Esophageal anastomotic severe stenosis after atresia repair: effectiveness of a multi-step strategy for an unusual endoscopic recanalization

Esophageal atresia occurs in one in every 2500 – 3000 live births [1]. Long gap esophageal atresia (LGA) represents 10 % – 30 % of cases, with gaps ranging from 2 cm to greater than 6 cm. The best treatment results are obtained if the native esophagus is preserved. Stenosis is estimated to be prevalent in up to 40 % of cases [2], most of which require repeated endoscopic dilatations. Rarely, the stricture can be so tight that endoscopic dilatation is impossible.

A 3-month-old baby who had undergone surgery for LGA at another hospital was admitted to our unit because of severe malnutrition. Barium swallow showed the absence of an anastomotic esophageal lumen. We used two scopes – one in the mouth and one via gastrostomy. Correct positioning of the scopes was verified by radiography ([Fig. 1]) and transillumination ([Fig. 2]).

Fig. 1 Radiograph showing correct position of the two endoscopes.

Fig. 2 Transillumination of the esophagus.

We located a suitable site and then perforated the lower esophageal end with an EchoTip (Ultra 19G, Cook Medical Inc., Winston-Salem, North Carolina, USA), entered the upper end of the esophagus, and inserted a guide wire ([Fig. 3]).

Fig. 3 EchoTip needle entering the upper end of the esophagus.

The guide wire was retrieved by the upper scope from the oral cavity. After conventional dilatation, two radio-opaque silicon pledgets were placed in the esophageal ends, and held in traction by two polypropylene stitches ([Fig. 4]).

Fig. 4 Polypropylene stitches hold a radio-opaque silicon pledget in place at the esophageal ends.

Repeat radiography verified the correct position of the pledgets ([Fig. 5]).

Fig. 5 Radiography verified the correct position of the pledgets.

After 7 days, a chest radiograph showed migration of the pledgets into the lower esophagus ([Fig. 6]).

Fig. 6 After 7 days, a chest radiograph showed migration of the pledgets into the lower esophagus.

Our standardized method of esophageal stenting [3] followed to achieve good caliber. The stent was left in place for 40 days. Resolution of the remnant stenosis was achieved by endoscopic radial section of the stenotic ring using a mucosectomy needle-knife.

Takamizawa [4] described a case of severe stenosis treated by magnetic compression of esophageal pouches. More than 20 years ago, Sauer and Kurz applied classical Rehbein’s thread-and-olive technique to children with type I esophageal atresia [5]. Similar studies were made by other authors in the early 1980s.

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References

• 1 Spitz L. Oesophageal atresia.  Orphanet J Rare Dis. 2007;  2 24
• 2 Chittmittrapap S, Spitz L, Kiely E M, Brereton R J. Anastomotic stricture following repair of esophageal atresia.  J Pediatr Surg. 1990;  25 508-511
• 3 De Peppo F, Zaccara A, Dall’Oglio L. et al . Stenting for caustic strictures: esophageal replacement replaced.  J Pediatr Surg. 1998;  33 54-57
• 4 Takamizawa S, Yamanouchi E, Murajia E. et al . MCRA of an anastomotic stenosis after esophagoesophagostomy for long gap esophageal atresia: a case report.  J Pediatr Surg. 2007;  42 769-772
• 5 Sauer H, Kurz R. Experiences in the treatment of esophageal atresia with Rehbein’s olive technique.  Prog Pediatr Surg. 1986;  19 93-102