Rules Are Meant to Be Broken

Clark, Susannah J.; Staffa, Steven J.; Ngo, Peter; Yasuda, Jessica L.; Zendejas, Benjamin; Hamilton, Thomas E.; Jennings, Russell W.; Manfredi, Michael A.

doi:10.1097/mpg.0000000000002687

Cited by 15 publications

(11 citation statements)

References 10 publications

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“…Esophageal dilation should not be increased by more than 3 mm in a single endoscopy to reduce the risk of perforation, the so-called "rule of 3"[ 18 , 19 ]. Clark, SJ founded that balloon dilations that expanded the initial esophageal osis ≤ 5 mm in a pediatric population appear to not unduly increase the risk of perforation in his research[ 20 ]. Non-adherence to the "rule of 3" does not appear to increase the risk of adverse events, particularly perforation, after esophageal dilation using bougie dilators[ 21 ].…”

Section: Discussionmentioning

confidence: 99%

The timing of oesophageal dilatations in anastomotic stenosis after one-stage anastomosis for congenital oesophageal atresia

Gao

Huang

Chen

et al. 2021

J Cardiothorac Surg

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Background In infants with congenital oesophageal atresia, anastomotic stenosis easily occurs after one-stage oesophageal anastomosis, leading to dysphagia. In severe cases, oesophageal dilatation is required. In this paper, the timing of oesophageal dilatation in infants with anastomotic stenosis was investigated through retrospective data analysis. Methods The clinical data of 107 infants with oesophageal atresia who underwent one-stage anastomosis in our hospital from January 2015 to December 2018 were retrospectively analysed. Data such as the timing and frequency of oesophageal dilatation under gastroscopy after surgery were collected to analyse the timing of oesophageal dilatation in infants with different risk factors. Results For infants with refractory stenosis, the average number of dilatations in the early dilatation group (the first dilatation was performed within 6 months after the surgery) was 5.75 ± 0.5, which was higher than the average of 7.40 ± 1.35 times in the normal dilatation group (the first dilatation was performed 6 months after the surgery), P = 0.038. For the infants with anastomotic fistula and anastomotic stenosis, the number of oesophageal dilatations in the early dilatation group was 2.58 ± 2.02 times, which was less than the 6.38 ± 2.06 times in the normal dilatation group, P = 0.001. For infants with non-anastomotic fistula stenosis, early oesophageal dilatation could not reduce the total number of oesophageal dilatations. Conclusion Starting to perform oesophageal dilatation within 6 months after one-stage anastomosis for congenital oesophageal atresia can reduce the required number of dilatations in infants with postoperative anastomotic fistula and refractory anastomotic stenosis.

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Section: Discussionmentioning

confidence: 99%

The timing of oesophageal dilatations in anastomotic stenosis after one-stage anastomosis for congenital oesophageal atresia

Gao

Huang

Chen

et al. 2021

J Cardiothorac Surg

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“…The method of measuring esophageal stricture diameter was previously described (8,18). During endoscopy, we used live fluoroscopy with contrast to determine the greatest anastomotic diameter.…”

Section: Methodsmentioning

confidence: 99%

“…After stricture dilation as previously reported (18), the stent was placed either comparable to final balloon size or 1-2 mm greater. The diameter of the upper and lower esophagus were also noted on fluoroscopy, at the time of the endoscopy, to ensure that the diameter of the flared ends of the stents were not too large for the esophagus.…”

Section: Stent Placement/monitoringmentioning

confidence: 99%

Predictors and Outcomes of Fully Covered Stent Treatment for Anastomotic Esophageal Strictures in Esophageal Atresia

Baghdadi

Yasuda²,

Staffa

et al. 2021

J. pediatr. gastroenterol. nutr.

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Background and Aims: Anastomotic strictures following surgical repair is one of the most common complications in esophageal atresia (EA). The utility of esophageal stenting to treat anastomotic esophageal strictures in pediatrics is unclear. Our primary aim was to evaluate whether esophageal stenting, in conjunction with dilation and other endoscopic therapies, prevented surgical stricture resection (SR). Our secondary aims were to evaluate predictors of successful esophageal stenting and evaluate adverse events from stent placement. Methods: A retrospective review of pediatric patients with EA complicated by esophageal strictures was performed. The change in stricture diameter in millimeters from the time of stent removal to subsequent endoscopy was defined as delta diameter (DD). A receiver operating characteristic (ROC) curve analysis was performed to determine the discriminatory ability of DD. Youden J index was used to identify optimal cutoff-point in predicting stent success. A univariate and multivariate analysis were done to assess predictors of success. Result: Forty-nine esophageal anastomoses were stented to treat esophageal strictures. Stents prevented SR in 41% of patients. ROC curve analysis utilizing Youden J index identified DD of 4 mm (area under the curve ¼ 0.790; 95% confidence interval: 0.655-0.924; P < 0.001) as the optimal cutoff point in differentiating stent success. The most common adverse events were erosions/ulcerations, granulation tissue formation, and vomiting/retching. Conclusion: Stent therapy in preventing SR at the site of EA repair was successful in 41% in our population with good long term follow-up. The most significant predictor of success in this study was the change in luminal diameter ( 4 mm) at initial poststent follow-up.

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“…Various etiologies can cause esophageal strictures and stenosis in children, with caustic, anastomotic, congenital, GERD, and eosinophilic esophagitis being the most common (22,(49)(50)(51)(52)(53)(54). To date, there are various endoscopic treatment options, of which endoluminal balloon dilatation is probably the most useful and safe.…”

Section: Advances In Endo-dilatation For Treatment Of Esophageal Sten...mentioning

confidence: 99%

“…The "rule of 3, " to prevent perforation, has been adopted from the ASGE recommendations and implies that the dilation of a stricture should not be greater than three times the diameter of the stricture. However, Clark et al have recently challenged this recommendation for children with stenosis of esophageal anastomosis: by reviewing charts from 284 children who underwent in total 1,384 balloon dilatations, they observed that dilatation of ≤5 mm did not unduly increase the risk of perforation, with a cumulative rate of perforation for dilatations ≤5 mm of 0.74%, whereas the risk increased to 4.85% in dilations ≥6 mm (49).…”

Section: Esophageal Dilatationmentioning

confidence: 99%