- Email: [email protected]
Application of the principles of myotomy and strictureplasty for treatment of esophageal strictures
Application of the Principles of Myotomy and Strictureplasty for Treatment of Esophageal Strictures By Kathryn D. Anderson, Juan M. Acosta, Michael S. Meyer, and Neil J. Sherman Los Angeles, California
Background/Purpose: Strictures of the esophagus in the pediatric population may be congenital or acquired. Regardless of the etiology, the treatment goal is to relieve the symptoms and allow patients to eat normally. The cornerstone of nonoperative management is repeated esophageal dilatations. However, when nonoperative management fails, operative intervention becomes necessary. In this report the authors present 4 cases of severe upper esophageal strictures managed by applying the principles of myotomy and strictureplasty. Methods: Retrospective review of 4 patients undergoing esophageal stricturotomy from January 1, 1993 to January 1, 2000 was conducted at Childrens Hospital Los Angeles, with a mean follow-up period of 5 years. Results: Three of the 4 patients reported in this report are
S
doing well and have not required any further surgical intervention. One patient in whom additional strictures developed has had a microvascularized free jejunal graft and also is doing well.
Conclusions: Currently accepted surgical management of strictures includes resection of the affected segment with end-to-end anastomosis or esophageal replacement. The authors propose that before embarking on a long and technically hazardous operation, consideration should be given to stricturotomy. In cases of isolated strictures, this may be the preferred approach. J Pediatr Surg 37:403-406. Copyright © 2002 by W.B. Saunders Company. INDEX WORDS: Esophageal stricture, stricturotomy, caustic esophageal injury.
TRICTURES of the esophagus in the pediatric population can be classified as congenital or acquired. Congenital strictures include achalasia and esophageal stenosis. The etiology of acquired strictures in childhood include corrosive ingestion, retained foreign bodies, reflux esophagitis, anastomotic scarring after surgery, and idiopathic causes. Regardless of the etiology, the final common pathway in the treatment of all lesions is to relieve symptoms and to insure establishment of normal alimentation. The cornerstone of nonoperative management is repeated esophageal dilatations with a goal of permanent resolution of the stricture. Unfortunately, not all strictures are responsive to such therapy, and surgical options must be considered if dilatation fails. We present 4 cases of upper esophageal stricture resulting from a variety of causes and discuss the surgical management by longitudinal stricturotomy using the principles used in myotomy (case 1, 4) and strictureplasty (case 2, 3). Myotomy of the lower esophageal sphincter (LES) often is used as definitive intervention for the most common functional disorder of the esophagus, achalasia. The goal of treatment is to relieve the functional outflow obstruction secondary to the loss of relaxation and compliance of the LES. Myotomy also has been used in the treatment of congenital esophageal stenosis.1 Strictureplasty has been used for the treatment of small bowel strictures secondary to Crohn’s disease. Surgery in these patients is bowel sparing with the goal of relief of obstructive symptoms while preserving as much intestine
as possible.2,3 From a technical standpoint, the goal is to increase the luminal diameter of the bowel without resection.4 Fazio et al5 reports success with HeineckeMikulicz strictureplasties for short strictures and Finney strictureplasties for long strictures up to 15 cm.5
Journal of Pediatric Surgery, Vol 37, No 3 (March), 2002: pp 403-406
403
CASE REPORTS
Case 1 A 6-year-old boy who was small for his age presented with a history of swallowing difficulties for most of his life. Although he could eat some solid foods, it took an inordinate amount of time, and each bite required a swallow of water. For 2 years before referral, he had undergone repeated dilatations every 3 months without relief of his symptoms or resolution of the stricture. Barium esophagram showed a stricture immediately below the cricopharyngeus muscle extending several centimeters distally (Fig 1A). Because of the position of the stricture, resection with anastamosis was not technically feasible. The lower cervical and thoracic esophagus was completely normal. Exploration showed a stricture beginning 3 cm below the cricopharyngeus
From the Division of Pediatric Surgery, Childrens Hospital Los Angeles and the University of Southern California Keck School of Medicine, Los Angeles, CA. Presented at the 32nd Annual Meeting of the American Pediatric Surgical Association, Naples, Florida, May 20-23, 2001. No reprints available. Copyright © 2002 by W.B. Saunders Company 0022-3468/02/3703-0025$35.00/0 doi:10.1053/jpsu.2002.30848
404
ANDERSON ET AL
Fig 1. (A) An esophagram of a 6-year-old boy with a stricture below the cricopharyngeus muscle (case 1). (B) Postoperative esophagram (case 1).
muscle and extending for 3 cm. The scarring appeared cartilaginous. The scar tissue was divided longitudinally, allowing the mucosa to expand (Fig 1B). He recovered uneventfully, required no further dilatations, and remains without symptoms 6 years after surgery. He is now of normal height and weight for his age.
Case 2 A 2-year-old boy without medical or developmental problems presented to a community emergency room with a several-hour history of drooling and crying spells as if in pain. At that time no radiographic studies were performed. For the next 5 months the patient was unable to swallow solid foods, and all attempts to speak had ceased. A chest film finally was obtained, which showed a battery in his upper esophagus. Barium esophagram, after removal of the battery, showed an esophageal stricture at the site of the impacted battery. He was seen by several physicians and repeated attempts were made at dilatation without success. He then was referred to our institution, and, after evaluation, which included unsuccessful dilatation, he was taken to the operating room where the esophagus was explored through the right neck. A thoracotomy was added when the stricture was found to extend below the thoracic inlet. A 5-cm stricturotomy was made. The esophagus was very dilated and thin above the stricture, and the mucosa also was extensively scarred. During the stricturotomy, the mucosa was entered; it was repaired using a transverse closure and buttressed by mobilizing the sternocleidomastoid muscle and suturing it to the stricturotomy site. He required 6 dilatations in the first postoperative year to maintain the lumen achieved with the stricturotomy. Now 6 years postoperatively, he is doing well without recurrent stricture and is able to eat normally. After extensive speech therapy he now speaks well.
Case 3 At 9 months of age, this patient was fed lye by a disturbed parent, and suffered for many years with an esophageal stricture, which required dilatation every few weeks. These treatments were not successful, and ultimately, the patient underwent esophagectomy with colonic interposition at 10 years of age. Over the next 3 years, a stricture developed at the esophagocolonic anastamosis. He underwent a series of dilatations without adequate improvement in his dysphagia. Because of the severity of his symptoms, he was taken to the
operating room for stricturotomy. This was completed over a 6-cm length that included part of the cervical esophagus and the coloesophageal anastamosis. There were multiple areas involving the mucosa, and therefore the esophagus was opened widely, and esophagoplasty was performed by mobilizing the sternal portion of the sternocleidomastoid muscle and suturing it longitudinally to the edges of the esophagus. The patient improved for a while, but, after 2 years and further dilatations, the esophagus at and immediately below the cricopharyngeus muscle developed additional strictures. He recently underwent a free jejunal graft, which was inserted into the pharynx and allowed the stricture of the cricopharyngeus to be eliminated. He is now doing well.
Case 4 A 5 year-old boy who throughout his entire life had been known as a “slow eater,” was found to have a stricture at the level of the thoracic inlet. Multiple attempts at dilatation were unsuccessful, and he continued to have difficulty swallowing. Because of the severity of his symptoms, he was taken to the operating room. The esophagus was mobilized through the right neck and right chest, and a long narrowed area was identified. The narrowed portion of the esophageal muscle was easily discernible. A stricturotomy was performed extending from the neck to the midthoracic esophagus. Postoperatively, the patient has done well without recurrence of symptoms.
Operative Technique Under general anesthesia, rigid esophagoscopy was performed, and the level of stricture identified. We attempted to assess the length of the stricture by dilating the esophagus, which was not always possible. Neck exploration was performed adding a thoracotomy as needed (cases 2 and 4). After surgical exposure of the esophagus was completed (Fig 2A), the stricture was localized, and a stricturotomy was performed using sharp dissection and electrocautery (Fig 2B). The stricturotomy was extended above and below the stricture into normal esophageal muscle (Fig 2C). A hemostat was used to distract the edges of the scar exposing the mucosa (Fig 2D). Dilators then were passed from above to document adequate relief of the obstruction.
DISCUSSION
Dilatation has been an accepted strategy for managing esophageal strictures for more than 30 years.6 Certain
MYOTOMY AND STRICTUREPLASTY FOR ESOPHAGEAL STRICTURE
405
Fig 2. (A) Exposure of the esophagus and identification of the stricture. (B) Stricturotomy of the affected segment with extension into normal tissue. (C) Separation of the edges and exposure of the esophageal mucosa. (D) Completed stricturotomy.
types of strictures may be more responsive than others. Buchin7 reviewed the records of 84 patients (adults and adolescents) with esophageal strictures of various etiologies (postoperative, corrosive, foreign body) and reported that 65% of patients were treated successfully with dilatation. However, in the subset of patients with corrosive injury, 67% required operative management. That study suggests that corrosive injuries may be less responsive to conservative management. When nonoperative management fails, surgical treatment is the only alternative. The surgical approach may vary according to etiology and extent of stricture formation. For patients with achalasia, esophageal myotomy is the first choice, either from a thoracic or an abdominal approach.8,9 Congenital stenosis may be treated differently depending on the type of lesion. Congenital webs and diaphragms often respond to dilatation. When they do not, endoscopic resection may be successful.10 Localized stenoses, caused by fibromuscular thickening of the midesophageal wall or the presence of cartilaginous remnants, usually can be treated by segmental resection of the esophagus.11,12 Strictures secondary to reflux esophagitis require an antireflux procedure along with esophageal dilatations.13 Strictures from retained foreign bodies such as button batteries and nasogastric tubes require individualized treatment.14 The treatment of strictures secondary to caustic ingestion also is variable. In caustic ingestion, early identification and classification of the damage is essential.
Although dilatation is useful for many strictures, Anderson et al15 found that 50% of children with third-degree injury16 eventually need esophageal replacement. Strictures greater than 5 cm in length are difficult to treat with dilatation. Gundogdu et al17 has reported that strictures 2 to 5 cm in length may be treated successfully by dilatation in over 90% of patients. However, the same study reports an esophageal perforation rate of 17%. Other studies report similar rates of perforation.18 This complication, aside from the emergency treatment of the perforation, may well preclude successful dilatation. Accepted operative management of strictures include resections of the affected esophageal segment with endto-end anastamosis and esophageal replacement. Short, high strictures in the neck, especially in proximity to the cricopharyngeus muscle, make esophageal mobilization impossible. Replacing the entire esophagus for a proximal stricture wastes a great deal of normal esophagus. In this report, we describe successful stricturotomy in 4 cases of undilatable strictures of the cervical and upper thoracic esophagus. The procedure is technically simple, and, if the mucosa is entered, the procedure can be converted to a strictureplasty. This procedure helps avoid the need for total esophageal replacement. In our experience, postoperative dilatation rarely has been needed. We propose that for undilatable strictures of the esophagus, stricturotomy is a useful alternative to esophageal replacement.
406
ANDERSON ET AL
REFERENCES 1. Hisayoshi K, Kenji I, Makoto Y, et al: Clinical characteristics of congenital esophageal stenosis distal to associated esophageal atresia. Surgery 129:29-38, 2001 2. Lee ECG: Surgery in Crohn’s disease, in Pen˜a AS, Weterman IT, Booth CC, et al (eds): Developments in Gastroenterology, Vol 1. The Hague, Martinus Nijof, 1980 3. Lee ECG, Papaionnou N: Minimal surgery for chronic obstruction in patients with extensive or universal Crohn’s disease. Ann R Coll Surg Engl 64:229-233, 1982 4. Alexander-Williams J, Haynes IG: Conservative operation for Crohn’s disease of the small bowel. World J Surg 9:945-951, 1985 5. Fazio VW, Galandiuk S, Jagelman DG, et al: Strictureplasty in Crohn’s disease. Ann Surg 210:621-625, 1989 6. Boix-Ochoa J, Rehbein F: Oesphageal stenosis due to reflux oesophagitis. Arch Dis Child 40:197, 1965 7. Buchin PJ: Therapy of esophageal stricture: A review of 84 patients. Clin Gastroenterol 3:121, 1981 8. Lemmer JH, Coran AG, Wesly JR, et al: Achalasia in children: Treatment by anterior esophageal myotomy (modified Heller operation). Pediatr Surg 20:333, 1985 9. Myers NA, Jolley SG, Taylor R: Achalasia of the cardia in children: A worldwide survey. J Pediatr Surg 29:1375, 1994
10. Bremner CG: Benign strictures of the esophagus. Current Prob Surgery 19:401, 1992 11. Valerio D, Jones PF, Stewart AM: Congenital oesophageal stenosis. Arch Dis Child 52:414, 1977 12. Murphy SG, Yazbeck S, Russo P: Isolated congenital esophageal stenosis. J Pediatr Surg 30:1238, 1995 13. O’Neill JA, Betts J, Ziegler MM, et al: Surgical management of reflux strictures of the esophagus in childhood. Ann Surg 196:453, 1982 14. Litovitz T, Schmitz BF: Ingestion of cylindrical and button batteries: An analysis of 2382 cases. Pediatrics 89:747, 1992 15. Anderson KD, Rouse TM, Randolph JG: A controlled trial of corticosteroids in children with corrosive injury of the esophagus. N Engl J Med 323:637-640, 1990 16. Holinger PH: Management of esophageal lesions caused by chemical burns. Ann Otol Rhinol Laryngol 77:786, 1968 17. Gundogdu HZ, Tanyel FC, Buyukpamukcu N, et al: Conservative treatment of caustic esophageal strictures in Children. J Pediatr Surg 27:767, 1992 18. Panieri E, Rode H, Millar AJ, et al: Oesophageal replacement in the management of corrosive strictures: When is surgery indicated? Pediatr Surg Int 13:336-340, 1998
Discussion “Application of the Principles of Myotomy and Strictureplasty for the Treatment of Esophageal Strictures.” Discussion by Stephen Greenholz, M.D. S. Greenholz (Sacramento, CA): With Dr Anderson’s
advice, we applied this technique to a long intrathoracic stricture and salvaged that esophagus, so I think the range of lesions amenable to this technique is quite broad. J.M. Acosta (response): Thank you Dr Greenholz.
Background/Purpose: Strictures of the esophagus in the pediatric population may be congenital or acquired. Regardless of the etiology, the treatment goal is to relieve the symptoms and allow patients to eat normally. The cornerstone of nonoperative management is repeated esophageal dilatations. However, when nonoperative management fails, operative intervention becomes necessary. In this report the authors present 4 cases of severe upper esophageal strictures managed by applying the principles of myotomy and strictureplasty. Methods: Retrospective review of 4 patients undergoing esophageal stricturotomy from January 1, 1993 to January 1, 2000 was conducted at Childrens Hospital Los Angeles, with a mean follow-up period of 5 years. Results: Three of the 4 patients reported in this report are
S
doing well and have not required any further surgical intervention. One patient in whom additional strictures developed has had a microvascularized free jejunal graft and also is doing well.
Conclusions: Currently accepted surgical management of strictures includes resection of the affected segment with end-to-end anastomosis or esophageal replacement. The authors propose that before embarking on a long and technically hazardous operation, consideration should be given to stricturotomy. In cases of isolated strictures, this may be the preferred approach. J Pediatr Surg 37:403-406. Copyright © 2002 by W.B. Saunders Company. INDEX WORDS: Esophageal stricture, stricturotomy, caustic esophageal injury.
TRICTURES of the esophagus in the pediatric population can be classified as congenital or acquired. Congenital strictures include achalasia and esophageal stenosis. The etiology of acquired strictures in childhood include corrosive ingestion, retained foreign bodies, reflux esophagitis, anastomotic scarring after surgery, and idiopathic causes. Regardless of the etiology, the final common pathway in the treatment of all lesions is to relieve symptoms and to insure establishment of normal alimentation. The cornerstone of nonoperative management is repeated esophageal dilatations with a goal of permanent resolution of the stricture. Unfortunately, not all strictures are responsive to such therapy, and surgical options must be considered if dilatation fails. We present 4 cases of upper esophageal stricture resulting from a variety of causes and discuss the surgical management by longitudinal stricturotomy using the principles used in myotomy (case 1, 4) and strictureplasty (case 2, 3). Myotomy of the lower esophageal sphincter (LES) often is used as definitive intervention for the most common functional disorder of the esophagus, achalasia. The goal of treatment is to relieve the functional outflow obstruction secondary to the loss of relaxation and compliance of the LES. Myotomy also has been used in the treatment of congenital esophageal stenosis.1 Strictureplasty has been used for the treatment of small bowel strictures secondary to Crohn’s disease. Surgery in these patients is bowel sparing with the goal of relief of obstructive symptoms while preserving as much intestine
as possible.2,3 From a technical standpoint, the goal is to increase the luminal diameter of the bowel without resection.4 Fazio et al5 reports success with HeineckeMikulicz strictureplasties for short strictures and Finney strictureplasties for long strictures up to 15 cm.5
Journal of Pediatric Surgery, Vol 37, No 3 (March), 2002: pp 403-406
403
CASE REPORTS
Case 1 A 6-year-old boy who was small for his age presented with a history of swallowing difficulties for most of his life. Although he could eat some solid foods, it took an inordinate amount of time, and each bite required a swallow of water. For 2 years before referral, he had undergone repeated dilatations every 3 months without relief of his symptoms or resolution of the stricture. Barium esophagram showed a stricture immediately below the cricopharyngeus muscle extending several centimeters distally (Fig 1A). Because of the position of the stricture, resection with anastamosis was not technically feasible. The lower cervical and thoracic esophagus was completely normal. Exploration showed a stricture beginning 3 cm below the cricopharyngeus
From the Division of Pediatric Surgery, Childrens Hospital Los Angeles and the University of Southern California Keck School of Medicine, Los Angeles, CA. Presented at the 32nd Annual Meeting of the American Pediatric Surgical Association, Naples, Florida, May 20-23, 2001. No reprints available. Copyright © 2002 by W.B. Saunders Company 0022-3468/02/3703-0025$35.00/0 doi:10.1053/jpsu.2002.30848
404
ANDERSON ET AL
Fig 1. (A) An esophagram of a 6-year-old boy with a stricture below the cricopharyngeus muscle (case 1). (B) Postoperative esophagram (case 1).
muscle and extending for 3 cm. The scarring appeared cartilaginous. The scar tissue was divided longitudinally, allowing the mucosa to expand (Fig 1B). He recovered uneventfully, required no further dilatations, and remains without symptoms 6 years after surgery. He is now of normal height and weight for his age.
Case 2 A 2-year-old boy without medical or developmental problems presented to a community emergency room with a several-hour history of drooling and crying spells as if in pain. At that time no radiographic studies were performed. For the next 5 months the patient was unable to swallow solid foods, and all attempts to speak had ceased. A chest film finally was obtained, which showed a battery in his upper esophagus. Barium esophagram, after removal of the battery, showed an esophageal stricture at the site of the impacted battery. He was seen by several physicians and repeated attempts were made at dilatation without success. He then was referred to our institution, and, after evaluation, which included unsuccessful dilatation, he was taken to the operating room where the esophagus was explored through the right neck. A thoracotomy was added when the stricture was found to extend below the thoracic inlet. A 5-cm stricturotomy was made. The esophagus was very dilated and thin above the stricture, and the mucosa also was extensively scarred. During the stricturotomy, the mucosa was entered; it was repaired using a transverse closure and buttressed by mobilizing the sternocleidomastoid muscle and suturing it to the stricturotomy site. He required 6 dilatations in the first postoperative year to maintain the lumen achieved with the stricturotomy. Now 6 years postoperatively, he is doing well without recurrent stricture and is able to eat normally. After extensive speech therapy he now speaks well.
Case 3 At 9 months of age, this patient was fed lye by a disturbed parent, and suffered for many years with an esophageal stricture, which required dilatation every few weeks. These treatments were not successful, and ultimately, the patient underwent esophagectomy with colonic interposition at 10 years of age. Over the next 3 years, a stricture developed at the esophagocolonic anastamosis. He underwent a series of dilatations without adequate improvement in his dysphagia. Because of the severity of his symptoms, he was taken to the
operating room for stricturotomy. This was completed over a 6-cm length that included part of the cervical esophagus and the coloesophageal anastamosis. There were multiple areas involving the mucosa, and therefore the esophagus was opened widely, and esophagoplasty was performed by mobilizing the sternal portion of the sternocleidomastoid muscle and suturing it longitudinally to the edges of the esophagus. The patient improved for a while, but, after 2 years and further dilatations, the esophagus at and immediately below the cricopharyngeus muscle developed additional strictures. He recently underwent a free jejunal graft, which was inserted into the pharynx and allowed the stricture of the cricopharyngeus to be eliminated. He is now doing well.
Case 4 A 5 year-old boy who throughout his entire life had been known as a “slow eater,” was found to have a stricture at the level of the thoracic inlet. Multiple attempts at dilatation were unsuccessful, and he continued to have difficulty swallowing. Because of the severity of his symptoms, he was taken to the operating room. The esophagus was mobilized through the right neck and right chest, and a long narrowed area was identified. The narrowed portion of the esophageal muscle was easily discernible. A stricturotomy was performed extending from the neck to the midthoracic esophagus. Postoperatively, the patient has done well without recurrence of symptoms.
Operative Technique Under general anesthesia, rigid esophagoscopy was performed, and the level of stricture identified. We attempted to assess the length of the stricture by dilating the esophagus, which was not always possible. Neck exploration was performed adding a thoracotomy as needed (cases 2 and 4). After surgical exposure of the esophagus was completed (Fig 2A), the stricture was localized, and a stricturotomy was performed using sharp dissection and electrocautery (Fig 2B). The stricturotomy was extended above and below the stricture into normal esophageal muscle (Fig 2C). A hemostat was used to distract the edges of the scar exposing the mucosa (Fig 2D). Dilators then were passed from above to document adequate relief of the obstruction.
DISCUSSION
Dilatation has been an accepted strategy for managing esophageal strictures for more than 30 years.6 Certain
MYOTOMY AND STRICTUREPLASTY FOR ESOPHAGEAL STRICTURE
405
Fig 2. (A) Exposure of the esophagus and identification of the stricture. (B) Stricturotomy of the affected segment with extension into normal tissue. (C) Separation of the edges and exposure of the esophageal mucosa. (D) Completed stricturotomy.
types of strictures may be more responsive than others. Buchin7 reviewed the records of 84 patients (adults and adolescents) with esophageal strictures of various etiologies (postoperative, corrosive, foreign body) and reported that 65% of patients were treated successfully with dilatation. However, in the subset of patients with corrosive injury, 67% required operative management. That study suggests that corrosive injuries may be less responsive to conservative management. When nonoperative management fails, surgical treatment is the only alternative. The surgical approach may vary according to etiology and extent of stricture formation. For patients with achalasia, esophageal myotomy is the first choice, either from a thoracic or an abdominal approach.8,9 Congenital stenosis may be treated differently depending on the type of lesion. Congenital webs and diaphragms often respond to dilatation. When they do not, endoscopic resection may be successful.10 Localized stenoses, caused by fibromuscular thickening of the midesophageal wall or the presence of cartilaginous remnants, usually can be treated by segmental resection of the esophagus.11,12 Strictures secondary to reflux esophagitis require an antireflux procedure along with esophageal dilatations.13 Strictures from retained foreign bodies such as button batteries and nasogastric tubes require individualized treatment.14 The treatment of strictures secondary to caustic ingestion also is variable. In caustic ingestion, early identification and classification of the damage is essential.
Although dilatation is useful for many strictures, Anderson et al15 found that 50% of children with third-degree injury16 eventually need esophageal replacement. Strictures greater than 5 cm in length are difficult to treat with dilatation. Gundogdu et al17 has reported that strictures 2 to 5 cm in length may be treated successfully by dilatation in over 90% of patients. However, the same study reports an esophageal perforation rate of 17%. Other studies report similar rates of perforation.18 This complication, aside from the emergency treatment of the perforation, may well preclude successful dilatation. Accepted operative management of strictures include resections of the affected esophageal segment with endto-end anastamosis and esophageal replacement. Short, high strictures in the neck, especially in proximity to the cricopharyngeus muscle, make esophageal mobilization impossible. Replacing the entire esophagus for a proximal stricture wastes a great deal of normal esophagus. In this report, we describe successful stricturotomy in 4 cases of undilatable strictures of the cervical and upper thoracic esophagus. The procedure is technically simple, and, if the mucosa is entered, the procedure can be converted to a strictureplasty. This procedure helps avoid the need for total esophageal replacement. In our experience, postoperative dilatation rarely has been needed. We propose that for undilatable strictures of the esophagus, stricturotomy is a useful alternative to esophageal replacement.
406
ANDERSON ET AL
REFERENCES 1. Hisayoshi K, Kenji I, Makoto Y, et al: Clinical characteristics of congenital esophageal stenosis distal to associated esophageal atresia. Surgery 129:29-38, 2001 2. Lee ECG: Surgery in Crohn’s disease, in Pen˜a AS, Weterman IT, Booth CC, et al (eds): Developments in Gastroenterology, Vol 1. The Hague, Martinus Nijof, 1980 3. Lee ECG, Papaionnou N: Minimal surgery for chronic obstruction in patients with extensive or universal Crohn’s disease. Ann R Coll Surg Engl 64:229-233, 1982 4. Alexander-Williams J, Haynes IG: Conservative operation for Crohn’s disease of the small bowel. World J Surg 9:945-951, 1985 5. Fazio VW, Galandiuk S, Jagelman DG, et al: Strictureplasty in Crohn’s disease. Ann Surg 210:621-625, 1989 6. Boix-Ochoa J, Rehbein F: Oesphageal stenosis due to reflux oesophagitis. Arch Dis Child 40:197, 1965 7. Buchin PJ: Therapy of esophageal stricture: A review of 84 patients. Clin Gastroenterol 3:121, 1981 8. Lemmer JH, Coran AG, Wesly JR, et al: Achalasia in children: Treatment by anterior esophageal myotomy (modified Heller operation). Pediatr Surg 20:333, 1985 9. Myers NA, Jolley SG, Taylor R: Achalasia of the cardia in children: A worldwide survey. J Pediatr Surg 29:1375, 1994
10. Bremner CG: Benign strictures of the esophagus. Current Prob Surgery 19:401, 1992 11. Valerio D, Jones PF, Stewart AM: Congenital oesophageal stenosis. Arch Dis Child 52:414, 1977 12. Murphy SG, Yazbeck S, Russo P: Isolated congenital esophageal stenosis. J Pediatr Surg 30:1238, 1995 13. O’Neill JA, Betts J, Ziegler MM, et al: Surgical management of reflux strictures of the esophagus in childhood. Ann Surg 196:453, 1982 14. Litovitz T, Schmitz BF: Ingestion of cylindrical and button batteries: An analysis of 2382 cases. Pediatrics 89:747, 1992 15. Anderson KD, Rouse TM, Randolph JG: A controlled trial of corticosteroids in children with corrosive injury of the esophagus. N Engl J Med 323:637-640, 1990 16. Holinger PH: Management of esophageal lesions caused by chemical burns. Ann Otol Rhinol Laryngol 77:786, 1968 17. Gundogdu HZ, Tanyel FC, Buyukpamukcu N, et al: Conservative treatment of caustic esophageal strictures in Children. J Pediatr Surg 27:767, 1992 18. Panieri E, Rode H, Millar AJ, et al: Oesophageal replacement in the management of corrosive strictures: When is surgery indicated? Pediatr Surg Int 13:336-340, 1998
Discussion “Application of the Principles of Myotomy and Strictureplasty for the Treatment of Esophageal Strictures.” Discussion by Stephen Greenholz, M.D. S. Greenholz (Sacramento, CA): With Dr Anderson’s
advice, we applied this technique to a long intrathoracic stricture and salvaged that esophagus, so I think the range of lesions amenable to this technique is quite broad. J.M. Acosta (response): Thank you Dr Greenholz.