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A method for recovering a lost retrieval line under direct visionin children with esophageal strictures
A Method for Recovering a Lost Retrieval Line Under D i r e c t Vision in Children With Esophageal S t r i c t u r e s By C.D. Mercer, S.F. Hall, and J.W. Kerr
Kingston, Ontario 9 Loss of a retrieval line for r e p e a t e d esophageal dilatations for caustic esophageal stricture m a y result in inability t o dilate these strictures. W e describe a simple m e a n s for retrieving s u c h a line once it has been removed. 9 1988 b y G r u n e & S t r a t t o n . Inc. I N D E X W O R D S : Esophageal stricture; esophageal dilatation,
Grosping Forceps Endoscope
H E S T A N D A R D T H E R A P Y for children with caustic esophageal strictures is to leave a retrieval line for retrograde or prograde esophageal dilatations. 1 F r e q u e n t dilatations are often necessary and the risk of esophageal perforation is high if this technique is used. M a n y ingenious methods of taping or c o n c e a l i n f a string or using other less irritating m a t e r i a l s ? have been devised. A major problem can occur, however, if this line is lost in a child with a tight stricture. W e present a simple method for retrieval of such a line.
T
tomy
CASE REPORT A 20-month-oldinfant suffered a caustic burn with formic acid in 1981. He was managed with repeated dilatations, but he eventually required a gastrostomy due to the development of esophageal strictures at 9 and 20 cm from the teeth. The midesophageal stricture was long and quite tight. Dilatations were then clone in a retrograde manner using a circumferential retrieval string, filiforms, and followers.The string was eventually removedas this stenosiswas softening but due to subsequent progressivetightness of the stenosis, it was imperative that the string be replaced. Oral intake consisted only of fluids, the upper stricture could be dilated up to 30 Fr and the lower end could be dilated under direct vision through an esophagoscope only to ] 8 Fr. Under general anesthesia, after the upper stricture was dilated, a 10 Fr Jackson dilator with a no. 1 silk suture tied to its tip, was passed through the lower stricture gently under direct vision using a no. 5 Stortz esophagoscope. A pediatric endoscope was inserted through the gastrostomy and the gastroesophageal junction identified. Using grasping forceps passed through the flexible endoscope, the string was captured and delivered through the gastrostomy site
From the Department of Surgery, Queen's University, Kingston, Ontario, Canada. Address reprint requests to C.D. Mercer, MD, Department of Surgery, Hotel Dieu Hospital, Kingston, Ontario, K7L 5G2, Canada. 9 1988 by Grune & Stratton, Inc. 0022-3468/88/2302-0013503.00/0
144
Fig 1. Jackson dilator with no. 1 silk suture tied at the tip is passed through the esophageal strictures into the stomach. The flexible endoscope is passed through the gastrostomy and the string is grasped with forceps passed through the endoscope.
at the tip of the dilator (Fig 1). The string was untied and the dilator removed from above. Dilations could then be safely done using a progression of Tucker dilators.
DISCUSSION W e present herein a simple, safe, a n d reliable method for recovery of a lost retrieval line. O t h e r methods have been devised for insertion of a retrieval line but both suffer from blind insertion techniques of either an i n t r a t r a c h e a l tube or a Teflon-coated arterial wire t h r o u g h the gastrostomy a n d up into the esophagus. 4'5 O u r method requires two operators, one to pass the dilator with a retrieval line a t t a c h e d t h r o u g h the rigid esophagoscope into the stomach and the other, skilled at flexible endoscopy, to grasp a n d recover the string. This method offers a distinct a d v a n t a g e as the entire procedure is performed u n d e r direct vision, thereby m i n i m i z i n g the risk of esophageal perforation.
Journal of Pediatric Surgery, Vo123, No 2 (February), 1988: pp 144-145
RETRIEVAL LINE RECOVERY IN ESOPHAGEAL STRICTURE
145
REFERENCES
1. Tucker CF: Cicatricial stenosis of the esophagus with particular reference to treatment by continuous string retrograde bougienage with the author's bougie. Ann Otol Rhinol Laryngol 3:11801181, 1927 2. Tepas JJ, Golladay ES: An improved method for retaining retrieval line in children undergoing repeated esophageal dilatation. J Pediatr Surg 13:371, 1978
3. Canty JC: Retrograde esophageal dilatation in children--An alternative to the indwelling string. Am J Surg 132:422-423, 1976 4. Andrassy R J, Weitzman J J, Brennan LP: Retrograde esophageal dilatation. Surg Gynecol Obstet 150:571, 1980 5. Saleh SS: Retrograde esophageal dilatation in children without the string. Ann Thorac Surg 25:568, 1978
Kingston, Ontario 9 Loss of a retrieval line for r e p e a t e d esophageal dilatations for caustic esophageal stricture m a y result in inability t o dilate these strictures. W e describe a simple m e a n s for retrieving s u c h a line once it has been removed. 9 1988 b y G r u n e & S t r a t t o n . Inc. I N D E X W O R D S : Esophageal stricture; esophageal dilatation,
Grosping Forceps Endoscope
H E S T A N D A R D T H E R A P Y for children with caustic esophageal strictures is to leave a retrieval line for retrograde or prograde esophageal dilatations. 1 F r e q u e n t dilatations are often necessary and the risk of esophageal perforation is high if this technique is used. M a n y ingenious methods of taping or c o n c e a l i n f a string or using other less irritating m a t e r i a l s ? have been devised. A major problem can occur, however, if this line is lost in a child with a tight stricture. W e present a simple method for retrieval of such a line.
T
tomy
CASE REPORT A 20-month-oldinfant suffered a caustic burn with formic acid in 1981. He was managed with repeated dilatations, but he eventually required a gastrostomy due to the development of esophageal strictures at 9 and 20 cm from the teeth. The midesophageal stricture was long and quite tight. Dilatations were then clone in a retrograde manner using a circumferential retrieval string, filiforms, and followers.The string was eventually removedas this stenosiswas softening but due to subsequent progressivetightness of the stenosis, it was imperative that the string be replaced. Oral intake consisted only of fluids, the upper stricture could be dilated up to 30 Fr and the lower end could be dilated under direct vision through an esophagoscope only to ] 8 Fr. Under general anesthesia, after the upper stricture was dilated, a 10 Fr Jackson dilator with a no. 1 silk suture tied to its tip, was passed through the lower stricture gently under direct vision using a no. 5 Stortz esophagoscope. A pediatric endoscope was inserted through the gastrostomy and the gastroesophageal junction identified. Using grasping forceps passed through the flexible endoscope, the string was captured and delivered through the gastrostomy site
From the Department of Surgery, Queen's University, Kingston, Ontario, Canada. Address reprint requests to C.D. Mercer, MD, Department of Surgery, Hotel Dieu Hospital, Kingston, Ontario, K7L 5G2, Canada. 9 1988 by Grune & Stratton, Inc. 0022-3468/88/2302-0013503.00/0
144
Fig 1. Jackson dilator with no. 1 silk suture tied at the tip is passed through the esophageal strictures into the stomach. The flexible endoscope is passed through the gastrostomy and the string is grasped with forceps passed through the endoscope.
at the tip of the dilator (Fig 1). The string was untied and the dilator removed from above. Dilations could then be safely done using a progression of Tucker dilators.
DISCUSSION W e present herein a simple, safe, a n d reliable method for recovery of a lost retrieval line. O t h e r methods have been devised for insertion of a retrieval line but both suffer from blind insertion techniques of either an i n t r a t r a c h e a l tube or a Teflon-coated arterial wire t h r o u g h the gastrostomy a n d up into the esophagus. 4'5 O u r method requires two operators, one to pass the dilator with a retrieval line a t t a c h e d t h r o u g h the rigid esophagoscope into the stomach and the other, skilled at flexible endoscopy, to grasp a n d recover the string. This method offers a distinct a d v a n t a g e as the entire procedure is performed u n d e r direct vision, thereby m i n i m i z i n g the risk of esophageal perforation.
Journal of Pediatric Surgery, Vo123, No 2 (February), 1988: pp 144-145
RETRIEVAL LINE RECOVERY IN ESOPHAGEAL STRICTURE
145
REFERENCES
1. Tucker CF: Cicatricial stenosis of the esophagus with particular reference to treatment by continuous string retrograde bougienage with the author's bougie. Ann Otol Rhinol Laryngol 3:11801181, 1927 2. Tepas JJ, Golladay ES: An improved method for retaining retrieval line in children undergoing repeated esophageal dilatation. J Pediatr Surg 13:371, 1978
3. Canty JC: Retrograde esophageal dilatation in children--An alternative to the indwelling string. Am J Surg 132:422-423, 1976 4. Andrassy R J, Weitzman J J, Brennan LP: Retrograde esophageal dilatation. Surg Gynecol Obstet 150:571, 1980 5. Saleh SS: Retrograde esophageal dilatation in children without the string. Ann Thorac Surg 25:568, 1978