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Reflux strictures of the esophagus in children
H Rode1, A J Millar, R A Brown
1Department of Paediatric Surgery, Red Cross War Memorial Children's Hospital, University of Cape Town, Rondebosch, South Africa.
Insights
This study shows that a comprehensive approach including nutritional support, dilatation, and fundoplication effectively manages pediatric esophageal strictures due to gastroesophageal reflux disease (GERD). Most children achieved satisfactory outcomes with no recurrence after long-term follow-up.
Area of Science:
- Pediatric Surgery
- Gastroenterology
- Esophageal Diseases
Background:
- Gastroesophageal reflux (GER) management in children is established, but esophageal stricture treatment varies.
- Reflux strictures are a significant complication, affecting 12% of children operated on for GER.
- Strictures present after a mean of 22.4 months, often fibrotic and lengthy.
Purpose of the Study:
- To evaluate a comprehensive management strategy for pediatric reflux strictures.
- To assess the efficacy of preoperative dilatation, nutritional resuscitation, and fundoplication.
- To determine long-term outcomes and recurrence rates.
Main Methods:
- Sixteen children with reflux strictures underwent intensive preoperative management.
- Treatment included antacids, H2-receptor blockers (Cimetidine), prokinetics, nutritional support, and dilatations (average 3.6 times).
- Fundoplication was performed after nutritional restoration and stricture dilation, with some requiring gastrostomies for further dilatations.
Main Results:
- 14 out of 16 children (88%) had satisfactory outcomes with no recurrence over an average 8.2-year follow-up.
- Growth velocity was restored in all patients.
- Two children required resection for unyielding strictures; one needed revision surgery for failed reflux surgery.
Conclusions:
- A preferred method involves preoperative in-hospital management of GER with nutritional support.
- Careful evaluation of esophagitis and scarring is crucial for successful treatment.
- This multidisciplinary approach yields high success rates and restores growth in pediatric reflux strictures.
Abstract:
Although the therapeutic approach to gastroesophageal reflux in children is well established, there are differences of opinion regarding the management of esophageal strictures, viz bougienage with medical therapy, fundoplication without dilatation, preoperative dilatation followed by fundoplication with intraoperative and postoperative dilatation, or resection and interposition. Sixteen consecutive children (mean age, 30.2 months) with reflux strictures were evaluated, constituting 12% of children operated on for gastroesophageal reflux. The strictures became clinically apparent 22.4 months (mean) from the onset of symptoms and were diagnosed by contrast studies and endoscopy. At first endoscopy all the patients had well-established fibrotic strictures. The strictures were mostly situated in the middle or lower esophagus and 7 were longer than 3 cm in length. All 16 were treated with antacids, H2-receptor blockers (Cimetidine), prokinetic agents, and intense nutritional resuscitation, together with preoperative stricture dilatations (average, 3.6 times). This was followed by fundoplication when nutritional parameters had been restored, esophagitis improved, and the strictures dilated to adequate size. Seven children required concomitant gastrostomies for prograde esophageal dilatations. Twelve children needed postoperative esophageal dilatations. The results were satisfactory in 14 (88%). Two required endoesophageal resection for localized unyielding strictures. One child responded only after failed reflux surgery was corrected at a second procedure. During an average follow-up of 8.2 years (range, 3 to 11) there has been no stricture recurrence and growth velocity was restored in all. We conclude that our preferred method is preoperative in-hospital management of gastroesophageal reflux with maximum nutritional support and careful evaluation of the degree and extent of esophagitis and fibrous scarring.(ABSTRACT TRUNCATED AT 250 WORDS)