The Safety of Intralesional Steroid Injections in Young Children and Their Effectiveness in Anastomotic Esophageal Strictures—A Meta-Analysis and Systematic Review

Abstract

ObjectiveIntralesional steroid injections (ISI) are a widely used technique for various pediatric indications and represent a possible adjuvant treatment for anastomotic esophageal strictures. Yet, no consensus has been reached neither on their safety in the pediatric population or their effectiveness in esophageal atresia patients. This systematic review aimed to assess the safety of ISI in young children through a meta-analysis and to summarize the current knowledge on the effectiveness of ISI in anastomotic esophageal strictures.MethodsA systematic literature search was performed in Embase, Medline, Web of Science Core Collection, Cochrane Central Register of Controlled Trials and Google Scholar up to August 16 2021. Studies focusing on ISI and involving children up to 2 years were included in the meta-analysis for the safety assessment. All studies evaluating the use of ISI as adjuvant treatment in anastomotic esophageal strictures in children were included in the systematic review to assess the effectiveness of the intervention.ResultsThe literature search yielded 8,253 articles. A total of 57 studies were included, of which 55 for the safety and five for the effectiveness assessment. The overall complication rate was 7%, with a greater incidence of local complications compared to systemic complications. Six studies (with a total of 367 patients) evaluated adrenocorticotropic hormone and cortisol levels, of which four reported hypothalamic-pituitary axis suppression. Two children (0.6%) received replacement therapy and all patients recovered uneventfully. A mean number of 1.67 ISI were performed per esophageal atresia (EA) patient. A reduction of needed dilatations was seen after ISI, compared to the number of dilatations performed before the intervention (5.2 vs. 1.3).ConclusionThe insufficient data emphasized the need for further prospective and comparative studies. Results from this meta-analysis and systematic review address ISI as a safe and effective technique. Close clinical follow-up and growth curve evaluation are advisable in patients receiving ISI.Systematic Review RegistrationPROSPERO, identifier: CRD42021281584.

Avoiding Surgery: Endoscopic Treatment of Congenital Duodenal Stenosis

“…Two recent meta-analyses suggest ISI is a safe and effective treatment in young children with refractory esophageal strictures ( 11 , 12 ). We believe corticosteroid injection in combination with EIT and balloon dilation may lead to less postdilation inflammation, scarring, and perhaps improved outcomes for infants and children with congenital duodenal stenosis.…”

Post-injection Complications. Nicolau Syndrome as a Consequence of Local Irritant Effects of Drugs, Including Antiseptics, Local Anesthetics, NSAIDs, Steroids and Anticoagulants

“…Despite the described promising results of injecting drugs into "inflamed" areas of the body, postinjection complications have been established in the clinic. For example, the complication rate after steroid injection has been reported to be 7% with a higher incidence of local complications compared to systemic complications [7]. Therefore, the risk of local postinjection complications is a limitation for the routine clinical use of injections of any medication, including steroids.…”

“…Therefore, there is still a lack of consensus among researchers about the efficacy and safety of all of these groups of drugs, including steroids and NSAIDs [5][6][7][8][9]. Further, it is well known fact that reports of post injection inflammations, infiltrates, necrosis, and abscesses continue to appear despite the preventive measures.…”