A child’s esophagus can become damaged through physical trauma or ingestion of toxic chemicals or foreign objects — such as oven and drain cleaners, lye, laundry and dishwasher detergents and batteries. Depending on the substance and the amount ingested, children can develop esophageal strictures (scar tissue that narrows the esophagus) or esophageal perforations (holes in the esophagus). These problems can also be complications of surgery for esophageal atresia, in which a baby is born without part of the esophagus.
Children with esophageal perforations have traditionally been treated with long courses of antibiotics and not eating by mouth. More recently, perforations have been treated with stents, and strictures with a combination of dilation and stenting. But stenting, while it can be effective, requires up to eight weeks of therapy and can have complications such as pain, retching and local pressure necrosis, a type of ulcer that may worsen perforation. Such concerns have led researchers to investigate alternative treatments for perforation and strictures.
In a pair of recent studies in the Journal of Pediatric Gastroenterology and Nutrition, Michael Manfredi, MD, and his colleagues in the Esophageal and Airway Treatment Center at Boston Children’s Hospital explored two adjunct approaches.
Opening up esophageal strictures with EIT
For the first paper, they analyzed data from 57 Boston Children’s patients who had undergone endoscopic electrocautery incisional therapy (EIT), an endoscopic approach that has been used in adults with refractory (hard to treat) strictures. EIT uses a small endoscopic knife to incise scar tissue at its thickest point to open up strictures prior to dilation.
Manfredi and his team found that 100 percent of children with non-refractory strictures and 61 percent with refractory strictures were treated successfully with EIT. Complications were relatively minor and included esophageal leaks. The team concluded that EIT shows promise as an adjunct treatment for esophageal strictures and may be considered before surgical resection, even in severe cases. The study is the largest to date to investigate EIT in either children or adults.
“Standard dilation treatment assumes that all strictures are completely circular,” says Manfredi. “However, we know in many instances this is not the case. Strictures are asymmetric and can have thick bands of scarring. EIT allows us to target the areas of the stricture that need to open up, making dilations more effective. Since EIT does have a higher risk of causing a perforation, it should only be undertaken by someone who has experience with advanced therapeutic endoscopy.”
Vacuum sponge helps heal perforations
The second study evaluated a customized esophageal vacuum-assisted closure (EVAC) device for esophageal perforations. Also known as negative-pressure wound therapy, EVAC is the standard of care for chronic surface wounds, ulcers and burns. It stimulates wound healing by removing fluid from the perforation site, decreasing infection and tissue edema and promoting blood flow to the area and the formation of granulation tissue, which helps close the perforation.
Manfredi and his colleagues reviewed data from 41 Boston Children’s patients with esophageal atresia whose perforations were caused by either surgery or endoscopic therapy. Twenty-four patients underwent traditional stenting, while 17 were treated with EVAC.
The team found that EVAC had an overall 88 percent success rate in sealing esophageal perforations, compared with 63 percent for stents. EVAC performed better than stenting in healing perforations caused by surgery; there was no significant difference in healing perforations caused by endoscopy. Although EVAC has been used to treat esophageal perforations since 2008, this study is the first of its kind to examine its efficacy for this purpose in children.
“EVAC has been a great innovation for our program: Perforations that would typically require surgery to repair can now be closed in weeks,” says Manfredi. “It also has been helpful to reduce the risk of perforation in patients with strictures that undergo EIT. We are also studying the benefits of using EVAC to prevent perforations from happening in the first place.”
Learn about the Esophageal and Airway Treatment Center.