Individually designed fully covered self-expandable metal stents for pediatric refractory benign esophageal strictures

To share our institutional experience of placing individually designed fully covered self-expandable metal stents (FCSEMSs) for the treatment of refractory benign esophageal strictures (RBESs) in pediatric patients. A 10-year retrospective study between May 2009 and July 2020 that includes 14 children with RBESs who were treated with individually designed FCSEMSs. Patients were followed-up regularly after stent placement to observe the improvement of vomiting and dysphagia, changes in stenosis diameter and complications. A total of 20 stents were successfully placed in 14 patients. During a follow-up period ranging from 5 to 83 months, except for one 4-year-old child who could not endure chest pain, the remaining 13 patients all benefited from stenting. Their Ogilvie & Atkinson scores improved from grade III–IV to grade 0-I, and the diameters of the stenosis’ were enlarged from 2–5 mm to 9–14 mm. Two patients developed restenosis and granulation tissue hyperplasia was found in 2 patients and stent migration and malapposition in 2 patients with esophageal perforations that required further endoscopic intervention. The use of FCSEMS for RBES is safe and effective in selected pediatric patients. Rationally designed stents and timely management of postoperative complications are critical to ensure the success of this new method.

Efficacy and Safety of Endoscopic Esophageal Dilatation in Pediatric Patients with Esophageal Strictures

Background and Objectives. Benign strictures are the main cause of esophageal strictures in children. They can be managed by different modalities but endoscopic dilatation is the standard therapy. This study is aimed at reviewing the efficacy and safety of endoscopic dilatations in children with esophageal strictures. Materials and Methods. In this retrospective cross-sectional single center study, records of patients with esophageal strictures presented to the pediatric department, Salmaniya Medical Complex, Bahrain, in the period between 1995 and 2019 were reviewed. Demographic data, indications of endoscopic dilatations, the procedure success rate, and possible complications were assessed. Results. Forty-six children were found to have esophageal strictures. Twenty-five (54.3%) patients were males. Most patients presented during infancy (86.5%, 32/37 patients). Twenty-six (56.5%) patients required 88 dilatation sessions, while the remaining 20 (43.5%) patients did not require dilatations. The median number of dilatation sessions per patient was three (interquartile range = 2 –5). Savary-Gilliard bougienages were the main dilators used (80.8%, 21/26 patients). Anastomotic stricture (post esophageal atresia/tracheoesophageal fistula repair) was the main cause of esophageal strictures and was found in 35 (76.1%) patients. Patients with nonanastomotic strictures had more frequent dilatations compared to those with anastomotic strictures ( P = 0.007 ). The procedure success rate was 98.8%. Yet, it was operator dependent ( P = 0.047 ). Complete response to dilatation was found in 18 (69.2%) patients, satisfactory in seven (26.9%), and an inadequate response in one (3.9%). Those with satisfactory responses still require ongoing dilatations based on their symptoms and radiological and endoscopic findings. No perforation or mortality was reported. Patients with dilatations had more recurrent hospitalization ( P < 0.0001 ), more dysphagia ( P = 0.001 ), but shorter hospital stay ( P = 0.046 ) compared to those without dilatations. Surgical intervention was required in one patient with caustic strictures. The median follow-up period was six years (interquartile range = 2.25 –9.0). Conclusions. Endoscopic esophageal dilatation in children with esophageal strictures is effective and safe. Yet, it was operator dependent. Nonanastomotic strictures require more dilatations compared to anastomotic strictures. Findings of this study are comparable to those reported worldwide.

Acquired Esophageal Strictures in Children: Morphometric and Immunohistochemical Analyses

Background Esophageal strictures (ES) in children are not well characterized pathologically. We report unique histopathologic analyses of resected acquired ES and control esophagi (CE). Methods Muscle layer thicknesses were measured in intact well-oriented areas; inflammatory cells were counted in the most inflamed high power field (hpf). Sections were stained with relevant antibodies. Results were expressed as median, lower and upper quartiles. Wilcoxon Rank Sums non-parametric test was used to compare groups; P ≤ 0.05 was considered significant. Results All ES (N = 10) showed focal replacement of lamina propria, muscularis mucosa and submucosa by actin+ fibers emanating from muscularis propria. Compared to CE (N = 8), ES displayed significantly thickened muscularis mucosa and propria, and increased mast cells (tryptase- and chymase-positive), and eosinophils in muscle layers (all P ≤ 0.01). Matrix proteins periostin and fibronectin were identified in the muscle layers of CE, and in the extracellular matrix in areas of disrupted architecture in ES. Conclusions Compared to CE, acquired ES in children show significant structural alterations, including obliterative muscularization, inflammatory cell mural infiltrates, and extracellular matrix protein deposits. Therapies targeting connective tissue expansion, mast cells, eosinophils and inflammation may be beneficial to treat ES.

Erythema multiforme in the esophagus

Erythema multiforme is an immune-mediated mucocutaneous disorder. Mucosal involvement usually affects the oral region, the genitals or the eyes. We report a case of esophagitis caused by erythema multiforme in a patient diagnosed with lung cancer. Esophageal manifestation in erythema multiforme is rarely seen. Besides esophagitis it can lead to esophageal strictures. Erythema multiforme is mostly triggered by infection or drugs but the association with malignancy has been described.