Management of Esophageal Stenosis and Strictures in Children | Congenital & Acquired w/ Dr. Walther
With Dr. Ashley Walther · hosted by Dr. Jill Knepprath
Chapter 1 of 6
Congenital types
Introduction and Congenital Esophageal Stenosis Types
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Dr. Ashley WaltherWhat the experts said
There are both congenital and acquired esophageal stenosis
Fibromuscular hypertrophy is the most common type of congenital esophageal stenosis
Congenital esophageal stenosis can also present as tracheal bronchial remnants or mucosal webs
Congenital esophageal stenosis is associated with EATEF, esophageal duplications, congenital heart disease, anorectal malformations, and VACTERL
Fibromuscular hypertrophy occurs in the middle to lower third of the esophagus
Tracheal bronchial remnants occur in the lower third of the esophagus
Acquired esophageal stenosis includes peptic stricture from GERD, caustic ingestion, or iatrogenic stricture from perforation
Workup for esophageal stenosis starts with an esophagram
The first treatment attempted is usually dilation
There are two types of dilators: bougie dilation and balloon dilators
Balloon dilation provides more controlled dilation with equal pressure and can be done under fluoroscopic guidance
Resection of congenital esophageal stenosis can be performed thoracoscopically
Three main esophageal replacement techniques are gastric pull-up, jejunal interposition, and colonic interposition
Gastric pull-ups carry long-term risks of dilation and redundancy, creating a space-occupying lesion in the chest over time
Jejunal interposition is a very complex surgery that should be performed at a major center with all important personnel in place
Colonic interposition uses pieces of transverse or descending colon, performed either isoperistaltic or antiperistaltic depending on mesenteric blood supply
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
Colonic interpositions sometimes become stretched out and redundant, requiring revision
For peptic strictures, treatment should address the underlying reflux rather than the stricture itself
Endoscopic options for strictures include needle knife stricturoplasty, which uses a thin device to score the strictured area in multiple places
EOE strictures are related to a disease process and are different from other stricture types
Dupixent, a monoclonal antibody given via weekly injection, is a medication for EOE
If EOE persists despite medical treatment, dilation is performed
CT is reserved for cases where extrinsic compression or vascular rings are suspected
Bougie dilators are tapered and pressure is applied until resistance is felt
Short congenital strictures that fail dilation are best treated with resection
Long strictures often require esophageal replacement
Jejunal interposition is the most similar to the esophagus and is less likely to dilate with lower risk of reflux
Jejunal interposition carries the highest risk of complication among the three replacement options, including high risk of ischemia and conduit loss
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
Complications of colonic interposition include leak or stricture at the proximal anastomosis
Management of peptic strictures usually involves high-dose proton pump inhibitors
If peptic stricture persists after medical management, Nissen fundoplication can be considered
Kenalog is injected during endoscopic stricturoplasty to prevent scarring and dilation
In eosinophilic esophagitis, inflammation leads to strictures
Diagnosis of EOE requires upper endoscopy and biopsy to show the presence of eosinophils
Treatment of EOE starts with food elimination and topical steroids
Esophageal replacement options all carry significant risk and should be performed at experienced centers