Congenital Esophageal Stenosis: To dilate or To resect

Congenital esophageal stenosis [CES] is a rare condition in children. The definitive preoperative diagnosis often is difficult to make, and a standard therapeutic protocol remains controversial. This study was carried out to determine the proper management strategy in children suffering from CES. The medical records of 17 patients with CES treated during a period of10 years [from 1995 to 2005] were retrospectively reviewed. Each patient was evaluated as regard to the clinical presentation, pathology, management, and outcome. The ages of patients at time of diagnosis ranged from 3 months to 9 years. The sites of stenosis were located more frequently at the lower third of the esophagus [n=10] than the upper third [n-3] and middle third [n=4], The diagnosis was made by esophagogram, esophagoscopy and was confirmed by histopathologic examination. Fifteen patients were diagnosed primarily, while 2 patients were diagnosed after unsuccessful surgical treatment for an initial misdiagnosed achalasia of the cardia. Six patients had confirmed tracheobronchial remnants [TBR], five had fibromuscular stenosis [FMS] and 2 had membranous web stenosis [MS]. The histopathology was unknown in 4 patients due to inadequate biopsies taken during esophagoscopy. All patients were treated initially by repeated esophageal dilatations [2-8 times] over two to thirty month period. The dilatation alone was successful in 11 patients, but was complicated by esophageal perforation in one case. Six patients required surgery; five of them were treated by resection and anastomosis, and one required esophageal replacement The pathology of this later group was TBR in 5 patients and FMS in one. 1. this study emphasizes the diagnostic difficulties in some children with CES; 2. Esophageal dilatation may be tried initially 3. Resection should be reserved for cases not responding to repeated dilatation particularly those with proven TBR

Ultrasonographic diagnosis of potential contralateral inguinal hernia in children

Several methods have been advocated to minimize the frequency of negative exploration of the contralateral side in children presenting with a unilateral congenital inguinal hernia [CIH]. This study was carried out to investigate the accuracy of ultrasonography in recognition of an unapparent CIH or a patent processus vaginalis [PPV] in the contralateral side in children presenting with a unilateral CIH. From November 2003 to March 2005, 173 children presented with a clinically apparent unilateral CIH. Their ages ranged between 1 week and 24 months [mean, 21.8 weeks]. The contralateral inguinal region was examined by ultrasound using a 7.5 MHz transducer. Presence of potential CIH was considered if one or more of the following features were noted: 1. A well defined viscous is observed in the inguinal canal; 2. A cystic pattern is seen at the internal ring of inguinal canal; 3. The presence of a PPV that enlarges when abdominal pressure increases 4. The PPV contains moving material without enlargement. Only patients with positive ultrasonographic findings undergone exploration of the contralateral inguinal canal at the same session following repair of the clinically detected hernia, follow up ranged from six to eleven months. Positive ultrasonographic findings were noted in 31 of the 173 patients [17.9%]. Twenty seven of the 31 patients [87.1%] proved to have a PPV or a definite hernial sac, while 4 [12.9% false positive] showed no hernial sac on exploration. Two of the 142 patients who had negative ultrasonographic findings at the contralateral side, developed an inguinal hernia after 4 and 6 months respectively [1.4% false negative]. The sensitivity and the specificity of utrasonography in detecting a potential CIA or PPV in the contralateral side was 87.1% and 98.6% respectively. The positive and negative predictive values of this diagnostic tool were 93.1% and 97.2% respectively, and the accuracy rate reached 96.5%. 1. Ultrasound is a non-invasive and relatively accurate method to determine which patient should have exploration of the contralateral side; 2. Routine contralateral inguinal exploration is not recommended anymore