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Endoscopy-guided balloon dilatation of esophageal strictures and anastomotic strictures after esophageal replacement in children
Endoscopy-Guided Balloon Dilatation of Esophageal Strictures and Anastomotic Strictures After Esophageal Replacement in Children By P.K.H. Tam, A. Sprigg, R.E. Cudmore, R.C.M. Cook, and H. Carty Liverpool, 0 This study evaluates the safety, efficacy, and technical problems of the new technique of endoscopy-guided balloon dilation (EGBD) in the treatment of strictures of the esophagus and its replacement. Between 1988 and 1990, the authors treated 33 children (aged 3 weeks to 20 years) with EGBD; 18 had esophageal strictures (primary esophageal atresia repair, 13; reflux esophagitis, 5). 13 had anastomotic strictures after esophageal replacement (colon, 12; stomach, I), and 2 had caustic strictures. The majority (23 of 33) had previously failed to respond to conventional bouginage (mean, 11.2 sessions; range, 1 to 32 sessions). EGBD was performed using flexible endoscopy and flouroscopic screening under general anesthesia. Endoscopy identified and resolved the errors or uncertainties of preoperative contrast studies in 7 patients, 5 of whom had colon interposition. EGBD was achieved in all 31 patients with esophageal or replacement strictures; the mean number of EGDB procedures per patient was 2.1 (range 1 to 7). Symptomatic relief was excellent in 24 and moderate in 7 patients. Both patients with caustic strictures had esophageal perforation from EGBD (excessive inflation, 1; false passage of guide wire, 1). Patients who had experienced both conventional bouginage and EGBD noticed less pain with EGBD and resumed eating sooner. The authors conclude that EGBD is safe and effective for treating esophageal and replacement strictures but not caustic strictures. Copyright o 1991 by W.B. Saunders Company INDEX WORDS: Esophageal stricture; esophageal atresia; colon interposition; endoscopic balloon dilatation of esophagus.
E
SOPHAGEAL STRICTURES can occur as a primary congenital anomaly or as complications of reflux esophagitis, caustic ingestion, or repair of esophageal atresia. Anastomotic strictures can also complicate esophageal replacement by gastric tube or colon interposition. Initial treatment of these strictures is usually by dilatation; surgery is reserved for strictures unresponsive to such treatment. Traditionally, dilatation is carried out by the passage of a series of bougies of increasing diameters. In small children, a gastrostomy is sometimes required for string-guided bouginage (Tucker’s dilatation).’ In 1974, Gruntzig and Hop@ introduced the balloon catheter for the dilatation of narrowed arteries, and soon this principle was adapted for use in esophageal strictures.3s4 Unlike bouginage, which generates an abrupt shearing axial force, the balloon catheter dilates a stricture gradually by a uniform radial force (Fig l), and superior results can be expected. However, experience in the use of balloon dilatation in the treatment of esophageal strictures and anastomotic strictures after esophageal replacement in infants and children JournalofPediatric
Surgery, Vol 26, No 9 (September), 1991: pp 1101-1103
England
is limited,‘-9 and the indications, safety, and efficacy of the procedure are not well defined. We report our experience with the use of endoscopy-guided balloon dilatation (EGBD) in 33 infants and children with such problems. MATERIALS AND METHODS Between 1986 and 1990,33 infants and children with esophageal strictures and anastomotic strictures after esophageal replacement were treated with EGBD in Royal Liverpool Children’s Hospital. Alder Hey. Median age was 3.7 years (range, 3 weeks to 20 years). Of 33 patients, 18 had esophageal strictures, following repair of esophageal atresia in 13 and secondary to reflux esophagitis in 5; 13 had anastomotic strictures after esophageal replacement (colon, 12; stomach, 1); and 2 had caustic strictures. Of 33 patients, 23 had previously failed to respond to conventional bouginage (mean, 11.2 sessions; range, 1 to 32 sessions). All patients underwent contrast studies before EGBD. Flexible upper gastrointestinal endoscopy was performed under general anesthesia using an Olympus GIF PQ 20 model (Olympus Optical Co Ltd, Tokyo, Japan). The stricture was cannulated with a guide wire, and correct positioning was confirmed fluoroscopically. A balloon catheter was chosen; a rough guide to the size of the patient’s esophagus is the “rule of thumb,” ie, the size of the patient’s own thumb. The endoscope was removed and the deflated balloon catheter was introduced over the guide wire so that the center of the balloon was at the level of the stricture. The balloon catheter was inflated cautiously with contrast by an experienced radiologist (AS. or H.C.) using an appropriate syringe. A definite “waist” in the balloon caused by the stricture should be visible radiologically (Fig 2A). Dilatation of the stricture was monitored both by flouroscopy and by the resistance the radiologist felt on further injection of contrast into the balloon: there was often a tight “grip” that slowly gave way to sustained pressure. Successful dilatation occurred when the “waist” in the balloon mostly disappeared (Fig 2B). Inflation of the balloon was maintained for a further 3 to 5 minutes. For tight strictures, it was necessary to perform dilatation with serial application of progressively larger balloon catheters. RESULTS
There were errors or uncertainties in the initial contrast studies in seven patients. Five had colon
From the Departments of Pediatric Surgery and Radiology, Royal Liverpool Children’s HospitalAlder Hey, Liverpool, England. Presented at the 42nd Annual Meeting of the Surgical Section of the American Academy of Pediatrics, Boston, Massachusetts, October 6 7, 1990. Address reprint requests to P. K.H. Tam, Nufietd Department of Surgery, John Radcliffe Hospital, Headington, Oxford OX3 9DU, England. Copyright o 1991 by U! B. Saunders Cornpam 0022-3468/9112609-0019$03.00/O 1101
TAM
ETAL
Table 1. Results of EGBD
Stricture
Physical forces with bouginage and balloon dilatation.
interposition, and the tortuosity of the colon made it difficult to distinguish whether angulation or stricture was the cause of the hold-up of the contrast; this was resolved by the demonstration of a “waist” on EGBD. The remaining two patients had gastroesophageal reflux that was seen on contrast studies after EGBD but was not shown on initial contrast studies. Results of EGBD are shown in Table 1. All 31 patients with esophageal or replacement strictures had uneventful EGBD (mean, 2.1; range, 1 to 7). Symptomatic relief was excellent in 24 and moderate in 7. Of these, 4 did not respond to EGBD before their gastroesophageal reflux was eradicated but
Fig 2. (A) Catheter in place showing “waist” in balloon caused by stricture. (B) Satisfactory dilatation resulted in disappearance of the “waist” in the balloon.
Mean EGBDl Patient (range)
RFJSp3lWS
Excellent
Moderate
Failed
Esophageal
18
2.2(l-7)
14
4
0
Replacement
13
2.1 (l-6)
10
3
0
2
1.5(1-2)
0
0
2
Caustic
Fig 1.
No. of Patients
rapidly responded to EGBD after fundoplication. Patients who had experienced both conventional bouginage and EGBD noticed less pain with EGBD and were able to resume solid feeding earlier. Both patients with caustic strictures had esophageal perforation complicating EGBD. Of these two perforations, one resulted from an overenthusiastic attempt at inflation of a larger-than-recommended balloon catheter to dilate the resistant stricture; the patient developed mediastinitis and pneumothorax. The other perforation resulted from the passage of the guide wire in a false track; the complication was immediately recognized, and EGBD was abandoned. Both patients responded to chest drainage, fasting, and intravenous antibiotic therapy. DISCUSSION
There are many potential advantages of EGBD over conventional bouginage in the treatment of esophageal strictures and anastomotic strictures complicating esophageal replacement: (1) because EGBD applies a uniform radial force rather than an axial force, dilatation of the stricture may be more effective and less traumatic; (2) the efficacy of dilatation is monitored fluoroscopically, and the end point of treatment need not be assumed; (3) because the balloon catheter is introduced in a deflated state, the size of the oropharynx is not a limiting factor as it is with larger bougies; (4) the use of flexible endoscopy allows placement of the catheter under direct vision, minimizing the risk of false passage of the dilator; (5) tortuosity of the conduit, a common problem with colon interposition, is not a prohibiting factor for dilatation; and (6) the necessity of gastrostomy and string placement for Tucker’s dilatation is obviated. Our experience confirms that EGBD is safe and effective for esopheagal and replacement strictures. The majority of such patients had excellent responses to a mean number of 2.1 sessions per patient. Importantly, these EGBD responders included 23 patients who had a history of failure to respond to multiple sessions of conventional bouginage. Subjectively, many patients also preferred EGBD to bouginage because it was associated with less residual pain. Young age is not a contraindication to EGBD: we have treated neonates in the immediate postoperative period (3 weeks) after primary repair of esophageal atresia. In
BALLOON
DILATATION
OF ESOPHAGEAL
STRICTURES
1103
centers where expertise in EGBD is readily available, conventional bouginage will seldom be required. However, EGBD is not indicated in patients who have extensive damage to the esophagus by caustic injury. In our experience, both patients with caustic strictures failed to respond to EGBD and developed perforations. Severe caustic strictures are unlikely to respond to dilatation, whether EGBD or bouginage, and often require surgical treatment by replacement with colon or stomach. Successful EGBD entails a team approach: the anesthetist, the radiologist, and the endoscopist. Although anesthesia was not used in some series of balloon dilatation of esophageal strictures,536 we preferred general anesthetisia for EGBD. Because the esophagus and the trachea are in close proximity, dilatation of the esophagus can cause airway compression; therefore, endotracheal intubation and cardiorespiratory monitoring are desirable. Radiological studies before EGBD help in the planning of the procedure. It is important, however, to realize the limitations of imaging techniques. In our experience, it was sometimes difficult to differentiate radiologically whether angulation or stricture was the cause of obstruction in colon interposition, but EGBD could resolve the issue. In some series,
balloon dilatation was carried out under flouroscopic control alone without endoscopy guidance,‘-* but few of their patients had tortuous conduits from colon interposition. The use of flexible endoscopy allowed us to perform balloon dilatation in this condition despite severe angulation and redundancy of the interposed colon. In addition, we feel that placement of guide wire under direct vision minimized the risk of inadvertent perforation of the esophagus when the stricture was severe. To ensure success of EGBD, it is important to rule out existing pathology which perpetuates stricture formation. The most common problem is gastroesophageal reflux (GER) complicating repair of esophageal atresia. In the presence of severe esophageal stricture, GER may not be apparent both clinically and radiologically. Two of our patients did not show GER in contrast studies before dilatation, and GER was revealed only afterwards. It is possible that a severe stricture does not allow enough contrast to enter the stomach to permit demonstration of GER until after adequate dilatation of the stricture. Effective treatment of GER is essential: four of our patients did not respond to EGBD until their reflux was controlled by fundoplication.
REFERENCES 1. Tucker JA, Yarington CT Jr: The treatment of caustic ingestion. Otolaryngol Clin North Am 12:343-350, 1979 2. Gruntzig Ai Hopff H: Perkutane Rekanalisation chronischer arterieller verschlusse mit einem neunen Dilatation-Katheter. Dtsch Med Wachs 99:2502-2505,1974 3. London RL, Trotman BW, Di Marino AJ Jr, et al: Dilatation of severe esophageal strictures by an inflatable balloon catheter. Gastroenterology 80:173-175,198l 4. Dawson SL, Mueller PR, Ferrucci JT Jr, et al: Severe esophageal strictures: Indications for balloon catheter dilatations. Radiology 153:631-635,1984 5. Johnsen A, Jensen LI, Mauritzen K: Balloon dilatation of esophageal strictures in children. Pediatr Radio1 16:388-391, 1986
6. Sato Y, Frey E, Smith EE, et al: Balloon dilatation esophageal stenosis in children. AJR 150:639-642, 1988
of
_ -
7. Goldthorn JF, Ball WS, Wilkinson LG, et al: Esophageal structures in children: Treatment by serial balloon catheter dilatation. Radiology 153:655-658, 1984 8. Ball WS, Strife JL, Rosenkrantz J, et al: Esophageal strictures in children: Treatment by balloon dilatation. Radiology 150-181. 1984 9. Hoffer FA, Winter HS, Fellows KE, et al: The treatment of post-operative and peptic esophageal strictures after esophageal atresic repair. Pediatr. Radiology 17:454-458, 1987
Discussion S. Ein (Toronto, Ontario): I don’t do endoscopy; therefore I can really be unbiased and objective. However, I do repair esophageal atresias and replace damaged esophagi, and in so doing I get my share of strictures, which, as tradition has it, the ENT service stretch. I have therefore been a more than interested observer of these endeavors for the last 21 years. This procedure was first performed at our hospital by Jack Friedberg (a pediatric ENT surgeon) in the late 1970s initially using Fogarty catheters. I showed him
this abstract, and he agreed with the conclusions of the authors. His only comment was to remember that it is not idiot-proof. I must also agree with Dr Tam and his coauthors that balloon dilatation (using the flexible endoscope) seems to be a relatively safe, gentle procedure that is more successful. I support this concept, and I prefer that this procedure be performed on my patients. P.K.H. Tam (response): I really have nothing more to add.
E
SOPHAGEAL STRICTURES can occur as a primary congenital anomaly or as complications of reflux esophagitis, caustic ingestion, or repair of esophageal atresia. Anastomotic strictures can also complicate esophageal replacement by gastric tube or colon interposition. Initial treatment of these strictures is usually by dilatation; surgery is reserved for strictures unresponsive to such treatment. Traditionally, dilatation is carried out by the passage of a series of bougies of increasing diameters. In small children, a gastrostomy is sometimes required for string-guided bouginage (Tucker’s dilatation).’ In 1974, Gruntzig and Hop@ introduced the balloon catheter for the dilatation of narrowed arteries, and soon this principle was adapted for use in esophageal strictures.3s4 Unlike bouginage, which generates an abrupt shearing axial force, the balloon catheter dilates a stricture gradually by a uniform radial force (Fig l), and superior results can be expected. However, experience in the use of balloon dilatation in the treatment of esophageal strictures and anastomotic strictures after esophageal replacement in infants and children JournalofPediatric
Surgery, Vol 26, No 9 (September), 1991: pp 1101-1103
England
is limited,‘-9 and the indications, safety, and efficacy of the procedure are not well defined. We report our experience with the use of endoscopy-guided balloon dilatation (EGBD) in 33 infants and children with such problems. MATERIALS AND METHODS Between 1986 and 1990,33 infants and children with esophageal strictures and anastomotic strictures after esophageal replacement were treated with EGBD in Royal Liverpool Children’s Hospital. Alder Hey. Median age was 3.7 years (range, 3 weeks to 20 years). Of 33 patients, 18 had esophageal strictures, following repair of esophageal atresia in 13 and secondary to reflux esophagitis in 5; 13 had anastomotic strictures after esophageal replacement (colon, 12; stomach, 1); and 2 had caustic strictures. Of 33 patients, 23 had previously failed to respond to conventional bouginage (mean, 11.2 sessions; range, 1 to 32 sessions). All patients underwent contrast studies before EGBD. Flexible upper gastrointestinal endoscopy was performed under general anesthesia using an Olympus GIF PQ 20 model (Olympus Optical Co Ltd, Tokyo, Japan). The stricture was cannulated with a guide wire, and correct positioning was confirmed fluoroscopically. A balloon catheter was chosen; a rough guide to the size of the patient’s esophagus is the “rule of thumb,” ie, the size of the patient’s own thumb. The endoscope was removed and the deflated balloon catheter was introduced over the guide wire so that the center of the balloon was at the level of the stricture. The balloon catheter was inflated cautiously with contrast by an experienced radiologist (AS. or H.C.) using an appropriate syringe. A definite “waist” in the balloon caused by the stricture should be visible radiologically (Fig 2A). Dilatation of the stricture was monitored both by flouroscopy and by the resistance the radiologist felt on further injection of contrast into the balloon: there was often a tight “grip” that slowly gave way to sustained pressure. Successful dilatation occurred when the “waist” in the balloon mostly disappeared (Fig 2B). Inflation of the balloon was maintained for a further 3 to 5 minutes. For tight strictures, it was necessary to perform dilatation with serial application of progressively larger balloon catheters. RESULTS
There were errors or uncertainties in the initial contrast studies in seven patients. Five had colon
From the Departments of Pediatric Surgery and Radiology, Royal Liverpool Children’s HospitalAlder Hey, Liverpool, England. Presented at the 42nd Annual Meeting of the Surgical Section of the American Academy of Pediatrics, Boston, Massachusetts, October 6 7, 1990. Address reprint requests to P. K.H. Tam, Nufietd Department of Surgery, John Radcliffe Hospital, Headington, Oxford OX3 9DU, England. Copyright o 1991 by U! B. Saunders Cornpam 0022-3468/9112609-0019$03.00/O 1101
TAM
ETAL
Table 1. Results of EGBD
Stricture
Physical forces with bouginage and balloon dilatation.
interposition, and the tortuosity of the colon made it difficult to distinguish whether angulation or stricture was the cause of the hold-up of the contrast; this was resolved by the demonstration of a “waist” on EGBD. The remaining two patients had gastroesophageal reflux that was seen on contrast studies after EGBD but was not shown on initial contrast studies. Results of EGBD are shown in Table 1. All 31 patients with esophageal or replacement strictures had uneventful EGBD (mean, 2.1; range, 1 to 7). Symptomatic relief was excellent in 24 and moderate in 7. Of these, 4 did not respond to EGBD before their gastroesophageal reflux was eradicated but
Fig 2. (A) Catheter in place showing “waist” in balloon caused by stricture. (B) Satisfactory dilatation resulted in disappearance of the “waist” in the balloon.
Mean EGBDl Patient (range)
RFJSp3lWS
Excellent
Moderate
Failed
Esophageal
18
2.2(l-7)
14
4
0
Replacement
13
2.1 (l-6)
10
3
0
2
1.5(1-2)
0
0
2
Caustic
Fig 1.
No. of Patients
rapidly responded to EGBD after fundoplication. Patients who had experienced both conventional bouginage and EGBD noticed less pain with EGBD and were able to resume solid feeding earlier. Both patients with caustic strictures had esophageal perforation complicating EGBD. Of these two perforations, one resulted from an overenthusiastic attempt at inflation of a larger-than-recommended balloon catheter to dilate the resistant stricture; the patient developed mediastinitis and pneumothorax. The other perforation resulted from the passage of the guide wire in a false track; the complication was immediately recognized, and EGBD was abandoned. Both patients responded to chest drainage, fasting, and intravenous antibiotic therapy. DISCUSSION
There are many potential advantages of EGBD over conventional bouginage in the treatment of esophageal strictures and anastomotic strictures complicating esophageal replacement: (1) because EGBD applies a uniform radial force rather than an axial force, dilatation of the stricture may be more effective and less traumatic; (2) the efficacy of dilatation is monitored fluoroscopically, and the end point of treatment need not be assumed; (3) because the balloon catheter is introduced in a deflated state, the size of the oropharynx is not a limiting factor as it is with larger bougies; (4) the use of flexible endoscopy allows placement of the catheter under direct vision, minimizing the risk of false passage of the dilator; (5) tortuosity of the conduit, a common problem with colon interposition, is not a prohibiting factor for dilatation; and (6) the necessity of gastrostomy and string placement for Tucker’s dilatation is obviated. Our experience confirms that EGBD is safe and effective for esopheagal and replacement strictures. The majority of such patients had excellent responses to a mean number of 2.1 sessions per patient. Importantly, these EGBD responders included 23 patients who had a history of failure to respond to multiple sessions of conventional bouginage. Subjectively, many patients also preferred EGBD to bouginage because it was associated with less residual pain. Young age is not a contraindication to EGBD: we have treated neonates in the immediate postoperative period (3 weeks) after primary repair of esophageal atresia. In
BALLOON
DILATATION
OF ESOPHAGEAL
STRICTURES
1103
centers where expertise in EGBD is readily available, conventional bouginage will seldom be required. However, EGBD is not indicated in patients who have extensive damage to the esophagus by caustic injury. In our experience, both patients with caustic strictures failed to respond to EGBD and developed perforations. Severe caustic strictures are unlikely to respond to dilatation, whether EGBD or bouginage, and often require surgical treatment by replacement with colon or stomach. Successful EGBD entails a team approach: the anesthetist, the radiologist, and the endoscopist. Although anesthesia was not used in some series of balloon dilatation of esophageal strictures,536 we preferred general anesthetisia for EGBD. Because the esophagus and the trachea are in close proximity, dilatation of the esophagus can cause airway compression; therefore, endotracheal intubation and cardiorespiratory monitoring are desirable. Radiological studies before EGBD help in the planning of the procedure. It is important, however, to realize the limitations of imaging techniques. In our experience, it was sometimes difficult to differentiate radiologically whether angulation or stricture was the cause of obstruction in colon interposition, but EGBD could resolve the issue. In some series,
balloon dilatation was carried out under flouroscopic control alone without endoscopy guidance,‘-* but few of their patients had tortuous conduits from colon interposition. The use of flexible endoscopy allowed us to perform balloon dilatation in this condition despite severe angulation and redundancy of the interposed colon. In addition, we feel that placement of guide wire under direct vision minimized the risk of inadvertent perforation of the esophagus when the stricture was severe. To ensure success of EGBD, it is important to rule out existing pathology which perpetuates stricture formation. The most common problem is gastroesophageal reflux (GER) complicating repair of esophageal atresia. In the presence of severe esophageal stricture, GER may not be apparent both clinically and radiologically. Two of our patients did not show GER in contrast studies before dilatation, and GER was revealed only afterwards. It is possible that a severe stricture does not allow enough contrast to enter the stomach to permit demonstration of GER until after adequate dilatation of the stricture. Effective treatment of GER is essential: four of our patients did not respond to EGBD until their reflux was controlled by fundoplication.
REFERENCES 1. Tucker JA, Yarington CT Jr: The treatment of caustic ingestion. Otolaryngol Clin North Am 12:343-350, 1979 2. Gruntzig Ai Hopff H: Perkutane Rekanalisation chronischer arterieller verschlusse mit einem neunen Dilatation-Katheter. Dtsch Med Wachs 99:2502-2505,1974 3. London RL, Trotman BW, Di Marino AJ Jr, et al: Dilatation of severe esophageal strictures by an inflatable balloon catheter. Gastroenterology 80:173-175,198l 4. Dawson SL, Mueller PR, Ferrucci JT Jr, et al: Severe esophageal strictures: Indications for balloon catheter dilatations. Radiology 153:631-635,1984 5. Johnsen A, Jensen LI, Mauritzen K: Balloon dilatation of esophageal strictures in children. Pediatr Radio1 16:388-391, 1986
6. Sato Y, Frey E, Smith EE, et al: Balloon dilatation esophageal stenosis in children. AJR 150:639-642, 1988
of
_ -
7. Goldthorn JF, Ball WS, Wilkinson LG, et al: Esophageal structures in children: Treatment by serial balloon catheter dilatation. Radiology 153:655-658, 1984 8. Ball WS, Strife JL, Rosenkrantz J, et al: Esophageal strictures in children: Treatment by balloon dilatation. Radiology 150-181. 1984 9. Hoffer FA, Winter HS, Fellows KE, et al: The treatment of post-operative and peptic esophageal strictures after esophageal atresic repair. Pediatr. Radiology 17:454-458, 1987
Discussion S. Ein (Toronto, Ontario): I don’t do endoscopy; therefore I can really be unbiased and objective. However, I do repair esophageal atresias and replace damaged esophagi, and in so doing I get my share of strictures, which, as tradition has it, the ENT service stretch. I have therefore been a more than interested observer of these endeavors for the last 21 years. This procedure was first performed at our hospital by Jack Friedberg (a pediatric ENT surgeon) in the late 1970s initially using Fogarty catheters. I showed him
this abstract, and he agreed with the conclusions of the authors. His only comment was to remember that it is not idiot-proof. I must also agree with Dr Tam and his coauthors that balloon dilatation (using the flexible endoscope) seems to be a relatively safe, gentle procedure that is more successful. I support this concept, and I prefer that this procedure be performed on my patients. P.K.H. Tam (response): I really have nothing more to add.