Fig. 19.1.
Short esophageal stricture secondary to caustic ingestion in a 5-year old that was recalcitrant to esophageal dilatation.
Fig. 19.2.
Long esophageal stricture secondary to accidental caustic ingestion in an 18-month-old infant.
Fig. 19.3.
Postoperative anastomotic stricture in a patient with pure esophageal atresia.
Fig. 19.4.
Double endoscopy with endoscopes introduced via oropharynx and gastrostomy tube.
Fig. 19.5.
Endoscope passed via gastrostomy up into mouth to access esophagus with a string, guidewire, or dilators.
Surgical Indications
Surgical indications for caustic esophageal strictures include symptomatic stricture requiring dilation, strictures refractory to endoscopic dilation, and inability to reinitiate oral feeding. Long strictures of the esophagus with inability to achieve oral feeding and long-term risk of esophageal cancer (2–30 %) [5, 6].
Surgical indications for managing anastomotic strictures include the same indications as for caustic strictures. The surgical approaches to esophageal strictures include multiple dilation techniques, segmental resection, or, in severe cases, esophageal replacement. The authors’ preferred esophageal substitute is the stomach, which is performed by minimally invasive esophagectomy with gastric pull-up when indicated and possible [7–9]. Multiple esophageal replacement techniques are discussed in depth in Chap. 20. Esophageal resection and anastomosis may be achieved using a thoracoscopic approach for short segment strictures [10].
Esophageal Dilation
Special Considerations
Antegrade dilation can generally be performed and is preferred. In the presence of a gastrostomy, retrograde dilation may also be performed, if necessary, such as when access to the mouth is impaired.
Bougienage dilation utilizes Maloney or Hurst dilators and requires the need to negotiate across a stricture. This technique often “shears” the mucosa during dilation, as evidenced by blood is seen on dilator. These dilators are blunt tipped (and less rigid) and thus may not enable passage across tight strictures with a proximally dilated esophagus.
Balloon dilation is performed with controlled-radial-esophageal (CRE) dilators, which are very effective in dilation of esophageal strictures (Figs. 19.6 and 19.7). Fluoroscopy may be a useful adjunct when using radiopaque contrast to distend the balloon dilator.
Fig. 19.6.
Controlled radial esophageal (CRE) dilator. Balloon pressure/diameter (atmospheres (ATM)/diameter and French guide).
Fig. 19.7.
Handgun for CRE dilator.
Tucker dilators , while no longer manufactured, are useful for retrograde esophageal dilation. Now filiform dilators with followers may be used for narrow strictures requiring retrograde or antegrade dilation [11].
Technique
The patient is placed in supine position on a fluoroscopy compatible table. Care is taken to protect the face and mouth from trauma. The Olympus GIF 180 (9.3 mm OD) and GIF XP 160 (4.9 mm OD) (Olympus America, Center Valley, PA) are used depending on the size of the patient. As described above, fluoroscopy, Maloney, Hurst and Tucker dilators, and filiform dilators and followers should be available depending on the technique elected.
Flexible endoscope is introduced orally to assess the stricture. The markings on the scope can assist in identifying the depth of the stricture from the teeth and estimating the appropriate depth of passage of the dilators to maximize stricture dilation but minimize accidental gastric perforation.
The CRE dilator may be passed through the working channel of the scope (9.3 mm OD) or alongside endoscope (4.9 mm OD). Both fixed balloons on the end of the wire and balloons that can be passed over a guidewire can be utilized, depending on surgeon preference. Both are available in a variety of diameters and should be affixed to a handheld manometer for safe usage. The packaging of the CRE selected should be consulted for correlating the balloon diameter to the appropriate inflation pressure.
Contrast may be injected into the esophageal lumen or injected into the dilating balloon and observed under fluoroscopy. Fluoroscopy images may show a waist on the balloon at the initiation of balloon dilation and loss of the waist at the completion of the dilation, demonstrating efficacy.
Inflate balloon to indicated diameter and manometer pressure and hold for 1 min before releasing the pressure. The dilation is generally repeated at least twice or increased to a larger diameter and pressure for sequential enlargement. If necessary, the balloon may be exchanged for a larger diameter balloon to achieve an appropriate diameter at the site of the stricture.
Caution should be used on dilating an esophagus further once blood has been seen on a withdrawn dilator.
Consider repeating your endoscopy or performing an on-table contrast esophagoscopy after dilation to reassess the stricture, evaluate the esophagus distal to the stricture for secondary concerns, and ensure no perforation of the esophagus or stomach is identified.
Pearls/Pitfalls
Tight, short strictures with proximal esophageal dilation may be difficult to access from the oropharynx.
If the patient has a gastrostomy tube, retrograde access with passage of a guidewire will enable the passage of serial dilators retrograde and subsequently in an antegrade manner.
A chest radiograph in the recovery room with mediastinal air should prompt evaluation for an esophageal leak with a contrast study.
Postoperative Care
Most dilations may be performed as an outpatient procedure. Depending upon the severity and length of the stricture, repeated dilations may be necessary. Dilations are generally started at 4–6 weeks following injury or anastomosis creation. There is no standard for length of interval or rate of diameter increase, and, although technical success is high, there is also a high recurrence rate [12]. Dilations may be done every 2 weeks for severe strictures or as needed for less severe ones. There is no role for esophageal stents although adjuvant application of topical agents (e.g., Mitomycin C, steroids) following dilation may be of benefit [13].
Esophageal perforation risk is 15–25 % but likely much less with advent of balloon dilation techniques [5]. Other possible complications include creation of false esophageal lumen, pneumothorax, and mediastinitis.
Esophageal Resection with Primary Anastomosis
Special Considerations
Short strictures of the esophagus, which do not respond to dilation, may be considered for resection with primary anastomosis . Distal and very proximal strictures are technically more challenging to resect and anastomose using MIS techniques. Segmental strictures are typically approached by right thoracoscopy with the exception being for very distal esophageal strictures, where left thoracoscopy affords better exposure.
Technique
The patient is placed in lateral decubitus with side of approach upright for thoracoscopic approaches (or supine for abdominal and cervical approaches).
Standard 3.5-mm or 5-mm laparoscopic/thoracoscopic instruments (depend on size of child) should be available, including Maryland® dissectors, DeBakey graspers, Ligasure™ device (Medtronic, Minneapolis, MN), and hook cautery. A flexible endoscope should be available in the case of segmental resection.
Flexible endoscopy is first used to identify the stricture. The scope is left in place to serve as a marker.
Right thoracoscopy is performed with 3–4 ports in anterior and midaxillary line.
The stricture is identified thoracoscopically, and the esophagus is circumferentially dissected with cautery or bluntly, taking care to exclude the vagus nerves.
The esophagus is encircled with Penrose® drain for retraction. Once fully exposed, the stricture is resected sharply.
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