British Journal of Radiology (2003) 76, 26-31
© 2003 British Institute of Radiology
doi: 10.1259/bjr/64412147
Balloon dilatation of anastomotic strictures secondary to surgical repair of oesophageal atresia
M Said, MD
1
M Mekki, MD
2
M Golli, MD
1
F Memmi, MD
1
C Hafsa, MD
1
R Braham, MD
1
M Belguith, MD
1
M Letaief, MD
3
M Gahbiche, MD
4
A Nouri, MD
2 and
A Ganouni, MD
1
Departments of 1 Medical Imaging, 2 Pediatric Surgery, 3 Epidemiology and Preventive Medecine 4 Anaesthesia, Fattouma Bourguiba University Hospital of Monastir, 5019 Monastir, Tunisia
Correspondence: Mourad Said, MD, 6-Rue du Caire, 5016 Cite Erriadh, Ksar Hellal, Tunisia
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Abstract
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The purpose of this study was to evaluate the efficiency and safety of oesophageal balloon dilatation in strictures secondary to surgical treatment of oesophageal atresia in 25 children. Patients comprised 15 males and 10 females, aged 1–36 months. Median age was 4 months (interquartile range (IQR)=19). The strictures were more than 50% of oesophageal lumen and the delay from surgical treatment to balloon dilatation varied from 1 month to 36 months. Associated gastroesophageal reflux was noted in 15 patients. All procedures were performed under sedation using fluoroscopic guidance. Balloons of increasing diameter, 4–20 mm were used. Water soluble contrast swallow was performed after each dilatation session. A total of 115 balloon dilatation sessions were performed with a range of 1–14 procedures per patient (median 4 dilatations, IQR=4.5). Dilatation relieved the stricture in all patients over a follow-up period varying from 4 months to 33 months. The best results were noted in children under 6 months, who needed two or few dilatation sessions, with relative risk (RR) of 0.52 and 95% confidence interval of 0.29–0.92. The presence of associated gastroesophageal reflux indicated a high risk (RR of 12, p<0.001) for undergoing more than two balloon dilatation sessions. The only serious complications observed were two cases of oesophageal perforation, which were treated conservatively. Fluoroscopically guided balloon dilatation is a safe and effective treatment in the management of strictures secondary to surgical repair of oesophageal atresia, especially when started early (within 6 months of surgery) and not associated with gastroesophageal reflux.
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Introduction
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Oesophageal atresia (OA), with or without tracheoesophageal fistula, is the most common congenital malformation of the oesophagus. It requires primary or delayed surgical anastomosis. Mortality after primary repair of OA is almost negligible when there are no associated severe cardiac, cerebral or pulmonary problems. Post-operative morbidity depends on the incidence of leakage, gastroesophageal reflux (GOR) and strictures. Anastomotic stricture occurs in 18–50% of patients undergoing repair of OA [1, 2]. Treatment of choice for symptomatic oesophageal strictures is dilatation. This is traditionally performed using rigid dilators in an antegrade manner or retrograde dilatation through a gastrostomy site. This procedure often causes significant injury to the mucosa and therefore leads to scars and further stricture. During the last two decades, balloon dilatation (BD) has become more frequently used [3–5]. This report details our experience using balloon dilatation to treat 25 children with anastomotic stricture following surgical repair of OA.
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Materials and methods
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A prospective and descriptive study was carried out between January 1998 and December 2001.
Patients
The study population comprised 25 children, 15 male and 10 female, treated with balloon dilatation for anastomotic oesophageal strictures secondary to OA surgical repair. Early post-operative contrast swallow (performed between the seventh and tenth post-operative day) following repair of OA was performed and neither leakage nor stricture was noted. Stricture was suspected on the basis of development of swallowing difficulties and vomiting. Before balloon dilatation, all patients underwent barium swallow to confirm the stricture and identify its location and severity. At the same time, presence of GOR was assessed . When GOR was present, medical treatment was commenced without delay prior to balloon dilatation. The selected strictures were more than 50% of oesophageal lumen (Figure 1
), determined by the stricture index (SI):
where A is the diameter of the oesophagus lower pouch and a is the stricture diameter.
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Figure 1. Oesophagogram. (a) Anteroposterior view and (b) lateral view of a 1-month-old girl demonstrating severe stricture (arrow) at the oesophageal atresia anastomosis site. *, oesophagus lower pouch.
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Balloon dilatation procedure
All procedures were performed under sedation and fluoroscopic guidance, with an attending anaesthetist present with two radiologists. Sedation was performed under cardiac monitoring and pulse oxymetry. The anaesthetic was comprised of halothane (1–2%) and oxygen, given by face mask, and intravenous (iv) midazolam (0.05–0.1 mg kg-1) to a maximum total iv dose of 0.5 mg kg-1. Patients were breathing spontaneously with cardiac monitoring and pulse oxymetry. Patients were placed on the fluoroscopic table in the supine position. Catheters and guidewires (Rigiflex® accessories; Microvasive-Boston Scientific Corporation, Natick, MA) were used to cross the stricture through the nose or mouth. The guidewire was manipulated into the stomach to provide as stable a position as possible. A deflated balloon catheter (Rigiflex® OTW Microvasive, Mansfield®; Boston Scientific Corporation, Natick, MA) was passed over the guidewire and positioned across the stricture. Once positioned, the balloon was filled with dilute contrast medium (Télébrix 35; Guerbet, Aulnay Sous-Bois, France) using a manometer syringe (Digiflator; Rigiflex® Microvasive. Boston Scientific Corporation, Natick, MA) (Figure 2). Applied pressure was gradually increased from 0.5 atmospheres (ATM) to 3 ATM over 1–2 min. This procedure was repeated 2–3 times per session depending on the ease with which the stricture responded to the balloon pressure (Figure 3). The diameter of the initial balloon depended upon the oesophageal lumen at the level of the stricture, which was generally slightly larger (2–5 mm) than the oesophageal stricture. The first dilatation was usually made with a balloon 4–6 mm in diameter. If dilatation was accomplished easily, the size of the balloon was gradually increased by a step of 2 mm during the same session, and each subsequent weekly session until the final diameter (SI<10%) was achieved. Balloons of increasing diameter were used, varying from 4 mm to 20 mm. Following dilatation the guidewire was removed and the balloon retracted above the level of the stricture. Water soluble material was injected via the catheter to evaluate results and look for any procedural complication, especially oesophageal perforation (Figure 4). Generally the procedure lasted 30–45 min. When sedation had sufficiently worn off, patients were allowed to drink and to commence a soft diet at least 2 h later.
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Figure 2. 3-month-old boy with oesophageal anastomotic stricture secondary to oesophageal atresia repair. (a) Anteroposterior and (b) lateral views show the oesophageal stricture "balloon waist" (arrowheads) on an inflated 12 mm diameter, 6 cm long balloon catheter.
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Figure 3. A 2-month-old boy with oesophageal stricture following oesophageal atresia surgery. (a) Anteroposterior and (b) lateral chest radiographs demonstrate disappearance of oesophageal stricture print (arrow) after application of 2 atmospheres pressure over 2 min.
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Figure 4. 1-month-old girl with oesophageal stricture following oesophageal atresia surgery. A water soluble contrast oesophagogram obtained at the end of the second session of balloon dilatation (8 mm diameter, 5.5 cm length) shows a leakage of contrast material (arrowheads) in the mediastinum at the level of the oesophageal stricture (arrow).
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Assessment of outcome
Dilatation was considered successful when the SI decreased on the oesophagogram to at least 10%, when swallowing problems were relieved up to 3 months after dilatation and when weight gain and growth were satisfactory. A successful end-point was relief of stricture in two or fewer balloon dilatation sessions. Data (age, sex, associated GOR and the number of dilatations required for treatment) were collected and recorded in Epi info software, version 6 (CDC, Atlanta, GA). Statistical analyses were performed using non-parametric tests and the association assessment was reported by the odds ratio.
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Results
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25 children (15 male, 10 female) aged 1–36 months (median 4 months, IQR=19) were treated with balloon dilatation for anastomotic stricture following surgical OA repair. The anastomotic stricture rate following OA repair in this series was 25.5% (25 of 98). All cases were type III OA of Ladd and Gross classification (OA with distal oesophagotracheal fistula). Stricture was more than 50% of oesophageal lumen in all patients. The delay from surgical treatment of OA and the first balloon dilatation varied from 1 month to 36 months (Table 1). Balloon dilatation was successful in all patients after a total of 115 sessions, ranging from 1–14 procedures per patient (median 4 dilatations, IQR=4.5). A requirement for two or fewer dilatation sessions was significantly associated with an age of less than 6 months (relative risk 0.52, 95% confidence interval 0.29–0.92) (Table 2).
On the first barium swallow, to evaluate the oesophageal stricture, GOR was noted in 15 patients (60%). This was treated initially by medication. In 11 cases of treatment failure, GOR was further treated by Nissen fundoplication during or after balloon dilatation sessions. The likelihood of requiring two or less dilatations was 12 times higher for patients without GOR than those presenting with associated GOR (Table 3). Observed complications included two cases of oesophageal perforation during 115 dilatation sessions (1.7%). These occurred in the second dilatation session for both the patients involved. No significant factors have been determined that can predict this complication. Oesophageal perforations were treated conservatively by stopping oral intake, administering antibiotics and parenteral alimentation. Minor complications were noted, such as minimal bleeding requiring only conservative management. Epistaxis was relatively frequent, occurring in nine balloon dilatation sessions. This can be explained by the per nasal route of the balloon catheter introduction in the oesophagus. This method was preferred because it gives more stability for the balloon in the oesophageal stenosis and allows rapid access if laryngeal intubation is required during sedation. No laryngeal intubation was needed in the patients described, and there were no complications related to anaesthesia. The follow-up period varied from 4–33 months and all patients were symptom free.
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Discussion
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Anastomotic stricture following OA repair is one of the main causes of oesophageal strictures in children [4–6]. It occurs in 18–50% of repaired OA. In this series it was noted in 25% of cases. Owing to a high reported rate of oesophageal perforation (8–9%) and the high number of dilatation sessions per patient [5], treatment of these strictures by bougienage under fluoroscopic or endoscopic control was replaced by balloon dilatation. This high rate of oesophageal perforation was related to the higher shearing force of bougienage [7] compared with balloon dilatation. Balloon dilatation generates direct dilating forces on the stricture with stationary radially applied forces depending on balloon inflation pressure. The rate of oesophageal perforation related to balloon dilatation is 0–2.7% [7–10]. It has been reported that better results from balloon dilatation are obtained in post-operative anastomotic oesophageal stricture when compared with oesophageal stenosis secondary to GOR and caustic ingestion [4, 6, 8, 10]. The study success rate of 100% reported here has confirmed these results. Dense scarring due to long duration of symptoms and diffuse oesophageal involvement noted in corrosive and peptic oesophageal strictures may be the reason for a lower rate of success and a higher rupture rate (33%) after balloon dilatation [8, 11]. The best results in anastomotic stricture following OA repair are related to early detection of oesophageal stricture and rapid initiation of balloon dilatation sessions before scar tissue and fibrosis occur, reducing the chance of stretching the stricture. Balloon dilatations performed after OA surgery in patients younger than 6 months in this series have required fewer dilatation sessions. Post-operative delay of less than 3 weeks may be too early in the healing process and could put the anastomosis at risk of perforation [7]. Gastroesophageal reflux is common in infants following repair of OA. Its incidence varies widely from 18% to 49% [12, 13], and was 38% (37 of 98 cases) in the series presented here. GOR was more frequent, at 60%, in patients with strictures secondary to surgical treatment of OA compared with 38% in the entire series of 98 patients. The likelihood of having a low number of dilatations (![{els]](/math/els.gif)
le;le;2 sessions) was 12 times higher for patients without GOR than those presenting with associated GOR (p<0.001). GOR is associated with a higher rate of oesophageal rupture [2, 12, 13]. In this series, the two cases of oesophageal perforation occurred in patients with strictures associated with GOR. GOR is a significant factor in the formation of resistant strictures and even in the genesis of post-operative stricture. It has been shown that early post-operative anastomotic narrowing does not correlate with subsequent stricture formation [2, 14]. Early detection of GOR and its treatment before oesophagitis occurs has reduced its morbidity [2, 3, 13, 14]. Chittmittrapap et al [13] noted that, after anti reflux surgery, the majority of strictures resolve with minimal dilatation procedures. The most serious complication of balloon dilatation is oesophageal rupture. We suggest the following technical precautions may reduce the incidence of oesophageal perforation during balloon dilatation: (a) use of a balloon longer than the stricture; (b) the balloon diameter must be adjusted to the stricture's size, with gradual increase of the balloon size in the same session; (c) avoid dilatation of the oesophageal lumen to its maximum diameter during a single episode; (d) choose a weekly interval between subsequent sessions; (e) pressure applied must not go beyond 3 ATM; and (f) avoid manipulation of the inflated balloon in the oesophageal lumen, like a bougie dilator, which can generate an abrupt shearing axial force.
Early detection of oesophageal rupture, using water soluble contrast swallow immediately after dilatation, is very important to prevent frank sepsis and mediastinitis. Overall mortality is higher when treatment is delayed 24 h after perforation [7]. Kang et al [9] have suggested a second oesophagogram with barium to detect small oesophageal tears, even when the water soluble contrast swallow was normal. Goldthorn et al [3] and Louhimo et al [15] have suggested the use of serial balloon dilatation as prophylaxis against anastomotic stricture secondary to OA surgery. This approach is difficult to justify since anastomotic stenosis occurs in only 18–50% of these patients. However, the favourable outcome observed with early treatment of anastomotic strictures and the important role of GOR suggests that routine barium swallow performed 4 weeks after surgery is helpful in planning appropriate management.
The limited number of patients in this series does not allow us meaningful statistical markers, but these results provide guidance for the optimal management of a relatively frequent sequela of OA treatment.
Received for publication February 18, 2002.
Revision received August 30, 2002.
Accepted for publication September 13, 2002.
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References
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|---|
- Chetcuti P, Phelan PD. Gatrointestinal morbidity and growth after repair of oesophageal atresia and tracheo-oesophageal fistula. Arch Dis Child 1993;68:163–6.[Abstract/Free Full Text]
- Nambirajan L, Rintala RJ, Losty PD, Carty H, Lloyd DA. The value of early post-operative oesophagraphy following repair of oesophageal atresia. Pediatr Surg Int 1998;13:76–8.[CrossRef][Medline]
- Goldthorn JF, Ball WS, Wilkinson LG, Siegel RS, Kosloske AM. Esophageal stricture in children: treatment by serial balloon dilatation. Radiology 1984;153:655–8.[Abstract/Free Full Text]
- Sandgren K, Malmfors G. Balloon dilatation of esophageal strictures in children. Eur J Pediatr Surg 1998;8:9–11.[Medline]
- Lang T, Hummer HP, Behrens R. Balloon dilation is preferable to bougienage in children with esophageal atresia. Endoscopy 2001;33:329–35.[CrossRef][Medline]
- Allmendinger N, Hallisey MJ, Markowitz SK, Hight D, Weiss R, McGowan G. Balloon dilation of oesophageal strictures in children. J Pediatr Surg 1996;31:334–6.[CrossRef][Medline]
- Kim IO, Yeon KM, Kim WS, Park KW, Kim JH, Han MCH. Perforation complicating balloon dilatation of esophageal strictures in infants and children. Radiology 1993;189:741–4.[Abstract/Free Full Text]
- McLean GM, Le Veen RE. Shear stress in the performance of esophageal dilation. Radiology 1992;184:373–8.[Abstract/Free Full Text]
- Kang SG, Song HY, Lim MK, Yoon HK, Goo DE, Sung KB. Esophageal rupture during balloon dilatation of strictures of benign or malignant causes: prevalence and clinical importance. Radiology 1998;209:741–6.[Abstract/Free Full Text]
- LaBerge JM, Kerlan RK Jr, Pogany AC, Ring EJ. Esophageal rupture: complications of balloon dilation. Radiology 1985;157:56.[Abstract/Free Full Text]
- Song HY, Han YM, Kim HN, Kim CS, Choi KS. Corrosive esophageal strictures: safety and effectiveness of balloon dilatation. Radiology 1992;184:373–8.
- Spitz L, Kiely E, Brereton RJ. Esophageal atresia: five years experience with 148 cases. J Pediatr Surg 1987;22:103–8.[CrossRef][Medline]
- Chittmittrapap S, Spitz L, Kiely EM, Brereton RJ. Anastomotic stricture following repair of esophageal atresia. J Pediatr Surg 1990;25:508–11.[CrossRef][Medline]
- Tam PK, Sprigg A, Cudmore RE, Cook RC, Carty H. Endoscopy-guided balloon dilatation of esophageal strictures and anastomotic strictures after esophageal replacement in children. J Pediatr Surg 1991;26:1101–3.[CrossRef][Medline]
- Louhimo I, Lindahl H. Esophageal atresia: primary result of 500 consecutively treated patients. J Pediatr Surg 1983;18:217–29.[CrossRef][Medline]
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Abstract
Introduction
