QUAD #13 Esophageal Strictures & Endoscopic Interventions with Dr. Phil Putnam

Globalcast MD along with Cincinnati Children's Hospital sharing knowledge to improve child health around the globe. Hello everyone. This is Kim Pribut 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 Aerodigestive Society Conference, the Cincinnati Children's airway course, and the Cincinnati Children's pediatric dysphagia series. Today, we will review esophageal dilation techniques in 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, a parent who's 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, regurgitation right after the attempt to swallow something, choking and coughing, or secretion management are 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. You know, familiar with controlled radio 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 bougienage with Maloney or Savory 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 cm dilators are wire guided, while the 8 cm 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 two, four, or six 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. Bougienage is certainly possible to do. Maloney dilators, I really like to use for things like esophilic esophagitis. Maloney dilators are not wire guided, they're passed by 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, they're a bit stiffer. They do require wire guided, 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, then pass the balloon down. You can actually put the scope down next to the wire and watch it happen, and 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's some more advantages to using fluoroscopy for dilation. Fluoroscopy allows us to do a pre dilation esophagram. We use water soluble contrast through 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. The fluoroscopy allows us to see the balloon in position to make sure it hasn't slid anywhere. A post dilation esophagram 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 ideology and the mechanism that formed the stricture, the time since it formed, prior attempts to dilate inform 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, so we'll 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 hypoplastic left heart syndrome. He also had a tracheal esophageal fistula at birth that was repaired, and 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 go up to it with the scope and tap on it and it would immediately go into spasm, and it's 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 they could see in. 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 8 ounce bottle in five minutes with no symptoms. Dilation generally works pretty well in 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 in 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. Diagnosis requires assessing nutritional status and considering endoscopy or esophagram. Balloon dilation options include controlled radio expansion, hurricane balloons, and bougienage. Fluoroscopy aids in dilation allowing pre and post dilation esophagrams. Incremental dilation with caution, minimizes complications like perforation. Choose between balloon dilation or bougienage judiciously, depending on the case. Tailor dilation to the patient's unique anatomy and focus on scar remnant removal. Don't forget to subscribe to the Stay Current MD YouTube channel. Follow our social media channels and download the Stay Current MD app for tons of content in pediatric surgery. Globalcast MD along with Cincinnati Children's Hospital sharing knowledge to improve child health around the globe.