Tricks - Indwelling Balloon Catheter For Refractory Esophageal Stenosis

Esophageal stenosis after atresia repair or reflux esophagitis can be managed with balloon dilatation, but persistent stenosis has increasing recurrence rates requiring repeated dilatation.

The technique was first tried approximately 10 years ago, involving transnasal insertion of dilatation balloons under direct esophagoscopic vision, placement at the stenosis site, and intermittent inflation three times daily for 10 seconds followed by desufflation.

The rationale is that the esophagus will heal at least to the diameter of the balloon (e.g., 10 millimeters for a 10mm balloon), which is usually sufficient.

Compared to stents, balloons have very little dislodgement because the balloon is fixed to the catheter exiting through the nose.

Children can drink or eat solid foods alongside the indwelling balloon.

Olympus endotherapy balloons were initially used, but when unavailable, Boston Scientific Ultrasin vascular stent balloons were substituted successfully.

Balloons are available in different sizes and lengths, allowing selection based on patient age and desired diameter; for extensive burns, two balloons can be used simultaneously (e.g., 8cm and 4cm balloons).

The patient series included 5 long-gap atresia cases with stenosis, 2 type C atresia cases, 7 caustic burns, 3 stenoses of unknown cause, and 2 persistent reflux cases despite anti-reflux surgery.

Caustic burn and unknown-cause stenosis patients required prolonged dilatation periods, but the technique reduced the number of required endoscopies to approximately once every 4 weeks.

The principle of frequent dilatation promoting healing in the open position is analogous to historical practice of passing Maloney bougies multiple times daily at the bedside.

Complications included restenosis in 6 children after balloon removal at 4-6 weeks, managed by reinsertion for another 4-6 weeks; occasional dislodgement when children manipulated the catheter; balloon leakage requiring replacement; and one case of sputum retention leading to removal.

The balloon technique differs from bougie dilatation in that after initial dilatation under anesthesia, subsequent inflations only maintain patency and are not painful.

There was no mortality and no patient required surgical intervention (reanastomosis, esophagoscopy, or esophageal replacement).

A small child who swallowed a battery lodged in the upper sphincter was successfully managed with a 4cm 10mm balloon using gradual inflation (5cc warning inflation followed by full inflation) to allow the child to swallow, with no complications.

In a 16-year-old with a 10cm lye burn stenosis, two balloons (8cm lower, 4cm upper) were used simultaneously, achieving complete healing in approximately 3 months with the patient able to eat solids within 2-3 weeks.

The catheters are stiffer than standard nasogastric or silastic tubes; the tip must be bent for nasal introduction, or a guide wire can be used to facilitate replacement without anesthesia.

Initial dilatation typically involves 1-3 sessions before recognizing persistence; at that point, the balloon is left indwelling for 2 weeks initially (if severe inflammation) or 4-week stretches for burns, with endoscopic reassessment and possible replacement.

In small children, the catheter may need to be forcefully bent into a hook shape at the nasal exit point and fixed with Duoderm and plaster; nasal wing distortion can be prevented by tying the catheter to the opposite side with umbilical tie material.

The technique can be taught to parents for home use, is safe, and obviates the need for reanastomosis, esophagoscopy, or esophageal replacement.

The dual-lumen catheters allow tube feeding through the catheter while the balloon is indwelling.

In the two reflux stricture cases, both experienced restenosis; one retarded child with mid-esophageal stenosis and pH study showing no reflux (pH=1) after anti-reflux surgery was ultimately treated with swallowed transanal steroid gels, leading to resolution and remaining symptom-free approximately 2 years later.

Caustic burn cases required indwelling periods of 3-6 months to ensure complete healing before catheter removal.

The inflation protocol uses a 20cc syringe with air only (no fluids to prevent balloon adhesion); initial 5cc inflation alerts the child to swallow, followed by full inflation to 15-20cc, then immediate complete desufflation with vacuum, performed three times daily.

First endoscopic reassessment occurs at 2 weeks; if progress is satisfactory, intervals can be extended to 4 weeks until complete healing is observed, at which point the catheter is removed and the child monitored for symptoms without routine contrast studies or endoscopy unless complaints arise.

Two patients in the series experienced recurrent stricture after initial successful treatment and catheter removal, requiring an additional 4-6 week period of balloon dilatation.

Balloon position is marked by two metal spots on the catheter visible on radiography; position can be confirmed with contrast swallow or, under anesthesia, by endoscopic visualization with placement approximately 1cm above the stenosis for a 4cm balloon, followed by fixation at the nose before deflation.

Dislodged balloons can be replaced under fluoroscopy without anesthesia.

Topical mitomycin application for recurrent esophageal strictures usually requires a few treatments and has maintained patency in patients with dozens of prior dilatations.

Mitomycin is applied topically, not injected, for esophageal strictures.

Fully covered metal stents do not require transnasal placement and may be more comfortable than balloons.

Metal expandable stents have caused catastrophic complications in pediatrics, including erosion through the esophagus into an aberrant innominate artery causing fatal exsanguination; multiple pediatric surgeons have had similar unreported disasters.

Injection of steroids into the esophageal wall has been useful for recalcitrant or recurrent strictures.

In small children with atresia, metal stents must be very carefully size-matched to the esophagus to prevent erosion; nitinol is unforgiving and will erode if not the right size.

Biodegradable stents are available in Europe and the UK with limited data but represent the future; they dissolve after 4-6 weeks.

Newer fully covered metal stents can be removed by pulling a central string to collapse them; nitinol stents should be pre-treated with cold water through the lumen to cause shrinkage before string-pulling and removal.

Patients with indwelling balloon catheters can tolerate semi-solid food.