies like intralesional triamcinolone and appropriate dilator selection can optimize outcomes and minimize complications.
- Surgical intervention remains an option for refractory cases where dilatation fails to maintain luminal patency.
Abstract:
Esophageal dilatation remains the primary treatment of esophageal strictures. Aggressive esophageal dilatation is indicated regardless of the etiology and length of the stricture. Esophageal dilatation causes iatrogenic trauma and tearing of scar tissue that may result in restricturing. Local infiltration of triamcinolone into the stricture site at the time of dilatation may markedly reduce subsequent scar formation and restricturing. Intralesional triamcinolone is most useful for short strictures and may decrease the need for future dilatation. Successful management of esophageal strictures requires the aggressive treatment of all pathogenic processes contributing to esophageal inflammation and restricturing following dilatation. Medically uncontrolled reflux esophagitis may require antireflux surgery to successfully dilate the stricture. Balloon dilators apply only radial forces and no longitudinal, shearing forces. They are most useful for two situations: circumstances under which it is desirable to minimize esophageal trauma (eg, epidermolysis bullosa) and short strictures. Savary-Gilliard dilators are useful for strictures resistant to balloon dilatation and for long strictures that require carefully controlled and graded dilatation. We routinely use dilators instead of guide wires for long strictures, multiple strictures, tortuous esophagus, and very narrow strictures, particularly when the state of the esophagus distal to the stricture is unclear. Failure of aggressive, frequent dilatation to maintain sufficient esophageal luminal diameter may necessitate surgical intervention (ie, resection of the stricture or esophageal replacement).
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