Journal of Pediatric Gastroenterology and Nutrition. 67(2):e20–e21, AUG 2018
DOI: 10.1097/MPG.0000000000001936
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PMID: 29470294
Issn Print: 0277-2116
Publication Date: 2018/08/01
Dilation of Esophageal Stricture in a Pediatric Patient Using Functional Lumen Imaging Probe Technology Without the Use of Fluoroscopy
Jordan Taylor;Enrico Danzer;William Berquist;James Wall;
+ Author Information
*Division of Pediatric Surgery†Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Lucile Packard Children's Hospital, Stanford, CA.
Excerpt
Esophageal atresia (EA) with tracheoesophageal fistula (TEF) is a rare congenital malformation with a “blind-ending” esophageal pouch and aberrant connection between the airway and esophagus. The incidence of EA-TEF is reportedly 1 in 2500 to 4000 live births (1). Prenatal diagnosis of EA-TEF is rare, but the condition is usually symptomatic within the first hours of life. Repair of EA-TEFs often occurs in the first 24 to 48 hours of life, once the infant is stable and associated malformations have been excluded. Survival rates in patients who undergo repair is between 85% and 95%, with reported in-hospital mortality rate of 5.4% (2).There are multiple short- and long-term complications after EA-TEF repair, including anastomotic leak, gastroesophageal reflux (GER), trachomalacia, esophageal motility dysfunction, and anastomotic stricture (incidence of 8%–59%) (3). Complications from poorly managed or undiagnosed GER and esophagitis can also lead to strictures. The standard of care for managing esophageal strictures is dilation, classically through fluoroscopic-guided balloon dilation. Strictures tend to recur and require serial dilations. In 2010, Serhal et al (4) published a 5-year review of 62 children who had undergone EA-TEF repair; 37% of patients developed anastomotic strictures, most within the first year of life (mean age, 149 days). Strictures in this group resolved after an average of 3.2 dilations per patient.Advances in recent years have expanded the options for evaluating and treating esophageal strictures. We present the first reported case of balloon dilation of TEF-related stricture in a child without the use of fluoroscopy, utilizing the Esophageal Treatment Functional Lumen Imaging Probe (EsoFLIP).Our patient is an 8-year-old boy born with proximal EA and a distal TEF, or type C EA-TEF, who underwent repair in infancy. His postoperative course was complicated by multiple esophageal anastomotic strictures, recurrent pneumonia, and eosinophilic esophagitis. He had 6 previous dilations of esophageal strictures because of dysphagia. On presentation, he had developed recurrent dysphagia to solid food, weight loss, and cough. He underwent an esophagram at an outside facility 2 months prior that showed a mid-esophageal stricture (6 mm diameter) with proximal esophageal distention.Endoluminal Functional Lumen Imaging Probe (EndoFLIP; Crospon, Galway, Ireland) is a novel device for endoscopic evaluation of gastrointestinal strictures. The esophageal-treatment iteration of this device, EsoFLIP, has both diagnostic and therapeutic capabilities. Using electrode arrays, voltage measurements are used to calculate impedance along the catheter and derive precise cross-sectional areas (CSA) and diameters (5). EsoFLIP takes measurements every 5 mm along the length of the 8 cm catheter, and can also dilate strictures with real-time feedback of the luminal diameter.EndoFLIP has been safely used in adults with GER, dysphagia, eosinophilic esophagitis, and those undergoing per-oral endoscopic myotomy (POEM) (6). EsoFLIP has recently been shown feasible for adults with achalasia, allowing for safe dilation without the use of fluoroscopy (7). In pediatrics, the system has had limited use, partly because of the novelty of advanced endoscopic surgeries within this population (8). The diagnostic features of the EndoFLIP catheter have been used to measure the diameter and CSA of the gastroesophageal junction following POEM for achalasia (9). To date, there is no published data on EsoFLIP use for therapeutic dilation of esophageal strictures in pediatric patients.The procedure was performed under general anesthesia after obtaining informed consent. Initial endoscopy revealed an esophageal stricture beginning at the anastomosis, 20 cm from the incisors. The scope was passed through the stricture, revealing evidence of mild distal mucosal inflammation consistent with GER as a contributing factor in the stricture.
