Advanced Endoscopic Procedures for Esophageal Disorders

Advanced Endoscopic Approaches

At Boston Children’s Hospital, we use advanced endoscopic approaches to treat problems in the esophagus such as esophageal strictures, leaks, and perforations. Our clinicians are leaders in the development, study, and use of these less-invasive approaches. Boston Children’s Esophageal and Airway Treatment Center is one of just a few pediatric centers in the world to offer these advanced endoscopic techniques.

Stenting

Certain problems, such as esophageal strictures, can affect the upper gastrointestinal tract, making it difficult for children to swallow. To treat a stricture, the doctor will typically first perform an esophageal dilation. An endoscopy is performed to guide a balloon into the esophagus and then inflate the balloon under high pressure. When the balloon inflates, it causes slight tearing in the scar tissue that has built up in the esophageal stricture and caused it to narrow. After the balloon has widened the esophageal stricture, the doctor may insert a flexible tube called a stent into the area of the stricture. The stent remains in place to keep the esophagus open as the tissue heals around it. It will be removed in a follow-up procedure later. 

Endoscopic incisional therapy

Endoscopic incisional therapy is an advanced endoscopic procedure used to treat esophageal strictures, often done in combination with dilation during the same procedure. In this innovative treatment, the physician uses a highly advanced endoscopic knife to make small cuts in the scar tissue that forms the stricture. This allows the physician to create targeted tears in the scar tissue of the stricture to have more control over how and where the stricture stretches open during the dilation procedure. Endoscopic incisional therapy helps decrease the need for repeated dilations and is particularly useful for strictures with thick or asymmetrical scar bands as it allows the endoscopist to reshape the contour of the esophagus.

Our skilled gastroenterologists have been performing this technique at Boston Children’s since 2011. Research at Boston Children’s suggests that endoscopic incisional therapy can be an effective treatment for recurrent esophageal strictures when performed by experienced physicians.

Endoscopic vacuum-assisted closure (EVAC)

Even in the most experienced and well-trained hands, endoscopic and surgical complications can occur. When esophageal perforation and leaks do occur (either as a result of surgery or endoscopic procedures), we offer a nonsurgical endoscopic procedure called EVAC. In this approach, the gastroenterologist positions a suction sponge into the esophagus at the site of the leak, which provides suction via a tube that is connected to the sponge and comes out of the child’s nose, or through a gastrostomy tube if one is present. This tube is connected to a suction machine that regulates the pressure and removes any fluid or saliva present near the leak, and remains in place for several days or sometimes longer. The sponge is removed later in a follow-up procedure.

This process may require one or more exchanges of the EVAC system to assess the response to therapy and make necessary adjustments. This technique helps to treat and prevent the infection that can be associated with the leak, promotes blood flow, and allows the perforation to heal more quickly than other treatments. We perform EVAC in our Gastroenterology Procedure Unit (GPU) and main operating room. Our EAT Center endoscopists are always prepared to place an EVAC in the unlikely scenario where an endoscopic treatment causes a leak in the esophagus to decrease the need for more invasive surgeries and prevent more serious complications. Some difficult to treat esophageal strictures are treated with a combination of Endoscopic Incisional Therapy and EVAC even when there is no leak or perforation to avoid the need for more invasive surgical procedures. Boston Children’s was the first pediatric institution to study EVAC in children and continues to do research in this area.

Peroral endoscopic myotomy (POEM)

POEM is a type of advanced endoscopic procedure used to treat esophageal achalasia — a disorder of the esophagus that makes swallowing difficult. 

Read about POEM.