Anastomotic strictures and endoscopic dilatations following esophageal atresia repair

Parolini, Filippo; Leva, Ernesto; Morandi, Anna; Macchini, Francesco; Gentilino, Valerio; Cesare, Antonio Di; Torricelli, Michela

doi:10.1007/s00383-013-3298-4

Cited by 49 publications

(49 citation statements)

References 16 publications

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“…Radiological images show the esophageal morphology and may detect associated anomalies (i.e., congenital esophageal stenosis) and pulmonary problems, while endoscopy allows combined diagnosis and treatment (14). Measurements are easier on the static radiologic images, while the endoscopic view may induce errors due to prospective effects; nonetheless, they can be minimized by shooting an instant view when endoscope lens is at a given distance (i.e., 2 cm) proximal to the identified AS (15). Simultaneous visualization of a probe with known diameter (guide wire or plastic tube) may help in measuring the degree of luminal narrowing.…”

Section: Definition and Diagnosismentioning

confidence: 99%

“…Said et al proposed the stricture index, SI = D − d / D , where D is the esophageal diameter of lower pouch and d is the stricture diameter (17). Although the SI has already been used in some studies to assess the degree of ASs by radiographic (18) and endoscopic measurements (15), its clinical usefulness and impact must be confirmed in larger series. More recently, Sun et al proposed the Esophageal Anastomotic Stricture Index (EASI), as a predictor of the development and severity of ASs after EA repair (19).…”

Section: Definition and Diagnosismentioning

confidence: 99%

“…It is true that most surgeons perform a baseline barium swallow about 5–10 days postoperatively to rule out the presence of an anastomotic leak, thus giving an early postoperative picture of esophageal lumen (19). Nevertheless, a varying degree of “physiological” stenosis can be found on the first esophagram as a normal healing process from the surgical procedure, without relation to the development of a clinically relevant stricture (15). Early routine screening for ASs, starting 1 month after surgery, has been proposed (15).…”

Section: Definition and Diagnosismentioning

confidence: 99%

“…Nevertheless, a varying degree of “physiological” stenosis can be found on the first esophagram as a normal healing process from the surgical procedure, without relation to the development of a clinically relevant stricture (15). Early routine screening for ASs, starting 1 month after surgery, has been proposed (15). Recent guidelines, according with the majority of authors, recommend that AS should be excluded only in symptomatic children and those who are unable to achieve feeding milestones (14, 20).…”

Section: Definition and Diagnosismentioning

confidence: 99%

“…Holder et al and Zein et al also reported good outcomes in three and one EA children, respectively (69, 70). Even though other centers probably use intralesional steroid injection in clinical practice (15, 22, 71), evidences in EA children are lacking.…”

Section: Treatmentmentioning

confidence: 99%

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Anastomotic Strictures after Esophageal Atresia Repair: Incidence, Investigations, and Management, Including Treatment of Refractory and Recurrent Strictures

et al. 2017

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Improved surgical techniques, as well as preoperative and postoperative care, have dramatically changed survival of children with esophageal atresia (EA) over the last decades. Nowadays, we are increasingly seeing EA patients experiencing significant short- and long-term gastrointestinal morbidities. Anastomotic stricture (AS) is the most common complication following operative repair. An esophageal stricture is defined as an intrinsic luminal narrowing in a clinically symptomatic patient, but no symptoms are sensitive or specific enough to diagnose an AS. This review aims to provide a comprehensive view of AS in EA children. Given the lack of evidence-based data, we critically analyzed significant studies on children and adults, including comments on benign strictures with other etiologies. Despite there is no consensus about the goal of the luminal diameter based on the patient’s age, esophageal contrast study, and/or endoscopy are recommended to assess the degree of the narrowing. A high variability in incidence of ASs is reported in literature, depending on different definitions of AS and on a great number of pre-, intra-, and postoperative risk factor influencing the anastomosis outcome. The presence of a long gap between the two esophageal ends, with consequent anastomotic tension, is determinant for stricture formation and its response to treatment. The cornerstone of treatment is endoscopic dilation, whose primary aims are to achieve symptom relief, allow age-appropriate capacity for oral feeding, and reduce the risk of pulmonary aspiration. No clear advantage of either balloon or bougie dilator has been demonstrated; therefore, the choice is based on operator experience and comfort with the equipment. Retrospective evidences suggest that selective dilatations (performed only in symptomatic patients) results in significantly less number of dilatation sessions than routine dilations (performed to prevent symptoms) with equal long-term outcomes. The response to dilation treatment is variable, and some patients may experience recurrent and refractory ASs. Adjunctive treatments have been used, including local injection of steroids, topical application of mitomycin C, and esophageal stenting, but long-term studies are needed to prove their efficacy and safety. Stricture resection or esophageal replacement with an interposition graft remains options for AS refractory to conservative treatments.

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Section: Definition and Diagnosismentioning

confidence: 99%