Two cases of esophageal perforation were observed. The first perforation occurred during an initial dilation of a peptic stricture, which had no need for additional dilations because it was cured as shown by endoscopy. The second perforation occurred in 1 case in the caustic group, a 4-year-old child who ingested a small quantity of lye. The incidence of perforation was then calculated for group A and group B, respectively, to 2% and 25% per patient and to 0.5% and 2.4% per dilation session. These patients responded well to conservative treatment.
The effectiveness of endoscopic treatment was evaluated based on clinical and endoscopic signs: improvement of nutritional status, which meant the disappearance of dysphagia and vomiting; disappearance of esophagitis lesions and regression of stricture in group A and B; and its disappearance in group C. Healing was reported after an average management duration of 1 year and a mean hindsight of 2 years. In group A, we obtained a favorable response in 70% of cases. Indeed, 29 patients (55.8%) were completely cured and 8 of 16 who continued to benefit from additional sessions started to respond well. Among all of these patients, 17 had a hiatal hernia and underwent a Nissen intervention, and 9 who had a small hernia were not operated on. Ten patients were scheduled for surgery after nutritional improvement. The cure rate of surgical patients was 69.6%, which means that 30.4% required postoperative dilation sessions. The average of dilation sessions was 2.8 preoperatively and 4.6 postoperatively. No cases of Barrett esophagus or other type of strictures were found. In group B, 2 patients were cured, 1 after 7 sessions and the other after 15. One failure was noted after 11 dilation sessions and that patient underwent esophagoplasty. The fourth case required additional dilations that were increasingly spaced out after 2 years of evolution. In group C, 2 patients responded favorably to endoscopic treatment, 1 after 10 months and the other after 1 year of evolution. Two other patients are still being followed up with repeated sessions (Table 4). In parallel, both group A and group B patients received medical treatment with a PPI before and after dilation to reduce the degree of underlying esophagitis. This treatment was administered to only 1 patient in group C because, in general, patients in this group had no evolving esophagitis. In addition, in group B, all of the patients initially received systemic injection corticosteroid therapy (methylprednisolone 1 g · 1.73 m2 · d−1) with a cessation of feeding for a variable period depending on the lesions. Only 1 child in the same group required a gastrostomy tube feeding concomitant with early dilation. No patient was treated with mitomycin C.
Esophageal pH monitoring was performed for all of the patients in group B and has shown an associated GER reflux in all of the cases. In group A, monitoring was done after clinical and endoscopic healing. The decision to stop treatment was made after a normal pH monitoring.
Esophageal strictures were mainly caused by peptic strictures in our context. The management of the pathology of gastroesophageal reflux disease (GERD) is still not up to our ambitions. Many of our patients had never consulted a clinician before the onset of dysphagia. These patients are generally living in remote rural areas, far from hospitals (>60% of cases). For others, antireflux treatment was either prescribed later after the start of symptoms or taken irregularly. In <10% of cases, patients developed a peptic stricture despite regular monitoring and appropriate treatment. Endoscopic explorations were requested by their physician only after signs of complication. These patients had relatively large hiatal hernias.
Theoretically, the time of peptic stricture onset is variable but most frequently occurs during the first 8 months of GERD; however, the outcome may be slower or even years after the beginning of symptoms, as shown in our series. The clinical diagnosis of peptic stricture is still uncertain. Gastrointestinal endoscopy, in some early forms, is the only examination that can confirm the stricture (1,2). Caustic stenosis was rare in our series. This cannot be explained by the nature of recruited patients because our center, which receives >25% of all Moroccan cases, manages all types of esophageal stricture. We estimate that caustic ingestions are common and certainly not all of them are seen in our center. In another study we conducted on caustic ingestion, the majority of patients ingested bleach, which generally does not cause injury. Ingestion of white spirit comes second and is not always complicated with stricture. Esophageal stricture occurred in 28% of white spirit ingestion cases and in 100% of lye-ingestion cases. Lye is highly corrosive.
The occurrence of anastomotic stricture after esophageal atresia surgery is frequently reported in the literature but not in our series. The frequency depends on the study and the type of atresia and on the quality of the surgical repair (3,4). Other types of stricture (congenital stricture, postinfection stricture, or those occurring after sclerosis of esophageal varicose veins) were not included in our study.
All of the symptomatic strictures could be dilated endoscopically, with good tolerability and ease of implementation (1,5). Two techniques are presently used in children: mechanical dilation by Savary-Gilliard bougies and pneumatic balloon dilation. The Savary-Gilliard technique is the oldest and is the one we adopted in our unit. The choice of dilation technique depends on personal experience. Balloon dilation appears, according to some authors, to be more effectively used and safe in caustic and postatresia strictures, although mechanical dilation in these indications also seems efficient (3,4,6–9). Norberto showed that balloon dilators are most useful for 2 situations: circumstances under which it is desirable to minimize esophageal trauma and short strictures. Savary-Gilliard dilators are useful for strictures resistant to balloon dilation and for long strictures that require carefully controlled and graded dilation (10). Studies comparing the response of peptic and caustic strictures using balloon dilation conclude that peptic strictures respond well to a smaller number of sessions (1,11). This observation is also true for Savary-Gilliard bougies, as shown in our work (8); however, there have been no studies comparing the 2 techniques in peptic strictures, and to the present time, we have no experience with hydrostatic dilation.
Endoscopic dilation of peptic stricture can improve outcomes and may avoid unnecessary surgical repair; however, long-term PPI treatment is required to cure GERD. The risk of relapse is still possible once the PPI treatment is interrupted, and a regular and long-term follow-up of these patients is required. Cases with a large hiatal hernia or those not responding to endoscopic treatment require surgery. For these patients, endoscopic treatment is still indicated to ensure proper nutritional status. Half of our patients had, at diagnosis, failure to thrive, usually resulting from a delay in disease management. After Nissen intervention, endoscopic control should occur; significant cases require more dilation sessions. Pearson et al (5) noted that children and adolescents with esophageal reflux stricture frequently require antireflux surgery (94%), repeat antireflux surgery (17%), and multiple dilations for recurrent symptoms. In our study, 30.4% of surgical cases still needed an average of 4.6 sessions of expansion. We noticed that patients who had several sessions after surgery were those who received laparoscopy instead of laparotomy.
Perforations occurred in 3% to 8% of cases depending on the series. This rarely occurred in our study if we consider the total number of sessions performed. The finding of a slight parietal break or moderate bleeding during postdilation control demonstrated the effectiveness of the expansion.
Caustic strictures are difficult to manage. Dilations must start after the healing of the esophageal mucosa, which is variable. In practice, as in the literature, we had not started the expansions before 1 month after caustic ingestion. Endoscopic treatment can be effective in 75% to 90% cases depending on the series, but it should be repeated over a long period of time (6,7,12). In our group, this period ranged from 18 to 24 months. Its purpose is to preserve the esophagus and prevent the use of esophagoplasty, which should be reserved for cases of failure of dilation or too-large strictures. Long-term careful follow-up must be ensured because of the risk of esophageal carcinoma, which remains poorly evaluated.
The risk of perforation in caustic stricture is higher (up to 15%). Such a perforation is not a contraindication for further dilations, once healing is completed. Finally, we must consider and treat GERD that occurs during treatment probably caused by dilations and contraction of the fibrotic esophagus (2,12). In our work, esophageal pH recording performed in the caustic stricture after an average period of 1 year showed GER.
Recurrence after dilation is frequently observed in both peptic and caustic strictures. Several techniques have been proposed to prevent fibrosis and are under development in our unit: the placement of esophageal prosthesis or stent, infiltration of corticosteroids, or application of mitomycin C in the lesion. Extractable metal prosthesis or biodegradable implants may soon become a good alternative for eradicating recurrent stricture that requires several rounds of dilation (13–15).
For esophageal atresia stricture, esophageal dilation with Savary-Gilliard bougies is an effective technique, but this usually requires several sessions to remove the stricture and circular fibrosis. Surgery of recurrent stricture on anastomosis consists of a resection of the stricture and the creation of a new anastomosis. This new anastomosis reexposes patients to the risk of stricture. Therefore, it is not proposed in initial treatment; however, the surgical treatment of GERD may be necessary in cases of recurrent stricture associated with persistent GERD despite well-followed treatment (3,4).
Esophageal strictures are severe and require extensive treatment. Endoscopic dilation using Savary-Gilliard bougies is an effective technique that ensures normal nutrition. Peptic stricture and esophageal atresia show better response to endoscopic dilation, with a smaller number of sessions than caustic stricture. Esophageal dilation may be an alternative to surgery; otherwise, it remains a complementary treatment that is almost mandatory either before or after surgery. We insist on the prevention of peptic complications whose frequency highlights the critical need for the intensification of management of GER.
We are grateful to Dr Mohammed El-Azami El-Idrissi (Laboratory of Immunology, Faculty of Medicine and Pharmacy, Fez) for the English revision of the manuscript.
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Keywords:Copyright 2012 by ESPGHAN and NASPGHAN
children; dilation; endoscopy; esophagus; stricture