Indications for surgical reconstruction of the esophagus include which of the following?

B. Failure or refusal of the patient to comply with a treatment regimen of regular dilation.

C. Development of a fistula between the esophagus and tracheobronchial tree.

D. Iatrogenic perforation of the esophagus during attempted dilation.

DISCUSSION: Development of a tracheobronchial fistula almost always necessitates some form of esophageal reconstruction because of the extensive damage usually associated with it. Failure of the patient to cooperate effectively condemns to failure any attempt at restoring esophageal patency by bougienage, because sporadic attempts at dilation do not allow progressive lumen enlargement but, rather, invite additional injury because of the necessity for repeated instrumentation of a recurrent, tight stricture. The need for repeated dilation of extensive or multiple strictures over a period exceeding 6 months should prompt surgical reconstruction of the esophagus, especially in young children, for whom the psychological and physical hazards are intensified by prolonged treatment. In such circumstances, a 2-year period of attempted bougienage is excessive. Although iatrogenic perforation often signals the need for esophageal reconstruction, this misadventure should not be considered an absolute indication but should be assessed in relation to (1) the extent and complexity of the stricture, (2) the potential for eventually achieving successful bougienage, and (3) the severity of complications caused by the secondary injury.