Endoscopic balloon dilatation of esophageal strictures in infants and children: 17 years' experience and a literature review

Purpose: Whereas endoscopic balloon dilatation (EBD) of benign esophageal strictures is an established mode of therapy in adults, this has not been accepted universally in the pediatric population. The aim of this study is to report the safety, efficacy, and long-term results of EBD for children in the authors’ center.Methods: Between 1986 and 2002, a total of 77 children (median age, 1.8 years; range, 2 months to 20 years) were treated by EBD for various causes: 2 had achalasia, and 75 had esophageal strictures (postesophageal atresia repair, 63; reflux esophagitis, 7; postfundoplication, 2; caustic injury, 3). Dilatations were performed using flexible endoscopy and fluoroscopic screening under general anesthesia.Results: A total of 260 dilatations were carried out with the mean number of EBD per patient being 3.4 (range, 1 to 19). A mean period of 5 months (maximum, 28 months) for each patient was required. Four complications of esophageal perforations (1.5%) were observed, but only one required surgical repair because of persistent leakage. The remaining patients have undergone long-term follow-up (median follow-up, 6.6 years), and all are asymptomatic.Conclusions: This large series has shown that EBD can provide a safe and effective mean of relieving esophageal strictures with good long-term results.     

Predictors of successful endoscopic management of caustic esophageal strictures in children: When to stop the dilatations?

BackgroundCaustic esophageal strictures are mainly managed by endoscopic dilatations. Cases that do not respond to the dilatations eventually require an esophageal replacement. The aim of our study was to identify factors that could allow us to predict if the dilatations will be successful or not.MethodsWe retrospectively reviewed the chart of 100 patients with caustic esophageal injuries treated at our center between 2012 and 2019. Collected data included age, gender, type of caustic substance, duration of the dilatations, length and extent of the strictures, number and time interval between dilatations, presence of gastroesophageal reflux, occurrence of esophageal perforation, and outcome of the dilatation program.ResultsThe patient ages ranged from 1 to 8 years old. The overall success rate was 98.2% for patients with short strictures and 81.8% for patients with long strictures (> 3 cm). A long stricture, a pharyngeal extension of the stricture, the occurrence of an esophageal perforation, and the presence of gastroesophageal reflux were strong predictors of the failure of the dilatation program. The median treatment time for the patients to achieve a cure was 5 months in cases of short strictures and 17 months in cases of long strictures. Within the subgroup of patients with long strictures, a dysphagia-free period within the first year of management of 8 weeks was associated with the success of the dilatation program.ConclusionA length of more than 3 cm, pharyngeal involvement, the occurrence of esophageal perforation, and the presence of gastroesophageal reflux are predictors of failure of dilatations for the management of caustic esophageal strictures. A dysphagia-free period of 8 weeks or more within the first year of dilatations is considered a predictor of success of dilatations in patients with long strictures.Level of EvidenceLevel II.     

Guide wire-assisted urethral dilatation for urethral strictures in pediatric urology

Purpose: The aim of this study was to report the results of 32 cases of dilatation of urethral stricture using a guide wire and sheath dilator technique supplemented by clean intermittent catheterization if further stabilization of the urethral stricture was felt warranted.Methods: The procedure involves insertion of a straight flexi-tip lubricated guide wire through the urethral stricture under cystoscopic guidance followed by insertion of a series of sheath dilators. Dilatation was followed by insertion of a Foley catheter, which was left in situ for 1 to 3 days. Patients underwent repeat cystoscopy to evaluate the urethra for recurrent stricture and those with a recalcitrant stricture were commenced on clean intermittent catheterization (CIC) to stabilize the narrowing.Results: Thirty-two patients were included. They have been followed up for up to 2 years after their last cystoscopy (mean, 16 months). Thirteen of 32 patients had more than 4 dilatations under anesthesia. Twelve patients had undergone CIC postoperatively. Complications included a urinary tract infection in 3 boys and bladder spasms in one. No false passage or sepsis occurred with this approach.Conclusions: Guide wire-assisted urethral dilatation helps avoid risks associated with blind dilatation techniques and appears to be a safe and simple alternative for management of urethral strictures in pediatric urology.     

Mitomycin C in the management of pediatric caustic esophageal strictures: A case report

Although the incidence of caustic ingestion is declining, the management of caustic esophageal strictures remains a challenge. Mitomycin C (MMC) inhibits fibroblast proliferation and is effective in reducing scar in animal experiments. We report the case of a child with a distal esophageal stricture from lye ingestion managed with MMC. Despite repeated dilatations, at 1 year post injury, the stricture was 20% of esophageal diameter. Mitomycin C (4 μg/mL) was applied topically and circumferentially by endoscopy and repeated 4 months later. At 20 months follow-up, the child eats normally, and esophagram showed decreased stenosis (stricture was 50% of esophageal diameter). No complications were observed. Although controlled trials are required to confirm its efficacy, MMC should be considered as an adjunct in the management of caustic esophageal strictures in children.     

Management of esophageal perforation secondary to caustic esophageal injury in children

Purpose To review our management of esophageal perforation in children with caustic esophageal injury. Method We reviewed the medical records of 22 children treated for esophageal perforations that occurred secondary to caustic esophageal injury. Results There were 18 boys and 4 girls (mean age, 5 years; range, 2–12 years). Three children were treated for perforation during diagnostic endoscopy and 19 were treated for a collective 21 episodes of perforation during balloon dilatation. One child died after undergoing emergency surgery for tracheoesophageal fistula and pneumoperitoneum. Another patient underwent esophagostomy and gastrostomy. Twenty patients were treated conservatively with a nasogastric tube, broad spectrum antibiotics, and tube thoracostomy, 16 of whom responded but 4 required esophagostomy and gastrostomy. Although the perforation healed in 21 patients, 20 were left with a stricture. Two children were lost to follow-up, 8 underwent colonic interposition, and 10 continued to receive periodic balloon dilatations. Two of these 10 patients underwent colonic interposition after a second perforation. The other 8 became resistant to dilatations: 4 were treated by colon interposition; 2, by resection and anastomosis; and 2, by an esophageal stent. Conclusions Esophageal perforation can be managed conservatively. Because strictures tend to become resistant to balloon dilatation, resection and anastomosis is preferred if they are up to 1 cm in length, otherwise colonic interposition is indicated.     

Mitomycin C in the management of pediatric caustic esophageal strictures: a case report

Although the incidence of caustic ingestion is declining, the management of caustic esophageal strictures remains a challenge. Mitomycin C (MMC) inhibits fibroblast proliferation and is effective in reducing scar in animal experiments. We report the case of a child with a distal esophageal stricture from lye ingestion managed with MMC. Despite repeated dilatations, at 1 year post injury, the stricture was 20% of esophageal diameter. Mitomycin C (4 microg/mL) was applied topically and circumferentially by endoscopy and repeated 4 months later. At 20 months follow-up, the child eats normally, and esophagram showed decreased stenosis (stricture was 50% of esophageal diameter). No complications were observed. Although controlled trials are required to confirm its efficacy, MMC should be considered as an adjunct in the management of caustic esophageal strictures in children.     

Usefulness of endoscopic ultrasonography in the diagnosis of congenital esophageal stenosis

Background/Purpose: Endoscopic ultrasonography (EUS) is considered a potentially useful tool to investigate structural abnormalities of the esophagus in pediatric patients, as in adults. The aim of this study was to evaluate the usefulness of EUS for the diagnosis of congenital esophageal stenosis. Methods: High-frequency catheter probe EUS was performed under general anesthesia in 2 patients who had congenital esophageal stenosis. Results: A 4-year-old boy with anorectal anomaly showed tapered narrowing in the distal esophagus, which was not ameliorated with balloon dilatation. High-frequency catheter probe EUS showed hypertrophy of the muscular layer in the esophageal wall at the narrowed portion, but no images suggested the presence of tracheobronchial remnants. The histologic diagnosis of fibromuscular hypertrophy was confirmed at esophagoplasty. A 5-month-old boy with Gross C-type esophageal atresia and symptomatic gastroesophageal reflux showed tapered narrowing in the middle esophagus on esophagography. The symptoms of stenosis were not ameliorated by balloon dilatation performed 4 times. High-frequency catheter probe EUS showed hyperechoic lesions suggesting cartilage at the esophageal narrowing. The diagnosis of tracheobronchial remnants was confirmed by the finding of 2 pieces of cartilage in the specimen obtained at the time of esophageal resection. Conclusion: EUS can be applied to show structural abnormalities of the esophageal wall even in pediatric patients with congenital esophageal stenosis and is useful for planning the therapeutic strategy.     

Severe caustic injuries of the esophagus: when to replace the esophagus

From June 1985 to May 1998, 20 patients have been treated in our hospital by esophageal dilatations due to serious esophageal caustic stenosis. A retrospective analysis of these 20 patients was performed, evaluating age, sex, causative agent, number and time of dilatations, iatrogenic esophageal perforations, gastroesophageal reflux (GER) and psychological and social consequences. Follow-up has ranged from 1.5 to 14.5 years (mean = 8.07 years). The mean age at the time of accidental swallow was 42.2 months. The causative agent was dishwashing detergent in 11 patients and caustic soda in 9 patients. The mean of dilatations needed was 19.1 and the average duration of dilatations was 24.7 months. Seven patients had esophageal perforation during dilatation and none of them required surgical treatment. All patients had improvement of swallowing and an easier esophageal dilatation afterwards. Oral contrast studies demonstrated distortion of the esophago-gastric junction in the majority of patients. Ten patients were screened for GER with 24-hour esophageal pH monitoring in the first year postburn and it was pathological in 5. Antireflux surgery was carried out in 4 patients with a conspicuous improvement following surgery. Dilatations proved successful in 16 patients in less than two years, and in more than two years in 3 patients. The authors conclude that the majority of children with esophageal caustic stenosis can be managed successfully by esophageal dilatations, even with dilatation periods longer than two years or when an esophageal perforation occur during the procedure. The paramount importance of early diagnosis and treatment of GER is stressed.     

Is there a role for balloon dilatation of pelvi-ureteric obstruction in children?

Purpose: The aim of this study was to examine the effectiveness of balloon dilatation with double J stenting in the management of children with pelvi-ureteric junction (PUJ) obstruction. Methods: A retrospective study of a 4-year experience of PUJ balloon dilatation in children was conducted in a single unit. Information was collected on patient demographics, clinical presentation, the procedure of balloon dilatation, renal function, and antero-posterior renal pelvis diameter both pre- and postoperatively. Results: There were 10 patients with a median age of 12.5 years (range, 21 months to 15 years). Four cases presented with ipsilateral flank pain, 3 with urinary tract infection, and 3 were discovered incidentally. Retrograde dilation was performed in all cases. Dilation was considered an initial success in 8 of 10 cases, and 1 patient deteriorated after 17 months. Double J stents were placed in all cases and remained in situ for a median of 7.5 weeks (range, 7 to 8.5). Median in-hospital stay was 2 days. Median follow-up was 34 months (range, 7 to 48). Ipsilateral renal excretion times (on MAG III isotope scanning) improved markedly from a median of 84 minutes (range 13 to 200) preoperatively to 7 minutes (range, 1 to 200) at 3 months and 7 minutes (range 1 to 113) at 12 months postoperatively. Median pelvic AP diameter reduced from 30 mm (range 22 to 74) to 16 mm (range, 8 to 36) at 2 months and 10 mm (range, 4 to 41) at 7 months. There were 2 immediate failed procedures, both occurred in patients who went on to open pyeloplasty and were found to have aberrant renal vessels causing extrinsic PUJ compression. One child deteriorated between 10 and 17 months and went on to open pyeloplasty. Twenty-two patients underwent open pyeloplasty in the unit during the same time period with a 95% success rate. Median stay was longer at 5 days and median age younger at 22 months (range, 6 weeks to 13 years). Conclusion: Balloon dilatation is a viable option in the management of PUJ obstruction, carrying minimal morbidity in experienced hands. J Pediatr Surg 37:893-896.     

纤维胃镜下气囊导管扩张治疗小儿食管狭窄30例

目的探讨纤维胃镜下气囊导管扩张治疗食管狭窄的疗效。方法1996年10月-2005年11月我院采用Olympus JIF—sP型纤维胃镜及美国波斯顿公司带压力表指示的充气气囊导管对30例食管狭窄进行扩张治疗。狭窄食管直径0．2—0．6cm，狭窄长度0．6～2．5cm，平均1．7cm。在纤维胃镜直视下将导管头部自咽部顺利送到狭窄处近端，通过胃镜下充气了解狭窄食管组织改变，有无瘢痕及炎症。将气囊导管头端经I：1腔送人狭窄段注气，扩张气囊同时通过压力表显示气囊压力大小，了解扩张情况，1支气囊导管扩张时间5min。结果29例共扩张113次。1例患儿于食管闭锁术后8个月发生严重狭窄，扩张困难转为手术治疗；29例食管狭窄患儿每月扩张2—3次，4～5次后食管狭窄处直径达到0．6～0．7cm，即为扩张成功。29例随访3个月-5年，患儿进食通畅，无食管再狭窄，生长发育良好。结论纤维胃镜直视下气囊导管扩张治疗食管狭窄是一种安全可靠的方法，并可通过纤维胃镜了解食管狭窄程度和病理改变。     

Management of traumatic urethral disruption in children: Oman experience, 1988-2000

Background: Traumatic urethral disruptions in children differ anatomically from those of adults. In children, the posterior urethra is not protected by the prostate and may be injured at any level. The management of traumatic rupture of the urethra still a matter of debate, and there is no agreement as to which is the best of 3 options. Methods: This was a retrospective analysis. Over a 12-year period the authors dealt with 21 urethral disruptions. The authors had detailed follow-up of 20 patients (14 posterior and 6 anterior). Trans-symphyseal urethroplasty (6 early primary repairs and 3 delayed repairs) for complete posterior urethral disruptions was performed. The early repairs were carried out within 7 days of the injury. Primary alignment was performed for 3 of the 4 partial ruptures of the posterior urethra and for all 6 anterior urethral disruptions. Postoperatively, the patients were evaluated for incontinence, penile erectile dysfunction, and stricture formation. Results: In one of the early repairs a stricture developed that responded to dilatations. A second patient with bladder neck injury had incontinence after the repair. She underwent a urethral lengthening procedure and still has stress incontinence. Erections were observed in all 4 boys. One of the delayed repairs developed a stricture postoperatively. Of the 9 partial ruptures (6 anterior and 3 posterior) that underwent primary alignment, 4 had strictures. Some of these strictures required up to 5 dilatations or internal urethrotomy for cure. One patient with complete rupture underwent primary alignment, which broke down, and a long stricture developed. This patient is still awaiting a delayed repair. One posterior partial rupture, repaired primarily at another hospital, had a stricture and an urethrocutaneous fistula that responded to curettage and dilatations. Conclusions: Primary repairs required less hopitalization and a shorter duration of indwelling catheters. In light of this experience the authors recommend a primary repair in patients with complete posterior urethral disruptions. J Pediatr Surg 37:1451-1455.     

Surgical treatment of reflux stricture of the esophagus

Ten children, aged 7 months to 15 years, with peptic esophageal stricture, were treated surgically. In four of the children, the stricture had occurred after esophageal anastomosis. Peptic stricture was diagnosed by esophagography, pH monitoring, manometry, and esophagoscopy. Barrett's esophagus was found in two children. Nine children underwent transabdominal Nissen fundoplication initially. In the first child of this series, a tight anastomotic stricture had been excised 2 weeks before fundoplication. Seven children became complaint-free within 2 or 3 months after fundoplication without any dilatation, and two children with anastomotic stricture improved after 1 or 2 postoperative dilatations. The condition of one boy, with a 6-year history of tight stricture, did not improve with repeat Nissen and subsequent dilatations. Histological examination showed proliferation of smooth muscle cells in the submucosa. A conservative surgical approach is effective for the management of peptic esophageal stricture in children, and direct surgical intervention for stricture should be attempted only in cases of stricture resistant to antireflux surgery with a long history of reflux.     

Management of congenital esophageal stenosis

Background/Purpose: The authors report the incidence, diagnosis, and treatment methods of congenital esophageal stenosis (CES) at their institution. Methods: A retrospective analysis of 123 patients with tracheoesophageal anomalies in a pediatric hospital between 1980 and 1999 was performed. Charts were reviewed for patient demographics, presence of true CES, associated congenital anomalies, method of diagnosis, methods of treatment, and histopathology. Results: Six of the 123 patients (4.9%) had true CES (one patient had 2 separate stenoses). Two patients had isolated CES, one patient had CES with isolated tracheoesophageal fistula (TEF), one patient had CES with isolated esophageal atresia (EA), and 2 patients had CES with EA/TEF. Diagnoses were made with an upper gastrointestinal (GI) contrast study in 5 patients, and one patient had one of 2 stenoses diagnosed by prenatal ultrasound and the other diagnosed intraoperatively. Four of the 7 stenoses were treated with surgical resection, and the remainder was treated with esophageal dilatation. Histopathology from the 4 resected stenoses showed tracheobronchial remnants in 3 specimens and submucosal thickening in 1 specimen. Conclusions: Although isolated CES is rare (2 of 123 = 1.6%), CES associated with other tracheoesophageal anomalies has a higher incidence (4 of 123 = 3.25%). Patients with this lesion should be treated first with dilatation. If ineffective, resection is required. J Pediatr Surg 37:1024-1026.     

Fluoroscopic balloon dilatation for caustic esophageal stricture in children: An 8-year experience

Purpose

Esophageal balloon dilatation (EBD), when performed early and correctly, can efficiently treat caustic esophageal stricture (ES). Herein, we present 8 years of experience treating caustic ES, and discuss the technique as well as the complications.

Methods

We retrospectively reviewed the medical records of 38 children in whom we performed fluoroscopic EBD under general anesthesia for caustic ES between November 2004 and November 2012 in our hospitals. The patients were grouped into the early dilatation group, who began EBD earlier (mean, 15 days) after caustic ingestion, and the late dilatation group who was referred later (mean, 34 days) for EBD by other centers. The ESs were classified into short and long strictures. Balloon size was increased gradually to a sufficient diameter over consecutive sessions. Characteristics of patients and ES, details of the EBD, and treatment results were analyzed.

Results

A total of 369 EBD sessions were successfully performed in 38 children (aged 14 months to 14 years, median 3.5 years). In six patients, EBD treatments are continuing, one patient was lost to follow up, one patient who received a stent was excluded, and three returned to their previous centers. The remaining 27 patients were treated successfully by repeated EBD treatments. Nevertheless, in the early dilatation group (n = 16), EBD treatment was significantly faster and shorter than that in the late dilatation group (n = 11). In addition, the short stricture treatment was also of significantly shorter duration than the long stricture treatment. Six (1.6%) esophageal perforations occurred in five patients (13.2%); all were treated conservatively. There was no mortality.

Conclusions

For treatment of caustic ES, fluoroscopically guided EBD is safe and has a low rate of complications as well as a 100% success rate. However, it should be begun earlier, and in children, should be performed gently with balloons of gradually increasing appropriate diameters over consecutive sessions.     

Early and Late Term Management in Caustic Ingestion in Children: A 16-year Experience

Accidental corrosive ingestion is one of the common problems causing serious esophageal strictures in children. The acute phase treatment has a great effect on stricture development. In this study we aim to present our experience in the management of caustic ingestion, particularly during the acute phase. From January 1990 to January 2005, 296 children were admitted to our clinic with caustic ingestion. Ninety-one patients who received dilatation treatment due to esophageal strictures constituted the present study group. Forty-three of them were admitted to our centre immediately after caustic ingestion (Group A) whereas 48 of them received some kind of treatment in other hospitals and were referred us with the diagnosis of stricture 6 to 12 weeks after ingestion (Group B). In the acute phase, the patients were given nothing orally until esophagoscopy was performed in the first 24–48 hours. The patients with grades 2b and 3 lesions underwent a week of esophageal rest by using a nasogastric tube. IV fluids and broad-spectrum antibiotics with a single-dose steroid were given. IV ranitidine was also added to the medical treatment. If there were stricture formations on barium meal after 3 weeks, these patients underwent esophageal dilatation programmes. The response rates to dilatation treatment were higher in group A. In addition, increased perforation rates were observed in group B. Sixty per cent of patients in group A but none of the patients in group B have recovered in the first year. In conclusion, after caustic ingestion, esophageal rest combined with supporting treatment seems to provide a good success rate with respect to prevention of stricture development and other troublesome complications.     

Early and late term management in caustic ingestion in children: a 16-year experience

Accidental corrosive ingestion is one of the common problems causing serious esophageal strictures in children. The acute phase treatment has a great effect on stricture development. In this study we aim to present our experience in the management of caustic ingestion, particularly during the acute phase. From January 1990 to January 2005, 296 children were admitted to our clinic with caustic ingestion. Ninety-one patients who received dilatation treatment due to esophageal strictures constituted the present study group. Forty-three of them were admitted to our centre immediately after caustic ingestion (Group A) whereas 48 of them received some kind of treatment in other hospitals and were referred us with the diagnosis of stricture 6 to 12 weeks after ingestion (Group B). In the acute phase, the patients were given nothing orally until esophagoscopy was performed in the first 24-48 hours. The patients with grades 2b and 3 lesions underwent a week of esophageal rest by using a nasogastric tube. IV fluids and broad-spectrum antibiotics with a single-dose steroid were given. IV ranitidine was also added to the medical treatment. If there were stricture formations on barium meal after 3 weeks, these patients underwent esophageal dilatation programmes. The response rates to dilatation treatment were higher in group A. In addition, increased perforation rates were observed in group B. Sixty per cent of patients in group A but none of the patients in group B have recovered in the first year. In conclusion, after caustic ingestion, esophageal rest combined with supporting treatment seems to provide a good success rate with respect to prevention of stricture development and other troublesome complications.     

Retrograde endoscopic dilatation for difficult caustic esophageal strictures: Feasibility and effectiveness

BackgroundDifficult caustic esophageal strictures may need a more sophisticated dilatation technique before referring for esophageal replacement surgery.Patients & methodRetrospective review of caustic esophageal strictures managed at our center between January 2010 and June 2018 was done. Twenty two patients labeled as undilatable strictures were enrolled. These patients had another trial for endoscopic dilatation using retrograde approach.ResultsAmong these 22 patients, 5 patients could be dilated by antegrade approach. Seventeen patients had a trial of retrograde dilatation after failed antegrade endoscopy. Retrograde dilatation was successful in 14 patients (82%). Nasogastric tube was left following dilatation in 4 patients to facilitate next sessions. Collectively, 19 out of the 22 patients could have their esophagus dilated in the first instance (86%). Among retrograde dilated patients; eight patients succeeded to retain their native esophagus (57%), two patients are still on dilatation with marked improvement (14%), and three patients underwent colon interposition owing to refractory stricture despite frequent dilatations.ConclusionEvery attempt should be tried to preserve the native esophagus. Retrograde endoscopic dilatation is a valuable alternative for undilatable stricture before referring the patient for replacement surgery.Level of evidenceThis is a case series with no comparison group (level IV).     

Esophageal motility changes in acute and late periods of caustic esophageal burns and their relation to prognosis in children

Background/Purpose: Esophageal burns as a result of accidental swallowing of caustic material are seen frequently in children. Severe motor function disorders of the esophagus after caustic burns are already reported covering the late periods. The aim of this study was to detect, follow, and report the clinical results of esophageal motility changes in acute as well as the late periods of caustic esophageal insult and its relation with prognosis in children. Methods: Esophageal motility was studied in 20 children aged 1.5 to 11 years (mean, 3.8). In the study group, motility of the esophagus was investigated on the fifth day of the burn (after decrease of the edema) and repeated at the end of the third month. To standardize the results, the amplitude and the duration of the pressure waves were recorded at 3 cm above the lower esophageal sphincter (LES), and the velocity in the distal esophagus was calculated. Then the mean values of amplitude, duration, and velocity of 15 swallows were obtained for each patient. Results: At the end of the fifth day, peristaltic response of the esophagus to swallowing was followed in 13 patients. Seven patients were able to swallow water, but no peristaltic response was detected. Therefore, the subjects were divided into 2 groups as motility (+) and motility ([minus ]), and each were compared with the control group separately. The amplitude of the pressure wave in the motility ([minus ]) group was significantly low when compared with the control group. All the subjects in this group had NaOH burns, and development of severe strictures was detected at the endoscopic examinations after 3 weeks. In motility (+) group, no pathologies were detected except significant decrease in the velocity of the peristaltic wave. Eleven of the subjects in this group had acid burns, and 2 had NaOH burns, and, at the follow-up endoscopic examination after 3 weeks, only one acid burn patient had a slight stricture. Motility measurements conducted at the end of the third month showed that the initial motility ([minus ]) group had no changes. No peristaltic response was detected after swallowing, and amplitude of the pressure wave measured at the distal esophagus was significantly lower than the controls. However, in the motility (+) group, decrease in the velocity of the peristaltic wave had disappeared, and there were no differences when compared with the control group. Conclusion: It is suggested that the manometric studies of the esophagus give important data about the severity of the initial esophageal injury and have an important role in determining the prognosis.     

Reflux strictures of the esophagus in children.

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 fundoplication with intraoperative 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, H2-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 gastrostomies for prograde esophageal dilatations. Twelve children needed postoperative esophageal dilatations. The results 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 esophagitis and fibrous scarring.(ABSTRACT TRUNCATED AT 250 WORDS)     

Anterior resection for megarectosigmoid in congenital anorectal malformations

Purpose: The aim of this study was to review the effectiveness of resecting dilated distal bowel in children suffering unmanageable constipation or soiling who have been operated on previously for anorectal malformations. Methods: A retrospective review was performed of 9 children. Each child underwent excision of dilated bowel to leave normal caliber bowel anastomosed by hand to a rectal reservoir at the peritoneal reflection. The documented follow-up was reviewed. Results: The 9 children had primary surgery for the following anomalies: high (n = 1), intermediate (n = 1), low (n = 3), rectal stenosis (n = 3), and anal stenosis (n = 3), Seven children had persistent fecalomas, and 7 had major problems with soiling. All were on large doses of laxatives, with 5 having regular rectal washouts and 4 having regular enemas. In all radiologic studies there was a prompt change from normal caliber bowel to dilated bowel at the upper limit of the dilatation. The mean age at operation for excision was 4 years, 11 months (range, 11 months to 9 years, 11 months). The mean period of follow-up was 4 years, 7 months (range, 2 years, 3 months to 10 years). Follow-up showed that all children improved. None had major complications. All were having between one and 3 bowel actions per day. Three continued to soil but improved. Of the remaining 6, only 2 required occasional laxatives and had regular spontaneous bowel actions without soiling. No child was having enemas or washouts. Conclusion: Anterior resection for the treatment of megarectosigmoid is a safe and effective procedure. J Pediatr Surg 37:1464-1466.