Colon patch esophagoplasty for esophageal strictures refractory to multi-modal treatment revisited.

INTRODUCTION/PURPOSE: Esophageal strictures due to caustic ingestion (CI) may require repeat esophageal dilations and dilation adjuvants, including local anti-fibrinogenic injection therapy, stent placement, and radial stricture incisions. Refractory strictures require surgical intervention. Pedicled colon patch esophagoplasty (CPE) may avoid the morbidity associated with total esophageal replacement, although reports of its use are limited. Indications and outcomes for CPE in patients undergoing repeat esophageal stricture dilations following caustic ingestion are described according to our local experience and literature reports. MATERIALS AND METHODS: A retrospective review of indications for surgical management of esophageal strictures to tertiary pediatric surgical services between 2015 and 2020 focused on patients undergoing CPE. English-language literature (PubMed, Google Scholar, and Scopus) describing CPE was also reviewed. RESULTS: Eight (12%) out of 65 patients with esophageal strictures requiring 7 or more esophageal dilations with poor response underwent surgical stricture management over a 6 year period, which included stricture resection and re-anastomosis in 2 patients, total esophageal replacement with colon graft in 2 patients, gastric pull-up in 1 patient, and CPE in 3 patients. The patients undergoing CPE were aged 3-8 years and had 17 to more than 25 dilations following caustic ingestion over a 2-5 year period. One patient had a 4 cm stricture; the other 2 had strictures 7 cm in length. A transverse colon patch based on the middle and left colic vessels was utilized in all three, with the vascular pedicle placed retrogastrically via the esophageal hiatus and the patch inlay esophagoplasty concluded via right thoracotomy. Post-operative contrast studies showed near-normal anatomy, and the patients could tolerate full oral diets. During a 9-36 month follow-up period, only 2 patients required dilations of a proximal anastomotic stricture at 1 and 5 months postoperatively. One patient required additional proximal stricturoplasty with advancement of the original graft across the stricture via a cervical surgical approach. CONCLUSION: Colon patch esophagoplasty to restore esophageal luminal continuity and allow a normal diet should be considered for refractory esophageal strictures. CPE had excellent functional outcomes in our 3 patients and should be considered in selected cases instead of total esophageal replacement.

Long term outcome of a subcutaneous colonic interposition after pharyngo-laryngectomy for strictures of the larynx and hypopharynx resulting from caustic ingestion: A case report.

INTRODUCTION: Caustic agents, also called corrosive agents, could be acids or alkali in nature. If ingested, these agents can injure any part of the aerodigestive tree. Extent of injury depends on the type, concentration, duration of exposure and volume of caustic agent ingested. Serious complications after caustic agent ingestion can occur both in the short term such as hollow viscus perforation and death and in the long term such as stricture formation causing obstruction and lifetime risk of development of carcinoma. PRESENTATION OF A CASE: This is a case of a 25-year-old female who ingested an unknown substance resulting to a severe stricture of the larynx, hypopharynx, esophagus and pyloroantral region of the stomach. Six months after her tracheostomy and tube jejunostomy, she sought further medical attention in our institution due to inability to swallow food and saliva. She underwent pharyngolaryngectomy (PL) with the strictured esophagus and stomach left in-situ due to extensive adhesions. The subcutaneous colonic interposition reestablished the alimentary continuity by providing enough length for tension-free anastomosis and a more direct route for cervical anastomosis. DISCUSSION: Stricture formation is one of the most challenging late complication of corrosive injury. It results from scar formation in response to inflammation of the aerodigestive tract. Key factors in managing caustic strictures include safety of strictured segment resection, choice of replacement organ for reconstruction and route of conduit. CONCLUSION: Timing of surgery and proper selection the surgical procedure for complications of caustic ingestion can result in excellent long term outcomes.

Comparación de vía mediastinal posterior versus vía retroesternal para el reemplazo de esófago con ascenso gástrico parcial. Motivo de un cambio de estrategia / Comparison of posterior mediastinal versus retrosternal route for esophageal replacement with partial gastric pull-up. Rationale for a change in strategy

Introducción: existen dos rutas para realizar el reemplazo de esófago (RE), la retroesternal (RRE) y la mediastinal posterior (RMP). El objetivo del estudio es comparar los pacientes que recibieron un ascenso gástrico parcial empleando estas dos rutas. Material y métodos: Se revisaron las historias clínicas de 51 pacientes con ascenso gástrico parcial, en 27 años en el Hospital Garrahan. Se utilizó la vía RRE en 25 casos y la RMP en 26. Fueron comparados los datos epidemiológicos de los grupos y las variables para valorar la dificultad del acto quirúrgico, evolución inmediata y alejada. El estudio es comparativo, retro-prospectivo y longitudinal. Resultados: las características generales de los pacientes fueron similares. Los que recibieron el ascenso gástrico por vía RMP presentaron una menor incidencia de dehiscencia (p=0,017), de enfermedad por reflujo gastroesofágico (ERGE) (p=0,001) y de dumping (p=0,0001). No hubo diferencias estadísticamente significativas entre los dos grupos al comparar la duración del procedimiento, días de internación total y en Unidad de Cuidados Intensivos (UCI), días de permanencia en asistencia respiratoria mecánica (ARM), inicio de alimentación oral y estenosis de la anastomosis. Se observó una tendencia clínicamente relevante, que no alcanzó significancia estadística en las complicaciones intraquirúrgicas y número de dilataciones postoperatorias. No hubo necrosis del ascenso. Fallecieron 2 pacientes. Conclusiones: considerando la menor incidencia de dehiscencia, ERGE y dumping reemplazados por RMP, elegimos a ésta como nuestra primera opción para el reemplazo esofágico en la infancia (AU)

Introduction: The two routes for esophageal replacement (ER) are retrosternal (RRE) and posterior mediastinal (PMR). The aim of the study was to compare patients who received a partial gastric pull-up using either of these two routes. Material and methods: The clinical records of 51 patients who underwent partial gastric pull-up over 27 years at the Garrahan Hospital were reviewed. The RRE route was used in 25 and the RMP in 26 cases. The epidemiological data of the groups and the variables to evaluate the complexity of the surgical procedure, and shortand long-term outcome were compared. A comparative, retroprospective, and longitudinal study was conducted. Results: the general characteristics of the patients were similar. Those who underwent gastric pull-up via PMR had a lower incidence of dehiscence (p=0.017), gastroesophageal reflux disease (GERD) (p=0.001), and dumping (p=0.0001). No statistically significant differences were found between the two groups when comparing the duration of the procedure, days of total hospital and intensive care unit (ICU) stay, days on mechanical ventilation (MV), initiation of oral feeding and stenosis of the anastomosis. A clinically relevant trend, which did not reach statistical significance, was observed in intraoperative complications and number of postoperative dilatations. There was no necrosis of the pull-up. Two patients died. Conclusions: considering the lower incidence of dehiscence, GERD, and dumping associated with PMR, this was our first choice for esophageal replacement in infancy (AU)

Assessment of long-term results of repeated dilations and impact of a scheduled program of dilations for refractory esophageal strictures: a retrospective case-control study.

INTRODUCTION: In patients with benign and refractory esophageal strictures (BES), repeating initial dilations in short intervals could be recommended, but little data are available to validate this strategy. Our aim was to evaluate long-term results of a scheduled program of repeated and sustained esophageal dilations in patients with refractory strictures. METHODS: Patients with BES requiring five or more dilations were retrospectively included and divided in two groups for analysis: a SCHEDULED group (SDG) where patients were systematically rescheduled for the 5 first dilations; ON-DEMAND group (ODG) where patients were dilated only in case of recurrence of the dysphagia. Comparison between SDG and ODG was done with a 1:1 matching analysis and etiology of stricture. Clinical success was defined as the absence of dysphagia for more than a year. RESULTS: 39 patients with refractory BES were included with post-operative stenosis in 51.2% and post-caustic injury 28.2%; 10 were in SDG and 29 in ODG. In overall analysis (39 patients), the follow-up was 64.4 ± 32 months, success rate was 79.5% and duration of treatment was 27.3 ± 20 months, and mean number of dilations was 11.7 per patient. The need for dilations decreased significantly after 18 months of treatment with an average of 0.56 dilations per semester. Self-expandable metallic stent insertion was associated with an increased rate of complications (5.9% vs 59.1% p = 0.001). In matched analysis (10 ODG vs 10 SDG patients), the duration of treatment was lower in SDG (18.8 vs 41.4 months, p = 0,032) with a higher probability of remission (survival analysis, Log-rank: p = 0,019) and the success rate did not differ between ODG and SDG patients (80% vs 90%; NS). CONCLUSION: Overall, long-term esophageal dilations resulted in a 79.5% success rate and the need for further dilatations decreased significantly in both groups after 18-month follow-up. A scheduled dilation program was associated with a higher probability of final success and lower treatment duration.

The Effectiveness of Combined Balloon and Bougie Dilatation Technique in Children with Impassable Esophageal Stricture.

Background: Impassable caustic esophageal strictures (CES) can be rendered passable through sophisticated dilatation techniques, hence avoiding the esophageal replacement surgery and its complications. Patients and Method: Patients with impassable CES who were presented to our hospital between January 2015 and April 2020 underwent a combined balloon and bougie dilatation. This technique aims at doing an initial partial dilatation of the proximal segment of the stricture, using a balloon catheter to pave the way for the endoscope to be advanced more distally. Therefore, a guide wire could be passed down to the stomach to complete the dilatation session using bougie dilators. Results: Seven patients out of 138 patients who underwent endoscopic dilatation for CES at the pediatric surgery department were enrolled in this study. Their ages ranged from 2.5 to 6 years. This technique was successful in 6 patients indicating technique reproducibility of 85.7%. These 6 patients continued their next dilatation sessions using bougie dilator only, whereas 4 patients were completely cured from dysphagia indicating technique efficiency of 57%, 1 is still on dilatation, and 1 patient had a resistant stricture. The dilatation through the proposed technique failed in 1 patient, who was referred for a replacement surgery. Conclusion: Combined dilatation is safe and effective to preserve the native esophagus in some difficult CES.

Iatrogenic esophageal perforation caused by endoscopic dilatation of caustic stricture: Current management and possibility of esophageal salvage.

BACKGROUND: Iatrogenic esophageal perforation (EP) is an undesirable complication of endoscopic dilatation of caustic esophageal stricture. We reported our current management protocol with possibility of continuing the dilatation program. PATIENTS AND METHODS: From January 2009 to January 2020 medical records were reviewed for patients presented with iatrogenic EP. Management according to each case condition was reported. RESULTS: 24 patients were enrolled, aged from 1.5 to 6 years old. Perforation was cervical in one case, abdominal in two cases, and thoracic in 21 cases. Immediate surgical repair was performed in the abdominal cases. Conservative management was chosen in 22 cases; two cases didn't respond and underwent esophageal diversion, and one of them died owing to severe sepsis. Three patients refused another trial of dilatation. Two cases failed to be redilated. 17 patients continued a dilatation program. Time passed between perforation and redilatation ranged from 35 days to 7 months. 15 patients were cured completely from dysphagia, one patient had marked improvement of his dysphagia, and one case with a resistant stricture was referred for esophageal replacement. CONCLUSION: Preserving the native esophagus is possible after iatrogenic EP of caustic esophageal stricture. A conservative approach should be attempted with caution not to endanger patient's life. Level IV of evidence.

Total esophageal substitution for combined hypopharyngeal and esophageal strictures after corrosive injury in children.

BACKGROUND/PURPOSE: The treatment of children with esophageal strictures and involvement of the hypopharynx caused by caustic substance ingestion continues to be challenging. The aims of the present study are to describe the peculiarities of the technique of complete esophageal substitution for the treatment of children with severe caustic strictures (pharyngocoloplasties) and to compare the results to those of classical esophagocoloplasty with thoracic and abdominal esophageal substitution in another group of children. METHODS: A total of 258 children underwent colon interposition for esophageal replacement. Among these patients, 19 had complex esophageal caustic strictures involving the high level of the esophagus and hypopharynx without response to endoscopic dilatations. This group was compared with another group who required partial esophagocoloplasty with intact hypopharynx and high esophagus (239 patients). For the pharyngocoloplasty procedure, the transverse and great parts of the right colon were the segments selected for interposition and were maintained by a double vascular pedicle based on the left colic vessels and the marginal paracolic arcade via the sigmoid vessels. RESULTS: In the pharyngocoloplasty group, 9 patients (47.4%) presented with cervical anastomosis stenosis with episodes of aspiration pneumonia, although good responses to endoscopic dilatation treatments were observed. All patients survived. In the esophagocoloplasty group, the main complications were cervical leaking (18.0%) and stenosis (16.7%). Statistical comparisons revealed that the pharyngocoloplasty patients exhibited a lower incidence of cervical leakage and increased incidences of cervical stenosis and aspiration pneumonia, although all patients could swallow normally. CONCLUSION: Pharyngocoloplasty with complete esophageal substitution is a safe and effective procedure for the treatment of esophageal caustic strictures with severe stenoses reaching the hypopharynx that are refractory to previous endoscopic treatment. LEVEL OF EVIDENCE: II.

Endoscopic management of esophageal stenosis in children: New and traditional treatments.

Post-esophageal atresia anastomotic strictures and post-corrosive esophagitis are the most frequent types of cicatricial esophageal stricture. Congenital esophageal stenosis has been reported to be a rare but typical disease in children; other pediatric conditions are peptic, eosinophilic esophagitis and dystrophic recessive epidermolysis bullosa strictures. The conservative treatment of esophageal stenosis and strictures (ES) rather than surgery is a well-known strategy for children. Before planning esophageal dilation, the esophageal morphology should be assessed in detail for its length, aspect, number and level, and different conservative strategies should be chosen accordingly. Endoscopic dilators and techniques that involve different adjuvant treatment strategies have been reported and depend on the stricture's etiology, the availability of different tools and the operator's experience and preferences. Balloon and semirigid dilators are the most frequently used tools. No high-quality studies have reported on the differences in the efficacies and rates of complications associated with these two types of dilators. There is no consensus in the literature regarding the frequency of dilations or the diameter that should be achieved. The use of adjuvant treatments has been reported in cases of recalcitrant stenosis or strictures with evidence of dysphagic symptoms. Corticosteroids (either systemically or locally injected), the local application of mitomycin C, diathermy and laser ES sectioning have been reported. Some authors have suggested that stenting can reduce both the number of dilations and the treatment length. In many cases, this strategy is effective when either metallic or plastic stents are utilized. Treatment complications, such esophageal perforations, can be conservatively managed, considering surgery only in cases with severe pleural cavity involvement. In cases of stricture relapse, even if such relapses occur following the execution of well-conducted conservative strategies, surgical stricture resection and anastomosis or esophageal substitution are the only remaining options.

Efficacy of endoscopic radial incision (ERI) for benign stricture of upper digestive system / 中国内镜杂志

Objective To evaluate the safety and efficacy of endoscopic radial incision (ERI) for benign stricture of upper digestive system. Methods Patients with benign esophageal or gastric stricture (including anastomotic stricture, stricture after ESD and caustic stricture) were enrolled in this study. The stage of stricture, length of the lesion and the thickness of the scar were recorded. ERI (maybe associated with balloon dilatation) were performed. Post-opera-tive symptoms, complications and follow-up were also recorded. Results 7 patients were enrolled and all received ERI, and 4 additional balloon dilatation were done. Dysphagia in all patients relieved. 1 case with hemorrhage oc-curred and relieved with conservative treatment. Majority of the patients got long-term remission after 1~2 times of ERI. Conclusion ERI is safe and effective for benign stricture of upper digestive system. It may prolong the dyspha-gia-free period, worth clinical promotion.

Mechanical bowel preparation for esophagocoloplasty in children: is it really necessary?

Esophagocoloplasty is a commonly performed procedure for esophageal replacement in children. Traditionally, mechanical bowel preparation (MBP) is performed before this operation. However, this practice has been questioned, initially in adults and now in children. The aim of this study was to evaluate the influence of MBP on esophagocoloplasty in a series of children. Data collected from 164 patients who underwent esophagocoloplasty in the Pediatric Surgery Division, University of São Paulo Medical School, from February 1978 to July 2011 were reviewed for postoperative complications. In 134 patients, at least one kind of MBP was performed before the surgery (PREP group). MBP was omitted in 30 patients (NO-PREP group). There was no statistical difference between the groups in the rates of evisceration, colocolic, or cologastric anastomotic dehiscence and death. However, in the NO-PREP group, the incidence of cervical leakage (6.6%) was significantly decreased in comparison with the classical PREP group (25.3%) (P= 0.03). The results of this study suggest that the omission of MBP has a positive impact on the incidence of postoperative complications in esophagocoloplasty.