Tricks - Indwelling Balloon Catheter For Refractory Esophageal Stenosis

Now here comes your talk. So the idea is that, uh, veal stenosis, either, it's after, uh, raresia or, uh, reflux esophagitis, um, we, we, we can use all kinds of dilatation, and the balloon dilatation is very popular. And, and usually that is enough, but sometimes, uh, if you have, uh, a persistent stenosis, the, uh, the, the recurrence rate is, is increasing, uh, and you have to dilate and dilate it over and over again. And it comes back every time. So what we decided to try out, and it's almost been, I think, 10 years ago for the first time, that if we would use one of these dilatation balloons, uh, insert them through the nose and, uh, under, uh, direct vision of, uh, an esophago scope, uh, place them at the site of the stenosis, and after a good dilatation and anesthesia, leave them there and then insufflate them three times a day. Uh, just for, for 10 seconds and then desufflate it again. And in order, with the idea behind it that it will heal at at least the diameter of this balloon. So if you have a 10 millimeter diameter balloon, it will heal at least at a diameter of 10 millimeters, and that is usually sufficient. Now, if you use all kinds of stents, they, they, they tend to obstruct, to dislodge, uh, because the balloon is fixed to the catheter, which is coming out through the nose, you have very little dislodgement. Uh, and the, the children can drink or even eat, eat solid foods, uh, alongside this balloon. So, therefore, it's, it's, uh, we thought it, it might be a very nice, uh, technique, and we had some very nice results. So the, uh, balloons we used were either, uh, the Olympus endotherapy as a balloon, but for some time, this was not available anymore. So, uh, we also used the Boston Scientific Ultrasin, uh, stent balloons, which are actually vascular, Balloons. Don't tell them, but it works. Uh, and you have them in, in different sizes. Uh, you have them in different lengths, uh, different diameters, so you can choose depending on the age, uh, of the patient or the, the diameter that you want to dilate to, uh, to take either of these balloons. And in particular, if you have, uh, burns, uh, light burns, they, they usually extend over a, a longer, uh, length of, of the esophagus, and there you can even use two balloons at the same time. So you can insert an 8 cm, 10 balloon, and above that, uh, put in another 4 cm, 10 balloon, or even an 8, depending on the age of the patient. So this is the, the picture that you see is, uh, the endoscope, uh, the flexible endoscope we use in the esophagus. You see the, the black, uh, line, which determines the upper level of the, the balloon, and in addition, you can see the stenosis that's been dilated. Now, this is a, a very awkward graph, but it just gives you, uh, an idea of the, the, the patients we used it in, uh, the, the, the, the, the, the indications, uh, and the number of endoscopies we needed, uh, the complications we had. Uh, so in short, we had 5 patients with a long gap, resia that, uh, healed with stenosis and needed dilatation. We had two patients with a Ty Cresia. We have 7 patients with caustic burns, uh, 3 patients with, uh, uh, a stenosis of an unknown cause, and in two patients of persistent reflux in spite of anti reflux surgery. Uh, and as you can see, it's particularly in the patients with, uh, caustic burns or, uh, stenosis for unknown causes that we needed to dilate for a prolonged period. But the good, the good thing of this is that you, uh, did not need to do that many endoscopies anymore. So you either did an endoscopy once in every 4 weeks, because you were sure that these balloons were keeping these, uh, esophagus at a, at a, at a one diameter. Um, and of course, at some occasions, uh, we had complications. Uh, we had a, a restenosis in, in, in, uh, uh, 6 children where, after, uh, taking out the balloon after, say, 4 to 6 weeks, uh, we, we had a restenosis and we just reinserted the balloon and went on for another 4 to 6 weeks and it cured the, the, the stenosis. We had a few occasions of dislodgement in spite of the fact that it's usually pretty, uh, severe, but, uh, sometimes the children are, uh, able to put a finger in between, uh, the catheter and the, uh, and the nose and pull it out. Uh, in, uh, some occasions we had a leakage, so the balloon, uh, broke, uh, so we had to replace it. And in one patient, it was a very young woman, at some point, she developed some, uh, sputum retention, uh, and my colleague thought it was better to take it out. Um, but in any case, she, she did well afterwards. Now, we had no mortality, but I think the most important thing is that we, in, in none of these occasions, we didn't, we need to do, uh, surgery afterwards. So this is, uh, an example of the, uh, an x-ray you can see. So, you see the upper dot and the lower dot of where the balloon is. You see where the stenosis is, the extension of the stenosis, uh, and you can see that the balloon is in, in the right position. We only use this this picture where we have doubts when they are complaining to see whether this is still in the in the right position. Uh, and this is an example of, uh, that, where we, where we were using two balloons. It's, it was a lye burn in a 16 year old kid. Uh, who at a party was given a lye to drink, um, and she had an extensive stenosis over approximately 10 cm. So, uh, on the right, you see the dots? Indicating the, the 8 cm lower, uh, balloon, and on the left, the 4 cm upper balloon. Uh, and in approximately 3 months' time, we were able to completely heal this esophagus, uh, before taking out the balloons. Uh, and she could just eat afterwards solids, initially fluids, but, uh, after, I think, two or three weeks, she started eating, eating solid foods. And they were complaining that they, uh, that they wanted to have, uh, champagne at New Year's eve, and, uh, if they could have the champagne, well, if you want to have champagne, you can have your champagne. OK. But this is how, how it looks like when you see an x-ray. So, in conclusion, I think it's safe, uh, to use. It can be used at home by parents. You, you can teach them. It's quite easy. Uh, the parents are comforted to use it at home. Um, and, What I think is more important is that it, it obviates the need for, uh, rearchotomy, uh, arthroscopy or esophageal replacement. So, uh, we are very happy with this technique, and, uh, I'm pleased to show it here. Well, it was fantastic. Uh, Jack, do you wanna make a comment? Yeah, I, I, I think this is wonderful. I, I mean, it takes me back to the old days, uh, when I was training where we didn't have balloon dilatation and we would uh have a Maloney bougie at the bedside. And uh we'd go by there a couple of times a day and pass a Maloney bougie and it was the same principle. I think the more times you dilate a stricture, the more likely it is to heal in that open position and uh so I think this is fantastic. I've got a child at home that I've been struggling with and I the first thing I'm going to do when I go home is uh. Is, is one of these things. Well, the good thing is that you dilate it, and under anesthesia, but thereafter, you only have to keep it open. You don't need to dilate it. It is not painful. Yeah. Uh, and we even had a very small child that, uh, swallowed one of these batteries, these, uh, I call them batteries, and it was in the upper sphincter. Uh, and we managed to put in a 4 centimeter 10 millimeter balloon in there and you know by inflating first a little bit to to let her know that we were going to do something and then quickly insufflated and again we were able to cure this without any complications so it was very, very elegant technique. So those catheters are fairly stiff or stiffer. Than the normal nasogastric tubes or silastic tubes that we leave for a long time. Have you had any problems with nasal notching? Uh, no, of course you need to improvise. Uh, at, uh, first you, you have to, um, let me see, can I see it? You have to bend the tip in order to be able to introduce through the nose. What I have learned recently is that in, in, in one case I just introduced a guide wire through the nose, and these, uh, candidates easily follow. This guide wire, and I could replace one without putting the, the, the patient under anesthesia. So, yes, they are a bit stiffer, uh, and sometimes in the small children at the, the level where they come out of the nose, you have to bend them and really a little forcefully to keep it in a, in a sort of a hook. Uh, and then you fix it on the cheek with some, Duoderm at the bottom and then some plaster over it, over it, uh, to, to fix it there. Um, sometimes you have the, the, the, that they have the, uh, the, uh, the tend, the tendency to, uh, pull out the, the wing of the nose, and then I can put some, uh, wire around, or I call it, uh, for tying down the umbilicus after birth. Uh, and, and put on the other side also a little duoderm, tie it around it and pull it back towards the middle of the nose so you don't get the destretching of the wing of the nose. It's a great technique actually. I really, I really like that. I have a patient tomorrow that I'm going to do the balloon dilatation, so I was going to just do the balloon dilatation, take it out, but I think it's a good idea just to leave it for, um, I don't know. So how, how long? You keep it or, well, you know, usually, um, when I have a patient with stenosis, I dilate them once or twice, maybe three times, but when it persists, you know that you have to do more, and then I introduce them and leave them behind. And initially I'll leave him behind for 2 weeks if you have severe inflammation to see how it's healing, if it's getting better, but particularly in burns, I'll leave him in for stretches of 4 weeks before going back to Look at it and, and maybe replace them. Uh, and that goes very well. You can also get tube feeding, uh, because it's a dual lumen, uh, catheters, they all are. So, uh, you can even give these patients tube feeding, uh, through, through the catheter. Um, I noticed in your chart, this is fascinating, and I too have a patient tomorrow that I'm dilating and uh, I may, I may do this, um, in, in your chart there were two patients with reflux strictures, and it seems they both failed. Is that correct? The, the chart's very tiny on my screen, so I couldn't read it. OK, um, let me see, um, over on the far right of the screen under reflex there were, I think N equals 2, and I think under complications restenosis, it was 2. Yes, True. So, uh, in these occasions, uh, we just put it back in again. And then, uh, for, there was, there was one patient that we did not really understand very well. He was a retarded child, uh, and we did an anti reflux surgery and the pH study was, uh, 1, for instance. So it was, there was no reflux anymore, and he was still having this mid esophageal, uh, stenosis. So ultimately, uh, we gave him, uh, to swallow, uh, steroid, uh, gels that you usually give transanally, uh, just to make it cure. Uh, and ultimately, uh, it, it, it helped, and, uh, the stenosis, uh, went away. Uh, we did, we could take out the balloon, and he's now, I think, maybe two years afterwards, and he's doing fine. But you left them in for how long? Um, uh, for stretches of, say, uh, 2 to 4 weeks. Uh, and particularly the, the, the caustic burns, they've been in for, uh, maybe 3 to 6 months. Because, you know, before it heals, it's, it's very long, uh, lasting, and you really have to be sure that it has healed completely, uh, before you take them out. Yeah, well, thank you, David. I think you had mentioned this, um, maybe you or somebody from your group at the IPEG in San Diego a couple of years ago, and so I, I think it's fantastic that you've actually published this experience, because when I came back, I tried to convince our GI doctors to try this, and they've just been thoroughly unexcited, although I think it's a fantastic. experience and also because not just the healing of the esophagus, but you've taken care of the problem of multiple anesthetics which is becoming an increasing issue in many of these young kids. Putting them through a general anesthetic every, every couple of weeks. Um, how, is there a set protocol? How often do you ask the parents to dilate, say, you know, to inflate the balloon? Is it once a day, several times a day? And then how do you decide to remove it? In other words, do you wait, for example, for a 2 or 3 week period without any balloon inflation, and then if the esophagus is holding, you remove it, or how, what are your criteria for removing it? Well, uh, to answer your first question, principally, I ask them to insufflate three times a day. Um, and like I said, I've, um, I use a, a 20 cc syringe, and I first have to inflate 5 cc of air, no fluids, because otherwise the balloon, uh, will, uh, glue together. So only, only air. Uh, and the 1st 5 cc is to get the, the child to know that, that something's going to happen. Because then it will swallow once, uh, before you increase it up to, well, usually between 15 and 20 cc of, of air. And then afterwards, you immediately desufflate it. You, uh, put the empty syringe on it again and desufflate again just to make it go vacuum completely. And you do it 3 times a day. So, um, the first time I, I go back after 2 weeks, and I do an anesthesia, uh, an endoscopy, see how the progress is, if we, if it's satisfying, and if I'm satisfied, I can, uh, extend it up to 4 weeks. If I know I need a prolonged time, uh, and then go back after 4 weeks, uh, until I see that it is completely healed, and I then just take it out. And then see how the child does, if he can continue to eat and drink well. Uh, and is having no more symptoms of stenosis. And unless they are not having new symptoms, I don't do any, uh, contrast studies or, uh, new endoscopies unless they have, they have complaints. You know, David. Have you had any patients who have failed after you thought you had succeeded? In other words, once you took it out, then a month or two later they come back with a, a recurrent stricture? There were, uh, I think, 2 in the series that we have to, uh, that we had to give another period of 4 to 6 weeks of dilatation because the stenosis recurred. David, you know, this is, uh, it's, you know, the Saintston Blakemore tubes that we used to use for esophageal varices, uh, has a balloon, a gastric balloon, and then the esophageal balloon. And then you, you, you, you'd pull up so you would know exactly where the length of the oesophageal portion of the balloon was. I wonder if we could construct one just designed so you know exactly the position every time. Well, it's quite easy because the balloon is marked, so there are, there are two little metal, uh, spots in the catheter. So if you want to know exactly where it is and, uh, uh, radiology, you can have them swallow a little bit of contrast, and you can determine exactly where the catheter is. I use, usually under anesthesia, the endoscope, because I can see where the, uh, the stenosis is, and like I showed on one of the pictures that you see the upper, Uh, black, uh, mark, then if you, if you, if you have a 4 cm balloon, uh, you place it approximately 1 cm above the level of the stenosis, and then you fix it at the corner of the nose. And, you know, um, when you inflate the balloon, and then, you know, be sure that you fix it to the nose, it, it won't move. So, uh, only after you have fixed it, you deflate the balloon and then you are sure that it's in the right position. Like I said, Yeah. During dislodgement, you can, uh, go back nowadays and under fluoroscopy, you can replace that, at the right position. Jack, I, I just don't feel that a discussion of recurrent esophageal strictures is complete without mentioning mitomycin. Right. Because, um, there has been quite a bit of experience with it, and I, I've had a couple of them that I've treated with mittamycin. Usually takes a, a few treatments that have, that have had, you know, dozens of dilatations before that. And have stayed open with the mitomycin. So, I'm wondering if you would go that route before you do this, or do you think this, you should just go straight to this, David? Um, I think this is, um, Well, the injection of, uh, mendamycin, again, you need also some, uh, uh, how do you call it, uh, expertise in that. Um, this is a, a, a pretty benign, uh, approach. Uh, you don't have to inject anything. The mitomycin is not injected, it's just topical, topical application of mittamycin. I think you could do both. I mean, I, I mean, I'm telling you, I know we're thinking the same. And actually the thing that's nice about these things when they come up when we do these talks, it's fun to see everyone in the faculty go tomorrow or two days from now on because everybody has everyone else has one of these. I have like 15 things I wrote down when I was reviewing this. Thanks for answering, David, and it's excellent piece, but I think we're all. Very intrigued. Yeah, I think this is gonna be one of those, uh, in innovations that we see on here. It's incredible. You've presented this. You published this, but I'm glad we were able to represent it again here because a lot of us here have not seen that, and I think it's gonna change practice drastically. We actually have a call from my father. He's a, uh, an a surgical endoscopist. He's a general surgeon, but it does all endoscopy. JP, are you there? Yeah, I'm here. What do you want to say? You know, I'm just getting over an illness, so I'm forced to watch pediatric surgical education, but it's wonderful. Uh, I just want to make a plug for uh endoscopic fully covered metal expandable stents. There's a recent article in this month's Journal of Gastrointestinal Surgery which reviews these results both for leaks and strictures, and the newer fully covered metal stents, and they do migrate, I agree, and sometimes you have to use one inside the other. They don't have to come out of the nose, and they're, I think they're more comfortable than balloons, and the results have been outstanding if you look at this current review. So I think in the future we're going to go to fully expandable, fully covered metal stents that are removable. They stay in. An average of about 4 to 5 weeks, and the injection of steroids into the wall of the esophagus for recalcitrant or recurrent strictures has been useful as well. So that's just a little bit of extra information. Can I, can I get a clarification? Can I just make a comment on that? Yeah, I mean, I think that's a fantastic experience and it has translated into pediatrics to some extent. But to just temper the experience, um, we, and, and then, you know, when you have a disaster, you speak to other people, it turns out they've had disasters too, but they've just not wanted to talk much about them. And so we've had a couple of these stents literally erode right through the esophagus, one into, um, uh, an aberrant innominate, and, you know, a child died from a fistula that exsanguinated. And speaking to others, um, in California and other places, um, several people who've tried the stents have had those experiences. So I think, um, you, you just, especially in the small kids with atresia, you have to be very, very careful about using them. And you have to match the size of the stent to the size of the esophagus. I agree 100%. Biodegradable stents, any experience with biodegradable stents? They're available in Europe and the UK, but There's very little data on those, but that will be the future. But nightanol, and you just alluded to the problem with nightanol, it's unforgiving. And it will erode if it's not the right size. So that's very important what you said. I, I've heard, I've heard that because we talked about putting a stent in one of my patients, and I've heard that the challenge of the stent is getting it out. Um, can you comment on that? Well, the right way, if it's, uh, the newer stents, you pull a little string in the middle and it collapses, but uh, The trick with nightanol is to put cold water through the middle of the lumen first, which causes the nightanol to shrink, and then you pull the string and wiggle it out. But there can be some problems sometimes as well, and that's apparently the huge advantage of the biodegradable stents. They dissolve after 4 to 6 weeks. Yes, yeah. Can they, can they have solid foods? Yeah, semi-solid food. Yes, semi-solid food, but I think this is the future and what you've demonstrated with these balloons is that they can be done now. We just have to make it easier. Yeah, I think that's the key point is that you show something staying there for a chronic period of time, even intermittently we'll we'll fix it. And what's the now it's designing something that'll work. I did not want a clarification because it may just for a little levity. I, I feel much better now because Jeff Ponsky, you're, you're obviously, I suspect using your wife's computer because it looks like Todd's mom is making these brilliant. You're right, she signed out and I'm looking at you that Todd's mom is saying, uh, you know, injection of steroids should be wow, this is an amazing family. It is, we know already, but that was really a. smile. Well, well, thanks for letting me intrude. Thanks for calling in. Uh, it's a good perspective and, and David, that was, I think you clearly, uh, made a huge impact, and I, I'm excited to, for, I think everyone here is gonna try it and we'll have to reconvene in a couple of years and see what we're doing. So thank you very much. Let's, uh.