Global Cast MD, along with Cincinnati Children's Hospital, sharing knowledge to improve child
health around the globe.
Hello, everyone.
This is Kim Perkin, and I'd like to welcome you back to the continuation of our Quad series.
In October 2022, Cincinnati Children's hosted the Quad Conference, which was a combination
of four conferences, the International Organization for Esophageal Atresia, the Air Digestive
Society Conference, the Cincinnati Children's Airway Course, and the Cincinnati Children's
Pediatric Dysphagia Series.
Today, we will review esophageal dilation techniques and TEF repairs with Dr. Phil Putnam,
a gastroenterologist from Cincinnati Children's Hospital Medical Center.
The symptoms related to esophageal strictures are related to the age and developmental status
of the patient or parent who is doing the reporting of symptoms.
The degree of stenosis and the nature of the oral intake that's being attempted.
Young infants are usually consuming liquids with purees and chewed solids as the child
ages.
Knowing what and how the child handles their food is so helpful in diagnosis.
It's also important to note if the symptoms are progressive or static in nature.
An abrupt change in swallowing in somebody with a known stricture has a foreign body
until proven otherwise.
Patients and their parents will describe the sensation of food getting stuck or going down
slow or regurgitation right after the attempt to swallow something, choking and coughing,
or secretion management.
They're all potential symptoms related to stenosis.
In regard to the physical exam, it is important to pay close attention to the nutritional
status of the patient, how they handle secretions, and if they have or have previously needed
any tubes for nutritional support.
Once the patient has been fully assessed, the clinician can determine how to further
investigate the problem.
Options for investigation include endoscopy or an esophagram.
We do a lot of endoscopy with fluoroscopy so that we get all the information we need
about location, diameter, and distance all at once.
But what tools are best used during endoscopy?
We have a lot of tools at our disposal for managing stenosis in the esophagus.
We're familiar with controlled radial expansion balloons because we use them quite commonly.
We also use hurricane balloons, which are intended for biliary dilation, and we have
the option to do bouchonage with Maloney or Saving Instruments.
Radial expansion balloon dilators only provide radial force once they are across the stenosis,
which can often be safer.
There are three sizes per balloon based on the amount of inflation that is needed.
The 5 centimeter dilators are wire guided, while the 8 centimeter dilators are not.
One of the advantages of the CRE balloons is that if you get them wet and pull the proximal
end of the balloon up against the lens of the scope, you can generally see down them
so you can observe what's happening at the business point where it's being dilated.
Hurricane balloon dilators, originally intended for ERCP, are wire guided and offer smaller
diameters of 2, 4, or 6 millimeters, and are shorter in length, only 2 to 4 centimeters.
They do generate a hard surface after inflation, which makes them ideal for smaller strictures,
as you would likely see in a child.
Bouchonage is certainly possible to do.
Maloney dilators I really like to use for things like eosinophilicus aftratus.
Maloney dilators are not wire guided.
In the past, I feel there is the potential for creating a false passage.
Maloney dilators generate both a longitudinal force as well as the radial force.
When using these in TEF, do so very cautiously as the tip can cause perforation.
The savory dilators are very nice.
They're a little more tapered than the Maloney's.
They're a bit stiffer.
They do require wire guidance, which is done with fluoroscopy under normal circumstances.
Here you see a child with a TEF-related anastomotic stricture on the left.
After a few weeks of dilation, it has improved.
However, some cases are more technically difficult, usually due to the size of the stricture or
even the size of the patient.
This is when fluoroscopic guidance is helpful to complement endoscopy.
We pass the scope down and put some contrast in to demonstrate the anatomy.
Pass a wire through the scope down into the stomach to guide the balloon and pass the
balloon down.
You can actually put the scope down next to the wire and watch it happen.
It's just as easy to do it under just fluoroscopy.
It's really important to remember that sometimes the pressure of the stricture will actually
exceed what the balloon can generate, and you may not achieve the full dilation diameter
of the balloon.
This, however, will be seen on fluoroscopy.
Here are some more advantages to using fluoroscopy or dilation.
Fluoroscopy allows us to do a pre-dilation esophogram.
We use water soluble contrast to the scope to assess the stricture and the diameter of
the rest of the esophagus, and then we compare that to what we achieved with the prior dilation
if it's not the first one for this individual.
Fluoroscopy allows us to see the balloon in position to make sure it hasn't slid anywhere.
A post-dilation esophogram gives you a rough sense of the remaining stenosis and if there
is a perforation, which can be an unfortunate complication of esophageal dilation.
Luckily, it is usually seen almost immediately.
These are my rules for esophageal dilation.
The first is just don't screw it up.
You have to be able to assess the stricture, both the diameter and the length.
You need to know the etiology and the mechanism that formed the stricture, the time since
it formed, prior attempts to dilate and form a lot of the decision making.
Observe the stricture between dilator passages or inflations to know what impact there may
be on the epithelium.
Estimate or measure the luminal diameter.
And lastly, match the method of stricture dilation to the type of stricture.
You also need to take into account the operator's experience.
We dilate things incrementally.
We go in small increments every one to three weeks depending on the stricture until we've
achieved a reasonable diameter.
What are complications that can occur with esophageal dilation?
Bleeding?
Chest pain?
The creation of a false tract and even submucosal dissection can take place.
I'll show you an example.
This is a child who's about two years old who had hypoblastic left heart syndrome.
He also had a tracheosophageal fistula at birth that was repaired.
He developed dysphagia with solid foods in the first year of life.
This little boy has had several dilations at this point and a fibromuscular stenotic
stricture.
When visualized during endoscopy, the anastomosis looks great, but sadly, distal to the stricture,
there was a second arrow of narrowing identified.
We'd go up to it with a scope and tap on it and it would immediately go into spasm.
It was very bizarre.
So we dilated it a couple of times and it wasn't making much progress.
So we made a little more balloon size and we immediately saw it pop.
There was a hole in the epithelium of the esophagus that I could see in.
But to further evaluate the degree of perforation, they added contrast to this study and were
able to better visualize the injury.
And you can see there's an opening here and then contrast outside the lumen of the esophagus
in this tract, not flowing into the mediastinum, just in the wall of the esophagus.
An NG tube was placed for decompression and they observed the patient for several days.
Since he remained asymptomatic, they did a follow-up contrast study via the NG tube,
which fortunately showed complete healing of the perforation.
Perforation is obviously one we don't want to deal with if we don't absolutely have to.
So conservative dilations over incremental dilations is probably preferable.
So should you choose balloon dilation or bougienage?
This is not a one-size-fits-all process.
The reality is both are quite safe and there are not very many perforations in a very large
series and only a couple percent actually went on to surgery.
So pick your weapon, learn how to use it judiciously.
Our final case is a seven-month-old with an incidental finding of stricture on a routine
follow-up contrast exam.
This child could drink an eight-ounce bottle in five minutes with no symptoms.
Dilation generally works pretty well on these guys.
There's always still a little bit of scar remnant left over.
You should never try to dilate to the diameter of the proximal pouch because it is always
much bigger than the distal.
Taking away the shoulder at the margin or the junction of the anastomosis and the distal
esophagus and getting the area to about the size of the distal esophagus tends to work
very well.
In summary, a patient-centered approach is essential in managing esophageal strictures
effectively.
Esophageal stricture symptoms vary with age, oral intake, and stenosis severity.
Stomachitis requires assessing nutritional status and considering endoscopy or esophogram.
Balloon dilation options include controlled radial expansion, hurricane balloons, and
bousinage.
Fluoroscopy aids in dilation, allowing pre- and post-dilation esophagrams.
Incremental dilation with caution minimizes complications like perforation.
Choose between balloon dilation or bousinage judiciously, depending on the case.
Tailor dilation to the patient's unique anatomy and focus on scar remnant removal.
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in pediatric surgery.
Global Cast MD, along with Cincinnati Children's Hospital, sharing knowledge to improve child
health around the globe.