BENIGN ESOPHAGEAL STRICTURES: ENDOSCOPIC OUTCOME AND FURTHER STRATEGIES OF IMPROVEMENT
Dr. Ujjal Poddar *
Assistant Professor, Pediatric Gastroenterology, Department of Gastroenterology, SGPGIMS, Lucknow.*
Dysphagia in children is usually due to a benign cause, unlike adults, in whom it is predominantly due to malignancy. The major causes of esophageal stricture in children are congenital, corrosive, post-operative and peptic due to reflux esophagitis. The commonest cause in India is corrosive stricture, whereas in the West it is post-operative stricture. In a study of 107 cases from PGI, Chandigarh over a period of 8.5 years, we have shown that 50% cases were due to corrosive ingestion, 21% were post-EST (sclerotherapy), 13% post-operative (following esophageal atresia repair), 9% congenital, 3.5% peptic and 2% were due to other causes 1. All these children presented with dysphagia and vomiting at a mean age of 4.8 years (1 month to 14 years). Classically, congenital stricture cases present at 6 to 12 months of age at the time of introduction of solid food. Barium swallow is the investigation of choice. Not only it gives the diagnosis, it provides detailed road map (site, size, extent and number of strictures) to the endoscopist as well as to a surgeon. The primary goal of therapy is to achieve an adequate esophageal lumen to relieve dysphagia, which can be achieved by endoscopic dilatation or by surgery. At present endoscopic dilatation is the treatment of choice as surgery carries an immediate post-operative mortality of 5 to 20% and longterm morbidity in the form of anastomotic stricture for which endoscopic dilatation is required. Endoscopic dilatation may be done by balloon or bougie. Although balloon is preferred over bougie as it is more effective and carries a lower risk of complication, it is very expensive and meant of one time use only. A majority of patients in India are due to corrosive ingestion and require multiple dilatation sessions, making bougie more cost-effective than balloon. In our study, we have shown that bougie dilatation was successful in 97% of cases and just 3 cases required surgery. The number of session required to achieve "initial adequate dilatation" (lumen diameter 15 mm in > 5 years of age and 11 mm in < 5 years of age with complete relief of dysphagia) was much more in corrosive stricture than in non-corrosive stricture. Among the corrosive strictures, those with > 5 cm strictures and/or multiple strictures required more session to achieve adequate dilatation. Recurrence of strictures after achieving adequate dilation is a rule than exception in corrosive strictures than non-corrosive strictures (94% vs. 35%). However, recurrent strictures are easily amenable to on demand dilatation. Perforation is the main complication of endoscopic dilatation. Perforation is the main complication of endoscopic dilatation and the reported risk is 1-2% 1, 2.

The main problem in managing long/multiple corrosive strictures is need for frequent dilation over a long period of time (for many years). Recently it has been shown that intra-lesion steroid (triamcinolone) injection during dilatation leads to symptomatic improvement and significantly reduces the frequency of dilatation 3, 4.

In a recent study from Turkey in children with corrosive stricture, it has been shown that prophylactic early dilatation (started in the first week of corrosive ingestion) is superior to late dilatation after stricture development (after 3 weeks of corrosive ingestion). Though the former modality does not prevent the development of stricture but strictures resolve early (within 6 months) than the later (more than 6 months) (5).

Another study from China has shown that retrievable self-expanding stent is very effective in refractory corrosive esophageal strictures in children. Retrievable expanding stents made of nitinol alloy were placed in eight children with refractory corrosive esophageal strictures (persistent dysphagia after 6-12 months of repeated balloon dilatation). The stents were removed within 1 to 4 weeks after placement. At 3 months, all children were dysphagia-free and after 6 months, only 2 children showed mild strictures and required 3 & 5 sessions of dilatation, rest were asymptomatic at the end of follow-up of 18 months, however, we need more information before recommending these methods. At present endoscopic dilatation and nitra-lesion steroid injection for refractory cases seems to be the only answer to corrosive stricture in children.
References :
  1. Poddar U, Thapa BR, Benign esophageal strictures in infants and children: results of Savary-Gilliard bougie dilatation in 107 Indian children. Gastrointest Endosc 2001;54:480-484.
  2. Broor SL, Lahoti D, Bose PP, Ramesh GN, Raju GS, Kumar A. Benign esophageal strictures in children and adolescents: etiology, clinical profile, and results of endoscopic dilatation. Gastrointest Endosc 1996;43:474-7.
  3. Kochhar R, Ray JD, Sriram PVJ, Kumar S, Singh K. Intralesional steroids augment the effect of endoscopic dilatation in corrosive esophageal strictures. Gastrointest Endosc 1999;49:509-13.
  4. Zein NN, Greseth JM, Perrault J. Endoscopic intralesional steroid injections in the management of refractory esophageal strictures. Gastrointest Endoscopy 1995;41:596-8.
  5. Tiryaki T, Livanelioglu Z, Atayurt H. Early bougienage for relief of stricture formation following caustic esophageal burn. Pediatr Surg Int 2005;21:78-80.
  6. Zhang C, Yu JM, Fan GP, Shi CR, Yu SY, Wang HP, Ge L, Zhong WX. The use of a retrievable self-expanding stent in treating childhood benign esophageal strictures. J Pediatric Surgery 2005;40:501-4.
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