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Successful management of esophageal strictures without resection or replacement
R P Gandhi1, A Cooper, B A Barlow
1Division of Pediatric Surgery, College of Physicians and Surgeons, Columbia University, New York.
Insights
This study shows that string-guided esophageal dilatation with steroid injections is a safe and effective treatment for severe esophageal strictures in children, avoiding the need for surgery. All patients remained symptom-free after treatment.
Area of Science:
- Pediatric Surgery
- Gastroenterology
- Interventional Endoscopy
Background:
- Severe esophageal strictures often necessitate surgical resection or replacement.
- Less aggressive treatments have historically had limited success in pediatric cases.
- Esophageal strictures in children can result from caustic ingestion or congenital anomalies.
Purpose of the Study:
- To evaluate the efficacy and safety of a combined endoscopic and surgical approach for severe pediatric esophageal strictures.
- To determine if this less invasive method can prevent the need for esophageal resection or replacement.
- To assess long-term outcomes in children treated with this technique.
Main Methods:
- A cohort of 12 infants and children with severe esophageal strictures underwent Stamm gastrostomy, string-guided esophageal dilatation, and endoscopic intralesional steroid injections.
- Nissen fundoplication was performed in cases with confirmed gastroesophageal reflux.
- Stricture etiology included lye ingestion (6 patients) and esophageal atresia repair (5 patients).
Main Results:
- All 12 patients achieved complete remission of symptoms with a mean of 4.3 steroid injections.
- The mean stricture length was 3.5 cm, with complete intolerance to solids prior to treatment.
- The mean follow-up duration was 6.2 years, with no major complications reported.
- One patient had a minor perforation after initial dilatation, managed successfully with antibiotics.
Conclusions:
- String-guided esophageal dilatation combined with endoscopic steroid injection is a safe and reliable treatment for severe pediatric esophageal strictures.
- This approach can obviate the need for esophageal resection or replacement in the majority of cases.
- Even if initial treatment fails, subsequent procedures may be less invasive than esophageal replacement.
Abstract:
Esophageal resection or replacement has become the standard therapy for severe esophageal strictures chiefly because less aggressive methods generally have failed. We hereby report our experience with 12 consecutive infants and children who have been managed successfully by means of Stamm gastrostomy and string-guided esophageal dilatation, coupled with endoscopically guided four-quadrant intralesional steroid injection, protected by Nissen fundoplication when gastroesophageal reflux has been demonstrated. In six patients, the stricture(s) were caused by ingestion of lye. In five, they were associated with repair of esophageal atresia. In one, the etiology was never determined. The strictures averaged 3.5 cm in length (range, 1 to 10 cm); the severity of the lesions was indicated by the fact that, in all instances, patients were completely intolerant of solids, and was confirmed fluoroscopically by demonstration of significant luminal narrowing. A mean of 4.3 steroid injections (range, 1 to 8) was required to obtain complete remission of symptoms; there have been no complications except in one lye ingestion patient who developed a tiny perforation following the initial dilatation, which responded to antibiotics alone. All patients remain symptom-free; the mean length of follow-up is 6.2 years (range, 1 to 11 years). We conclude that string-guided esophageal dilatation, when coupled with endoscopically guided steroid injection, is a safe and reliable method for treatment of severe esophageal strictures, which should obviate the need for esophageal resection or replacement in most patients. Moreover, even if treatment should ultimately fail, a procedure of lesser magnitude than esophageal replacement will likely be possible.(ABSTRACT TRUNCATED AT 250 WORDS)