University of Texas at Austin - Dell Medical School
Anastomotic strictures following surgical repair of esophageal atresia is common. Symptomatic strictures may require periodic dilation or, in refractory cases, surgery. Placement of an endoscopic metal stent is a less invasive alternative to surgical revision. Few cases describe an early, proactive approach to stent placement in premature infants who have increased risk for complications.
A 31 week-old 1.3 kg female presented with hypoxia after birth. Type C esophageal atresia was identified and tracheoesophageal fistula division was completed but anastomosis was deferred for ~3.5 weeks given proximal-distal esophageal gap. GJ tube placed for feeds.
Patient had ongoing, episodic hypoxic episodes requiring HFNC. Bronchoscopy and laryngoscopy were largely unremarkable. Attempt at EGD was unsuccessful, and gastroscope was unable to be advanced secondary to esophageal stenosis. Esophagram revealed severe anastomotic stenosis. Attempt at wire guided dilation via radiology was unsuccessful. Therefore, combined anterograde-retrograde EGD was attempted and luminal continuity was achieved via guidewire using transillumination. The tract was sequentially dilated to 9Fr and a fully covered 8mm metal biliary stent was placed. Within one week, the patient discharged, tolerating feeds without apnea. On repeat EGD, four weeks later, the lumen was patent and the stent was exchanged for another fully covered 8mm biliary stent to assist with further healing. No further dilation was required. Six weeks from initial EGD, the biliary stent was removed with a widely patent lumen. Repeat esophagram revealed no stricture, leak or fistula.
Discussion: Stent placement for anastomotic stricture in pediatrics is traditionally reserved for patients who fail serial balloon dilations or surgical revision. Although balloon dilation therapy has good safety and efficacy profiles, the vast majority of patients require serial dilations and 20% of patients experience ineffective symptom relief.
In this patient, in consideration of young age and risk for repeated procedures, it was opted for early intervention via esophageal stent. Lumen patency was achieved within 6 weeks and therapy for oral ingestion could take place. This case represents an important clinical scenario where esophageal stenting should be considered initially and is one of the earliest successful uses of biliary stent in the management of severe esophageal stricture after esophageal atresia repair.
Figure 1. A series of endoscopic images revealing successful guidewire placement through severe anastomotic stricture (Image 1) followed by metal biliary stent placement (Image 2) using combined anterograde-retrograde endoscopy. On repeat endoscopy six weeks later, the metal biliary stent (Image 3) was removed revealing a widely patent lumen (Image 4) and resolution of the esophageal stricture.
Figure 2. Left image: Initial esophagram revealing a patulous proximal esophageal pouch with no obvious luminal continuity with the distal esophagus. Right image: Esophagram after esophageal stent removal revealing mild proximal esophageal dilation and no evidence of contrast extravasation or residual tracheoesophageal fistula.
Paul Guzik indicated no relevant financial relationships.
Jessica Trevino indicated no relevant financial relationships.