Management of Esophageal Stenosis and Strictures in Children | Congenital & Acquired w/ Dr. Walther
There are both congenital and acquired esophageal stenosis
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Fibromuscular hypertrophy is the most common type of congenital esophageal stenosis
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Congenital esophageal stenosis can also present as tracheal bronchial remnants or mucosal webs
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Congenital esophageal stenosis is associated with EATEF, esophageal duplications, congenital heart disease, anorectal malformations, and VACTERL
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Fibromuscular hypertrophy occurs in the middle to lower third of the esophagus
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Tracheal bronchial remnants occur in the lower third of the esophagus
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Acquired esophageal stenosis includes peptic stricture from GERD, caustic ingestion, or iatrogenic stricture from perforation
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Workup for esophageal stenosis starts with an esophagram
guidelineAshley Walther1:23 ↗
CT is reserved for cases where extrinsic compression or vascular rings are suspected
Host summaryJill Knepprath summarizes what Dr. Ashley Walther said — not the host's own clinical position1:37 ↗
The first treatment attempted is usually dilation
guidelineAshley Walther1:42 ↗
There are two types of dilators: bougie dilation and balloon dilators
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Bougie dilators are tapered and pressure is applied until resistance is felt
Host summaryJill Knepprath summarizes what Dr. Ashley Walther said — not the host's own clinical position1:49 ↗
Balloon dilation provides more controlled dilation with equal pressure and can be done under fluoroscopic guidance
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Short congenital strictures that fail dilation are best treated with resection
Host summaryJill Knepprath summarizes what Dr. Ashley Walther said — not the host's own clinical position2:12 ↗
Resection of congenital esophageal stenosis can be performed thoracoscopically
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Long strictures often require esophageal replacement
Host summaryJill Knepprath summarizes what Dr. Ashley Walther said — not the host's own clinical position2:24 ↗
Three main esophageal replacement techniques are gastric pull-up, jejunal interposition, and colonic interposition
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Gastric pull-ups carry long-term risks of dilation and redundancy, creating a space-occupying lesion in the chest over time
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Jejunal interposition is the most similar to the esophagus and is less likely to dilate with lower risk of reflux
Host summaryJill Knepprath summarizes what Dr. Ashley Walther said — not the host's own clinical position2:57 ↗
Jejunal interposition is a very complex surgery that should be performed at a major center with all important personnel in place
opinionAshley Walther3:03 ↗
Jejunal interposition carries the highest risk of complication among the three replacement options, including high risk of ischemia and conduit loss
Host summaryJill Knepprath summarizes what Dr. Ashley Walther said — not the host's own clinical position3:12 ↗
Most jejunal interposition patients require G-tube feeds because it is hard to take in a normal volume of food with jejunum as the conduit
Host summaryJill Knepprath summarizes what Dr. Ashley Walther said — not the host's own clinical position3:20 ↗
Colonic interposition uses pieces of transverse or descending colon, performed either isoperistaltic or antiperistaltic depending on mesenteric blood supply
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Complications of colonic interposition include leak or stricture at the proximal anastomosis
Host summaryJill Knepprath summarizes what Dr. Ashley Walther said — not the host's own clinical position3:42 ↗
The colon does not peristalse like the esophagus or bowel, so with antiperistaltic placement gravity pulls food down and the colon becomes dilated over time
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Colonic interpositions sometimes become stretched out and redundant, requiring revision
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For peptic strictures, treatment should address the underlying reflux rather than the stricture itself
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Management of peptic strictures usually involves high-dose proton pump inhibitors
Host summaryJill Knepprath summarizes what Dr. Ashley Walther said — not the host's own clinical position4:16 ↗
If peptic stricture persists after medical management, Nissen fundoplication can be considered
Host summaryJill Knepprath summarizes what Dr. Ashley Walther said — not the host's own clinical position4:20 ↗
Endoscopic options for strictures include needle knife stricturoplasty, which uses a thin device to score the strictured area in multiple places
clinicalAshley Walther4:30 ↗