Refractory strictures post-esophageal atresia repair: what are the alternatives?

Abstract

Esophageal strictures remain the most frequent complication after esophageal atresia (EA) repair despite refinements in operative techniques. With an incidence of anastomotic stricture between 8% and 49%, EA is the most frequent cause of benign esophageal stricture in children. The mainstay of treatment for esophageal stricture is dilatation with a 58-96% success rate. In order to relieve dysphagia, between 1 and 15 dilatations will be required in each EA patient with an esophageal stricture. However dilatations may lead to complications including perforation (0.1-0.4% of all esophageal benign strictures) and sociopsychological morbidity. Fifty percent of EA strictures will improve in 6 months. However, 30% will persist and require repeat dilatations. The present article explores the variety of non-surgical alternative treatments for anastomotic strictures after EA repair, focusing on triamcinolone acetonide, mitomycin C and esophageal stents. We propose an algorithm for a more standardized therapeutic approach, with the hope that an international panel of experts could meet and establish a consensus.

Postoperative Complications and Functional Outcome after Esophageal Atresia Repair: Results from Longitudinal Single-Center Follow-Up

“…35 Significant tension on the anastomotic site due to long-gap disease, previous history of anastomotic leakage, and recurrent GERD are known risk factors for stricture formation. 30,34 Unsurprisingly, all of our longgap cases, and seven patients with a preceding leak, later developed an anastomotic stricture. In addition, most of our infants with EA/TEF that presented with recurrent strictures also had GERD, and in almost half of these a fundoplication became necessary around the age of 2 years.…”

“…34 The majority usually respond well to repeated dilatations with bougies or hydrostatic balloons without need for further intervention. Only 24 (25.0%) children in our series with a stricture had more than five anastomotic dilatations.…”

Endoscopic Management of Anastomotic Esophageal Strictures Secondary to Esophageal Atresia

“…3,[8][9][10][11][12][13][14][15] There are several factors implicated in the pathogenesis of anastomotic stricture. These include creation of the esophageal anastomosis under excessive tension, ischemia at the ends of the esophageal pouches, creation of the anastomosis with 2 suture layers, use of silk suture material, anastomotic leak, esophageal gap length greater than 4 cm (long gap EA), and postoperative gastroesophageal reflux.…”

“…A recalcitrant stricture would be a persistent SI greater than 10% after 5 dilation sessions, and a recurrent stricture would be an SI greater than 50% 4 weeks after SI less than 10% had been achieved. 9 Nambirajan and colleagues 24 described an anastomotic index (AI) calculated as a ratio of the diameter of the upper pouch to the diameter of the anastomosis on contrast study. In this study, the AI did not predict the development of a recalcitrant stricture.…”

“…47 Last, there has been one report of intralesional steroids contributing to the spontaneous rupture of a right aortic arch, presumably secondary to the steroids weakening the arterial wall. 9 It is our group's practice to start intralesional steroid injections once a stricture is at its third or fourth dilation, if there has been no significant improvement in intraluminal diameter. We use triamcinolone acetate at a concentration of 10 mg/mL at a dose of 1 to 2/mg/kg per dose with a maximum dose of 80 mg.…”