A three-month old boy has life long symptoms of excessive drooling and regurgitation of undigested food. Both a barium esophagram and esophagoscopy show a short, tight, circular stenosis in the distal esophagus. A balloon dilation was performed and his symptoms did not improve.

 

 

[size=20px]For this patient with esophageal stenosis, the next step should be

 

A soft diet trial for six weeks.

 

B resection of the stricture.

 

C fundoplication.

 

D inhaled steroids.

 

E repeat esophagoscopy and dilation.[/size]

B

E

B

correct answer

B resection of the stricture.

 

Congenital esophageal stenosis is defined as a fixed, intrinsic narrowing of the esophagus that obstructs normal swallowing. There are three types of congenital esophageal stenosis.

 

fibromuscular stenosis (FMS)

esophageal membranes or web

tracheobronchial remnant (TBR)

 

FMS usually occurs in the middle third of the esophagus and can be treated with bougienage.

 

Tracheobronchial remnants generally occur in the distal esophagus usually within 3.5 cm of the gastroesophageal junction. The lesion is usually one to two cm in length. These lesions may be refractory to dilatations. Dilation for TBR poses risk of esophageal perforation.

 

If balloon dilation is unsuccessful then surgical treatment with resection of the stenotic segment should be performed. Resection can be performed through either abdominal or thoracic approach depending on the location of the lesion. The esophagus is reconstructed with an end to end anastomosis. If the gastroesophageal junction is removed, an antireflux procedure is necessary in anticipation of possible postoperative reflux esophagitis. Postoperative complications are unusual with anastomotic stenosis being the most prevalent. For the patient discussed above, achalasia would be very unusual in this age group as would be an acid reflux stricture. Repeat endoscopy in three months would be of no benefit as the stricture will not resolve spontaneously.