Classification of Esophageal Strictures following Esophageal Atresia Repair

Abstract

Introduction The aim of this study was to stratify anastomotic strictures (AS) following esophageal atresia (EA) repair and to establish predictors for the need of dilations.

Materials and Methods A retrospective study on children operated on for EA between 2004 and 2014 was conducted. The stricture index (SI) was measured both radiologically (SI_XR) and endoscopically (SI_END). A correlation analysis between the SI and the number of dilations was performed using Spearman's test and linear regression analysis.

Results In this study, 40 patients were included: 35 (87.5%) presented with Gross's type C EA, 3 (7.5%) type A, 1 (2.5%) type B, and 1 (2.5%) type D. The mean follow-up time was 101 ± 71.1 months (range: 7.8–232.5, median: 97.6). The mean SI_XR was 0.56 ± 0.16 (range: 0.15–0.86). The mean SI_END was 0.45 ± 0.22 (range: 0.15–0.85). Twenty-four patients (60%) underwent a mean of 2 endoscopic dilations (range: 1–9). The number of dilations was poorly correlated with SI_XR, while significantly correlated with SI_END. Patients who did not need dilations had a SI_END < 0.33, patients who needed only one dilation had 0.33 ≤ SI_END < 0.44, and those with SI_END ≥ 0.44 needed two or more dilations. No significant association with other clinical variables was found. All patients were asymptomatic at the time of the first endoscopy.

Conclusion SI_END is a useful tool to classify AS and can represent a predictor of the need for endoscopic dilation. The role of the SI_END becomes even more important as clinical characteristics have a low predictive value for the development of an AS and the need for subsequent endoscopic esophageal dilatations.

Keywords

anastomotic stricture - esophageal dilation - esophageal atresia - stricture index - infant

• References

• 1 Goyal A, Jones MO, Couriel JM, Losty PD. Esophageal atresia and trachea-esophageal fistula. Arch Dis Child Fetal Neonatal Ed 2006; 91: F381-F384
• 2 Deurloo JA, Ekkelkamp S, Schoorl M, Heij HA, Aronson DC. Esophageal atresia: historical evolution of management and results in 371 patients. Ann Thorac Surg 2002; 73 (01) 267-272
• 3 Chittmittrapap S, Spitz L, Kiely EM, Brereton RJ. Anastomotic leakage following surgery for esophageal atresia. J Pediatr Surg 1992; 27 (01) 29-32
• 4 Serhal L, Gottrand F, Sfeir R. , et al. Anastomotic stricture after surgical repair of esophageal atresia: frequency, risk factors, and efficacy of esophageal bougie dilatations. J Pediatr Surg 2010; 45 (07) 1459-1462
• 5 Spitz L. Esophageal atresia: past, present, and future. J Pediatr Surg 1996; 31 (01) 19-25
• 6 Spitz L. Esophageal atresia. Lessons I have learned in a 40-year experience. J Pediatr Surg 2006; 41 (10) 1635-1640
• 7 Said M, Mekki M, Golli M. , et al. Balloon dilatation of anastomotic strictures secondary to surgical repair of oesophageal atresia. Br J Radiol 2003; 76 (901) 26-31
• 8 Zhao R, Li K, Shen C, Zheng S. The outcome of conservative treatment for anastomotic leakage after surgical repair of esophageal atresia. J Pediatr Surg 2011; 46 (12) 2274-2278
• 9 Parolini F, Leva E, Morandi A. , et al. Anastomotic strictures and endoscopic dilatations following esophageal atresia repair. Pediatr Surg Int 2013; 29 (06) 601-605
• 10 Spitz L. Oesophageal atresia. Orphanet J Rare Dis 2007; 11: 2-24
• 11 Koivusalo A, Pakarinen MP, Rintala RJ. Anastomotic dilatation after repair of esophageal atresia with distal fistula. Comparison of results after routine versus selective dilatation. Dis Esophagus 2009; 22 (02) 190-194
• 12 Lang T, Hümmer HP, Behrens R. Balloon dilation is preferable to bougienage in children with esophageal atresia. Endoscopy 2001; 33 (04) 329-335
• 13 Berger M, Ure B, Lacher M. Mitomycin C in the therapy of recurrent esophageal strictures: hype or hope?. Eur J Pediatr Surg 2012; 22 (02) 109-116
• 14 Baird R, Laberge JM, Lévesque D. Anastomotic stricture after esophageal atresia repair: a critical review of recent literature. Eur J Pediatr Surg 2013; 23 (03) 204-213
• 15 Omari T, Davidson G, Bondarov P, Nauclér E, Nilsson C, Lundborg P. Pharmacokinetics and acid-suppressive effects of esomeprazole in infants 1-24 months old with symptoms of gastroesophageal reflux disease. J Pediatr Gastroenterol Nutr 2007; 45 (05) 530-537
• 16 Hagander L, Muszynska C, Arnbjornsson E, Sandgren K. Prophylactic treatment with proton pump inhibitors in children operated on for oesophageal atresia. Eur J Pediatr Surg 2012; 22 (02) 139-142
• 17 Alshehri A, Lo A, Baird R. An analysis of early nonmortality outcome prediction in esophageal atresia. J Pediatr Surg 2012; 47 (05) 881-884
• 18 Lakhdar-Idrissi M, Khabbache K, Hida M. Esophageal endoscopic dilations. J Pediatr Gastroenterol Nutr 2012; 54 (06) 744-747
• 19 Morikawa N, Honna T, Kuroda T. , et al. High dose intravenous methylprednisolone resolves esophageal stricture resistant to balloon dilatation with intralesional injection of dexamethasone. Pediatr Surg Int 2008; 24 (10) 1161-1164
• 20 Harmon CM, Coran AG. Congenital anomalies of the esophagus.. In: Grosfeld JL, O'Neill JA, Fonkalsrud EW, Coran AG. , eds. Pediatric Surgery. Philadelphia: Mosby Elsevier; 2006: 1051-1081
• 21 Krishnan U, Mousa H, Dall'Oglio L. , et al. ESPGHAN-NASPGHAN guidelines for the evaluation and treatment of gastrointestinal and nutritional complications in children with esophageal atresia-tracheoesophageal fistula. J Pediatr Gastroenterol Nutr 2016; 63 (05) 550-570
• 22 Spitz L, Hitchcock RJ. Oesophageal atresia and tracheoesophageal fistula. In: Freeman NV. , eds. Surgery of the Newborn. New York: Churchill Livingstone; 1994: 353-373
• 23 Michaud L, Guimber D, Sfeir R. , et al. Anastomotic stenosis after surgical treatment of esophageal atresia: frequency, risk factors and effectiveness of esophageal dilations [in French]. Arch Pediatr 2001; 8: 268-274
• 24 Thyoka M, Barnacle A, Chippington S. , et al. Fluoroscopic balloon dilation of esophageal atresia anastomotic strictures in children and young adults: single-center study of 103 consecutive patients from 1999 to 2011. Radiology 2014; 271 (02) 596-601
• 25 Koivusalo AI, Pakarinen MP, Rintala RJ. Modern outcomes of oesophageal atresia: single centre experience over the last twenty years. J Pediatr Surg 2013; 48 (02) 297-303
• 26 Laín A, Cerdá J, Cañizo A. , et al. Analysis of esophageal strictures secondary to surgical correction of esophageal atresia [in Spanish]. Cir Pediatr 2007; 20 (04) 203-208
• 27 Kim IO, Yeon KM, Kim WS, Park KW, Kim JH, Han MC. Perforation complicating balloon dilation of esophageal strictures in infants and children. Radiology 1993; 189 (03) 741-744
• 28 Koivusalo A, Turunen P, Rintala RJ, van der Zee DC, Lindahl H, Bax NM. Is routine dilatation after repair of esophageal atresia with distal fistula better than dilatation when symptoms arise? Comparison of results of two European pediatric surgical centers. J Pediatr Surg 2004; 39 (11) 1643-1647
• 29 Altintas E, Kacar S, Tunc B. , et al. Intralesional steroid injection in benign esophageal strictures resistant to bougie dilation. J Gastroenterol Hepatol 2004; 19 (12) 1388-1391