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Endoscopic balloon dilation of esophageal strictures in children
0016-5107/93/3902-0153$1.00 + .10 GASTROINTESTINAL ENDOSCOPY Copyright © 1993 by the American Society for Gastrointestinal Endoscopy
Endoscopic balloon dilation of esophageal strictures in children Mahendra D. Shah, MD Wallace F. Berman, MD Richmond, Virginia
A total of 17 patients, ages 3 weeks to 14112 years, had 20 esophageal strictures develop after repair of esophageal atresia (9 strictures); primary gastroesophageal reflux (3 strictures); Nissen fundoplication (4 strictures); epidermolysis bullosa congenita dystrophica (1 stricture); congenital esophageal stenosis (2 strictures); or colonic interposition (1 stricture). These strictures were treated with 132 endoscopic balloon catheter dilations (average, 6.6/patient, range, 1 to 24) during a period of 42 months (average, 8 months; range, 2 to 42 months). Fifteen of the 17 patients are now asymptomatic. Thirteen of the 17 patients had documented reflux esophagitis and were also medically treated. The two residually symptomatic patients included a patient with severe proximal esophagitis secondary to epidermolysis bullosa congenita dystrophica who had only a temporary response to dilations and another patient with a tight Nissen fundoplication who did not improve after dilation but is now asymptomatic after corrective surgery. The 10 patients with tracheoesophageal fistula repair were asymptomatic within 3 to 21 months (average, 10.8 months). Only one patient had perforation develop as a result of the procedure. Sixteen of 17 patients had the procedures performed as outpatients. All patients were given oral feedings throughout the course of dilation and had normal growth. (Gastrointest Endosc1993;39:153-6.)
An esophageal stricture may be present in a child as a primary anomaly, develop as a result of chemical injury or after esophageal surgery, or as a result of protracted severe gastroesophageal reflux disease. Esophageal dilation is a nonsurgical method for treating most esophageal strictures. One's choice of dilators are mercury-filled bougies (the Eder-Puestow system 1), Savary dilators, and polyethylene balloons. Savary and balloon dilators are currently used in dilating most types of esophageal strictures. We Received February 20, 1992. For revision April 1, 1992. Accepted August 17, 1992. From the Medical College of Virginia/Virginia Commonwealth University, Department of Pediatrics, Children's Medical Center, Division of Pediatric Gastroenterology and Nutrition, Richmond, Virginia. Reprint requests: Wallace F. Berman, MD, Division of Pediatric Gastroenterology and Nutrition, Box 529, Richmond, VA 23298. 37/1/43156
VOLUME 39, NO.2, 1993
present our experience using the balloon catheter passed through the endoscope under direct vision to dilate benign esophageal strictures in children. METHODS AND MATERIALS
A retrospective review was conducted in 17 children with symptomatic esophageal stenosis referred to the Medical College of Virginia for balloon dilation. The children, ages 3 weeks to 14 V2 years, had 132 dilations (average, 6.6/patient; range, 1 to 24 dilations/patient) between 1985 and 1991. These 17 patients had 20 strictures. Nine of the strictures occurred at the site of the primary anastomosis for the repair of esophageal atresia in patients with esophageal atresia and tracheoesophageal fistula. Four patients had Nissen fundoplications. In three patients esophageal strictures were caused by esophagitis as a result of primary gastroesophageal reflux. In four patients esophageal strictures were associated with one of the following: epidermolysis bullosa congenita dystrophica, Apert's syndrome, congenital fibromuscular esophageal stenosis,2 or at the anastomosis of colonic inter-
153
Table 1. Clinical data of children with esophageal strictures Patient
Age
Sex
Diagnosis
Repair
1
6wk
F EA-TEF
EA
2 3 4
5 mo 3wk 7% yr
M EA-TEF M EA-TEF
EA EA
5
5'/2 yr
6 7
2 mo 10 yr
8
3 wk
9
lOV2 yr M Gastroesophageal reflux 7 yr F EA-TEF 14 yr M Gastroesophageal reflux 3 yr M EA-TEF 2% yr F EA-TEF 14V2 yr M Prader Willi syndrome 10 yr F EA-TEF/reflux esophagitis 5 yr M EA-TEF
10 11
12 13 14 15 16
F Apert's syndrome F Epidermolysis bullosa M EA-TEF EA M Gastroesophageal Nissen reflux M EA-TEF
EA EA Nissen EA EA Nissen EA
Stricture location
Reflux esophagitis
15 cm 18 cm 10 cm 10 cm 20 cm
+ + +
20cm
+
+
8cm 40 cm (gastroesophageal jun) Below anastomosis Distal third narrowing 20 cm Sip Nissen narrowing 13 cm 12 cm 12 cm 13 cm 20 cm 13 cm 19 cm 8cm
Response to dilation 5 mo upper 12 mo lower 3'/2 mo 21 mo 42 mo Temporary; still needs dilations 7 mo No response
154
Number of dilations
Asymptomatic Asymptomatic Asymptomatic Asymptomatic
5 upper 14 lower 7 18 24
Symptomatic
7
Asymptomatic Symptomatic after dilation
10 4
3 mo
Asymptomatic
4
+
2 mo
Asymptomatic
1
+ +
4 mo 2mo
Asymptomatic Asymptomatic
3 1
+
5 mo 4 mo 3 mo
Asymptomatic Asymptomatic Asymptomatic
3 8 2
2 yr Asymptomatic 3 mo 12 mo immediately Asymptomatic after dilation Asymptomatic 5mo
8 2 6 1 4
+
+
EA + Nissen 17 7 yr F Lye ingestion Colonic + esophagitis interposition EA, esophageal atresia; EA- TEF, esophageal atresia and tracheoesophageal fistula; SIP, status post. position that was performed to treat an irreversible lye stricture. Three patients with esophageal atresia and tracheoesophageal fistulas had two strictures each in addition to the stricture at the site of repair of esophageal atresia. Two patients had strictures secondary to ongoing gastroesophageal reflux, and one patient had an excessively tight Nissen fundoplication. Gastroesophageal reflux was suspected clinically and proven by barium esophagogram and gastroesophageal scintigraphy. Esophageal manometry and esophagoscopy were performed in all patients. All patients underwent the barium esophagogram and endoscopy to confirm the presence of esophageal narrowing before dilation. Endoscopic balloon catheter dilation was performed with the patients under general anesthesia in all but one instance. The stricture was visualized with the endoscope. Then, using "through the scope" balloon catheters (Rigiflex TTS balloon dilators; Microvasive, Watertown, Mass.), the balloon was positioned across the area of stricture. The balloon was slowly inflated with methylene blue-colored sterile water to specified pressures for each balloon. A pressure gauge was used to monitor the pressures (1.5 to 6 atm, 1 atm = 15 Ib/in 2, 760 mm Hg). The inflation was maintained for 60 seconds and then repeated three times during each dilation. The lumen of the esophagus could be seen through the inflated balloon using the endoscope. Thus effective dilation
Result
was confirmed by direct visualization during the procedure. After the procedure, the integrity of the mucosa of the esophagus was visualized by endoscopy. The size of the initial dilating balloon was chosen on the basis of the estimated caliber of the esophagus and the diameter of the stricture, which was determined by the initial barium swallow and endoscopy. In neonates, the first dilation usually was made with a balloon that was 6 to 8 mm in diameter. In infants, the balloon diameter was 8 to 10 mm. The size of the balloon was increased in increments of 2 mm for each subsequent dilation. The initial two or three dilations were performed weekly and then subsequently as indicated by symptoms such as dysphagia, vomiting, or esophageal obstruction or by the recurrence of the stricture as seen on barium esophagogram. The patient with epidermolysis bullosa had dilations using endoscopic visualization. A soft-tipped guide wire 0.035 inches in diameter was placed across the stricture under fluoroscopic guidance. Dilating catheters with balloons 10 to 20 mm in diameter were passed over the guide wire, and the balloon was positioned across the stricture using fluoroscopic guidance. The balloon was inflated and maintained for 60 seconds and then deflated. The procedure was repeated three times. After the procedure the mucosa of the esophagus in this particular patient was not visualized because of the friability and bleeding surface seen in this
GASTROINTESTINAL ENDOSCOPY
condition. The procedure was followed by Gastrograffin esophagogram for the first several dilations to rule out the possibility of perforation. The patient was kept in the hospital overnight to watch for the development of any complications. None were seen. All other patients (16 of 17) had dilations as outpatients. The children were allowed to drink clear liquids after recovery from anesthesia (within 2 hours), and the diet given was appropriate for the age. The response time was defined as the time between the first dilation and the last dilation, after which the child had been asymptomatic and did not need further dilations. RESULTS
The results of the treatment regimen are listed in Table 1. We performed 132 dilations (average, 6.6/patient, range, 1 to 24) in 17 children with 20 strictures. In 10 patients with tracheoesophagal fistula repair, nine strictures existed at the anastomotic site and four strictures existed below the anastomosis secondary to chronic gastroesophageal reflux. The dilations were started as indicated by symptomatolic analysis when the patients were 3 weeks to 5 months old. The total number of dilations required was 3 to 18 (average, 6.6), and they were conducted for a period of3 to 24 months (average, 8.8 months). None of the patients with esophageal atresia and tracheoesophageal fistulas are currently symptomatic (observed for 1 to 10 years), nor do they require repeat dilations. All patients were given oral feedings during the period of dilation and had normal growth. During the first dilation 3 weeks after the initial corrective surgery, perforation occurred in patient 8 as a result of the dilation procedure at a site below the anastomosis. The perforation was attributed to overly aggressive dilation with a large balloon (10 mm in diameter) on the first session. The perforation was surgically repaired (perforation was sutured), and the patient recovered without sequelae. The patient had three subsequent nonendoscopic dilations with bougies and is now totally asymptomatic. DISCUSSION
The balloon catheter is not a new discovery in the search for a nonsurgical means of dilating esophageal strictures. In 1898, Russe1l 3 described the first pneumatic dilator to treat lower esophageal strictures and achalasia. During the next 50 years many different inflatable catheters were developed to dilate esophageal strictures. 4 More recently, smaller, more evenly distensible catheters have been sought to treat such strictures. 5,6 Currently, the Gruntzig balloon dilating catheter has been used successfully for strictures in the cardiac and peripheral vasculature,7,8 the biliary and urinary tracts,9, 10 the colons of neonates after inflammatory disease,l1 and in the esophagus. 12 Real and theoretical advantages exist with regard to VOLUME 39, NO.2, 1993
balloon catheter dilation as compared with bougienage in children who have strictures after the repair of esophageal atresia. The traditional surgical management of this congenital anomaly included the placement of a gastrostomy and the passage of string from the stomach into the esophagus and out through the patient's nose to guide subsequent bougie dilations. The advantage of balloon dilation is that the string and gastrostomy are not necessary. In some infants anastomotic strictures are so restrictive that conventional dilators cannot be used safely. Also, the tortuosity of the esophagus above a stricture may prevent manipulation of a bougie dilator through the stricture. The theoretical advantage of balloon dilation as compared with bougienage is that only axial and not shear forces are applied to the stricture, increasing the effectiveness of dilation and lessening the chance of perforation. 13 In addition, because the balloon is expandable, dilation to larger sizes is not usually limited by the size ofthe pharynx. This method of stricture treatment has decreased the number of second operations that were performed in the past to resect the stricture or replace the esophagus. 14 We preferred to use general anesthesia in most of our patients for better control of the airway. During balloon dilation respiratory compromise exists because of the volume of the balloon compressing the airway. Most ofthese patients were very young infants in whom respiratory competency was of great concern. The advantages of using endoscopy instead of fluoroscopy during dilation are the following: (1) visualization of the stricture before and after dilation; (2) ability to directly inspect the mucosa of the esophagus; (3) insertion ofthe balloon catheter under direct vision to assess the effectiveness of dilation; and (4) avoidance of exposure to radiation. In two patients the dilation was started 3 weeks after corrective surgery for esophageal atresia. Sato et al.l 5 have also performed the procedure 3 weeks after surgery, whereas Goldthorn et al. 5 have performed the procedure as early as 2 weeks after surgery. It generally is felt safe to perform balloon dilation 3 weeks after surgery. For infants undergoing dilation of esophageal anastomotic strictures, balloon catheter dilation initiated early in the postoperative period provided rapid relief of the obstruction. All these infants had complete symptomatic and radiographic resolution of the obstruction after a limited series of dilations. Hoffer et al. 16 reported an 8 % perforation rate in nine patients treated with 26 balloon catheter dilations. Johnsen, Ingemann Jensen, and Mauritzen17 did not report any perforation in 10 patients treated with 47 balloon dilations. Goldthorn et a1. 5 did not report any perforation in eight patients treated with 46 balloon dilations. Myer, Ball, and Bisset18 reported a 6.7% perforation rate in 15 patients treated with 43 155
balloon dilations. In our series, one perforation occurred in 17 patients (5.8 %) treated with 132 dilations (0.76%).
REFERENCES 1. Lanza FL. Bougienage is effective therapy for most benign esophageal strictures. JAMA 1978;240:844-7. 2. Nihoul-Fekete C, DeBacker A, Lortat-Jacob S, Pellerin D. Congenital esophageal stenosis. Pediatr Surg Int 1987;2:86-92. 3. Russell JC. Diagnosis and treatment of spasmodic strictures of the esophagus. BMJ 1898;1:1450-1. 4. Ellis FH, Olsen AM. Nonsurgical treatment of achalasia. In: Ellis FH, ed. Achalasia of the esophagus. Philadelphia: W.E. Saunders Co., 1969:122-49. 5. Goldthorn JF, Ball WS, Wilkinson LG, Beigel RS, Koslosko AM. Esophageal strictures in children: treatment by serial balloon catheter dilatation. Radiology 1984;153:655-8. 6. Friedberg J. Dilatation of esophageal strictures in children using a Fogarty balloon catheter. J OtolaryngoI1979;8:541-3. 7. Gruntzig AR, Senning A, Siegenthater WE. Non-operative dilatation of coronary artery stenosis: percutaneous transluminal coronary angioplasty. N Engl J Med 1979;301:61-6. 8. Lu CT, Zarins CK, Yang CF. Percutaneous transluminal angioplasty for limb salvage. Radiology 1982;142:337-41. 9. Berk RN, Cooperberg PL, Gold RP, et al. Radiology of the bile duct. Radiology 1982;145:1-9.
156
10. Kadir S, White RI, Engel R. Balloon catheter dilatation of a ureteropelvic junction obstruction. Radiology 1982;143:263-4. 11. Ball WS, Seigel RS, Goldthorn JF, Kosloske A. Colonic strictures in infants following intestinal ischemia: treatment by balloon catheter dilatation. Radiology 1983;149:469-72. 12. London RL, Trotman BW, Dimarino AJ Jr, et al. Dilatation of severe esophageal strictures by an inflatable balloon catheter. Gastroenterology 1981;80:173-5. 13. Dawson SL, Meuller PR, Ferrucci JT, et al. Severe oesophageal strictures: indications for balloon catheter dilatation. Radiology 1984;153:631-5. 14. Myers NA, Beasley SW, Auldist AW. Secondary esophageal surgery repair of esophageal atresia with distal tracheoesophageal fistula. J Pediatr Surg 1990;25:773-7. 15. Sato Y, Frey EE, Smith WL, Pringle KC, Soper RT, Franken EA Jr. Balloon dilatation of esophageal stenosis in children. AJR 1988;150:639-42. 16. Hoffer FA, Winter HS, Fellows KE, Folkman J. The treatment of post-operative and peptic esophageal strictures after esophageal atresia repair. Pediatr Radiol 1987;17:454-8. 17. Johnsen A, Ingemann Jensen L, Mauritzen K. Balloon-dilatation of esophageal strictures in children. Pediatr Radiol 1986; 16:388-91. 18. Myer CM III, Ball WS, Bisset GS. Balloon dilatation of esophageal strictures in children. Arch Otolaryngol Head Neck Surg 1991;117:529-32.
GASTROINTESTINAL ENDOSCOPY
Endoscopic balloon dilation of esophageal strictures in children Mahendra D. Shah, MD Wallace F. Berman, MD Richmond, Virginia
A total of 17 patients, ages 3 weeks to 14112 years, had 20 esophageal strictures develop after repair of esophageal atresia (9 strictures); primary gastroesophageal reflux (3 strictures); Nissen fundoplication (4 strictures); epidermolysis bullosa congenita dystrophica (1 stricture); congenital esophageal stenosis (2 strictures); or colonic interposition (1 stricture). These strictures were treated with 132 endoscopic balloon catheter dilations (average, 6.6/patient, range, 1 to 24) during a period of 42 months (average, 8 months; range, 2 to 42 months). Fifteen of the 17 patients are now asymptomatic. Thirteen of the 17 patients had documented reflux esophagitis and were also medically treated. The two residually symptomatic patients included a patient with severe proximal esophagitis secondary to epidermolysis bullosa congenita dystrophica who had only a temporary response to dilations and another patient with a tight Nissen fundoplication who did not improve after dilation but is now asymptomatic after corrective surgery. The 10 patients with tracheoesophageal fistula repair were asymptomatic within 3 to 21 months (average, 10.8 months). Only one patient had perforation develop as a result of the procedure. Sixteen of 17 patients had the procedures performed as outpatients. All patients were given oral feedings throughout the course of dilation and had normal growth. (Gastrointest Endosc1993;39:153-6.)
An esophageal stricture may be present in a child as a primary anomaly, develop as a result of chemical injury or after esophageal surgery, or as a result of protracted severe gastroesophageal reflux disease. Esophageal dilation is a nonsurgical method for treating most esophageal strictures. One's choice of dilators are mercury-filled bougies (the Eder-Puestow system 1), Savary dilators, and polyethylene balloons. Savary and balloon dilators are currently used in dilating most types of esophageal strictures. We Received February 20, 1992. For revision April 1, 1992. Accepted August 17, 1992. From the Medical College of Virginia/Virginia Commonwealth University, Department of Pediatrics, Children's Medical Center, Division of Pediatric Gastroenterology and Nutrition, Richmond, Virginia. Reprint requests: Wallace F. Berman, MD, Division of Pediatric Gastroenterology and Nutrition, Box 529, Richmond, VA 23298. 37/1/43156
VOLUME 39, NO.2, 1993
present our experience using the balloon catheter passed through the endoscope under direct vision to dilate benign esophageal strictures in children. METHODS AND MATERIALS
A retrospective review was conducted in 17 children with symptomatic esophageal stenosis referred to the Medical College of Virginia for balloon dilation. The children, ages 3 weeks to 14 V2 years, had 132 dilations (average, 6.6/patient; range, 1 to 24 dilations/patient) between 1985 and 1991. These 17 patients had 20 strictures. Nine of the strictures occurred at the site of the primary anastomosis for the repair of esophageal atresia in patients with esophageal atresia and tracheoesophageal fistula. Four patients had Nissen fundoplications. In three patients esophageal strictures were caused by esophagitis as a result of primary gastroesophageal reflux. In four patients esophageal strictures were associated with one of the following: epidermolysis bullosa congenita dystrophica, Apert's syndrome, congenital fibromuscular esophageal stenosis,2 or at the anastomosis of colonic inter-
153
Table 1. Clinical data of children with esophageal strictures Patient
Age
Sex
Diagnosis
Repair
1
6wk
F EA-TEF
EA
2 3 4
5 mo 3wk 7% yr
M EA-TEF M EA-TEF
EA EA
5
5'/2 yr
6 7
2 mo 10 yr
8
3 wk
9
lOV2 yr M Gastroesophageal reflux 7 yr F EA-TEF 14 yr M Gastroesophageal reflux 3 yr M EA-TEF 2% yr F EA-TEF 14V2 yr M Prader Willi syndrome 10 yr F EA-TEF/reflux esophagitis 5 yr M EA-TEF
10 11
12 13 14 15 16
F Apert's syndrome F Epidermolysis bullosa M EA-TEF EA M Gastroesophageal Nissen reflux M EA-TEF
EA EA Nissen EA EA Nissen EA
Stricture location
Reflux esophagitis
15 cm 18 cm 10 cm 10 cm 20 cm
+ + +
20cm
+
+
8cm 40 cm (gastroesophageal jun) Below anastomosis Distal third narrowing 20 cm Sip Nissen narrowing 13 cm 12 cm 12 cm 13 cm 20 cm 13 cm 19 cm 8cm
Response to dilation 5 mo upper 12 mo lower 3'/2 mo 21 mo 42 mo Temporary; still needs dilations 7 mo No response
154
Number of dilations
Asymptomatic Asymptomatic Asymptomatic Asymptomatic
5 upper 14 lower 7 18 24
Symptomatic
7
Asymptomatic Symptomatic after dilation
10 4
3 mo
Asymptomatic
4
+
2 mo
Asymptomatic
1
+ +
4 mo 2mo
Asymptomatic Asymptomatic
3 1
+
5 mo 4 mo 3 mo
Asymptomatic Asymptomatic Asymptomatic
3 8 2
2 yr Asymptomatic 3 mo 12 mo immediately Asymptomatic after dilation Asymptomatic 5mo
8 2 6 1 4
+
+
EA + Nissen 17 7 yr F Lye ingestion Colonic + esophagitis interposition EA, esophageal atresia; EA- TEF, esophageal atresia and tracheoesophageal fistula; SIP, status post. position that was performed to treat an irreversible lye stricture. Three patients with esophageal atresia and tracheoesophageal fistulas had two strictures each in addition to the stricture at the site of repair of esophageal atresia. Two patients had strictures secondary to ongoing gastroesophageal reflux, and one patient had an excessively tight Nissen fundoplication. Gastroesophageal reflux was suspected clinically and proven by barium esophagogram and gastroesophageal scintigraphy. Esophageal manometry and esophagoscopy were performed in all patients. All patients underwent the barium esophagogram and endoscopy to confirm the presence of esophageal narrowing before dilation. Endoscopic balloon catheter dilation was performed with the patients under general anesthesia in all but one instance. The stricture was visualized with the endoscope. Then, using "through the scope" balloon catheters (Rigiflex TTS balloon dilators; Microvasive, Watertown, Mass.), the balloon was positioned across the area of stricture. The balloon was slowly inflated with methylene blue-colored sterile water to specified pressures for each balloon. A pressure gauge was used to monitor the pressures (1.5 to 6 atm, 1 atm = 15 Ib/in 2, 760 mm Hg). The inflation was maintained for 60 seconds and then repeated three times during each dilation. The lumen of the esophagus could be seen through the inflated balloon using the endoscope. Thus effective dilation
Result
was confirmed by direct visualization during the procedure. After the procedure, the integrity of the mucosa of the esophagus was visualized by endoscopy. The size of the initial dilating balloon was chosen on the basis of the estimated caliber of the esophagus and the diameter of the stricture, which was determined by the initial barium swallow and endoscopy. In neonates, the first dilation usually was made with a balloon that was 6 to 8 mm in diameter. In infants, the balloon diameter was 8 to 10 mm. The size of the balloon was increased in increments of 2 mm for each subsequent dilation. The initial two or three dilations were performed weekly and then subsequently as indicated by symptoms such as dysphagia, vomiting, or esophageal obstruction or by the recurrence of the stricture as seen on barium esophagogram. The patient with epidermolysis bullosa had dilations using endoscopic visualization. A soft-tipped guide wire 0.035 inches in diameter was placed across the stricture under fluoroscopic guidance. Dilating catheters with balloons 10 to 20 mm in diameter were passed over the guide wire, and the balloon was positioned across the stricture using fluoroscopic guidance. The balloon was inflated and maintained for 60 seconds and then deflated. The procedure was repeated three times. After the procedure the mucosa of the esophagus in this particular patient was not visualized because of the friability and bleeding surface seen in this
GASTROINTESTINAL ENDOSCOPY
condition. The procedure was followed by Gastrograffin esophagogram for the first several dilations to rule out the possibility of perforation. The patient was kept in the hospital overnight to watch for the development of any complications. None were seen. All other patients (16 of 17) had dilations as outpatients. The children were allowed to drink clear liquids after recovery from anesthesia (within 2 hours), and the diet given was appropriate for the age. The response time was defined as the time between the first dilation and the last dilation, after which the child had been asymptomatic and did not need further dilations. RESULTS
The results of the treatment regimen are listed in Table 1. We performed 132 dilations (average, 6.6/patient, range, 1 to 24) in 17 children with 20 strictures. In 10 patients with tracheoesophagal fistula repair, nine strictures existed at the anastomotic site and four strictures existed below the anastomosis secondary to chronic gastroesophageal reflux. The dilations were started as indicated by symptomatolic analysis when the patients were 3 weeks to 5 months old. The total number of dilations required was 3 to 18 (average, 6.6), and they were conducted for a period of3 to 24 months (average, 8.8 months). None of the patients with esophageal atresia and tracheoesophageal fistulas are currently symptomatic (observed for 1 to 10 years), nor do they require repeat dilations. All patients were given oral feedings during the period of dilation and had normal growth. During the first dilation 3 weeks after the initial corrective surgery, perforation occurred in patient 8 as a result of the dilation procedure at a site below the anastomosis. The perforation was attributed to overly aggressive dilation with a large balloon (10 mm in diameter) on the first session. The perforation was surgically repaired (perforation was sutured), and the patient recovered without sequelae. The patient had three subsequent nonendoscopic dilations with bougies and is now totally asymptomatic. DISCUSSION
The balloon catheter is not a new discovery in the search for a nonsurgical means of dilating esophageal strictures. In 1898, Russe1l 3 described the first pneumatic dilator to treat lower esophageal strictures and achalasia. During the next 50 years many different inflatable catheters were developed to dilate esophageal strictures. 4 More recently, smaller, more evenly distensible catheters have been sought to treat such strictures. 5,6 Currently, the Gruntzig balloon dilating catheter has been used successfully for strictures in the cardiac and peripheral vasculature,7,8 the biliary and urinary tracts,9, 10 the colons of neonates after inflammatory disease,l1 and in the esophagus. 12 Real and theoretical advantages exist with regard to VOLUME 39, NO.2, 1993
balloon catheter dilation as compared with bougienage in children who have strictures after the repair of esophageal atresia. The traditional surgical management of this congenital anomaly included the placement of a gastrostomy and the passage of string from the stomach into the esophagus and out through the patient's nose to guide subsequent bougie dilations. The advantage of balloon dilation is that the string and gastrostomy are not necessary. In some infants anastomotic strictures are so restrictive that conventional dilators cannot be used safely. Also, the tortuosity of the esophagus above a stricture may prevent manipulation of a bougie dilator through the stricture. The theoretical advantage of balloon dilation as compared with bougienage is that only axial and not shear forces are applied to the stricture, increasing the effectiveness of dilation and lessening the chance of perforation. 13 In addition, because the balloon is expandable, dilation to larger sizes is not usually limited by the size ofthe pharynx. This method of stricture treatment has decreased the number of second operations that were performed in the past to resect the stricture or replace the esophagus. 14 We preferred to use general anesthesia in most of our patients for better control of the airway. During balloon dilation respiratory compromise exists because of the volume of the balloon compressing the airway. Most ofthese patients were very young infants in whom respiratory competency was of great concern. The advantages of using endoscopy instead of fluoroscopy during dilation are the following: (1) visualization of the stricture before and after dilation; (2) ability to directly inspect the mucosa of the esophagus; (3) insertion ofthe balloon catheter under direct vision to assess the effectiveness of dilation; and (4) avoidance of exposure to radiation. In two patients the dilation was started 3 weeks after corrective surgery for esophageal atresia. Sato et al.l 5 have also performed the procedure 3 weeks after surgery, whereas Goldthorn et al. 5 have performed the procedure as early as 2 weeks after surgery. It generally is felt safe to perform balloon dilation 3 weeks after surgery. For infants undergoing dilation of esophageal anastomotic strictures, balloon catheter dilation initiated early in the postoperative period provided rapid relief of the obstruction. All these infants had complete symptomatic and radiographic resolution of the obstruction after a limited series of dilations. Hoffer et al. 16 reported an 8 % perforation rate in nine patients treated with 26 balloon catheter dilations. Johnsen, Ingemann Jensen, and Mauritzen17 did not report any perforation in 10 patients treated with 47 balloon dilations. Goldthorn et a1. 5 did not report any perforation in eight patients treated with 46 balloon dilations. Myer, Ball, and Bisset18 reported a 6.7% perforation rate in 15 patients treated with 43 155
balloon dilations. In our series, one perforation occurred in 17 patients (5.8 %) treated with 132 dilations (0.76%).
REFERENCES 1. Lanza FL. Bougienage is effective therapy for most benign esophageal strictures. JAMA 1978;240:844-7. 2. Nihoul-Fekete C, DeBacker A, Lortat-Jacob S, Pellerin D. Congenital esophageal stenosis. Pediatr Surg Int 1987;2:86-92. 3. Russell JC. Diagnosis and treatment of spasmodic strictures of the esophagus. BMJ 1898;1:1450-1. 4. Ellis FH, Olsen AM. Nonsurgical treatment of achalasia. In: Ellis FH, ed. Achalasia of the esophagus. Philadelphia: W.E. Saunders Co., 1969:122-49. 5. Goldthorn JF, Ball WS, Wilkinson LG, Beigel RS, Koslosko AM. Esophageal strictures in children: treatment by serial balloon catheter dilatation. Radiology 1984;153:655-8. 6. Friedberg J. Dilatation of esophageal strictures in children using a Fogarty balloon catheter. J OtolaryngoI1979;8:541-3. 7. Gruntzig AR, Senning A, Siegenthater WE. Non-operative dilatation of coronary artery stenosis: percutaneous transluminal coronary angioplasty. N Engl J Med 1979;301:61-6. 8. Lu CT, Zarins CK, Yang CF. Percutaneous transluminal angioplasty for limb salvage. Radiology 1982;142:337-41. 9. Berk RN, Cooperberg PL, Gold RP, et al. Radiology of the bile duct. Radiology 1982;145:1-9.
156
10. Kadir S, White RI, Engel R. Balloon catheter dilatation of a ureteropelvic junction obstruction. Radiology 1982;143:263-4. 11. Ball WS, Seigel RS, Goldthorn JF, Kosloske A. Colonic strictures in infants following intestinal ischemia: treatment by balloon catheter dilatation. Radiology 1983;149:469-72. 12. London RL, Trotman BW, Dimarino AJ Jr, et al. Dilatation of severe esophageal strictures by an inflatable balloon catheter. Gastroenterology 1981;80:173-5. 13. Dawson SL, Meuller PR, Ferrucci JT, et al. Severe oesophageal strictures: indications for balloon catheter dilatation. Radiology 1984;153:631-5. 14. Myers NA, Beasley SW, Auldist AW. Secondary esophageal surgery repair of esophageal atresia with distal tracheoesophageal fistula. J Pediatr Surg 1990;25:773-7. 15. Sato Y, Frey EE, Smith WL, Pringle KC, Soper RT, Franken EA Jr. Balloon dilatation of esophageal stenosis in children. AJR 1988;150:639-42. 16. Hoffer FA, Winter HS, Fellows KE, Folkman J. The treatment of post-operative and peptic esophageal strictures after esophageal atresia repair. Pediatr Radiol 1987;17:454-8. 17. Johnsen A, Ingemann Jensen L, Mauritzen K. Balloon-dilatation of esophageal strictures in children. Pediatr Radiol 1986; 16:388-91. 18. Myer CM III, Ball WS, Bisset GS. Balloon dilatation of esophageal strictures in children. Arch Otolaryngol Head Neck Surg 1991;117:529-32.
GASTROINTESTINAL ENDOSCOPY