A recent letter to the editor describes a cool approach to treating the midaortic syndrome (NEJM 2012; 367: 2361-62).

In this 3-year-old girl, after IRB approval, a tissue expander was placed in the lower abdomen and placed tension on the aortic bifurcation.  Over a nine month period, saline was added.  This enabled stretching and subsequently a 4 cm resection of the mid-aorta.  Subsequent to the operation, the anastomosis appears patent and the patient’s hypertension is much easier to manage with two antihypertensives rather than five.

Perhaps a similar approach would improve the outcomes of our patients with refractory esophageal strictures.  In the case report, the treatment was based on studies that had previously shown that arteries and veins elongate in response to longitudinal stretch.  I don’t know whether the esophagus would have the same response.

Related references:

• -Refractory strictures (NASPGHAN 2011): -if not >14 mm after 5 sessions Complex strictures: >2 cm long, tortuous, or if scope cannot be passed predilatation. Consider Fluoro for complex strictures. Described technique of endoknife if only one-sided stricture –hard to dilate.
• -Am J Gastroenterol 2005; 100: 2419.  Double-blind, randomized trial showed benefit of steroid injection for Rx of recalcitrant peptic strictures. Consider triamcinolone along length of stricture; max ~10mg (2-4mg/injection)
• -JPGN 2007; 44: 336. n=16 pts. Mitomycin 0.1mg/mL; apply for 2-3min c pledget.
  -JPGN 2006; 42: 437.  Case report of using indwelling balloon for daily dilatation in refractory patients.
• -Endoscopy. 2006 Apr;38(4):404-7).  Mitomycin C: an alternative conservative treatment for refractory esophageal stricture in children?
• -JPGN 2005; 41: 35A (pg503).  use of stents for refractory benign strictures, n=10.
• -Gastroenterol 1999; 117: 229 & 233. AGA position statement and technical review.

**Dosing regarding triamcinolone or mitomycin C has not been clearly established for esophageal strictures.  Doses listed above are based on my reading of the references but no specific dose is advocated on this posting.