[size=20px]A 12-month old boy who underwent repair of tracheoesophageal fistula and esophageal atresia as a newborn now presents with difficulty transitioning from milk to table food. He underwent balloon dilation at 8 and 10 months of age. An esophagram shows an anastomotic stricture with about 30% patency of the lumen and hangup of contrast flow at the anastomosis. He is currently on weight-appropriate doses of proton pump inhibitor. pH impedance studies show no significant gastroesophageal reflux. The esophageal anastomotic stricture should next be managed with,

 

A higher doses of proton pump inhibitor

 

B bougienage with Savary dilator

 

C dilation with or without intralesional steroid injection

 

D laparoscopic fundoplication

 

E segmental esophageal resection​[/size]

Edited October 22, 20233 yr by Admin

B

C

I would recommend segmental esophageal resection

Nothing! Try modifying the table food so that it thickens gradually and dilates

B

E

E

B

Option b

E

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correct answer

C dilation with or without intralesional steroid injection

 

Anastomotic strictures after esophageal atresia repair are reported to occur in about 40% of patients. Currently, the preferred method of dilation among pediatric surgeons, gastroenterologists, and interventional radiologists is using a radially expandable balloon compared to bougienage with traditional dilators such as Savary or Maloney dilators that exert tangential (shear) forces, leading to more frequent dilations.

 

Recent data are supportive of using intralesional steroid injection (ISI) in conjunction with balloon dilation in esophageal strictures after EA. Ngo et al compared esophageal diameters before a subsequent dilation when balloon dilation alone is used vs dilation with ISI. The ISI group had a greater percentage of improved diameter and lesser percentages of unchanged and decreased diameters at subsequent endoscopy. The benefit of ISI over dilation alone was limited to the first 3 interventions, and ISI did not increase risk of adverse events. Ten Kate et al published a small series of children who had refractory esophageal strictures that showed resolution of strictures with ISI. Although additional dilation alone may resolve symptoms, using adjunctive intralesional steroids in this patient may lead to a more durable duration of being symptom-free. It should be noted that thus far, no study has documented fewer episodes of dilation or longer duration between dilations.

 

In this patient who is symptomatic, increasing PPI dosage would not relieve obstructive symptoms. If reflux is documented on pH impedance study or there evidence of reflux esophagitis, a fundoplication would be a reasonable choice. A segmental esophageal resection would not be advisable at this stage.

 

Other adjuncts used in this clinical scenario include mitomycin C application at the time of dilation, use of an esophageal stent, or cutting the stricture using an endoscopic needle knife.

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