Reflux Strictures
of the Esophagus
in Children
By Ii. Rode, A.J.W. Millar, R.A. Brown, and S. Cywes Rondebosch, South Africa 0 Although the therapeutic approach to gastroesophageal reflux in children is well established, there are differences of opinion regarding the management of esophageal strictures, viz bougienage with medical therapy, fundoplication without dilatation, preoperative dilatation followed by fundoplicetion with intreoperative and postoperative dilatation, or resection and interposition. Sixteen consecutive children (mean age, 30.2 months) with reflux strictures were evaluated, constituting 12% of children operated on for gastroesophageal reflux. The strictures became clinically apparent 22.4 months (mean) from the onset of symptoms and were diagnosed by contrast studies and endoscopy. At first endoscopy all the patients had well-established fibrotic strictures. The strictures were mostly situated in the middle or lower esophagus and 7 were longer than 3 cm in length. All 16 were treated with antacids, H,-receptor blockers (Cimetidine), prokinetic agents, and intense nutritional resuscitation, together with preoperative stricture dilatations (average, 3.6 times). This was followed by fundoplication when nutritional parameters had been restored, esophagitis improved, and the strictures dilated to adequate size. Seven children required concomitant gastrostomieo for prograde esophageal dilatations. Twelve children needed postoperative esophsgeal diletations. The resufts were satisfactory in 14 (88%). Two required endoesophageal resection for localized unyielding strictures. One child responded only after failed reflux surgery was corrected at a second procedure. During an average follow-up of 8.2 years (range, 3 to 11) there has been no stricture recurrence and growth velocity was restored in all. We conclude that our preferred method is preoperative in-hospital management of gastroesophageal reflux with maximum nutritional support and careful evaluation of the degree and extent of esophagi& and fibrous scarring. Antireflux surgery is delayed until nutritional deficiencies have been corrected, the esophagus adequately dilated, and acute esophagitis controlled. Long-term follow-up with endoscopic surveillance is advocated. Copyright o 1992 by W.8. Saunders Company INDEX WORDS: Esophageal flux, management.
stricture;
gastroesophageal
re-
E
SOPHAGEAL stricture as a consequence of uncontrolled gastroesophageal reflux (GER) is the end result of a process of repeated insults to the esophageal mucosa. The benign fibrous stricture is characterized by two histological features: viz chronic
From the Depatimeni of Paediatric Sugery, Red Cross War Memorial Children’s Hospital. Universityof Cape Town, Rondebosch, South Africa. Date accepted: October 23, 1990. Address reprint requests to H. Rode, FCS, Department of Paediatric Surgery, Red Cross War Memorial Children’s Hospital, Institute of Child Health, 7700 Rondebosch, South Africa. Copyright 0 1992 by K B. Saunders Company 0022-3468192/2704-0011$03.00/0 462
superficial esophagitis and fibrous replacement of damaged tissue, commencing in the submucosa and spreading outwards, disorganizing atid replacing esophageal architecture.’ Due to the soft or liquid diet of the infant, dysphagia may not be apparent until extensive fibrosis and stricturing are established. Basic to the management of the stricbred esophagus is complete control of GER, in order to halt and to reverse the pathological process.‘” This is best achieved with an antireflux operation. However, the management of the stricture itself warrants closer examination. This article reviews our eyperience with the management of 16 patients with peptic esophageal strictures. MATERIALS AND METHODS Sixteen children with strictures resulting from TeAuxesophagitis were treated at the Red Cross War Memorial Cqildren’s Hospital, Cape Town, over the 13-year period 1977 to 1989. Patients with stenosis or strictures following esophageal atresia repair or caustic ingestion were excluded. All 16 underwent antiireflux surgery as part of their management program, constituting 12% of 130 antireflux procedures performed during this period. Diagnosis of GER, associated with the strictqre, was suggested by contrast swallow and confirmed with 18-hotir intraesophageal pH studies, gastroesophageal scintigaphy, and esophagoscopy. Stricture length was defined by the distance from the narrowing and/or irregularity of the esophageal wall proximally to the disappearance of such findings distally. Stricture
ikknagement
All patients received intensive preoperative medical management of their GER and any complicating respiratory disease; treatment included oral antacids, prokinetic a$ents, Hz-receptor blockers. together with maximum nutritional support, and intensive chest physiotherapy. Antireflux surgery was delayed until nutritional parameters were corrected and esopbagitis, as assessed by serial esophagoscopies, had been controlled4 A careful assessment of the site, extent, and rigidity of the stricture was performed at each esophagoscopy. Preferentially prograde dilatation was attempted using a spring-tipped guide wire and ‘the Eder-Peustow dilator system. Alternatively prograde dilatation in 7 children was performed using the Riisch dilators with the aid of a transesophageal string brought out through a gastrostomy. Gradual esophageal dilatations were done at l- to 3-week intervals until the esophagus was of adequate size, esophagitis hadishown evidence of significant improvement, and serum albumin Ievel had returned to within normal limits (> 35 g/L). From 1977 to 1986 we used the Nissen fundophcation (n = 13) and since April 1987 have performed the Boix-Ochoa partial anterior fundofilication with fundopexy (n = 3).0 In all patients adequate intrsabdominal length was obtained despite perioperative esophagitis and apparent shortening of the esophagus. Postoperative dilatation of the stricture was continued until esophagitis had healed and final resolution of the stricture occurred. Journal of Pediatric Surgery, Vol27, No 4 (April), 1992: pp 462-465
REFLUX STRICTURES OF THE ESOPHAGUS
463
RESULTS 16 patients
had a history of vomiting (5 with hematemesis) and failure to thrive; 13 had associated pulmonary disease. Symptomatic esophageal obstruction became apparent on average 22.4 months (range, 6 to 44 months) after onset of symptoms suggestive of GER, which were present on average from 2.9 months of age. The mean age of presentation was 30.2 months (range, 9 to 48 months). Eleven strictures were confined to the lower third of the esophagus and 4 were located in the middle third. Of interest, one short stricture was found in the upper third of the thoracic esophagus. An associated hiatus hernia was present in 6 patients. The stricture length varied from short ( < 3 cm) to 9 cm long. One infant had complete occlusion of his esophagea1 lumen. Preoperative preparation prior to surgery took an average of 3 months, with a mean of 3.6 dilatations performed per patient. Twelve children required several postoperative dilatations for up to 12 months (mean, 4.9 dilatations over a mean period of 4.2 months). Complete resolution of the stricture and associated GER was achieved in 14 children (88%). One Nissen fundoplication failed to control reflux and had to be revised before stricture resolution was achieved. Two patients failed to respond to this management protocol both with unyielding fibrotic strictures requiring endoesophageal resection of the strictures. Candida &cans esophagitis contributed to slow resolution in another patient. With an average follow-up of 8.2 years (range, 3 to 11 years), all patients had restoration of growth and development with no stricture recurrence (Fig 1). All
DlSCUSSlON Established peptic strictures of the esophagus have become a less frequent indication for antireflux surgery in children in recent years, implying earlier recognition of reflux disease with adequate medical
-I 15
12
9
NO OF DILATATIONS
6
3 PER
0
3
6
9
12
15
PATIENT
Fii 1. The number of dilatations par patient for benign reflux strictures before [m) and after IFZ4)antireflux surgery. 0, C8rr&& esophagitis; #, slipped Nissen; l, endoesophageal stricture resection.
treatment. However, in children reflux esophagitis may develop into severe fibrosis and stenosis within weeks,7 although there is usually a much longer duration of symptoms before obstructive symptoms appear.4 The development of the stricture may occur silently and symptoms of significant dysphagia are often delayed with the infant’s diet consisting initially of liquids and then solids, which are either refined cereals or mashed toddlers’ diet. Recurrent acid reflux, often with added inadequate esophageal clearance, results in either chronic superficial esophagitis, localized penetrating ulceration, or a combination of these.’ Chronic superficial circumferential ulceration with replacement fibrosis, which may extend to all layers of the esophageal wall, is more commonly found in children. Periesophageal inflammation and fibrosis are often considerable and tend to be maxima1 around the vagus nerve.’ In the majority of patients with established strictures, both pathological processes are found in combination. Strictures are usually located just above the squamocolumnar mucosal junction, although proximal strictures do occur. Strictures may be short and annular or extensive and longitudinal, and may be associated with cephalad migration of the squamocolumnar junction (Barrett’s esophagus).’ Barrett’s esophagus is far more common than once believed, reportedly present in 9% to 13% of paediatric patients with established esophagitis.’ Histological assessment of the esophagus at the site of the stricture and more distally following dilatation appears to be prudent because Barrett’s esophagus can predispose to malignancy and such cases should be identified and followed-up endoscopically long term.8~‘B’2Surgical cure of reflux may reverse the histological changes, but the long-term incidence of adenocarcinoma following control of reflux is not known.“,13 Although there is’general agreement on the medical management ti’GER, there is considerable variation of opinion with regard to management of the peptic esophageal stricture (Table 1). We prefer preoperative control of esophagitis and adequate dilatation of the stricture prior to performing the antireflux procedure. The periesophagitis is allowed to resolve, the patient is able to resume a normal eating pattern, malnutrition is treated, and any respiratory consequences from reflux are also attended to during this period. Medical therapy as the only treatment modality is associated with a failure rate of 15% to 37%.14-16 The argument against esophageal dilatation followed by immediate antireflux surgery at the same time, is that the concomitant esophagitis and periesophagitis make surgery more hazardous; the operation is better
RODE ET AL
464
Table 1. Management
Authors
Boix-Ochoa et al2
of Reflux Strictures of the Esophagus
No. of
MEWI
Patients
age w
Method
28
-
Preoperative dilatation, Boerema antireflux
Comments
Perforation
Nil
Good results
operation, and postoperative dilatation Monerco et al’
2%
-
Preoperative dilatation, Nissen fundoplica-
1
85.7% good results; 71% required repeated
1
76% resolved strictures; 3 patients required
dilatations for 1 year
tion. and postoperative dilatations Hicks et al3
14
2.5
lntraoperative esophageal dilatation, Nissen
ongoing dilatations; 1 dicirupted Nissen
fundoplication, postoperative stricture healed with medical therapy, dilatations O’Niell et al’
18
6.3
lntraoperative esophageal dilatation, Nissen
Nil
94% well with the stricture completely re-
Nil
88% complete resolution; 1 disrupted Nis-
solved in 67%
fundoplication, postoperative dilatations Present series
16
2.6
Preoperative esophageal dilatation, Nissen and Boix-Ochoa fundoplication, and post-
sen; 2 esophageal resections
operative esophageal dilatation
tolerated with improved wound healing in a well nourished patient, avoiding later breakdown of the antireflux procedure and it is postoperatively technically more difficult to dilate a stricture just proximal to an antireflux procedure. Because the immediate response of the stricture to dilatation is unpredictable, we are wary of relying on a single intraoperative dilatation, although others have reported success with this method.3.4 Prograde dilatation is preferred, if possible without gastrostomy and transesophageal string, because the gastrostomy itself may promote GER if incorrectly sited. However, with tight strictures and severe esophagitis, placement of a transesophageal string may make prograde dilatations safer.‘Prolonged postoperative dilatation is to be avoided if possible because it may disrupt the antireflux procedure. However, 8 patients did require more than one postoperative dilatation, one of whom required a repeat antireflux procedure (Fig 1). Persisting stricture may also be due to extensive mature fibrosis (2 cases), or fungal infection complicating esophagitis (1 case). Where the stricture has persisted, local resection has proved satisfactory. Both the children requiring resection had very delayed presentation. It is worth attempting a period of dilatation in all peptic strictures because some of the
cases most resistant at first present&ion have responded to our regimen. With regard tb preoperative assessment of the pathological process, ‘motility of the whole foregut is examined and significant delay in gastric emptying may necessitate pylotomyotomy or pyloroplasty at time of antireflux surgery. However, we have seen significant improvem$nt in gastric function as assessed by scintigraphy Following fundoplication and, thus, do not routindly advocate a pyloroplasty.4 In conclusion, peptic strictures of the esophagus are not uncommon and usually have an insiduous onset. Barium esophagogram and endoscopy are sufficient to confirm the diagnosis and plan further management. Our current experience supports preoperative dilatation with concomitant ag$essive antireflux therapy as the treatment of choice In children: viz surgery is safer with reduced periesophagitis, surgery is better tolerated with restoration ;of nutritional parameters, possible breakdown of ‘the antireflux procedure is decreased, and even ,dense fibrotic strictures dilate well once reflux is controlled. Both the Nissen fundoplication rpnd the BoixOchoa procedure have proved satisfactory in controlling reflux. Long-term histological sueeillance of the esophagus is required to detect the presence of Barrett’s esophagus.
REFERENCES 1. Sandry RJ: The pathology of chronic esophagitis. Gut 3:189200,1962 2. Boix-Ochoa J, Rehbein F: Esophageal stenosis due to reflux esophagitis. Arch Dis Child 40:197-199,196s 3. Hicks LM, Christie DL, Hall DC, et al: Surgical treatment of esophageal strictures secondary to gastroesophageal reflux. J Pediatr Surg 15:863-868,198O 4. O’Neill JA, Betts J, Ziegler MM, et al: Surgical management of reflux strictures of the esophagus in childhood. Ann Surg 196:453-460, 1982 5. Monereo I, Cartes L, Bless E: Peptic esophageal stenosis in children. J Pediatr Surg 8:475-478,1973
6. Boix-Ochoa J: Address of honored guest: The physiologic approach to the management of gastric esophag&al reflux. J Pediatr Surg 21:1032-1039,1986 7. Belsey RHR, Skinner DB: Management af esophageal strictures, in Skinner DB, Belsey RH, Hendrix TR, et al (eds): Gastro-esophageal Reflux and Hiatal Hernia. *ton, MA, Little. Brown, 1972, pp 173-196 8. Sjogren RW, Johnson LF: Barrett’s esophagus: A review. Am J Med 74:313-321,1983 9. Groben PA, Siegal GP, Shub MD, et al:, Gastroesophageal reflux and esophagitis in infants and childred. Perspect Pediatr Pathol 11:124-151,1987
REFLUX STRICTURES OF THE ESOPHAGUS
10. Naef AP, Savary M, Ozzello L: Columnar-lined lower esophagus: An acquired lesion with malignant predisposition. Report on 140 cases of Barrett’s esophagus with 12 adenocarcinomas. J Thorac Cardiovasc Surg 70826-835, 197.5 11. Bremner CG: The columnar-lined (Barrett’s esophagus). Surg Ann 9:103-123,1977 12. Thompson JJ, Zinsser RR, Enterline HT: Barrett’s metaplasia and adenocarcinoma of the esophagus and gastroesophageal junction, Hum Path01 14:42-61,1983 13. Brand DL, Ylvisaker JT, Gelfand M, et al: Regression of
465
columnar esophageal (Barrett’s) epithelium after anti-reflux surgery. N Engl J Med 302:&W848,198O 14. Pattersen DJ, Graham DY, Smith JL, et al: Natural history of benign esophageal stricture treated by dilatation. Gastroenterology 85346-350, 1983 15. Toledo-Pereyra LH, Michel H, Manifacio G, et al: Management of acid-peptic esophageal strictures. J Thorac Cardiovasc Surg 72:518-524,1976 16. Caste11 DO: Future medical therapy of reflux esophagitis. J Clin Gastroenterol8:81-85,1986 (suppl I)
of the Esophagus
in Children
By Ii. Rode, A.J.W. Millar, R.A. Brown, and S. Cywes Rondebosch, South Africa 0 Although the therapeutic approach to gastroesophageal reflux in children is well established, there are differences of opinion regarding the management of esophageal strictures, viz bougienage with medical therapy, fundoplication without dilatation, preoperative dilatation followed by fundoplicetion with intreoperative and postoperative dilatation, or resection and interposition. Sixteen consecutive children (mean age, 30.2 months) with reflux strictures were evaluated, constituting 12% of children operated on for gastroesophageal reflux. The strictures became clinically apparent 22.4 months (mean) from the onset of symptoms and were diagnosed by contrast studies and endoscopy. At first endoscopy all the patients had well-established fibrotic strictures. The strictures were mostly situated in the middle or lower esophagus and 7 were longer than 3 cm in length. All 16 were treated with antacids, H,-receptor blockers (Cimetidine), prokinetic agents, and intense nutritional resuscitation, together with preoperative stricture dilatations (average, 3.6 times). This was followed by fundoplication when nutritional parameters had been restored, esophagitis improved, and the strictures dilated to adequate size. Seven children required concomitant gastrostomieo for prograde esophageal dilatations. Twelve children needed postoperative esophsgeal diletations. The resufts were satisfactory in 14 (88%). Two required endoesophageal resection for localized unyielding strictures. One child responded only after failed reflux surgery was corrected at a second procedure. During an average follow-up of 8.2 years (range, 3 to 11) there has been no stricture recurrence and growth velocity was restored in all. We conclude that our preferred method is preoperative in-hospital management of gastroesophageal reflux with maximum nutritional support and careful evaluation of the degree and extent of esophagi& and fibrous scarring. Antireflux surgery is delayed until nutritional deficiencies have been corrected, the esophagus adequately dilated, and acute esophagitis controlled. Long-term follow-up with endoscopic surveillance is advocated. Copyright o 1992 by W.8. Saunders Company INDEX WORDS: Esophageal flux, management.
stricture;
gastroesophageal
re-
E
SOPHAGEAL stricture as a consequence of uncontrolled gastroesophageal reflux (GER) is the end result of a process of repeated insults to the esophageal mucosa. The benign fibrous stricture is characterized by two histological features: viz chronic
From the Depatimeni of Paediatric Sugery, Red Cross War Memorial Children’s Hospital. Universityof Cape Town, Rondebosch, South Africa. Date accepted: October 23, 1990. Address reprint requests to H. Rode, FCS, Department of Paediatric Surgery, Red Cross War Memorial Children’s Hospital, Institute of Child Health, 7700 Rondebosch, South Africa. Copyright 0 1992 by K B. Saunders Company 0022-3468192/2704-0011$03.00/0 462
superficial esophagitis and fibrous replacement of damaged tissue, commencing in the submucosa and spreading outwards, disorganizing atid replacing esophageal architecture.’ Due to the soft or liquid diet of the infant, dysphagia may not be apparent until extensive fibrosis and stricturing are established. Basic to the management of the stricbred esophagus is complete control of GER, in order to halt and to reverse the pathological process.‘” This is best achieved with an antireflux operation. However, the management of the stricture itself warrants closer examination. This article reviews our eyperience with the management of 16 patients with peptic esophageal strictures. MATERIALS AND METHODS Sixteen children with strictures resulting from TeAuxesophagitis were treated at the Red Cross War Memorial Cqildren’s Hospital, Cape Town, over the 13-year period 1977 to 1989. Patients with stenosis or strictures following esophageal atresia repair or caustic ingestion were excluded. All 16 underwent antiireflux surgery as part of their management program, constituting 12% of 130 antireflux procedures performed during this period. Diagnosis of GER, associated with the strictqre, was suggested by contrast swallow and confirmed with 18-hotir intraesophageal pH studies, gastroesophageal scintigaphy, and esophagoscopy. Stricture length was defined by the distance from the narrowing and/or irregularity of the esophageal wall proximally to the disappearance of such findings distally. Stricture
ikknagement
All patients received intensive preoperative medical management of their GER and any complicating respiratory disease; treatment included oral antacids, prokinetic a$ents, Hz-receptor blockers. together with maximum nutritional support, and intensive chest physiotherapy. Antireflux surgery was delayed until nutritional parameters were corrected and esopbagitis, as assessed by serial esophagoscopies, had been controlled4 A careful assessment of the site, extent, and rigidity of the stricture was performed at each esophagoscopy. Preferentially prograde dilatation was attempted using a spring-tipped guide wire and ‘the Eder-Peustow dilator system. Alternatively prograde dilatation in 7 children was performed using the Riisch dilators with the aid of a transesophageal string brought out through a gastrostomy. Gradual esophageal dilatations were done at l- to 3-week intervals until the esophagus was of adequate size, esophagitis hadishown evidence of significant improvement, and serum albumin Ievel had returned to within normal limits (> 35 g/L). From 1977 to 1986 we used the Nissen fundophcation (n = 13) and since April 1987 have performed the Boix-Ochoa partial anterior fundofilication with fundopexy (n = 3).0 In all patients adequate intrsabdominal length was obtained despite perioperative esophagitis and apparent shortening of the esophagus. Postoperative dilatation of the stricture was continued until esophagitis had healed and final resolution of the stricture occurred. Journal of Pediatric Surgery, Vol27, No 4 (April), 1992: pp 462-465
REFLUX STRICTURES OF THE ESOPHAGUS
463
RESULTS 16 patients
had a history of vomiting (5 with hematemesis) and failure to thrive; 13 had associated pulmonary disease. Symptomatic esophageal obstruction became apparent on average 22.4 months (range, 6 to 44 months) after onset of symptoms suggestive of GER, which were present on average from 2.9 months of age. The mean age of presentation was 30.2 months (range, 9 to 48 months). Eleven strictures were confined to the lower third of the esophagus and 4 were located in the middle third. Of interest, one short stricture was found in the upper third of the thoracic esophagus. An associated hiatus hernia was present in 6 patients. The stricture length varied from short ( < 3 cm) to 9 cm long. One infant had complete occlusion of his esophagea1 lumen. Preoperative preparation prior to surgery took an average of 3 months, with a mean of 3.6 dilatations performed per patient. Twelve children required several postoperative dilatations for up to 12 months (mean, 4.9 dilatations over a mean period of 4.2 months). Complete resolution of the stricture and associated GER was achieved in 14 children (88%). One Nissen fundoplication failed to control reflux and had to be revised before stricture resolution was achieved. Two patients failed to respond to this management protocol both with unyielding fibrotic strictures requiring endoesophageal resection of the strictures. Candida &cans esophagitis contributed to slow resolution in another patient. With an average follow-up of 8.2 years (range, 3 to 11 years), all patients had restoration of growth and development with no stricture recurrence (Fig 1). All
DlSCUSSlON Established peptic strictures of the esophagus have become a less frequent indication for antireflux surgery in children in recent years, implying earlier recognition of reflux disease with adequate medical
-I 15
12
9
NO OF DILATATIONS
6
3 PER
0
3
6
9
12
15
PATIENT
Fii 1. The number of dilatations par patient for benign reflux strictures before [m) and after IFZ4)antireflux surgery. 0, C8rr&& esophagitis; #, slipped Nissen; l, endoesophageal stricture resection.
treatment. However, in children reflux esophagitis may develop into severe fibrosis and stenosis within weeks,7 although there is usually a much longer duration of symptoms before obstructive symptoms appear.4 The development of the stricture may occur silently and symptoms of significant dysphagia are often delayed with the infant’s diet consisting initially of liquids and then solids, which are either refined cereals or mashed toddlers’ diet. Recurrent acid reflux, often with added inadequate esophageal clearance, results in either chronic superficial esophagitis, localized penetrating ulceration, or a combination of these.’ Chronic superficial circumferential ulceration with replacement fibrosis, which may extend to all layers of the esophageal wall, is more commonly found in children. Periesophageal inflammation and fibrosis are often considerable and tend to be maxima1 around the vagus nerve.’ In the majority of patients with established strictures, both pathological processes are found in combination. Strictures are usually located just above the squamocolumnar mucosal junction, although proximal strictures do occur. Strictures may be short and annular or extensive and longitudinal, and may be associated with cephalad migration of the squamocolumnar junction (Barrett’s esophagus).’ Barrett’s esophagus is far more common than once believed, reportedly present in 9% to 13% of paediatric patients with established esophagitis.’ Histological assessment of the esophagus at the site of the stricture and more distally following dilatation appears to be prudent because Barrett’s esophagus can predispose to malignancy and such cases should be identified and followed-up endoscopically long term.8~‘B’2Surgical cure of reflux may reverse the histological changes, but the long-term incidence of adenocarcinoma following control of reflux is not known.“,13 Although there is’general agreement on the medical management ti’GER, there is considerable variation of opinion with regard to management of the peptic esophageal stricture (Table 1). We prefer preoperative control of esophagitis and adequate dilatation of the stricture prior to performing the antireflux procedure. The periesophagitis is allowed to resolve, the patient is able to resume a normal eating pattern, malnutrition is treated, and any respiratory consequences from reflux are also attended to during this period. Medical therapy as the only treatment modality is associated with a failure rate of 15% to 37%.14-16 The argument against esophageal dilatation followed by immediate antireflux surgery at the same time, is that the concomitant esophagitis and periesophagitis make surgery more hazardous; the operation is better
RODE ET AL
464
Table 1. Management
Authors
Boix-Ochoa et al2
of Reflux Strictures of the Esophagus
No. of
MEWI
Patients
age w
Method
28
-
Preoperative dilatation, Boerema antireflux
Comments
Perforation
Nil
Good results
operation, and postoperative dilatation Monerco et al’
2%
-
Preoperative dilatation, Nissen fundoplica-
1
85.7% good results; 71% required repeated
1
76% resolved strictures; 3 patients required
dilatations for 1 year
tion. and postoperative dilatations Hicks et al3
14
2.5
lntraoperative esophageal dilatation, Nissen
ongoing dilatations; 1 dicirupted Nissen
fundoplication, postoperative stricture healed with medical therapy, dilatations O’Niell et al’
18
6.3
lntraoperative esophageal dilatation, Nissen
Nil
94% well with the stricture completely re-
Nil
88% complete resolution; 1 disrupted Nis-
solved in 67%
fundoplication, postoperative dilatations Present series
16
2.6
Preoperative esophageal dilatation, Nissen and Boix-Ochoa fundoplication, and post-
sen; 2 esophageal resections
operative esophageal dilatation
tolerated with improved wound healing in a well nourished patient, avoiding later breakdown of the antireflux procedure and it is postoperatively technically more difficult to dilate a stricture just proximal to an antireflux procedure. Because the immediate response of the stricture to dilatation is unpredictable, we are wary of relying on a single intraoperative dilatation, although others have reported success with this method.3.4 Prograde dilatation is preferred, if possible without gastrostomy and transesophageal string, because the gastrostomy itself may promote GER if incorrectly sited. However, with tight strictures and severe esophagitis, placement of a transesophageal string may make prograde dilatations safer.‘Prolonged postoperative dilatation is to be avoided if possible because it may disrupt the antireflux procedure. However, 8 patients did require more than one postoperative dilatation, one of whom required a repeat antireflux procedure (Fig 1). Persisting stricture may also be due to extensive mature fibrosis (2 cases), or fungal infection complicating esophagitis (1 case). Where the stricture has persisted, local resection has proved satisfactory. Both the children requiring resection had very delayed presentation. It is worth attempting a period of dilatation in all peptic strictures because some of the
cases most resistant at first present&ion have responded to our regimen. With regard tb preoperative assessment of the pathological process, ‘motility of the whole foregut is examined and significant delay in gastric emptying may necessitate pylotomyotomy or pyloroplasty at time of antireflux surgery. However, we have seen significant improvem$nt in gastric function as assessed by scintigraphy Following fundoplication and, thus, do not routindly advocate a pyloroplasty.4 In conclusion, peptic strictures of the esophagus are not uncommon and usually have an insiduous onset. Barium esophagogram and endoscopy are sufficient to confirm the diagnosis and plan further management. Our current experience supports preoperative dilatation with concomitant ag$essive antireflux therapy as the treatment of choice In children: viz surgery is safer with reduced periesophagitis, surgery is better tolerated with restoration ;of nutritional parameters, possible breakdown of ‘the antireflux procedure is decreased, and even ,dense fibrotic strictures dilate well once reflux is controlled. Both the Nissen fundoplication rpnd the BoixOchoa procedure have proved satisfactory in controlling reflux. Long-term histological sueeillance of the esophagus is required to detect the presence of Barrett’s esophagus.
REFERENCES 1. Sandry RJ: The pathology of chronic esophagitis. Gut 3:189200,1962 2. Boix-Ochoa J, Rehbein F: Esophageal stenosis due to reflux esophagitis. Arch Dis Child 40:197-199,196s 3. Hicks LM, Christie DL, Hall DC, et al: Surgical treatment of esophageal strictures secondary to gastroesophageal reflux. J Pediatr Surg 15:863-868,198O 4. O’Neill JA, Betts J, Ziegler MM, et al: Surgical management of reflux strictures of the esophagus in childhood. Ann Surg 196:453-460, 1982 5. Monereo I, Cartes L, Bless E: Peptic esophageal stenosis in children. J Pediatr Surg 8:475-478,1973
6. Boix-Ochoa J: Address of honored guest: The physiologic approach to the management of gastric esophag&al reflux. J Pediatr Surg 21:1032-1039,1986 7. Belsey RHR, Skinner DB: Management af esophageal strictures, in Skinner DB, Belsey RH, Hendrix TR, et al (eds): Gastro-esophageal Reflux and Hiatal Hernia. *ton, MA, Little. Brown, 1972, pp 173-196 8. Sjogren RW, Johnson LF: Barrett’s esophagus: A review. Am J Med 74:313-321,1983 9. Groben PA, Siegal GP, Shub MD, et al:, Gastroesophageal reflux and esophagitis in infants and childred. Perspect Pediatr Pathol 11:124-151,1987
REFLUX STRICTURES OF THE ESOPHAGUS
10. Naef AP, Savary M, Ozzello L: Columnar-lined lower esophagus: An acquired lesion with malignant predisposition. Report on 140 cases of Barrett’s esophagus with 12 adenocarcinomas. J Thorac Cardiovasc Surg 70826-835, 197.5 11. Bremner CG: The columnar-lined (Barrett’s esophagus). Surg Ann 9:103-123,1977 12. Thompson JJ, Zinsser RR, Enterline HT: Barrett’s metaplasia and adenocarcinoma of the esophagus and gastroesophageal junction, Hum Path01 14:42-61,1983 13. Brand DL, Ylvisaker JT, Gelfand M, et al: Regression of
465
columnar esophageal (Barrett’s) epithelium after anti-reflux surgery. N Engl J Med 302:&W848,198O 14. Pattersen DJ, Graham DY, Smith JL, et al: Natural history of benign esophageal stricture treated by dilatation. Gastroenterology 85346-350, 1983 15. Toledo-Pereyra LH, Michel H, Manifacio G, et al: Management of acid-peptic esophageal strictures. J Thorac Cardiovasc Surg 72:518-524,1976 16. Caste11 DO: Future medical therapy of reflux esophagitis. J Clin Gastroenterol8:81-85,1986 (suppl I)
