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Endoscopic management of esophageal stenosis
Dr. Paolo Gandullia Pediatric gastroenterology
G.Gaslini Institute for Child Health
Introduction
common problem in pediatric gastroenterology
benign etiology
disfagia: leading symptom
indication for terapeutic endoscopy
endoscopic dilation: successful endoscopic treatment of choice
refractory stenosis: association of more techniques
surgical treatment: rare indication
Etiology
Congenital stenosis (1: 25.000-50.000)
fibromuscolar thickening
tracheobronchial remnants
membranous diaphragm
Esophageal atresia (1: 3500 )
Congenital anomalies of esophagus
Etiology
surgical anastomosis
caustic ingestion
peptic esophagitis
eosinophilic esophagitis
sclerotherapy
epidermolysis bullosa
Candidiasis
drugs
GVHD
Acquired stenosis of esophagus
Clinical signs and symptoms
odinofagia
vomiting
drooling
Digestive symptoms
DISFAGIA
acute or chronic
Respiratory symptoms
hoarseness
laringitis
pneumonia
fibrosis
foreign body sensation
hyporexia
malnutrition
¹
² ³
Diagnosis Onset Features
Esophageal atresia prenatal:
perinatal
polidramnios, proximal stump dilation, undetectable stomach failure of tube insertion, drooling, inhalation
Congenital stenosis >6 months vomiting, bolus obstruction
Caustic ingestion <5 years disfagia, vomiting, chest pain, hoarseness, odinofagia
Peptic disease ? comorbidity, chest pain, disfagia, heartburn
Eosinophilic esophagitis < 2 years 10-14 years
food allergy, asthma, rinitis, dermatitis
Diagnosis for age
Investigation Stenosis other features
Esophagogram level lenght shape single or multiple
hernia fistula GE-reflux follow-up
Upper endoscopy as above + diameter
biopsy endoscopy via gastrostomy
Ultrasound with mini probe thickness DD congenital stenosis
relationship with aorta, trachea, pericardium
Laryngo-tracheo-bronchoscopy
fistula
Chest CT as above fistula relationship with organs
Manometry LES pressure
MII GE-reflux
Angio-MRI aortic arch anomalies
Instrumental diagnosis
Esophagogram
Stenosis of anastomosis in esophageal atresia
Esophagogram
Congenital stenosis GVHD Peptic stenosis Nissen stenosis
Esophagogram
Actinic stricture Caustic ingestion
ZG, 9 anni, medulloblastoma operato , RT sulla colonna:
stenosi esofagea lunga e tortuosa ≈ 3,5 cm
Esophagogram
Leakage from anastomosis
Esophagogram
Gastric trasposition
Management of esophageal stenosis
Conservative approach
endoscopic treatment:
dilation stent placement other:
intralesional steroids injection electrocautery mitomycin C
association with PPI treatment
Surgery correction :
esophagus replacement
gastric transposition
supportive:
management of GER-disease
Endoscopic dilations
Overall success of dilations: 58/96%
Complication/technique: ???????
Successful/etiology: anastomotic s.
Number of endoscopic sessions: caustic s.>anastomotic s.
Caustic s.: high % of recurrence
GERD: role in recurrence
Nissen fundoplication: reduce recurrence
Perforation: most frequent complication
Serhal L, 2010, Lang T, 2001, Michaud L,2001; Antoniou D,2010;Said M,
2003; Temiz A,2010; Gender GW,2009; Jacobs JW,2010, Broor SL,1996
233 children
7- 22 children/pubblication (79 in 1 study)
case reports or single centre experience
etiology: - caustic ingestion
- anastomosis
type of stent: SEMs, Dynamico, Poliflex, Biodegradable
stent left in place: 1 week-14 months
dislocation: more frequent complication (range 0-29%)
success rate: 50-89%
Stent placement
ZB Gerzic et al. 1990, S.L. Broor et al. 1996, LC Lan et al. 2003, S. Qureshi et al. 2010, Serhal L et al. 2010, Bicakci U et al. 2010 F.Foschia et al. 2011
Success: 89% (50%,1 stent)
Lenght treated: 1-11,5 cm
Left in place: 40 days
Displacement: 14,7%
Less complications than dilation
Patient is able to eat
Outcome
Stent placement
Endoscopic management of esophageal stricture
Savary dilators/Balloon TTS
Steroids injection
Stent placement
Local application
of Mitomycin C
1 line treatment: endoscopic dilation
2 line treatment: association of dilation with other techniques
Dilation for esophageal strictures: practical issues
“Feature the stricture”:
simple: short, straight
complex: long (>2 cm.), winding
refractory:
- failure to achieve a planned diameter
- close sessions of dilations
- relapse < 2-4 wks
Plan the diameter to achieve:
“thumb rule”:
“3” rule:
“age rule”: 11 mm < 5 yrs; 15 mm > 5 yrs
Balloon dilation
Hourglass effect
Balloon dilation
Stenting
Full covered SEMS Dynamico™
Stenting
Stenting complications
Ulcer
Perforation
Migration
Other techniques
Endocut Steroids injection
Anastomotic s. Anastomotic s. + congenital s.
Conclusions
esophageal stenosis is a benign disease in pediatrics
most common causes are surgical esophageal anastomosis and caustic ingestion endoscopic dilation is the definitive treatment of choice in most cases
more recently, for refractory stricture, stent placement is a technique used with positive promising results even in children