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The treatment of patients with esophageal strictures by local steroid injections
The Treatment of Patients with Esophageal by Local Steroid Injections
Strictures
By THOMASM. HOLDER,KEITH W. ASHCRAFTANDLUCIANLEAPE HE TREATMENT OF ESOPHAGEAL STRICTURES is often trying, troublesome and unsuccessful. In children these strictures most often follow anastomosis or caustic bums. While the anastomotic stricture occurring after repair of esophageal atresia is short, it often requires multiple dilatations and rarely may require resection with reanastomosis. Caustic bums usually produce a long, irregular stricture and are difficult to treat by any method short of replacement. The success reported in the treatment of cutaneous hypertrophic scars, burn contractures and keloids by the local infiltration of triamcinolone diacetate led to the thought that this same form of therapy might be of value in treatment of esophageal narrowing due to scar tissue. I22 Such treatment depends on the ability to inject the entire scar, and thus only very short strictures would be amenable to this treatment. To test this hypothesis, very short esophageal strictures were produced in dogs by topical lye burns and then treated by triamcinolone diacetate injection without dilatation. In 7 of 9 treated animals at least a fourfold increase in luminal area at the stricture was noted. None of the control animals demonstrated improvement? This treatment technic has subsequently been applied to 10 children with esophageal stricture, the outcome of which forms the basis for this report.
T
BACKGROUND For about 10 years a potent anti-inflammatory corticosteroid, triamcinolone diacetate, has been used by local injection into the substance of keloids, hypertrophic scars and burn contractures. Approximately 90 per cent of such lesions undergo permanent remission with this form of treatment. We chose triamcinolone diacetate because of its potent anti-inflammatory action and its slow absorption, which results in high local concentration with very little systemic effect. Although the mechanism of action is poorly understood, steroids apparently interfere with the formation of mucopolysaccharides necessary in collagen synthesis. In addition, steroids have been shown to increase the saline extractable fraction of formed collagen in vivo and of rat-tail collagen in vitro when used From the Section of Pediatric Surgery, Department of Surgery, University of Kansas School of Medicine and Medical Center, Kansas City, Kansas. THOMAS M. HOLDER, M.D.: Associate Professor of Surgery: Head, Section of Pediatric Surgery, University of Kansas School of Medicine and Medical Center. KEITH W. ASHCRAFT, M.D.: Resident in Pediatric Surgery, Vniversify of Kansas Medical Center. LUCIAN L. LEAPE, M.D.: Assistant Professor of Surgery, University of Kansas School of Medicine. Presented before the British Association of Paediatric Surgeons, University College, Dublin, August 27-29, 1969. 646
JOURNAL OF PEDIATRICSURGERY,VOL. 4, No. 6 (DECEMBER), 1969
TREATMENT OF PATIENTS WITH ESOPHAGEAL STRICTURES
647
Fig. l.-The apparatus for endoscopic injection consists of a steel tubing fabricated with male and female syringe fittings and the Titus needles modified to prevent penetration of the esophagal wall.
with bacterial collagenase. There is growing evidence that collagenase exists in the human, and thus at least two possible mechanisms of action of this drug can be postulated-inhibition of collagen synthesis and enhancement of collagen breakdown. The concept that collagen is metabolically dynamic rather than inert is probably true; however, it is probable that the older the collagen, the less metabolically active it becomes through tighter and more frequent cross linking of collagen bundles. Considering the properties of the drug and its postulated mechanisms of action, triamcinolone diacetate exerts this effect best when injected directly into the lesion. Only very short “injectable” scars are therefore amenable to this form of treatment. This excludes the majority of caustic strictures. TECHNIC Under esophagoscopic visualization the stricture is inspected and its diameter estimated. Using a tuberculin syringe fitted with an extension tubing of stainless steel and a needle, 40 mg. of triamcinolone diacetate (Aristocorte Forte@) is injected into the scar-10 mg. being placed in each of four quadrant sites. The needle is made from a Titus needle ground to a short bevel with the metal collar placed 2 mm. from the tip (Fig. 1). The collar prevents penetration through the esophageal wall. The drug must be injected directly into the scar, which is a bit difficult through the esophagoscope. When the needle is accurately placed, there is a moderate resistance to the injection. CLINICAL MATERIAL
Ten children with esophageal stricture have been treated with this form of therapy. Three of the patients had anastomotic strictures following repair of esophageal atresia, one had a very short distal stricture following the ingestion of hydrochloric acid and 6 were due to caustic burns. Of these latter, 2 were caused by Drano” (solid caustic drain cleaner) and 4 by Liquid-plump (liquid caustic cleaner containing 30 per cent sodium hydroxide). CASE MATERIAL CASE 1: KS. developed a tight stricture of the esophagus 5 weeks following correction of esophageal atresia with distal tracheoesophageal fistula. She had seven endoscopic dilatations
HOLDER
648
ET AL.
Fig. 2.-X-rays of case 1 showing a severe anastomotic stricture about T, which was relieved by the injections and dilatations.
of the esophagus
Fig. 3.-Patient tion and dilatation
by a single injec-
4 had a distal esophageal acid stricture with follow-up at 10 months.
relieved
in 8 months and still had only a 2-3 mm. diameter at the point of constriction. She then received three injections of 40 mg. of triamcinolone diacetate into the stricture-11, 15 and 20 months postoperatively. Figure 2 shows the stricture prior to dilatation and a normal esophagus 2 years after the last injection. She has remained asymptomatic. CASE 2: S. R. also had an esophageal anastomotic stricture, developing approximately 3 weeks after her esophagoesophagostomy for correction of esophageal atresia and tracheoe-
TREATMENT
OF PATIENTS
WITH
ESOPHAGEAL
STRICTURES
Fig. 4.-Patient 5 had a somewhat irregular narrowing of the esophagus jestion of a Drano-soaked potato that was relieved completely by repeated of steroid and dilatation.
649
after ininjection
sophageal fistula. She underwent twelve dilatations over a period of 16 months and at the time of her first injection had a 3 mm. stricture. Two injections spaced 4 weeks apart completely relieved the stricture. CASE 3: G. W. developed an esophageal anastomotic stricture 3 weeks following repair of his esophageal atresia. The stricture was injected with 40 mg. triamcinolone diacetate and dilated to a #20 French. Five weeks later he was reinjected and dilated to 24F, following which he did well. At 8 months he was admitted for a hernia repair. The mother noted that he had had some difficulty in swallowing for several days prior to admission, so he was esophagoscoped. A foreign body was removed from above a 3 mm. stricture at the anastomotic site. He was then reinjected and dilated to 30F. He has subsequently had no symptoms of dysphagia, and 8 months following his last injection shows resolution of the stricture by barium swallow. CASE 4: G. K. was 18 months old at the time he ingested hydrochloric acid in his father’s blacksmith shop. He was admitted to this hospital one month later with a wellformed but very short, tight, distal esophageal stricture. He was injected one time with 40 mg. of triamcinolone diacetate and dilated to #22 French with filiforms and followers. One month later his symptoms had subsided, and tine esophagram revealed a completely normal esophagus with no evidence of residual stricture (Fig. 3). CASE 5: R. S. had a stricture resulting from the ingestion of a Drano-soaked potato retrieved from a clogged skin drain. Fifteen dilatations had been carried out over a period of 7% months with very little change in his course. Within 3 days following dilatations he could no longer eat solids. He was then begun on injections coupled with retrograde dilatations. He required fifteen of these treatments over the course of the next 8 months. He has now been asymptomatic for nearly 3 years, and a recent x-ray shows no evidence of residual stricture (Fig. 4).
650
HOLDER
ET AL.
Fig. 5.-Patient 6 had a long esophageal stricture secondary to Drano ingestion. This type of stricture is not amenable to injection therapy, and the patient required colon interposition. CASE 6: K. M., a two-year-old child, had ingested solid Drano and 3 days later had an esophagoscopy, at which time severe burns were noted. A Stamm gastrostomy and an esophageal string were placed. She then had ten dilatations and on eight of these occasions was injected with triamcinolone diacetate. The stricture was long and irregular (Fig. 5). Only the uppermost part of the stricture could be injected. After 4 months it became evident that she was not improving, and colon interposition was performed. She has subsequently been asymptomatic and has grown well. We would no longer attempt injection therapy for a long stricture such as this. CASE 7: R. G. ingested a liquid drain cleaner and was treated initially at another hospital with systemic steroids and antibiotics. He was admitted here one month postinjury with a 1 mm. stricture of the esophagus 2.5 cm. below the superior constrictors. Only a trickle of barium would pass (Fig. 6, left). The stricture appeared to be short and was injected with 40 mg. of triamcinolone diacetate. Dilatation was not done because a filiform
TREATMENT
OF PATIENTS
WITH
ESOPHAGEAL
STRICTURES
651
Fig. 6.-An initial x-ray study of Case 7 shows a caustic stricture at the thoracic inlet. During the course of treatment of this upper stricure, a larger irregular mid esophageal stricture became apparent (right). catheter could not be passed. A gastrostomy was done. Three weeks later the stricture, now 6 mm. in diameter, was reinjected and a string passed. Retrograde dilatation was then done to #3OF. He has had seven injections with dilatation at 3 weekly intervals. During the course of his treatment it became apparent that he had an additional long and irregular narrowing in the mid esophagus (Fig. 6, right). Although the upper stricture has almost completely resolved, the mid esophageal stricture now prevents his eating. A long stricture such as this is not amenable to complete injection, and therefore a colon interposition is being contemplated. This patient illustrates that dilatation with injection (proximal stricture) may be considered to have been successful, while dilatation alone (long mid esophageal stricture) has been disappointing. Also demonstrated is the absence of a “remote” effect from triamcinolone injected into the upper stricture upon the mid esophageal stricture. CASE 8: M. M. also ingested liquid drain cleaner, and her initial treatment consisted of gastrostomy, tracheostomy, systemic steroids and antibiotics. Five weeks postinjury she had a severe esophageal stricture, which was injected and dilated and a string was passed. She subsequently has undergone five further injections and dilatations spaced at approximately one-month intervals. She is now able to eat and gain weight. Esophagoscopy 7 months postinjury demonstrated a web of scar across the posterior wall of the esophagus with narrowing to about 7 mm. at the site of the proximal stricture, but a barium study suggested a longer and more irregular stricture below this, beyond the limitation of intralesional injections. Her follow-up continues requiring repeated dilatations. CASE 9: T. M. also had ingested Liquid-plumre and was treated initially with systemic Decadrone and ampicillin. She was admitted here 3 weeks postinjury with at least two, and perhaps three, short strictures spaced approximately 2.5 cm. apart in the upper
652
HOLDER
ET AL.
Table 1 Etiology 2 3 4 5 6 7 8 9 10 --
Anastomotic Anastomotic Anastomotic Acid ingestion Drano ingestion Drano ingestion Liquid-plumr ingestion Liquid-plumr ingestion Liquid-plumr ingestion Liquid-plumr ingestion
Length of Stricture
Result
Short
Excellent Excellent Excellent Excellent Excellent Failure, colon interposition Probable failure Possible failure Undetermined but questionable Probable failure
Sh0l-t Short Short Moderately short Long Short above, long below Short above, long below Multiple short Moderately short
esophagus. A gastrostomy was performed and the upper stricture, 1 mm. in diameter, injected at this time. It was impossible to dilate because of the distal strictures. Two further injections without dilatations followed. She was then able to take pureed foods with ease, and for 6 weeks did not require treatment. She was readmitted because of dysphagia, and the proximal stricture was found to be 7 mm. in diameter. It was possible to pass a bronchoscope down to the second stricture, which was injected, and a filiform and follower used to pass a string. Retrograde dilatation was carried out. She has since had several injections of the upper and the second stricture and clinically has improved although she continues under treatment. This patient’s experience suggests that multiple short strictures may respond to step-wise injections of the accessible lesion. CASE 10: S. E. also ingested the same liquid drain cleaner. Esophagoscopy revealed marked burns of the esophagus. Systemic steroids and ampicillin were given for a period of 3 weeks, at which time a moderately tight stricture at the thoracic inlet was seen. She was injected and dilated to 30F. Gastrostomy was not done. She was then readmitted at 3 weeks for another injection and dilatation. She developed a fever postoperatively which cleared after 24 hours, and she was discharged with no problem. Dysphagia developed after about 21% weeks, and she underwent an uneventful injection and dilatation. She was readmitted one week later with what was felt initially to be croup, but barium swallow showed extravasation of contrast media into a small para-esophageal abscess at the thoracic inlet. This was drained surgically through the base of the left neck, and her fever and some dysphagia cleared. She has subsequently undergone three injection and dilatation procedures with only transient relief of her dysphagia. Her treatment also continues, but colon interposition is being considered. DISCUSSION
Table 1 summarizes the result in these patients. The first 5 patients-with short or moderately short strictures- have had an excellent result. What is the evidence that the triamcinolone had any effect upon the course of this lesion? First, there is a vast amount of clinical data to show that triamcinolone diacetate resolves scar tissue in cutaneous lesions. Second, patients 1, 2 and 5 had undergone multiple dilatations prior to the beginning of injection, and this repetitious unsuccessful course was altered after the drug was injected. Third, animal experimental data demonstrate clearly that without dilatations triamcinolone diacetate will relieve esophageal obstruction due to short strictures. Fourth, patients 7 and 9 had significant improvement in the short upper strictures injected but not dilated during the early course of their treatment. We assume then that a drug with a known effect in cutaneous lesions, proven effective in a similar lesion in the dog esophagus and with marked improvement in 2 pa-
TREATMENT OF PATIENTS WITH ESOPHAGEAL STRICTURES
653
tients who could not be dilated, will only enhance the effect of dilatations in the treatment of esophageal strictures. Five patients have had poor or questionable response to this drug. One patient (Case 6) should not have been tried on this form of therapy, for her stricture was too long to be injected in its entirety. Two (Cases 7 and 8) appear to be failures because a second, long stricture has become clinically apparent with resolution of the uppermost short striction by injection. One (Case 10) is deemed a failure because four injections have failed to resolve the scar. The result in the remaining child is doubtful because a series of strictures exist, although each separately would appear to be amenable to this treatment. Failures, therefore, are attributable to problems preventing intrulesional placement of the drug. One serious complication resulted from the 53 injections accompanied by dilatations. This resulted in a localized para-esophageal abscess due to perforation. It is impossible to know whether this was the result of perforation by the needle or by the dilator. The problem was rather easily managed by incision and drainage through a supraclavicular incision, and further treatments have been uneventful. SUMMARY
Ten children have been treated with intralesional injection of triamcinolone diacetate into esophageal strictures. Five have responded well, and one result remains undetermined at present. Four patients are considered failures-3 due to long strictures and one with failure to improve significantly after four injections. No systemic effect of this dose of steroid has been observed, and only one complication has resulted. The apparent good result in the short strictures warrants continued clinical trials of this form of treatment. The treatment of strictures longer than 1.5 cm. by intralesional steroid injection is not recommended. SUMMARIO IN INTERLINGUA Dece juveniles esseva tractate con un injection intralesional de diacetato de triamcinolona ad in le stricturas esophagee. Cinque respondeva ben, e in un le resultato remane al tempore presente inderterminate. In 4 patientes, le resultato esseva nonsuccessose. In 3, isto esseva le consequentia de longe stricturas. In le quarte, quatro injectiones resultava in nulle significative melioration. Nulle effect0 consititutional de1 steroide al nivello de dosage usate esseva observate, e le serie includeva un sol complication. Le apparentemente bon resultatos in curte stricturas justifica le continuation de essayos clinic de iste modo de tractamento. Le tractamento de stricturas de un longor de plus que 1,5 cm per le injection intralesional de steroides non es recommendate. ADDENDUM
Patients R. G., M. M. and S. E. have now undergone Patient T. M. is responding well to steroid injections.
colon interposition.
REFERENCES 1. Ketchum,
L. D., Smith, J., Robinson, D. W. and Masters, F. W.: The treatment of hypertrophic scar, keloid and scar contracture by triamcinolone acetonide. Plast. Reconstr. Surg. 38:209, 1966. 2. Griffith, B. H.: The treatment of
keloids with triamcinolone acetonide. Plast. Reconstr. Surg. 38:202, 1966. 3. Ashcraft, K. W. and Holder, T. M.: The experimental treatment of esophageal strictures by intralesional steroid injections. J. Thorac. Cardiov. Surg. In press.
Strictures
By THOMASM. HOLDER,KEITH W. ASHCRAFTANDLUCIANLEAPE HE TREATMENT OF ESOPHAGEAL STRICTURES is often trying, troublesome and unsuccessful. In children these strictures most often follow anastomosis or caustic bums. While the anastomotic stricture occurring after repair of esophageal atresia is short, it often requires multiple dilatations and rarely may require resection with reanastomosis. Caustic bums usually produce a long, irregular stricture and are difficult to treat by any method short of replacement. The success reported in the treatment of cutaneous hypertrophic scars, burn contractures and keloids by the local infiltration of triamcinolone diacetate led to the thought that this same form of therapy might be of value in treatment of esophageal narrowing due to scar tissue. I22 Such treatment depends on the ability to inject the entire scar, and thus only very short strictures would be amenable to this treatment. To test this hypothesis, very short esophageal strictures were produced in dogs by topical lye burns and then treated by triamcinolone diacetate injection without dilatation. In 7 of 9 treated animals at least a fourfold increase in luminal area at the stricture was noted. None of the control animals demonstrated improvement? This treatment technic has subsequently been applied to 10 children with esophageal stricture, the outcome of which forms the basis for this report.
T
BACKGROUND For about 10 years a potent anti-inflammatory corticosteroid, triamcinolone diacetate, has been used by local injection into the substance of keloids, hypertrophic scars and burn contractures. Approximately 90 per cent of such lesions undergo permanent remission with this form of treatment. We chose triamcinolone diacetate because of its potent anti-inflammatory action and its slow absorption, which results in high local concentration with very little systemic effect. Although the mechanism of action is poorly understood, steroids apparently interfere with the formation of mucopolysaccharides necessary in collagen synthesis. In addition, steroids have been shown to increase the saline extractable fraction of formed collagen in vivo and of rat-tail collagen in vitro when used From the Section of Pediatric Surgery, Department of Surgery, University of Kansas School of Medicine and Medical Center, Kansas City, Kansas. THOMAS M. HOLDER, M.D.: Associate Professor of Surgery: Head, Section of Pediatric Surgery, University of Kansas School of Medicine and Medical Center. KEITH W. ASHCRAFT, M.D.: Resident in Pediatric Surgery, Vniversify of Kansas Medical Center. LUCIAN L. LEAPE, M.D.: Assistant Professor of Surgery, University of Kansas School of Medicine. Presented before the British Association of Paediatric Surgeons, University College, Dublin, August 27-29, 1969. 646
JOURNAL OF PEDIATRICSURGERY,VOL. 4, No. 6 (DECEMBER), 1969
TREATMENT OF PATIENTS WITH ESOPHAGEAL STRICTURES
647
Fig. l.-The apparatus for endoscopic injection consists of a steel tubing fabricated with male and female syringe fittings and the Titus needles modified to prevent penetration of the esophagal wall.
with bacterial collagenase. There is growing evidence that collagenase exists in the human, and thus at least two possible mechanisms of action of this drug can be postulated-inhibition of collagen synthesis and enhancement of collagen breakdown. The concept that collagen is metabolically dynamic rather than inert is probably true; however, it is probable that the older the collagen, the less metabolically active it becomes through tighter and more frequent cross linking of collagen bundles. Considering the properties of the drug and its postulated mechanisms of action, triamcinolone diacetate exerts this effect best when injected directly into the lesion. Only very short “injectable” scars are therefore amenable to this form of treatment. This excludes the majority of caustic strictures. TECHNIC Under esophagoscopic visualization the stricture is inspected and its diameter estimated. Using a tuberculin syringe fitted with an extension tubing of stainless steel and a needle, 40 mg. of triamcinolone diacetate (Aristocorte Forte@) is injected into the scar-10 mg. being placed in each of four quadrant sites. The needle is made from a Titus needle ground to a short bevel with the metal collar placed 2 mm. from the tip (Fig. 1). The collar prevents penetration through the esophageal wall. The drug must be injected directly into the scar, which is a bit difficult through the esophagoscope. When the needle is accurately placed, there is a moderate resistance to the injection. CLINICAL MATERIAL
Ten children with esophageal stricture have been treated with this form of therapy. Three of the patients had anastomotic strictures following repair of esophageal atresia, one had a very short distal stricture following the ingestion of hydrochloric acid and 6 were due to caustic burns. Of these latter, 2 were caused by Drano” (solid caustic drain cleaner) and 4 by Liquid-plump (liquid caustic cleaner containing 30 per cent sodium hydroxide). CASE MATERIAL CASE 1: KS. developed a tight stricture of the esophagus 5 weeks following correction of esophageal atresia with distal tracheoesophageal fistula. She had seven endoscopic dilatations
HOLDER
648
ET AL.
Fig. 2.-X-rays of case 1 showing a severe anastomotic stricture about T, which was relieved by the injections and dilatations.
of the esophagus
Fig. 3.-Patient tion and dilatation
by a single injec-
4 had a distal esophageal acid stricture with follow-up at 10 months.
relieved
in 8 months and still had only a 2-3 mm. diameter at the point of constriction. She then received three injections of 40 mg. of triamcinolone diacetate into the stricture-11, 15 and 20 months postoperatively. Figure 2 shows the stricture prior to dilatation and a normal esophagus 2 years after the last injection. She has remained asymptomatic. CASE 2: S. R. also had an esophageal anastomotic stricture, developing approximately 3 weeks after her esophagoesophagostomy for correction of esophageal atresia and tracheoe-
TREATMENT
OF PATIENTS
WITH
ESOPHAGEAL
STRICTURES
Fig. 4.-Patient 5 had a somewhat irregular narrowing of the esophagus jestion of a Drano-soaked potato that was relieved completely by repeated of steroid and dilatation.
649
after ininjection
sophageal fistula. She underwent twelve dilatations over a period of 16 months and at the time of her first injection had a 3 mm. stricture. Two injections spaced 4 weeks apart completely relieved the stricture. CASE 3: G. W. developed an esophageal anastomotic stricture 3 weeks following repair of his esophageal atresia. The stricture was injected with 40 mg. triamcinolone diacetate and dilated to a #20 French. Five weeks later he was reinjected and dilated to 24F, following which he did well. At 8 months he was admitted for a hernia repair. The mother noted that he had had some difficulty in swallowing for several days prior to admission, so he was esophagoscoped. A foreign body was removed from above a 3 mm. stricture at the anastomotic site. He was then reinjected and dilated to 30F. He has subsequently had no symptoms of dysphagia, and 8 months following his last injection shows resolution of the stricture by barium swallow. CASE 4: G. K. was 18 months old at the time he ingested hydrochloric acid in his father’s blacksmith shop. He was admitted to this hospital one month later with a wellformed but very short, tight, distal esophageal stricture. He was injected one time with 40 mg. of triamcinolone diacetate and dilated to #22 French with filiforms and followers. One month later his symptoms had subsided, and tine esophagram revealed a completely normal esophagus with no evidence of residual stricture (Fig. 3). CASE 5: R. S. had a stricture resulting from the ingestion of a Drano-soaked potato retrieved from a clogged skin drain. Fifteen dilatations had been carried out over a period of 7% months with very little change in his course. Within 3 days following dilatations he could no longer eat solids. He was then begun on injections coupled with retrograde dilatations. He required fifteen of these treatments over the course of the next 8 months. He has now been asymptomatic for nearly 3 years, and a recent x-ray shows no evidence of residual stricture (Fig. 4).
650
HOLDER
ET AL.
Fig. 5.-Patient 6 had a long esophageal stricture secondary to Drano ingestion. This type of stricture is not amenable to injection therapy, and the patient required colon interposition. CASE 6: K. M., a two-year-old child, had ingested solid Drano and 3 days later had an esophagoscopy, at which time severe burns were noted. A Stamm gastrostomy and an esophageal string were placed. She then had ten dilatations and on eight of these occasions was injected with triamcinolone diacetate. The stricture was long and irregular (Fig. 5). Only the uppermost part of the stricture could be injected. After 4 months it became evident that she was not improving, and colon interposition was performed. She has subsequently been asymptomatic and has grown well. We would no longer attempt injection therapy for a long stricture such as this. CASE 7: R. G. ingested a liquid drain cleaner and was treated initially at another hospital with systemic steroids and antibiotics. He was admitted here one month postinjury with a 1 mm. stricture of the esophagus 2.5 cm. below the superior constrictors. Only a trickle of barium would pass (Fig. 6, left). The stricture appeared to be short and was injected with 40 mg. of triamcinolone diacetate. Dilatation was not done because a filiform
TREATMENT
OF PATIENTS
WITH
ESOPHAGEAL
STRICTURES
651
Fig. 6.-An initial x-ray study of Case 7 shows a caustic stricture at the thoracic inlet. During the course of treatment of this upper stricure, a larger irregular mid esophageal stricture became apparent (right). catheter could not be passed. A gastrostomy was done. Three weeks later the stricture, now 6 mm. in diameter, was reinjected and a string passed. Retrograde dilatation was then done to #3OF. He has had seven injections with dilatation at 3 weekly intervals. During the course of his treatment it became apparent that he had an additional long and irregular narrowing in the mid esophagus (Fig. 6, right). Although the upper stricture has almost completely resolved, the mid esophageal stricture now prevents his eating. A long stricture such as this is not amenable to complete injection, and therefore a colon interposition is being contemplated. This patient illustrates that dilatation with injection (proximal stricture) may be considered to have been successful, while dilatation alone (long mid esophageal stricture) has been disappointing. Also demonstrated is the absence of a “remote” effect from triamcinolone injected into the upper stricture upon the mid esophageal stricture. CASE 8: M. M. also ingested liquid drain cleaner, and her initial treatment consisted of gastrostomy, tracheostomy, systemic steroids and antibiotics. Five weeks postinjury she had a severe esophageal stricture, which was injected and dilated and a string was passed. She subsequently has undergone five further injections and dilatations spaced at approximately one-month intervals. She is now able to eat and gain weight. Esophagoscopy 7 months postinjury demonstrated a web of scar across the posterior wall of the esophagus with narrowing to about 7 mm. at the site of the proximal stricture, but a barium study suggested a longer and more irregular stricture below this, beyond the limitation of intralesional injections. Her follow-up continues requiring repeated dilatations. CASE 9: T. M. also had ingested Liquid-plumre and was treated initially with systemic Decadrone and ampicillin. She was admitted here 3 weeks postinjury with at least two, and perhaps three, short strictures spaced approximately 2.5 cm. apart in the upper
652
HOLDER
ET AL.
Table 1 Etiology 2 3 4 5 6 7 8 9 10 --
Anastomotic Anastomotic Anastomotic Acid ingestion Drano ingestion Drano ingestion Liquid-plumr ingestion Liquid-plumr ingestion Liquid-plumr ingestion Liquid-plumr ingestion
Length of Stricture
Result
Short
Excellent Excellent Excellent Excellent Excellent Failure, colon interposition Probable failure Possible failure Undetermined but questionable Probable failure
Sh0l-t Short Short Moderately short Long Short above, long below Short above, long below Multiple short Moderately short
esophagus. A gastrostomy was performed and the upper stricture, 1 mm. in diameter, injected at this time. It was impossible to dilate because of the distal strictures. Two further injections without dilatations followed. She was then able to take pureed foods with ease, and for 6 weeks did not require treatment. She was readmitted because of dysphagia, and the proximal stricture was found to be 7 mm. in diameter. It was possible to pass a bronchoscope down to the second stricture, which was injected, and a filiform and follower used to pass a string. Retrograde dilatation was carried out. She has since had several injections of the upper and the second stricture and clinically has improved although she continues under treatment. This patient’s experience suggests that multiple short strictures may respond to step-wise injections of the accessible lesion. CASE 10: S. E. also ingested the same liquid drain cleaner. Esophagoscopy revealed marked burns of the esophagus. Systemic steroids and ampicillin were given for a period of 3 weeks, at which time a moderately tight stricture at the thoracic inlet was seen. She was injected and dilated to 30F. Gastrostomy was not done. She was then readmitted at 3 weeks for another injection and dilatation. She developed a fever postoperatively which cleared after 24 hours, and she was discharged with no problem. Dysphagia developed after about 21% weeks, and she underwent an uneventful injection and dilatation. She was readmitted one week later with what was felt initially to be croup, but barium swallow showed extravasation of contrast media into a small para-esophageal abscess at the thoracic inlet. This was drained surgically through the base of the left neck, and her fever and some dysphagia cleared. She has subsequently undergone three injection and dilatation procedures with only transient relief of her dysphagia. Her treatment also continues, but colon interposition is being considered. DISCUSSION
Table 1 summarizes the result in these patients. The first 5 patients-with short or moderately short strictures- have had an excellent result. What is the evidence that the triamcinolone had any effect upon the course of this lesion? First, there is a vast amount of clinical data to show that triamcinolone diacetate resolves scar tissue in cutaneous lesions. Second, patients 1, 2 and 5 had undergone multiple dilatations prior to the beginning of injection, and this repetitious unsuccessful course was altered after the drug was injected. Third, animal experimental data demonstrate clearly that without dilatations triamcinolone diacetate will relieve esophageal obstruction due to short strictures. Fourth, patients 7 and 9 had significant improvement in the short upper strictures injected but not dilated during the early course of their treatment. We assume then that a drug with a known effect in cutaneous lesions, proven effective in a similar lesion in the dog esophagus and with marked improvement in 2 pa-
TREATMENT OF PATIENTS WITH ESOPHAGEAL STRICTURES
653
tients who could not be dilated, will only enhance the effect of dilatations in the treatment of esophageal strictures. Five patients have had poor or questionable response to this drug. One patient (Case 6) should not have been tried on this form of therapy, for her stricture was too long to be injected in its entirety. Two (Cases 7 and 8) appear to be failures because a second, long stricture has become clinically apparent with resolution of the uppermost short striction by injection. One (Case 10) is deemed a failure because four injections have failed to resolve the scar. The result in the remaining child is doubtful because a series of strictures exist, although each separately would appear to be amenable to this treatment. Failures, therefore, are attributable to problems preventing intrulesional placement of the drug. One serious complication resulted from the 53 injections accompanied by dilatations. This resulted in a localized para-esophageal abscess due to perforation. It is impossible to know whether this was the result of perforation by the needle or by the dilator. The problem was rather easily managed by incision and drainage through a supraclavicular incision, and further treatments have been uneventful. SUMMARY
Ten children have been treated with intralesional injection of triamcinolone diacetate into esophageal strictures. Five have responded well, and one result remains undetermined at present. Four patients are considered failures-3 due to long strictures and one with failure to improve significantly after four injections. No systemic effect of this dose of steroid has been observed, and only one complication has resulted. The apparent good result in the short strictures warrants continued clinical trials of this form of treatment. The treatment of strictures longer than 1.5 cm. by intralesional steroid injection is not recommended. SUMMARIO IN INTERLINGUA Dece juveniles esseva tractate con un injection intralesional de diacetato de triamcinolona ad in le stricturas esophagee. Cinque respondeva ben, e in un le resultato remane al tempore presente inderterminate. In 4 patientes, le resultato esseva nonsuccessose. In 3, isto esseva le consequentia de longe stricturas. In le quarte, quatro injectiones resultava in nulle significative melioration. Nulle effect0 consititutional de1 steroide al nivello de dosage usate esseva observate, e le serie includeva un sol complication. Le apparentemente bon resultatos in curte stricturas justifica le continuation de essayos clinic de iste modo de tractamento. Le tractamento de stricturas de un longor de plus que 1,5 cm per le injection intralesional de steroides non es recommendate. ADDENDUM
Patients R. G., M. M. and S. E. have now undergone Patient T. M. is responding well to steroid injections.
colon interposition.
REFERENCES 1. Ketchum,
L. D., Smith, J., Robinson, D. W. and Masters, F. W.: The treatment of hypertrophic scar, keloid and scar contracture by triamcinolone acetonide. Plast. Reconstr. Surg. 38:209, 1966. 2. Griffith, B. H.: The treatment of
keloids with triamcinolone acetonide. Plast. Reconstr. Surg. 38:202, 1966. 3. Ashcraft, K. W. and Holder, T. M.: The experimental treatment of esophageal strictures by intralesional steroid injections. J. Thorac. Cardiov. Surg. In press.