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

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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