Early bougienage for relief of stricture formation following caustic esophageal burns

Accidental ingestion of concentrated white vinegar in Hatay children in Turkey

White vinegar which contains high concentrations (~85 %) of acetic acid is a staple ingredient used in food preparation in many Mediterranean cuisines but in small amounts. Being corrosive, it can cause ulcerative injury to the oropharynx and oesophagus and upset the stomach with resulting nausea and vomiting. This study presents 11 cases of paediatric patients (five boys and six girls, aged between 11 and 89 months) with oesophageal strictures who drank white vinegar by accident. They all received endoscopic oesophageal dilation (with a bougie) ranging from one to 28 per patient, depending on the severity of the injury. Follow-up showed uneventful healing in eight patients, who at the time of the telephone call were able to swallow solids and liquids normally. Two patients who could not be reached by telephone were found healthy by consulting the national database (e-Nabız). Unfortunately, one patient, who was discharged without any symptoms after the first dilation, suffered massive gastrointestinal bleeding 24 hours after the dilation and died. The loss of this patient shows that ingesting white vinegar can be very dangerous in children, especially if parents delay seeking medical help. We believe that controlling the production and sales of highly concentrated white vinegar and selling it in child-proof containers can help to prevent accidental ingestions by children and tragic outcomes such as the one reported here.

Endoscopic dilation with bougies versus balloons in caustic esophageal strictures: 17-year experience from a tertiary care center

INTRODUCTION

Endoscopic dilation is the preferred management strategy for caustic esophageal strictures (CES). However, the differences in outcome for different dilators are not clear. We compared the outcome of CES using bougie and balloon dilators.

METHODS

Between January 2000 and December 2016, the following data of all the patients with CES were collected: demographic parameters, substance ingestion, number of strictures, number of dilations required to achieve ≥ 14 mm dilation, post-dilation recurrence, and total dilations. Patients were divided into two groups for the type of dilator, i.e., bougie or balloon. The two groups were compared for baseline parameter, technical success, short- and long-term clinical success, refractory strictures, recurrence rates, and major complications.

RESULTS

Of the 189 patients (mean age 32.17 ± 12.12 years) studied, 119 (62.9%) were males. 122 (64.5%) patients underwent bougie dilation and 67 (35.5%) received balloon dilation. Technical success (90.1% vs. 68.7%, p < 0.001), short-term clinical success (65.6% vs. 46.3%, p value 0.01), and long-term clinical success (86.9% vs. 64.2%, p < 0.01) were higher for bougie dilators compared to balloon dilators. Twenty-four (12.7%) patients developed adverse events which were similar for two groups. On multivariate analysis, use of bougie dilators (aOR 4.868, 95% CI 1.027-23.079), short-term clinical success (aOR 5.785, 95% CI 1.203-27.825), and refractory strictures (aOR 0.151, 95% CI 0.033-0.690) were independent predictors of long-term clinical success.

CONCLUSION

Use of bougie dilators is associated with better clinical success in patients with CES compared to balloon dilators with similar rates of adverse events.

Procedural and Surgical Interventions for Esophageal Stricture Secondary to Caustic Ingestion in Children

BACKGROUND

Esophageal injury after caustic ingestion can vary in severity and may result in significant long-term morbidity due to stricture development. The optimal management remains unknown. We aim to determine the incidence of esophageal stricture due to caustic ingestion and quantify current procedural and operative management strategies.

METHODS

The Pediatric Health Information System (PHIS) was utilized to identify patients 0-18 years old who experienced caustic ingestion from January 2007-September 2015 and developed subsequent esophageal stricture until December 2021. Post-injury procedural and operative management was identified utilizing ICD-9/10 procedure codes for esophagogastroduodenoscopy (EGD), esophageal dilation, gastrostomy tube placement, fundoplication, tracheostomy, and major esophageal surgery.

RESULTS

1,588 patients from 40 hospitals experienced caustic ingestion of which 56.6% were male, 32.5% non-Hispanic White, and the median age at time of injury was 2.2 years (IQR: 1.4,4.8). Median length of initial admission was 1.0 day (IQR: 1.0, 3.0). 171/1,588 (10.8%) developed esophageal stricture. Among those who developed stricture, 144 (84.2%) underwent at least 1 additional EGD, 138 (80.7%) underwent dilation, 70 (40.9%) underwent gastrostomy tube, 6 (3.5%) underwent fundoplication, 10 (5.8%) underwent tracheostomy, and 40 (23.4%) underwent major esophageal surgery. Patients underwent a median of 9 dilations (IQR 3, 20). Major surgery was performed at a median of 208 (IQR: 74, 480) days after caustic ingestion.

CONCLUSION

Many patients with esophageal stricture after caustic ingestion will require multiple procedural interventions and potentially major surgery. These patients may benefit from early multi-disciplinary care coordination and the development of a best-practice treatment algorithm.

LEVEL OF EVIDENCE

III.

Investigation of the histopathological level of Ki-67, caspase-3 expressions of the effects of hesperidin on wound healing in the rat esophagus

PURPOSE

The effects of hesperidin application on the wound caused by esophageal burns were investigated in this study.

METHODS

Wistar albino rats were divided into three groups: Control group: only 1 mL of 0.09% NaCl was administered i.p. for 28 days; Burn group: An alkaline esophageal burn model was created with 0.2 mL of 25% NaOH orally by gavage-1 mL of 0.09% NaCl was administered i.p. for 28 days; Burn+Hesperidin group: 1 mL of 50 mL/kg of hesperidin was given i.p. for 28 days to rats after burn injury. Blood samples were collected for biochemical analysis. Esophagus samples were processed for histochemical staining and immunohistochemistry.

RESULTS

Malondialdehyde (MDA) and myeloperoxidase (MPO) levels were significantly increased in Burn group. Glutathione (GSH) content and histological scores of epithelialization, collagen formation, neovascularization was decreased. After hesperidin treatment, these values were significantly improved in the Burn+Hesperidin group. In the Burn group, epithelial cells and muscular layers were degenerated. Hesperidin treatment restored these pathologies in Burn+Hesperidin group. Ki-67 and caspase-3 expressions were mainly negative in control group; however, the expression was increased in the Burn group. In the Burn+Hesperidin group, Ki-67 and caspase-3 immune activities were reduced.

CONCLUSIONS

Hesperidin dosage and application methods can be developed as an alternative treatment for burn healing and treatment.

Household cleaning products poisoning in a pediatric emergency center: A 10- year cross-sectional study and literature review

BACKGROUND

Poisoning by household cleaning products(HCPs) is common in children. Some HCPs are toxic and may cause severe complications. We assessed HCP poisonings treated in a pediatric emergency department(PED).

METHODS

This was a retrospective study of patients aged under 18 years with HCP poisoning admitted to the largest PED in Taiwan from 2011 to 2020 were recruited.

RESULTS

The records over a 10-year period from 103 children admitted to the PED because of HCP poisoning(70 boys [68%] and 33 girls [32%]), mean age 3.54 years(standard deviation [SD] = 3.15 years) were evaluated. Most poisonings were unintentional(99%, n = 102) and occurred at home(96%, n = 99). The HCPs included alkaline(74%, n = 76), acidic(25%, n = 26), and neutral(1%, n = 1) agents. Most were orally ingested(86%, n = 89). Panendoscopy was performed in 25 patients(24%), and the endoscopic(Zargar) grade was used to determine the severity of injury. Medications(steroids [9%, n = 9], antibiotics [10%, n = 10], or antacids [30%, n = 23]) were prescribed. Alkaline HCP ingestion induced severe esophageal injury(p = 0.04) and esophageal stricture(p = 0.04). Five patients(5%) exhibited esophageal strictures and required balloon dilation. On multivariate analysis, alkaline HCP ingestion(p = 0.04), severe esophageal caustic injury(Zargar grade ≥ 3) (p < 0.001), and medications(steroids [p < 0.001], antibiotics [p < 0.001], and antacids [p = 0.001]) were associated with esophageal stricture.

CONCLUSION

Alkaline HCP ingestion and severe esophageal caustic injury(Zargar grade ≥ 3) were associated with esophageal stricture. Physicians tended to prescribe medications(steroids, antibiotics, or antacids) for patients with severe esophageal injuries to reduce the risk of esophageal stricture. The usefulness of these medications requires further study.

Effectiveness of Hypericum perforatum Extract in the Treatment of Corrosive Esophageal Burns

PURPOSE

The purpose of our study is to determine the effectiveness of "Hypericum perforatum" extract in corrosive esophageal burns and to shed light on the search for new treatments.

MATERIALS AND METHODS

A total of 32 Sprague Dawley rats were separated into 4 groups. A standard esophageal burn model was created. Group 1 was identified as the sham group. Group 2 was burned and no treatment was performed afterward. Group 3 was burned and then 2 cc/day H. perforatum extract was given for 21 days. Group 4 was not applied any process and 2 cc/day H. perforatum extract was given for 21 days. The rats were sacrificed and biopsy specimens were taken for histopathological examination for the presence of inflammation, fibrosis, and necrosis.

RESULTS

There was a significant difference between groups in terms of inflammation, fibrosis, and necrosis. Furthermore, in the bilateral comparisons between the groups, there was a meaningful difference in terms of inflammation and fibrosis between Group 2 and Group 3. However, there was no meaningful difference between the same groups in terms of necrosis.

CONCLUSION

H. perforatum extract may be effective on inflammation, fibrosis, and necrosis in corrosive esophageal burns.

Alkaline substances gastroesophageal injury in young children: emphasis on Asian food preparation habits

BACKGROUND

Ingestion of alkaline substances should not be disregarded because a small amount can cause chemical burns in the esophagus, with esophageal stricture being the most common late complication.

METHODS

We enrolled children with alkaline corrosive damage receiving treatment at China Medical University Children's Hospital's emergency department between 2008 and 2018. Patients were divided into groups A (ingested causative agents other than alkaline oil), and B (ingested alkaline oil).

RESULTS

Altogether, 40 (27 [67.5%] male and 13 [32.5%] female) patients aged 7 months-7 years were enrolled. The most commonly ingested agent was alkaline oil (13 cases, 32.5%), followed by oven and drainage cleaners (8 cases, 20%), bleach (6 cases, 15%), laundry and dish cleaners (4 cases, 10%), sodium hydroxide (4 cases, 10%), sodium carbonate (2 cases, 5%), sodium phosphate (2 cases, 5%), and sodium citrate (1 case, 2.5%). High proportions of children had esophagitis (40/40, 100%), erosive gastritis (7/40, 17.5%), and gastric ulcer (6/40, 15%). The incidence of esophageal stricture was 38.4% (5/13) and 7.4% (2/27) in groups B and A, respectively. In group B, 4 children developed growth stunting or malnutrition during the first decade after onset, with reduced immunity and feelings of inferiority.

CONCLUSION

Alkaline ingestion usually results in esophageal injury that is difficult to cure. Corrosive esophageal strictures cause swallowing difficulties and growth stunting in children. Young children who ingested alkaline oil have more complications. Given that alkaline corrosive injuries are often accidental, prevention of corrosive agent ingestion is crucial.

Potential therapeutic effects of ethyl pyruvate and N-acetyl cysteine in an experimental rat model of corrosive esophageal

BACKGROUND AND STUDY AIMS

Esophageal burns due to ingestion of corrosive substances are frequently seen in both children and adults. However, there is no standard method of treatment to prevent associated mortality and morbidity. Therefore, this study aimed to evaluate the effects of known antioxidants, namely N-acetyl cysteine and ethyl pyruvate, on esophageal damage due to sodium hydroxide-induced corrosive burns.

MATERIALS AND METHODS

Thirty-five female rats were randomly assigned to five equal groups. Group 1 was the sham group, while Group 2 was the control group. Group 3 received N-acetyl cysteine, Group 4 received ethyl pyruvate, and Group 5 received both N-acetyl cysteine and ethyl pyruvate. Rats in the "burn" groups were gavage-fed with 0.2mL of 25% NaOH. All esophagi were extracted on day 4 for histopathological evaluation.

RESULTS

Total histopathological damage scores were evaluated at the end of the study. Groups 3 and 5 were significantly different from the control group in terms of total histopathological scores (p = 0.001), while no significant difference was seen with Group 4. Stenosis index results in groups 3 and 5 were similar to those seen with total histopathological scores (p = 0.004).

CONCLUSION

N-acetyl cysteine, alone or in combination with ethyl pyruvate, may be useful in the treatment of esophageal damage associated with corrosive substances and in achieving histopathological improvement in an experimental setting.

Foreign Body and Caustic Substance Ingestion in Childhood

Foreign body and caustic substance ingestion in childhood are common and require accurate and timely diagnosis to provide appropriate management consistent with the ingested substance/foreign body and clinical presentation as well as the associated risk status to prevent significant complications and morbidity. The aim of this paper was to present foreign body and caustic ingestion in childhood in terms of epidemiology, pathophysiology, diagnostic work-up and appropriate management and potential complications in accordance with clinical presentation and the type of ingested substance/foreign body.

Corrosive ingestion managements in children

Corrosive (caustic) material ingestion remains a major health issue, particularly in developing countries. The management strategy after corrosive ingestion should be planned according to the signs and symptoms. The management of corrosive ingestion based on endoscopic grading, nothing by mouth, and barium studies should be abandoned. With the new management protocol, esophageal stricture can be predicted with high accuracy using the simple new prognostic DROOL score (≤ 4) rather than endoscopic grading, reduced by immediate oral feeding as soon as the patient can swallow saliva instead of nothing by mouth, diagnosed earlier (10-14 days) by fluoro-endoscopic balloon-assisted esophageal examination for patients with persistent dysphagia instead of relying on a barium study (≥ 21 days), and adequately treated by initiating balloon dilation earlier during the same anesthesia procedure. Fluoroscopically guided balloon dilatation with large balloons (18-20 mm) seems to be safe, with a low frequency of complications and a high success rate. If dilatation fails after a few months, esophagectomy and replacement surgery using the stomach should be considered. The increased risk of developing esophageal carcinoma after ingestion of corrosive substances should be kept in mind.

Corrosive substances ingestion: a review

Corrosive chemical substance ingestions are a major problem, especially in developing countries, but also in developed countries such as the United States, France, and Belgium. Ingestions may be deliberate as suicide attempts (mostly in adolescents and adults) or accidental (mostly in children). The results can be devastating in terms of individual suffering and disability, but also in terms of resource utilization and costs. In developing countries, outcomes may be worse because of limited medical/surgical resources. Common sequelae include gastrointestinal (GI) tract (esophagus, stomach, pylorus, and duodenum) stricture formation, GI tract perforation, and hemorrhage. Systemic effects may also occur, such as disseminated intravascular coagulation (DIC), multi-organ system failure, and sepsis. Various interventions in the acute phase to reduce the severity of injury have been attempted, but there are no large controlled clinical trials to demonstrate efficacy. Dilation therapy in various forms is commonly used for the treatment of strictures and a variety of surgical procedures including esophagectomy and delayed replacement may be required in severe corrosive injury cases.

Four Year Results of Conservative Treatment of Benign Strictures of the Esophagus with Savary Gilliard Technique of Bougienage: Cross-Sectional Study Representing First Experiences in Republic of Macedonia

Background: Benign esophageal strictures are complications resulting from various causes. They can be structurally categorized in two groups: simple and complex. Treatment is similar in most cases that require dilatation and means use of three general types of dilators that are currently in use. However, despite the last guidelines on esophageal dilatation, the therapeutic response, optimal timing of treatment and interval between sessions may vary and there is no strong consensus in the literature regarding this fact.

Aims: To analyzethe first 4 year experience of Digestive Endoscopy Unit at the University Clinic of Gastroenterohepatology of the Medical Faculty, Skopje, Republic of Macedonia in treating benign esophageal strictures, since the Savary-Gilliard technique of “bougienage” was introduced for the first time in Republic of Macedonia, at our Institution, in December 2013, by assessing etiology, length of stricture, number of dilations required to achieve satisfactory therapeutic response, as well as the relationship between the type, extent of stenosis and therapeutic response.

Methods: One hundred and forty five dilations, during a period from 20th December 2013, until March 2017, have been analyzed in 31 patients

Results: The caustic strictures were the most prevalent, occurring in 15 (48%) of patients, followed by peptic stenosis presenting 26% of patients. The long and corrosive strictures needed more sessions to the absence of dysphagia. Peptic and short stenoses best respondedon treatment and needed fewer dilatation sessions per patient.

Conclusion: Caustic stricture is the most common type of benign esophageal stenosis and the most refractory to treatment, especially the long one. Peptic stenosis is the second cause of benign esophageal strictures and responded well to endoscopic therapy. The higher the extent of stenosis, the greater the number of sessions required. Short strictures have good prognoses in most cases. The number of dilations depended directly on the cause and extent of stenosis. Bouginage using Savary-Gilliard or American type of technique, irrespective of the type and the extent of esophageal stenosis, is safe and purposeful procedure.

Halofuginone improves caustic-induced oxidative injury of esophagus in rats

BACKGROUND

The aim of this study is to evaluate the anti-inflammatory and anti-fibrotic effects of halofuginone in caustic esophageal burn injury in rats.

MATERIALS AND METHODS

Corrosive esophageal injury (CEI) was produced in male Wistar albino rats by instilling NaOH solution (1 ml, 37.5%) into the distal esophagus. Rats were decapitated on the 3rd day (early group) or 28th day (late group), and treated daily with either saline or halofuginone (100 µg/kg/day; i.p.), continued on alternate days after the third day. Histopathological evaluation and measurement of nitric oxide (NO), peroxynitrite (ONOO-) and oxygen-derived radicals by chemiluminescence (CL) were made in the distal 2 cm of the esophagus. Non-irrigated proximal esophageal samples were assessed for the levels of nuclear factor (NF)-κB, caspase-3, glutathione (GSH), malondialdehyde (MDA) and myeloperoxidase (MPO) activity.

RESULTS

GSH, MDA, NF-κB and caspase-3 levels, and MPO activity in the proximal esophagus were not different among groups. Increased number of TUNEL (+) cells in the irrigated esophagus of the early and late caustic injury groups was reduced by halofuginone treatment. High microscopic damage scores in both early and late CEI groups were decreased with halofuginone treatment. NO, ONOO- and CL levels, which were elevated in the saline-treated early CEI group, were reduced by halofuginone treatment, but reduced NO and ONOO- levels in the late period of saline-treated group were increased by halofuginone.

CONCLUSION

In addition to its anti-fibrotic effects, current findings demonstrate that halofuginone exerts antioxidant and anti-apoptotic actions and supports therapeutic potential for halofuginone in CEI-induced oxidative stress.

Caustic ingestion in children-A review

Various domestic or industrial chemicals may cause significant upper aerodigestive tract burns. Preventive measures should be up-scaled, especially in the developing world, to reduce the epidemic of accidental victims, largely unsupervised preschool children. External signs do not predict degree of injury. Non-invasive diagnostic screening includes radio-nuclear imaging, but early oesophago-gastroduodenoscopy remains the standard to predict stricture formation from circumferential submucosal scarring. Serial dilation is the mainstay of oesophageal stricture therapy, with oesophageal replacement reserved for severe refractory strictures. Intra-lesional steroid or mitomycin C may decrease the dilatations required for severe strictures, although long-term effects are unknown. Risk of secondary oesophageal carcinoma mandates long-term surveillance.

Caustic Ingestion in Children: a Systematic Review and Meta-Analysis

Introduction: Caustic ingestion that occurs accidently is one of the most common problems in children. Methods: This systematic review has been performed by searching the databases including Science Direct, ProQuest, Google Scholar, and PubMed. A strategic search was performed with keywords including caustic, corrosive, ingestion, and children, and was limited to articles in English and Persian. Data were analyzed using Comprehensive Meta-Analysis2 and PASW Statistics 18. Results: We selected 64 articles regarding caustic ingestion with a total sample of 11,345 cases. The data analysis indicated a higher consumption in young boys (age range 2.78 (2.02) years (OR=0.53 with a 95% confidence interval of 0.49-0.57 (P=0.08)). The most common caustic substances were household cleaning agents, particularly bleaches and cleaners. Esophageal cancer and death were reported as well as digestive and respiratory complications. Invasive and expensive techniques are frequently used for diagnosis, treatment and follow up. Conclusion: The results demonstrated that although caustic ingestion is a serious problem among children, it is a preventable and manageable issue. Therefore, appropriate efforts by families, government, factories, health team and media should be made to handle adequately this matter.

Caustic oesophagitis in children: prevalence, the corrosive agents involved, and management from primary care through to surgery

PURPOSE OF REVIEW

Caustic substance ingestion (CSI) remains a major health issue, particularly in developing countries, where laws are not effectively enforced. This review offers a thorough analysis of the current epidemiology, clinical features, management, treatment, and long-term complications of CSI in children.

RECENT FINDINGS

Strong alkalis sold in liquid and granular forms, particularly crystalline grease cleaners (concentrated sodium hydroxide), are the principal causes of severe oesophageal damage. Currently, early endoscopy to assess the gastro-oesophageal mucosa is not considered necessary for all CSI cases. Oesophageal stricture is a major complication developing after CSI, and should be diagnosed and treated earlier, 10-14 days after CSI via commencement of a dilation program. Fluoroscopically guided oesophageal balloon dilatation seems to be safe, with a low frequency of complications and a high success rate. However, it should commence earlier than is currently the case, and should be performed gently, using balloons of gradually increasing diameter. If dilation fails after a few months, oesophageal replacement surgery should be performed.

SUMMARY

Unfortunately, neither dilatation treatment nor oesophageal bypass surgery can prevent the development of oesophageal carcinoma, the incidence of which is high after CSI. The continuing unacceptably high incidence of CSI accidents would be reduced if corrosive materials were sold in their original childproof containers, highlighting the need for preventive and adult education programmes.

Caustic Esophageal Stenosis: A Case Report of Endoscopic Dilation With a Dynamic Stent

INTRODUCTION

The management of esophageal strictures has evolved from surgical treatment to the endoscopic dilation and, more recently, esophageal stenting.

CLINICAL CASE

We describe a case of a two-year-old boy with a double stenosis of the esophagus resulting from accidental ingestion of strong alkaline liquid. After several unsuccessful endoscopic dilations for three years and even topical mitomicin, it was decided to place a dynamic stent developed by the Digestive Surgery and Endoscopic Unit of the Bambino Gesù Hospital, Rome. The stent is a custom silicon device built coaxially on a nasogastric tube that is inserted after stricture dilations, by endoscopic guidance, and then fixed outside the nose. The device was removed after seven weeks with good clinical outcome (no dysphagia more than a year of follow-up).

CONCLUSION

This case confirms that the dynamic stent is a simple device that may avoid aggressive surgical substitution in cases of refractory strictures.

Evaluation of 968 children with corrosive substance ingestion

Background and Aims:

The aim of the study was to evaluate the etiology, treatment, and prognosis in children who had presented at our clinic with corrosive substance ingestion and comparison of our results with the literature.

Materials and Methods:

The patients were put on nil by mouth and broad-spectrum antibiotics were administered. Oral fluids were started for patients whose intraoral lesions resolved and who could swallow their saliva. Steroids were not given, a nasogastric catheter was not placed, and early endoscopy was not used.

Results:

A total of 968 children presented at our clinic for corrosive substance ingestion during the 22-year period. The stricture development rate was 13.5%. Alkali substance ingestion caused a stricture development rate of 23%. A total of 54 patients required 1–52 sessions (mean 15 ±12) of dilatation.

Conclusion:

We do not perform early endoscopy, administer steroids, or place a nasogastric catheter at our clinic for patients who had ingested a corrosive substance. This approach has provided results similar to other series. We feel that determining the burn with early esophagoscopy when factors that prevent or decrease the development of corrosive strictures will be very important.

Foregut caustic injuries: results of the world society of emergency surgery consensus conference

INTRODUCTION

Lesions of the upper digestive tract due to ingestion of caustic agents still represent a major medical and surgical emergency worldwide. The work-up of these patients is poorly defined and no clear therapeutic guidelines are available.

PURPOSE OF THE STUDY

The aim of this study was to provide an evidence-based international consensus on primary and secondary prevention, diagnosis, staging, and treatment of this life-threatening and potentially disabling condition.

METHODS

An extensive literature search was performed by an international panel of experts under the auspices of the World Society of Emergency Surgery (WSES). The level of evidence of the screened publications was graded using the Oxford 2011 criteria. The level of evidence of the literature and the main topics regarding foregut caustic injuries were discussed during a dedicated meeting in Milan, Italy (April 2015), and during the 3rd Annual Congress of the World Society of Emergency Surgery in Jerusalem, Israel (July 2015).

RESULTS

One-hundred-forty-seven full papers which addressed the relevant clinical questions of the research were admitted to the consensus conference. There was an unanimous consensus on the fact that the current literature on foregut caustic injuries lacks homogeneous classification systems and prospective methodology. Moreover, the non-standardized definition of technical and clinical success precludes any accurate comparison of therapeutic modalities. Key recommendations and algorithms based on expert opinions, retrospective studies and literature reviews were proposed and approved during the final consensus conference. The clinical practice guidelines resulting from the consensus conference were approved by the WSES council.

CONCLUSIONS

The recommendations emerging from this consensus conference, although based on a low level of evidence, have important clinical implications. A world registry of foregut caustic injuries could be useful to collect a homogeneous data-base for prospective clinical studies that may help improving the current clinical practice guidelines.

Caustic injury of the oesophagus

Caustic ingestion continues to be a significant problem world-wide especially in developing countries and particularly in the under 6 years age group. The presence or absence of symptoms or oral lesions does not reliably predict the existence or severity of oesophageal lesions. Upper endoscopy remains the mainstay diagnostic modality for evaluation to define the extent and severity of the injury. The best predictor of morbidity and mortality is the extent of injury as assessed during initial evaluation. Early management strategies for caustic ingestion are well defined. Controversy still surrounds the use of steroids, antibiotics, antacid therapy in the acute phase, and the use of oesophageal stents and the frequency, timing and method of dilatation in the prevention and management of oesophageal strictures. There is a pressing need for non-invasive diagnostic modalities and effective therapeutic options to evaluate and treat the complications associated with caustic ingestion. Indications for definitive surgery or bypass and the type of procedure to use are also subject to ongoing debate.

Efficacy of keratinocyte growth factor (palifermin) for the treatment of caustic esophageal burns

Current treatment strategies against the development of corrosive esophageal strictures remain unsatisfactory. Thus, the aim of the present study was to investigate the efficacy of keratinocyte growth factor, in the form of palifermin, for the prevention of stricture development following esophageal caustic injuries in a rat model. A total of 32 female Wistar albino rats were divided into four groups, which included the control (C), burn (B), steroid (S) and steroid plus palifermin (S/P) groups. An experimental corrosive esophageal burn model was established in the B, S and S/P groups. Weight gain was recorded and histopathological evaluation was performed for each group. Weight gain in the S and B groups was compared with the control group and statistically significant differences were observed. In addition, statistically significant differences in weight gain were observed between the S/P group and the B group. Histopathologically, statistically significant differences were identified with regard to submucosal collagen deposition, muscularis mucosa and tunica muscularis damage when comparing the B group with the C group. In addition, statistically significant differences were observed when comparing the S and S/P groups with the B group. Furthermore, significant submucosal collagen deposition and tunica muscularis damage were observed in the S group when compared with the S/P group. The stenosis indexes in the C and S groups were significantly lower compared with the B group. In addition, the stenosis index in the S/P group was significantly lower compared with the S group. To the best of our knowledge, the present study is the first to investigate the effect of palifermin on corrosive esophageal burns. The addition of palifermin to the corrosive esophageal burn standard treatment regimen was found to reduce the degree of fibrosis and ameliorate histopathological damage in an experimental model of corrosive esophagitis in rats.

Corrosive substance ingestion in children

OBJECTIVES

To evaluate children who ingested corrosive substances, in terms of demographic features, nature of ingested substances, clinical findings, management and complications.

METHODS

A total of 1709 cases aged between 0 and 16 y who ingested corrosive substance were analyzed retrospectively by evaluating the medical records of the patients.

RESULTS

The mean age of the cases was 35.23 ± 30.65 mo and male:female ratio was 1.45. Forty one percent of corrosive substances causing intoxication contained NaOH. Thirty percent of the families consisted of 5 or more members. Fourteen percent of the mothers were illiterate. Stricture formation was observed in 29 (1.69 %) of the cases during follow-up. In 79.31 % of those cases alkaline substance ingestion was responsible for stricture development. It was found that stricture formation occurred more frequently among cases who were older than 5 y of age and this finding was statistically significant (p = 0.001).

CONCLUSIONS

The cases older than 5 y of age with the diagnosis of grade 2b esophagitis must be followed up closely for the stricture formation. In order to protect children from corrosive ingestion, importance must be given to preventive measures such as education of families, keeping and storing these agents out of the reach of children and providing safety caps for these products.

High doses of methylprednisolone in the management of caustic esophageal burns

OBJECTIVE

Caustic substance ingestion in childhood is a public health issue in developing countries, and several management protocols have been proposed to prevent the resulting esophageal strictures. The role of corticosteroids in preventing corrosive-induced strictures is controversial. Our aim was to study the influence of high doses of corticosteroids in preventing esophageal strictures.

METHODS

Eighty-three children with a mean age of 4.10 6 2.63 years and with grade IIb esophageal burns (an esophagogastroscopy was performed within 24–48 hours of injury) due to corrosive substance ingestion were enrolled in our study between 2005 and 2008. Forty-two children (study group) received methylprednisolone (1 g/1.73 m2 per day for 3 days), ranitidine, ceftriaxone, and total parenteral nutrition. Forty-one children (control group) were administered the same regimen excluding methylprednisolone. Stricture development was compared between groups based on endoscopic and radiologic findings.

RESULTS

During the endoscopic examination, stricture development was observed in 4 patients (10.8%) in the study group and in 12 patients (30%) in the control group. The difference was statistically significant (P = .038). The stricture development rate in the upper gastrointestinal system with barium meal was 14.3% and 45.0% in the study and control groups, respectively. The difference was statistically significant (P = .004). The duration of total parenteral nutrition was shorter in the study group compared with the control group (P = .001). High doses of methylprednisolone were well tolerated in the study group without any side effects.

CONCLUSIONS

High doses of methylprednisolone used for the management of grade IIb esophageal burns may reduce stricture development.

Modifications in endoscopic practice for pediatric patients

We recommend that endoscopy in children be performed by pediatric-trained endoscopists whenever possible. We recommend that adult-trained endoscopists coordinate their services with pediatricians and pediatric specialists when they are needed to perform endoscopic procedures in children. We recommend that endoscopy be performed within 24 hours in symptomatic pediatric patients with known or suspected ingestion of caustic substances. We recommend emergent foreign-body removal of esophageal button batteries, as well as 2 or more rare-earth neodymium magnets. We recommend that procedural and resuscitative equipment appropriate for pediatric use should be readily available during endoscopic procedures. We recommend that personnel trained specifically in pediatric life support and airway management be readily available during sedated procedures in children. We recommend the use of endoscopes smaller than 6 mm in diameter in infants and children weighing less than 10 kg. We recommend the use of standard adult duodenoscopes for performing ERCP in children who weigh at least 10 kg. We recommend the placement of 12F or 16F percutaneous endoscopic gastrostomy tubes in children who weigh less than 50 kg.

Fluoroscopic balloon dilatation for caustic esophageal stricture in children: an 8-year experience

PURPOSE

Esophageal balloon dilatation (EBD), when performed early and correctly, can efficiently treat caustic esophageal stricture (ES). Herein, we present 8 years of experience treating caustic ES, and discuss the technique as well as the complications.

METHODS

We retrospectively reviewed the medical records of 38 children in whom we performed fluoroscopic EBD under general anesthesia for caustic ES between November 2004 and November 2012 in our hospitals. The patients were grouped into the early dilatation group, who began EBD earlier (mean, 15 days) after caustic ingestion, and the late dilatation group who was referred later (mean, 34 days) for EBD by other centers. The ESs were classified into short and long strictures. Balloon size was increased gradually to a sufficient diameter over consecutive sessions. Characteristics of patients and ES, details of the EBD, and treatment results were analyzed.

RESULTS

A total of 369 EBD sessions were successfully performed in 38 children (aged 14 months to 14 years, median 3.5 years). In six patients, EBD treatments are continuing, one patient was lost to follow up, one patient who received a stent was excluded, and three returned to their previous centers. The remaining 27 patients were treated successfully by repeated EBD treatments. Nevertheless, in the early dilatation group (n=16), EBD treatment was significantly faster and shorter than that in the late dilatation group (n=11). In addition, the short stricture treatment was also of significantly shorter duration than the long stricture treatment. Six (1.6%) esophageal perforations occurred in five patients (13.2%); all were treated conservatively. There was no mortality.

CONCLUSIONS

For treatment of caustic ES, fluoroscopically guided EBD is safe and has a low rate of complications as well as a 100% success rate. However, it should be begun earlier, and in children, should be performed gently with balloons of gradually increasing appropriate diameters over consecutive sessions.

Topical application of basic fibroblast growth factor reduces esophageal stricture and esophageal neural damage after sodium hydroxide-induced esophagitis in rats

PURPOSE

To investigate the effect of topical application of basic fibroblast growth factor (bFGF) after caustic esophageal injury in rats.

METHODS

Thirty-six male rats were randomly divided into three groups. Corrosive esophageal injury was produced by internal application of 30% sodium hydroxide (NaOH) solution to the distal esophagus. Group A rats were uninjured. Group B rats were injured and untreated. Group C rats were injured and received topical bFGF (10 μg/ml). Surviving rats were killed at 28 days. The survival rate, body weight gain, symptoms and histopathological changes that included tissue damage score, ratio of esophageal luminal area/total esophageal area (LA/TA) and the proportion of a neural marker PGP 9.5-positive area were assessed.

RESULTS

The survival rate and the prevalence of symptoms were not significantly different between Groups B and C. Although the tissue damage score did not differ in Groups B and C, LA/TA was significantly higher in Group C than in Group B. The proportion of the PGP 9.5-positive area was significantly lower in Groups B and C than in Group A; however, it was higher in Group C than in Group B.

CONCLUSION

Topical application of bFGF was effective in preventing stricture after NaOH-induced esophagitis.

Caustic ingestion in children

Caustic ingestion continues to be a significant problem worldwide especially in developing countries. In 2008 over 200,000 exposures to caustic substances were reported to the National Poison Data System. The presence or absence of symptoms or oral lesions does not predict the existence or severity of lesions. The best predictor of morbidity and mortality is the extent of injury as assessed during initial evaluation. Upper endoscopy remains the mainstay diagnostic modality for the evaluation of patients with caustic ingestion. There is a pressing need for noninvasive diagnostic modalities and effective therapeutic options to evaluate and treat the complications associated with caustic ingestion.

Custom dynamic stent for esophageal strictures in children

BACKGROUND

Esophageal stenting represents a new strategy to avoid multiple dilations owing to stenosis relapse. Our custom stent improves esophageal motility unlike the widespread self-expandable plastic esophageal stents. The aim of the study was to confirm the efficacy of treatment with silicone custom stents in esophageal stenosis (ES) in pediatric patients.

METHODS

A silicone stent of 7-, 9-, or 12.7-mm external diameter is built coaxially on a nasogastric tube that guarantees the correct position. The 2 ends are tailored to allow food passage between stent and esophageal wall. All patients received dexamethasone (2 mg/kg per day) for 3 days and ranitidine/proton-pump inhibitors. Study approval was obtained from our ethical board.

RESULTS

From 1988 to 2010, 79 patients with ES, mean age 35.4 months (3-125 months), underwent esophageal hydrostatic/Savary dilations and custom-stent placement, left in place for at least 40 days. Stenting was effective in 70 (88.6%) of 79 patients. Fifty percent of the patients with effective treatment received only one dilation for stent placement. Fourteen patients received more stents successfully. There was one stent-related major complication.

CONCLUSION

Our custom stent improves treatment in ES. In caustic injuries, ES stenting represents the first option. In postsurgical ES, we stent after at least 5 dilations.

Early endoscopic balloon dilation in caustic-induced gastric injury

BACKGROUND

There are no reports on endoscopic balloon dilation (EBD) for caustic-induced gastric outlet obstruction (GOO) in the acute or subacute phase.

OBJECTIVE

To study the efficacy of early EBD in patients with caustic-induced gastric injury.

SETTING

Tertiary care center in India.

DESIGN

Retrospective analysis of data.

PATIENTS

Out of 41 patients with caustic-induced GOO who reported to us in the subacute phase between January 2001 and December 2008, 31 were treated by EBD. All 31 had ingested an acid 14.39 +/- 4.65 days earlier. EBD was achieved by using wire-guided balloons under endoscopic guidance.

INTERVENTION

The balloon was negotiated across the narrowed segment and inflated for 60 seconds using a pressure gun. Balloons of incremental diameter, up to a maximum of 3 sizes, were used in each sitting. Procedural success was defined as reaching the end point of dilation (15 mm) and absence of symptoms.

RESULTS

All 31 patients (18 male, mean age 32.06 +/- 11.04 years) could be successfully dilated. All but 1 underwent successful dilations to achieve the end point of 15 mm, requiring a median of 9 (range 3-18) dilations over a period of 7 (range 1.5-16) weeks. Complications included self-limiting pain (n = 10), bleeding at the time of the procedure (n = 9), and perforation in 1 patient (3.2%) who required surgery. Thirty patients were followed up for a median of 21 (range 3-72) months with no recurrence.

CONCLUSION

Early EBD by an expert endoscopist is a safe and effective treatment modality in the management of caustic-induced GOO.

Minimally invasive management of children with caustic ingestion: less pain for patients

PURPOSE

Management of caustic ingestion in children is still controversial. In this study, we evaluate a minimally invasive management consisting of flexible endoscopy, balloon dilatation and intralesional steroid injection in children, with a history of caustic ingestion.

METHODS

Between April 2002 and January 2009, 350 (206 males and 144 females) children with a history of caustic ingestion were admitted. Enteral feeding was discontinued for 24 h. Parenteral feeding was started in patients with inadequate oral intake. No patient underwent an early esophagoscopy or gastrostomy. A contrast study of upper gastrointestinal tract was performed in all patients with persistent dysphagia within 3 weeks after injury. In case of an esophageal stricture, a dilatation program was initiated. For this purpose, a flexible esophagoscopy was performed. A guidewire was placed through the narrowed segment into the stomach and a balloon dilatator was inserted with the assistance of the guidewire. Balloon dilatations were performed every 1-3 weeks. In intractable strictures, triamcinolone acetonide (TAC) was injected into the narrowed segment via flexible endoscopy.

RESULTS

Seventeen patients (8 males, 9 females, median 3 years old) required esophageal dilatation. All of the patients completed dilatation program with complete relief of symptoms. None of the patients required any stent application nor esophageal replacement or gastrostomy. Ten patients underwent intralesional TAC injection. No patient had an esophageal perforation or any other complication related to dilatation. In all patients, the symptoms have been alleviated completely and no further dilatation was necessary after a median of five dilatation sessions (1-19 dilatations).

CONCLUSION

Minimally invasive management of caustic ingestion consisting of flexible endoscopy, guidewire-assisted esophageal balloon dilatation and intralesional TAC injection without any gastrostomy or esophageal stent/placement is effective and leads to relief of dysphagia in almost all patients. This method of dilatation is also safe and iatrogenic esophageal perforation is very unlikely.

Estenoses benignas de esôfago: abordagem endoscópica com velas de Savary-Gilliard

RACIONAL: As estenoses benignas de esôfago são complicações decorrentes de diversas causas. Possuem tratamentos similares, na maioria dos casos necessitando de dilatação endoscópica, no entanto a resposta terapêutica, tempo ideal de tratamento, assim como intervalo entre as sessões podem ser variáveis. OBJETIVO: Analisar, do ponto de vista endoscópico, as estenoses benignas de esôfago em 14 anos de experiência no Hospital Universitário Clementino Fraga Filho da Universidade Federal do Rio de Janeiro, RJ, avaliando etiologia, a extensão da estenose, o número de dilatações necessário para atingir resposta terapêutica satisfatória, assim como a relação entre a extensão da estenose e a resposta terapêutica. MÉTODO: Foram analisadas 2.568 dilatações endoscópicas com uso de velas de Savary-Gilliard em 236 pacientes, durante um período de 14 anos e 10 meses, até junho de 2007. RESULTADOS: A estenose péptica foi a causa mais freqüentemente encontrada, seguida pela estenose cáustica. As estenoses longas e cáusticas necessitaram de maior número de sessões para ausência de disfagia. Estenoses pépticas e curtas responderam melhor a número menor de sessões de dilatação. CONCLUSÃO: A estenose péptica foi a causa mais comum e respondeu bem à terapia endoscópica, em concordância com a literatura. As estenoses cáusticas foram as mais refratárias, principalmente as longas. Quanto maior foi a extensão da estenose, também maior foi o número de sessões necessárias. Estenoses curtas apresentaram boa evolução na maioria dos casos. O número de dilatações necessárias dependeu diretamente da causa e da extensão da estenose.

Prevention and management of complications after colon interposition for corrosive esophageal burns

We present our experience in the management of complications after a colon interposition for corrosive esophageal burns. From April 1976 to December 2006, 85 patients with caustic esophageal burns were included in this study. The superior belly median incision with an anterior border incision of the left sternocleidomastoid was used. Anastomosis between the colon and the cervical esophagus was performed in 68 and between the colon and pharyngeal portion in 14 patients. An esophageal scar part resection and gastric-esophageal anastomosis was performed in one patient who had been given an unsuccessful colon and jejunum interposition at another institute. An anastomotic modeling operation was performed in one patient with anastomotic stricture who had been managed with colon interposition at another institute. Exploratory thoracotomy and gastrostomy was performed in one patient who had an unsuccessful colon interposition at another institute. Seven of 14 patients (8.5% of 17.1%) died with serious complications such as aspirated pneumonia, interposition colon necrosis, abdominal wound dehiscence and degradation of swallowing and concordance function. However, others with such serious complications survived and were discharged for rehabilitation after corresponding treatment. The 25 patients (30.1%) with other mild complications were discharged for rehabilitation and corresponding management. Two patients from other institutes were discharged for rehabilitation and one was lost to follow-up. The most dangerous complication of this procedure is colon necrosis, and the stomach is the best organ for re-operation. Otherwise, aspiration in infants due to hypoplasia and degradation of swallowing co-ordination needs attention. Peri-operative management is very important, including the control of mediastinal and pulmonary infection and systemic nutritional support to avoid abdominal wound dehiscence. The platysma flap is an excellent method for the treatment of anastomotic stricture.

Corrosive esophageal injuries in children. A shortlived experience in Sierra Leone

OBJECTIVE

Children with caustic ingestions in developing countries are often treated at home, sometimes by traditional healers, or are referred, frequently late, to tertiary hospitals, which only seldom offer adequate endoscopic and dilatation facilities. Therefore, when dilatations are performed, the stricture is often already well established, making dilatation more difficult. The aim of this paper is to report our experience in the management of corrosive injuries in a group of children of Sierra Leone, all complaining accidental ingestion of caustic soda, many of them treated months after the ingestion.

METHOD

We considered all children admitted after corrosive ingestion, from November 2001 to November 2005, to the "Emergency" Surgical Center in Goderich-Freetown, Sierra Leone. In December 2005 the hospital was supplied with endoscopes and dilatation devices. The children still followed up clinically were recalled to submit them to an endoscopic follow-up and to a dilatation, if needed.

RESULTS

Forty children were admitted (mean age: 4.5 years): 16 (group A) after an esophageal perforation during dilatation performed elsewhere (death rate: 56%). Twenty-four children (group B) were observed after ingestion, 58% being submitted to a surgical gastrostomy. Death rate after ingestion was nil. The mean interval between ingestion and endoscopy was 8.8 months. Fifty-three dilatations were carried out in 17 children over a 3 months period. We report three perforations (17.6%) and a death rate of 5.8% (1/17). Two patients were lost to follow-up. Three patients (17.6%) did not show any improvement. Four children complained recurrent dysphagia after the first dilatation cycle. Overall, 10 children (58.8%) showed a clear-cut improvement at 6 months.

CONCLUSIONS

The majority of treated strictures were late, therefore difficult to dilate and at higher risk of perforation. Dilatation with Savary bougies seems safer than with balloon catheters. Recurrent strictures and a long-term dilatation treatment should be expected. Retrograde dilatations through gastrostomies should be the preferred method of treatment and surgical gastrostomies should be performed without hesitation. Esophageal replacement is unlikely in these countries, except in very few referral centres. Therefore, any effort should be made to treat caustic strictures by timely dilatation programs.

Updates on the Evaluation and Management of Caustic Exposures

In 2004, the American Association of Poison Control Centers' Toxic Exposure Surveillance System documented over 200,000 exposures to caustic substances, in both household and industrial products. Although the most commonly affected body areas are the face, eyes, and extremities, all reported fatalities were as a result of ingestion. Little controversy exists in patient management following dermal or ocular caustic exposure. Immediate water irrigation of the site of caustic exposure, followed by routine burn care, analgesia, intravenous fluids, and electrolyte replacement are standards of care. In this manuscript, a thorough review of the management of gastrointestinal caustic exposure is explored, not only because of the high rates of morbidity and mortality associated with these exposures, but also because there remains controversy regarding appropriate management of such exposures. Hydrofluoric acid, a weak acid in its aqueous form, requires special consideration and specific antidotes, and as such, is addressed separately.