To the Editor: Esophageal strictures occur in children after surgery for congenital esophageal atresia or as a complication of caustic ingestion or reflux esophagitis. The initial treatment consists of intraluminal dilatations (bouginage or balloon dilatations) (1). Conservative treatment is always preferable to surgical correction. However, stenosis often recurs and iterative dilatations are therefore necessary, increasing the risk of complications.
In their recent article, Broto et al. (2) reported a new technique involving the placement of a silicone stent in 10 children presenting with severe esophageal stenosis to prevent further dilatation. After stent placement, five of 10 patients were completely cured, with follow-up ranging from 4 to 19 months. The other five patients suffered restenosis. In one patient, the stent migrated into the stomach and the other four developed esophagitis. The morbidity rate for stent placement was high, mainly because of the nausea, vomiting or pain induced by the procedure. Several issues raised by this procedure remain unresolved: the requirement for two stents in one patient that results from the slippage of the first stent, the induction of gastroesophageal reflux requiring systematic antacid treatment, retrograde migration of the stent into the larynx and the outcome of stenting in a rapidly growing child.
Mitomycin C is an antiproliferative agent that can inhibit fibroblast proliferation and activity (3). It has been used successfully with no complications as an adjuvant treatment in several ophthalmological procedures and in laryngeal and tracheal stenosis (3,4). Local application of mitomycin C after dilatation is a new technique, recently used for esophageal stricture in children (4,5). The successful use of topical mitomycin C to prevent the recurrence of caustic esophageal strictures has been reported in two patients (4,5). We recently used mitomycin C to treat three children, aged 2.5, 4 and 6 years, suffering refractory caustic esophageal stenosis. They required four, 10 and 10 esophageal dilatations, respectively, before the first application of mitomycin C. After endoscopic dilatation using a Savary or balloon dilator, mitomycin C was applied locally using a rigid endoscope. No complications were observed after the application procedure. After one application, no further dilatation was necessary, with follow-up ranging from 8 to 14 months, and all children remained asymptotic. The assessment of long-term outcomes and a large series is required before any definitive conclusion can be drawn on the use of mitomycin C in such patients. Long-term studies comparing treatments with stent and mitomycin C are necessary to definitively identify the best conservative treatment for esophageal stricture in children.
*Unit of Gastroenterology; Hepatology and Nutrition; Department of Pediatrics; Lille, France
†Department of Otolaryngology-Head and Neck Surgery; Lille, France.
1. Michaud L, Guimber D, Sfeir R, et al. Anastomotic stenosis after surgical treatment of esophageal atresia: frequency, risk factors and effectiveness of esophageal dilatations [in French]. Arch Pédiatr
2. Broto J, Asensio M, Vernet JM. Results of a new technique in the treatment of severe esophageal stenosis in children: poliflex stents. J Pediatr Gastroenterol Nutr
3. Rahbar R, Shapshay SM, Healy GB. Mitomycin: effects on laryngeal and tracheal stenosis, benefits, and complications. Ann Otol Rhinol Laryngol
4. Rahbar R, Jones DT, Nuss RC, et al. The role of mitomycin in the prevention and treatment of scar formation in the pediatric aerodigestive tract: friend or foe? Arch Otolaryngol Head Neck Surg
5. Afzal NA, Albert D, Thomas AL, Thomson M. A child with oesophageal strictures. Lancet