1 00:00:00,000 --> 00:00:07,000 Global Cast MD, along with Cincinnati Children's Hospital, sharing knowledge to improve child 2 00:00:07,000 --> 00:00:08,600 health around the globe. 3 00:00:08,600 --> 00:00:10,040 Hello, everyone. 4 00:00:10,040 --> 00:00:14,600 This is Kim Perkin, and I'd like to welcome you back to the continuation of our Quad series. 5 00:00:14,600 --> 00:00:19,960 In October 2022, Cincinnati Children's hosted the Quad Conference, which was a combination 6 00:00:19,960 --> 00:00:25,720 of four conferences, the International Organization for Esophageal Atresia, the Air Digestive 7 00:00:25,720 --> 00:00:31,160 Society Conference, the Cincinnati Children's Airway Course, and the Cincinnati Children's 8 00:00:31,160 --> 00:00:33,640 Pediatric Dysphagia Series. 9 00:00:33,640 --> 00:00:40,080 Today, we will review esophageal dilation techniques and TEF repairs with Dr. Phil Putnam, 10 00:00:40,080 --> 00:00:43,800 a gastroenterologist from Cincinnati Children's Hospital Medical Center. 11 00:00:43,800 --> 00:00:49,000 The symptoms related to esophageal strictures are related to the age and developmental status 12 00:00:49,000 --> 00:00:52,600 of the patient or parent who is doing the reporting of symptoms. 13 00:00:52,600 --> 00:00:57,880 The degree of stenosis and the nature of the oral intake that's being attempted. 14 00:00:57,880 --> 00:01:02,120 Young infants are usually consuming liquids with purees and chewed solids as the child 15 00:01:02,120 --> 00:01:03,320 ages. 16 00:01:03,320 --> 00:01:07,720 Knowing what and how the child handles their food is so helpful in diagnosis. 17 00:01:07,720 --> 00:01:11,960 It's also important to note if the symptoms are progressive or static in nature. 18 00:01:11,960 --> 00:01:17,240 An abrupt change in swallowing in somebody with a known stricture has a foreign body 19 00:01:17,240 --> 00:01:20,120 until proven otherwise. 20 00:01:20,120 --> 00:01:23,840 Patients and their parents will describe the sensation of food getting stuck or going down 21 00:01:23,840 --> 00:01:30,160 slow or regurgitation right after the attempt to swallow something, choking and coughing, 22 00:01:30,160 --> 00:01:31,160 or secretion management. 23 00:01:31,160 --> 00:01:35,080 They're all potential symptoms related to stenosis. 24 00:01:35,080 --> 00:01:39,520 In regard to the physical exam, it is important to pay close attention to the nutritional 25 00:01:39,520 --> 00:01:44,960 status of the patient, how they handle secretions, and if they have or have previously needed 26 00:01:44,960 --> 00:01:47,400 any tubes for nutritional support. 27 00:01:47,400 --> 00:01:50,760 Once the patient has been fully assessed, the clinician can determine how to further 28 00:01:50,760 --> 00:01:52,280 investigate the problem. 29 00:01:52,280 --> 00:01:57,240 Options for investigation include endoscopy or an esophagram. 30 00:01:57,240 --> 00:02:03,280 We do a lot of endoscopy with fluoroscopy so that we get all the information we need 31 00:02:03,280 --> 00:02:08,360 about location, diameter, and distance all at once. 32 00:02:08,360 --> 00:02:10,800 But what tools are best used during endoscopy? 33 00:02:10,800 --> 00:02:17,240 We have a lot of tools at our disposal for managing stenosis in the esophagus. 34 00:02:17,240 --> 00:02:22,760 We're familiar with controlled radial expansion balloons because we use them quite commonly. 35 00:02:22,760 --> 00:02:27,520 We also use hurricane balloons, which are intended for biliary dilation, and we have 36 00:02:27,520 --> 00:02:32,680 the option to do bouchonage with Maloney or Saving Instruments. 37 00:02:32,680 --> 00:02:38,320 Radial expansion balloon dilators only provide radial force once they are across the stenosis, 38 00:02:38,320 --> 00:02:39,760 which can often be safer. 39 00:02:39,760 --> 00:02:43,880 There are three sizes per balloon based on the amount of inflation that is needed. 40 00:02:43,880 --> 00:02:49,000 The 5 centimeter dilators are wire guided, while the 8 centimeter dilators are not. 41 00:02:49,000 --> 00:02:54,080 One of the advantages of the CRE balloons is that if you get them wet and pull the proximal 42 00:02:54,080 --> 00:02:57,800 end of the balloon up against the lens of the scope, you can generally see down them 43 00:02:57,800 --> 00:03:03,800 so you can observe what's happening at the business point where it's being dilated. 44 00:03:03,800 --> 00:03:09,200 Hurricane balloon dilators, originally intended for ERCP, are wire guided and offer smaller 45 00:03:09,200 --> 00:03:15,840 diameters of 2, 4, or 6 millimeters, and are shorter in length, only 2 to 4 centimeters. 46 00:03:15,840 --> 00:03:21,000 They do generate a hard surface after inflation, which makes them ideal for smaller strictures, 47 00:03:21,000 --> 00:03:23,120 as you would likely see in a child. 48 00:03:23,120 --> 00:03:26,360 Bouchonage is certainly possible to do. 49 00:03:26,360 --> 00:03:31,120 Maloney dilators I really like to use for things like eosinophilicus aftratus. 50 00:03:31,120 --> 00:03:32,600 Maloney dilators are not wire guided. 51 00:03:32,600 --> 00:03:37,440 In the past, I feel there is the potential for creating a false passage. 52 00:03:37,440 --> 00:03:42,320 Maloney dilators generate both a longitudinal force as well as the radial force. 53 00:03:42,320 --> 00:03:47,760 When using these in TEF, do so very cautiously as the tip can cause perforation. 54 00:03:47,760 --> 00:03:49,240 The savory dilators are very nice. 55 00:03:49,240 --> 00:03:52,040 They're a little more tapered than the Maloney's. 56 00:03:52,040 --> 00:03:53,040 They're a bit stiffer. 57 00:03:53,040 --> 00:03:59,360 They do require wire guidance, which is done with fluoroscopy under normal circumstances. 58 00:03:59,360 --> 00:04:04,040 Here you see a child with a TEF-related anastomotic stricture on the left. 59 00:04:04,040 --> 00:04:07,080 After a few weeks of dilation, it has improved. 60 00:04:07,080 --> 00:04:12,760 However, some cases are more technically difficult, usually due to the size of the stricture or 61 00:04:12,760 --> 00:04:14,400 even the size of the patient. 62 00:04:14,400 --> 00:04:17,920 This is when fluoroscopic guidance is helpful to complement endoscopy. 63 00:04:17,920 --> 00:04:23,400 We pass the scope down and put some contrast in to demonstrate the anatomy. 64 00:04:23,400 --> 00:04:27,480 Pass a wire through the scope down into the stomach to guide the balloon and pass the 65 00:04:27,480 --> 00:04:28,480 balloon down. 66 00:04:28,480 --> 00:04:33,640 You can actually put the scope down next to the wire and watch it happen. 67 00:04:33,640 --> 00:04:38,360 It's just as easy to do it under just fluoroscopy. 68 00:04:38,360 --> 00:04:43,040 It's really important to remember that sometimes the pressure of the stricture will actually 69 00:04:43,040 --> 00:04:48,400 exceed what the balloon can generate, and you may not achieve the full dilation diameter 70 00:04:48,400 --> 00:04:49,400 of the balloon. 71 00:04:49,400 --> 00:04:51,960 This, however, will be seen on fluoroscopy. 72 00:04:51,960 --> 00:04:55,600 Here are some more advantages to using fluoroscopy or dilation. 73 00:04:55,600 --> 00:04:57,960 Fluoroscopy allows us to do a pre-dilation esophogram. 74 00:04:57,960 --> 00:05:04,040 We use water soluble contrast to the scope to assess the stricture and the diameter of 75 00:05:04,040 --> 00:05:09,160 the rest of the esophagus, and then we compare that to what we achieved with the prior dilation 76 00:05:09,160 --> 00:05:11,800 if it's not the first one for this individual. 77 00:05:11,800 --> 00:05:16,240 Fluoroscopy allows us to see the balloon in position to make sure it hasn't slid anywhere. 78 00:05:16,240 --> 00:05:21,560 A post-dilation esophogram gives you a rough sense of the remaining stenosis and if there 79 00:05:21,560 --> 00:05:26,360 is a perforation, which can be an unfortunate complication of esophageal dilation. 80 00:05:26,360 --> 00:05:29,320 Luckily, it is usually seen almost immediately. 81 00:05:29,320 --> 00:05:32,520 These are my rules for esophageal dilation. 82 00:05:32,520 --> 00:05:34,800 The first is just don't screw it up. 83 00:05:34,800 --> 00:05:38,320 You have to be able to assess the stricture, both the diameter and the length. 84 00:05:38,320 --> 00:05:44,560 You need to know the etiology and the mechanism that formed the stricture, the time since 85 00:05:44,560 --> 00:05:49,720 it formed, prior attempts to dilate and form a lot of the decision making. 86 00:05:49,720 --> 00:05:55,000 Observe the stricture between dilator passages or inflations to know what impact there may 87 00:05:55,000 --> 00:05:57,240 be on the epithelium. 88 00:05:57,240 --> 00:05:59,480 Estimate or measure the luminal diameter. 89 00:05:59,480 --> 00:06:03,680 And lastly, match the method of stricture dilation to the type of stricture. 90 00:06:03,680 --> 00:06:06,780 You also need to take into account the operator's experience. 91 00:06:06,780 --> 00:06:08,780 We dilate things incrementally. 92 00:06:08,780 --> 00:06:15,200 We go in small increments every one to three weeks depending on the stricture until we've 93 00:06:15,200 --> 00:06:17,800 achieved a reasonable diameter. 94 00:06:17,800 --> 00:06:21,120 What are complications that can occur with esophageal dilation? 95 00:06:21,120 --> 00:06:22,120 Bleeding? 96 00:06:22,120 --> 00:06:23,200 Chest pain? 97 00:06:23,200 --> 00:06:27,480 The creation of a false tract and even submucosal dissection can take place. 98 00:06:27,480 --> 00:06:28,920 I'll show you an example. 99 00:06:28,920 --> 00:06:33,400 This is a child who's about two years old who had hypoblastic left heart syndrome. 100 00:06:33,400 --> 00:06:37,600 He also had a tracheosophageal fistula at birth that was repaired. 101 00:06:37,600 --> 00:06:43,080 He developed dysphagia with solid foods in the first year of life. 102 00:06:43,080 --> 00:06:47,960 This little boy has had several dilations at this point and a fibromuscular stenotic 103 00:06:47,960 --> 00:06:49,040 stricture. 104 00:06:49,040 --> 00:06:55,520 When visualized during endoscopy, the anastomosis looks great, but sadly, distal to the stricture, 105 00:06:55,520 --> 00:06:57,680 there was a second arrow of narrowing identified. 106 00:06:57,680 --> 00:07:02,880 We'd go up to it with a scope and tap on it and it would immediately go into spasm. 107 00:07:02,880 --> 00:07:04,680 It was very bizarre. 108 00:07:04,680 --> 00:07:08,880 So we dilated it a couple of times and it wasn't making much progress. 109 00:07:08,880 --> 00:07:14,720 So we made a little more balloon size and we immediately saw it pop. 110 00:07:14,720 --> 00:07:18,820 There was a hole in the epithelium of the esophagus that I could see in. 111 00:07:18,820 --> 00:07:23,400 But to further evaluate the degree of perforation, they added contrast to this study and were 112 00:07:23,400 --> 00:07:25,280 able to better visualize the injury. 113 00:07:25,280 --> 00:07:31,120 And you can see there's an opening here and then contrast outside the lumen of the esophagus 114 00:07:31,120 --> 00:07:36,880 in this tract, not flowing into the mediastinum, just in the wall of the esophagus. 115 00:07:36,880 --> 00:07:41,760 An NG tube was placed for decompression and they observed the patient for several days. 116 00:07:41,760 --> 00:07:46,720 Since he remained asymptomatic, they did a follow-up contrast study via the NG tube, 117 00:07:46,720 --> 00:07:51,120 which fortunately showed complete healing of the perforation. 118 00:07:51,120 --> 00:07:55,600 Perforation is obviously one we don't want to deal with if we don't absolutely have to. 119 00:07:55,600 --> 00:08:01,520 So conservative dilations over incremental dilations is probably preferable. 120 00:08:01,520 --> 00:08:04,840 So should you choose balloon dilation or bougienage? 121 00:08:04,840 --> 00:08:07,880 This is not a one-size-fits-all process. 122 00:08:07,880 --> 00:08:13,440 The reality is both are quite safe and there are not very many perforations in a very large 123 00:08:13,440 --> 00:08:17,480 series and only a couple percent actually went on to surgery. 124 00:08:17,480 --> 00:08:22,480 So pick your weapon, learn how to use it judiciously. 125 00:08:22,480 --> 00:08:26,880 Our final case is a seven-month-old with an incidental finding of stricture on a routine 126 00:08:26,880 --> 00:08:28,760 follow-up contrast exam. 127 00:08:28,760 --> 00:08:34,500 This child could drink an eight-ounce bottle in five minutes with no symptoms. 128 00:08:34,500 --> 00:08:37,360 Dilation generally works pretty well on these guys. 129 00:08:37,360 --> 00:08:40,440 There's always still a little bit of scar remnant left over. 130 00:08:40,440 --> 00:08:45,200 You should never try to dilate to the diameter of the proximal pouch because it is always 131 00:08:45,200 --> 00:08:47,000 much bigger than the distal. 132 00:08:47,000 --> 00:08:51,840 Taking away the shoulder at the margin or the junction of the anastomosis and the distal 133 00:08:51,840 --> 00:08:57,320 esophagus and getting the area to about the size of the distal esophagus tends to work 134 00:08:57,320 --> 00:08:58,320 very well. 135 00:08:58,320 --> 00:09:03,060 In summary, a patient-centered approach is essential in managing esophageal strictures 136 00:09:03,060 --> 00:09:04,640 effectively. 137 00:09:04,640 --> 00:09:10,280 Esophageal stricture symptoms vary with age, oral intake, and stenosis severity. 138 00:09:10,280 --> 00:09:15,640 Stomachitis requires assessing nutritional status and considering endoscopy or esophogram. 139 00:09:15,640 --> 00:09:21,000 Balloon dilation options include controlled radial expansion, hurricane balloons, and 140 00:09:21,000 --> 00:09:22,000 bousinage. 141 00:09:22,000 --> 00:09:27,240 Fluoroscopy aids in dilation, allowing pre- and post-dilation esophagrams. 142 00:09:27,240 --> 00:09:31,760 Incremental dilation with caution minimizes complications like perforation. 143 00:09:31,760 --> 00:09:38,320 Choose between balloon dilation or bousinage judiciously, depending on the case. 144 00:09:38,320 --> 00:09:43,440 Tailor dilation to the patient's unique anatomy and focus on scar remnant removal. 145 00:09:43,440 --> 00:09:47,160 Don't forget to subscribe to the Stay Current MD YouTube channel. 146 00:09:47,160 --> 00:09:51,920 Follow our social media channels and download the Stay Current MD app for tons of content 147 00:09:51,920 --> 00:09:54,960 in pediatric surgery. 148 00:09:54,960 --> 00:10:00,600 Global Cast MD, along with Cincinnati Children's Hospital, sharing knowledge to improve child 149 00:10:00,600 --> 00:10:08,320 health around the globe.