Long-term management of corrosive esophageal stricture with balloon dilation in children

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.

Clinical outcome of endoscopic balloon dilatations employed in benign paediatric oesophageal pathologies

Background

Oesophageal dilatations can be done either by bougies or balloons for differing aetiologies in children. We investigated the efficacy and safety of endoscopic balloon dilatations (EBDs) employed by a single surgeon.

Patients and Methods

Relevant data over 12 years were retrospectively evaluated with an ethical committee approval.

Results

Ninety-seven children underwent 514 EBD with a median EBD of 3 (1-50). The primary diagnoses were oesophageal atresia (OA) in 51 children, corrosive ingestion in 21, peptic strictures in 13, achalasia in 8 and congenital oesophageal stenosis in 4. The balloon size varied between 3 and 30 mm. The EBD was successfully ended in 72 patients and unsuccessful in six patients. Six children are still under EBD and 13 are lost to follow-up. The overall success rate was 92%. The age at the time of first dilatation was the youngest in OA group followed by corrosive strictures. The balloon sizes differed regarding the age of the patients with larger balloons used as the patient age increased. The sizes of the balloons used at the first and the last EBD differed among diagnostic groups. The total number of dilatations or the time interval between the first and the last EBD dilatation did not show a statistically significant difference among groups. The anatomical type of OA or the height of corrosive stricture revealed no significant difference in any of the above parameters. A transmural oesophageal perforation occurred during 2 (0.4%) EBD sessions.

Conclusions

EBD is an effective mean in relieving paediatric oesophageal pathologies with a variety of aetiologies and has a low complication rate.

Perforations from Endoscopic Dilation of Corrosive Strictures in Adults: A Systematic Review and Meta-Analysis

BACKGROUND AND AIMS

Endoscopic dilation is an important therapeutic option for treatment of corrosive strictures. Its safety is unclear with variable perforation rates in previous studies. We aimed to evaluate its safety with regard to perforations and the effect of dilator type to perforation risk.

METHODS

A systematic review of published literature from inception to April 24, 2021, using PubMed and EMBASE databases was conducted. Studies in adult subjects (mean age ≥ 18 years) reporting perforation rates of endoscopic dilation of corrosive esophageal and/or gastric strictures were included. Pooled cumulative perforation rates were computed as primary outcome. Secondary outcomes included, perforation with each dilator subtypes, surgical or conservative modes of management and mortality. Random effect meta-analysis was used to estimate the frequency of each of these outcomes. Variables were reported as percentages with 95% CI.

RESULTS

A total of 712 subjects (N) who underwent 4840 dilations (n) were noted in the 15 studies that were included. Of which, eight were retrospective, while the remaining seven were prospective. On meta-analysis, the cumulative pooled perforation rate was 1% (1-2%) of the number of dilations (n%). The perforation rates with SG (1%, 0-3%) and balloon (1%, 0-5%) dilators were similar (p value < 0.01). 45/64 (59%, 11-94%) perforations were subjected to surgery while the remaining 14/64 (41%, 6-89%) was managed conservatively. Choice of management strategy was biased to the norms of the treating team. About 3/712 patients (0%, 0-2%) succumbed following perforation.

CONCLUSION

Perforation from endoscopic dilation of corrosive strictures occurs rarely, and there is no significant difference in perforation risk related to the type of dilator.

Predictors of clinical response of esophageal dilatations in pediatric population

INTRODUCTION

Esophageal strictures are a common condition, and pediatric surgeons confront them regularly. Despite being performed very frequently, there ared not studies that clearly identify prognostic factors for pediatric patients.

METHODS

Medical records of the children who were taken to esophageal dilatation due to strictures from January 2015 to December 2018 were reviewed. Statistical analysis was performed to establish prognostic factors.

RESULTS

Six hundred sixty-three procedures were performed in 111 patients. The majority of patients had antecedent of esophageal atresia 56%, corrosive stricture in 24%, idiopathic 11%, and Gastroesophageal Reflux (GER) in 9%. The effectiveness of the dilatations was evaluated against three parameters: Dysphagia 0 or 1 in the last assessment 82%. Discharge from dilatation protocol 64%, and no need for surgery 74%. The Global effectiveness was determined by fulfilling the three previous outcomes and was of 49%. The complication rate was 1.9%, being esophageal perforation the most frequent. The statistically significant predictors for the ineffective dilations were airway compromise and history of feeding surgery. The length fewer than 2 cm of the stricture, the location in the middle third of the esophagus and the endoscope passage in the first procedure were factors associated with a better prognosis. Airway involvement was also a variable associated with more significant complications.

CONCLUSIONS

Esophageal dilatations are a fundamental part of the management of strictures. This study found relevant prognostic factors for both the effectiveness of the dilatations and the complications of these. More studies are needed for a gold standard of effectiveness in this condition.

LEVEL OF EVIDENCE

This is a retrospective study of level III of evidence.

Corrosive upper gastrointestinal strictures in children: Difficulties and dilemmas

Children constitute 80% of all corrosive ingestion cases. The majority of this burden is contributed by developing countries. Accidental ingestion is common in younger children (< 5 years) while suicidal ingestion is more common in adolescents. The severity of injury depends on nature of corrosive (alkali or acid), pH, amount of ingestion and site of exposure. There are multiple doubts and dilemmas which exist in management of both acute ingestion and chronic complications. Acute ingestion leads to skin, respiratory tract or upper gastrointestinal damage which may range from trivial to life threatening complications. Esophagogastroduodenoscopy is an important early investigation to decide for further course of management. The use of steroids for prevention of stricture is a debatable issue. Upper gastrointestinal stricture is a common long-term sequelae of severe corrosive injury which usually develops after three weeks of ingestion. The cornerstone of management of esophageal strictures is endoscopic bougie or balloon dilatations. In case of resistant strictures, newer adjunctive therapies like intralesional steroids, mitomycin and stents can be utilized along with endoscopic dilatation. Surgery is the final resort for strictures resistant to endoscopic dilatations and adjunctive therapies. There is no consensus on best esophageal replacement conduit. Pyloric strictures require balloon dilatation , failure of which requires surgery. Patients with post-corrosive strictures should be kept in long term follow-up due to significantly increased risk of carcinoma. Despite all the endoscopic and surgical options available, management of corrosive stricture in children is a daunting task due to high chances of recurrence, perforation and complications related to poor nutrition and surgery.

Predictors of successful endoscopic management of caustic esophageal strictures in children: When to stop the dilatations?

BACKGROUND

Caustic esophageal strictures are mainly managed by endoscopic dilatations. Cases that do not respond to the dilatations eventually require an esophageal replacement. The aim of our study was to identify factors that could allow us to predict if the dilatations will be successful or not.

METHODS

We retrospectively reviewed the chart of 100 patients with caustic esophageal injuries treated at our center between 2012 and 2019. Collected data included age, gender, type of caustic substance, duration of the dilatations, length and extent of the strictures, number and time interval between dilatations, presence of gastroesophageal reflux, occurrence of esophageal perforation, and outcome of the dilatation program.

RESULTS

The patient ages ranged from 1 to 8 years old. The overall success rate was 98.2% for patients with short strictures and 81.8% for patients with long strictures (>3 cm). A long stricture, a pharyngeal extension of the stricture, the occurrence of an esophageal perforation, and the presence of gastroesophageal reflux were strong predictors of the failure of the dilatation program. The median treatment time for the patients to achieve a cure was 5 months in cases of short strictures and 17 months in cases of long strictures. Within the subgroup of patients with long strictures, a dysphagia-free period within the first year of management of 8 weeks was associated with the success of the dilatation program.

CONCLUSION

A length of more than 3 cm, pharyngeal involvement, the occurrence of esophageal perforation, and the presence of gastroesophageal reflux are predictors of failure of dilatations for the management of caustic esophageal strictures. A dysphagia-free period of 8 weeks or more within the first year of dilatations is considered a predictor of success of dilatations in patients with long strictures.

LEVEL OF EVIDENCE

Level II.

Accuracy of contrast swallow study in assessment of caustic esophageal stricture length in children: Agreement study

BACKGROUND

Caustic esophageal stricture length assessment is essential for planning endoscopic management and predicting its prognosis. We aimed to assess the accuracy of contrast swallow study (CSS) in measuring stricture length in comparison to endoscopy (definitive investigation for actual length measurement).

METHOD

Medical records of caustic esophageal strictures between 2010 and 2020 were retrospectively reviewed. Reliability study was done to compare between radiological and endoscopic measurement of stricture length.

RESULT

124 CSSs for 91 patients were analyzed. Six studies showed no stricture, single stricture was reported in 101 studies, double strictures were reported in 16 studies, triple strictures were reported in one study (136 radiological stricture). Endoscopy revealed 133 true strictures. Number of the strictures was consistent between CSS and endoscopy in 112 studies (90.3%) and different in 12 studies (9.7%). Eight endoscopies revealed strictures not reported in CSS (5.5% false negative strictures), while 10 CSSs reported 11 strictures that were not detected during the endoscopy (7.6% false positive strictures). Reliability analysis revealed interclass correlation coefficient = 0.6 (95% CI 0.5 to 0.7) indicating moderate reliability.

CONCLUSION

CSS is not accurate in assessing caustic esophageal stricture length. Combination of CSS and endoscopic investigation is better for proper evaluation of these patients. Level III of evidence.

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.

Factors affecting the outcome of endoscopic dilatation in refractory post-corrosive oesophageal stricture in Egyptian children: a single-centre study

BACKGROUND

An important complication of corrosive ingestion is oesophageal stricture. Improvements in endoscopes and accessories have supported an increase in the number of patients who are conservatively treated with endoscopic dilations. In this study, we aimed to detect factors affecting the outcome of endoscopic dilatation for refractory post-corrosive oesophageal stricture.

METHODS

This study was carried out in the Paediatric Endoscopy Unit in the Children's Hospital and included 100 children older than 2 years of age of both sexes who had an established diagnosis of post-corrosive oesophageal stricture on repeated endoscopic dilatation sessions. The duration of the condition was more than 6 months, and dilatation failed to achieve a diameter of 14 mm during the first five sessions at 2-week intervals (refractory), excluding other causes of oesophageal stricture.

RESULTS

Males represented 63% of patients. The mean age of enrolled children was 5.9 ± 2.6 years; 90% of patients ingested an alkaline corrosive substance (potash). The total number of dilatation sessions ranged from 16 to 100, with a mean number of sessions ranging from 37.2 ± 14.9. Fifty-four patients (54%) were well controlled by regular endoscopic dilatation with good clinical and endoscopic outcomes, and no more dilatations were needed.

CONCLUSION

Endoscopic dilation is an effective method for managing refractory post-corrosive oesophageal strictures that require a long follow-up period. There are a lot of factors affecting the outcome.

Caustic Ingestion in Children: 1 Year Experience in 3 Italian Referral Centers

OBJECTIVES

Despite the efforts to reduce the exposure to corrosive household products, caustic ingestion in children is currently a significant medical problem. The aims of the present study were to evaluate the clinical consequences of caustic ingestion and to identify prognostic factors that could concur in driving both diagnostic and therapeutic management.

METHODS

All consecutive children referred for ingestion of a caustic substance from June 2017 to June 2018 were enrolled. Medical records, laboratory and endoscopic findings were reviewed and analyzed.

RESULTS

We enrolled 44 children with caustic ingestion. Alkaline agents were ingested by 26 of 44 (59.1%) patients, whereas acid agents were ingested by 18 of 44 patients (40.9%). Alkaline rather than acid agents were associated with a worse endoscopic score (r: 0.45) and a higher probability of early esophageal stricture occurrence (r: 0.38). The specific risk of the presence of severe esophageal lesions rose progressively with increasing number of symptoms whereas no esophageal injury was found in asymptomatic patients.

CONCLUSIONS

Our data suggest that endoscopic evaluation is mandatory in symptomatic patients to direct therapeutic management, but it could be avoided in asymptomatic patients after accidental ingestion, particularly if the ingestion is only suspected and patients have no oropharyngeal burns.

Caustic Agents Ingestion in Children: A 51-Year Retrospective Cohort Study

OBJECTIVES

Children experience serious gastrointestinal tract injuries due to consumption of caustic agents more often than adults. The aim of the study was to analyze diagnostic methods and treatment of children with esophageal burns according to the degree of the injury.

METHODS

Our one-center population-based retrospective cohort study included 150 children admitted between 1967 and 2018 to Clinic of Pediatric Otolaryngology, Phoniatrics and Audiology of University Children's Hospital in Lublin, Poland, due to the chemical burn of the mouth, throat, larynx, and esophagus. Each patient underwent a thorough laryngological examination and endoscopy to assess the place and degree of injury.

RESULTS

Of 150 patients, 65.3% were male and 34.7% female. The median age was 4 years and 3 months. Salivation, dysphagia, burning sensation, edema, and whitish coating on the oral mucosa, palate, and throat were the most common clinical symptoms. In addition, dyspnea and chest pain were observed in 30% of patients. Esophagus endoscopy results were: Zargar grade I burn (84.7%), grade IIA (8%), grade IIB (2.6%), grade III (0%), and grade 0 (4.7%). Treatment included antibiotics, proton pump inhibitors, analgesics, and intravenous fluid therapy. Late sequelae (scarred esophageal strictures) developed in 20 (13.3%) patients.

CONCLUSIONS

Accidental intake of caustic agents is observed in young children, especially younger than the age of 5. Early esophagus endoscopy should be performed in all patients to assess the grade of injury, plan initial treatment, and predict the risk of developing complications. Early diagnosis and immediate pharmacological treatment reduce the number of late sequelae.

Long-Term Outcomes of Caustic Esophageal Stricture with Endoscopic Balloon Dilatation in Chinese Children

Caustic esophageal stricture (CES) in children still occurs frequently in developing countries. We aimed to evaluate the long-term outcomes of endoscopic balloon dilatation (EBD) in treating CES in children and the influencing factors associated with outcome. We retrospectively reviewed the data of all patients who had a diagnosis of CES and underwent EBD from August 1, 2005, to December 31, 2014. The primary outcome was EBD success, which was defined as the maintenance of dysphagia-free status for at least 12 months after the last EBD. The secondary outcome was to analyze influencing factors associated with EBD success. Forty-three patients were included for analysis (29 males; mean age at first dilatation 44 months with range 121 months). 26 (60.5%) patients had long segment (>2 cm) stricture. A total of 168 EBD procedures were performed. Twenty-six (60.5%) patients were considered EBD success. Seventeen (39.5%) patients failed EBD and required stent placement and/or surgery. Patients in the EBD success group had significantly shorter stricture segments when compared to the EBD failure group (t = 2.398, P = 0.018, OR = 3.206, 95% OR: 1.228-8.371). Seven (4.4%) esophageal perforations occurred in 6 patients after EBD. Stents were placed in 5 patients, and gastric tube esophagoplasty was performed in 14 patients. In conclusion, 26 (60.5%) of 43 children with CES had EBD success. Length of stricture was the main influencing factor associated with EBD treatment outcome.

Surgical management of corrosive-induced gastric injury in children: 10years' experience

AIM

The purpose of this study was to report surgical management and outcome of corrosive-induced gastric injuries in children at our institute over the last decade.

PATIENTS & METHOD

Medical records of patients admitted for corrosive-induced gastric injury at the Pediatric Surgery Department of Ain Shams University between January 2007 and January 2017 were retrospectively reviewed.

RESULTS

Twenty six cases (17 boys and 9 girls) were enrolled. Mean age was 3.61±1.29. Ingested agent was acid in all the patients. Main presenting symptom was gastric output obstruction in 22 cases. The interval between corrosive ingestion and presentation ranged from one to 135days (mean=43.9±34). Surgical procedure included total gastrectomy (n=2), partial gastrectomy (n=2), augmentation gastroplasty (n=1), Billroth I (n=2), antrectomy (n=2), antroplasty (n=3), gastrojejunostomy (n=2), Heineke-Mikulicz pyloroplasty (n=9), Finney pyloroplasty (n=5), and feeding jejunostomy (n=4). Anastomotic stricture requiring a second operation developed in one patient. There were three mortalities related to the associated esophageal strictures. The mean follow-up period is 3.5years. All patients are free of symptoms and gained adequate weight.

CONCLUSION

Surgery is the mainstay of management for corrosive-induced gastric injuries with good long-term results. Surgical procedure should be tailored according to the patient's general condition and extent of gastric injury.

LEVEL OF EVIDENCE

This is a case series with no comparison group (level IV).

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 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.

Incidence and management of oesophageal ruptures following fluoroscopic balloon dilatation in children with benign strictures

OBJECTIVES

The purpose of this study is to investigate the incidence and management of oesophageal ruptures following fluoroscopic balloon dilatation (FBD) in children with benign oesophageal strictures.

METHODS

Sixty-two children with benign oesophageal strictures underwent FBDs. Oesophageal rupture was categorized as intramural (type 1), transmural (type 2), or transmural with free leakage (type 3). The possible risk factors for oesophageal ruptures were analyzed.

RESULTS

One hundred and twenty-nine FBDs were performed in these patients. The oesophageal rupture rate was 17.1 % (22/129). The majority (21/22) of ruptures were type 1 and type 2, both were treated conservatively. Only one patient had a type 3 rupture and underwent oesophagoesophagostomy. The patient gender, age, and the length and cause of the stricture showed no significant effect on the rupture (P > 0.05). However, for the patients ≤2 years old, the initial balloon with a diameter ≥10 mm showed a higher oesophageal rupture rate than those <10 mm during the first session (P = 0.03).

CONCLUSIONS

Although the oesophageal rupture rate in children was 17.1 %, the type 3 rupture rate was 0.8 %, which usually requires aggressive treatment. For children ≤2 years old, the initial balloon diameter should be <10 mm in the first session for decreasing the risk of oesophageal rupture.

KEY POINTS

• The oesophageal rupture rate following balloon dilatation in children was 17.1 %. • The incidence of transmural rupture with free leakage is very low. • Only transmural rupture with free leakage needs aggressive treatment. • For children ≤2 years, the initial balloon diameter should be <10 mm.

Endoscopic therapy of oesophageal strictures in children - a multicentre study

INTRODUCTION

Oesophageal strictures are rare in children but may require endoscopic dilation.

AIM

To gather information on centres performing endoscopic oesophageal dilation in Poland.

MATERIAL AND METHODS

The data were obtained from questionnaires concerning the relevant data mailed to 22 paediatric endoscopy centres. Completed questionnaires were received from 11 centres.

RESULTS

In 2010 the 11 Polish paediatric endoscopy centres performed a total of 10,650 endoscopic procedures. This included 347 oesophageal dilations in 106 paediatric patients aged from 1 month to 18 years. The numbers of patients treated at individual centres ranged from 2 to 40. The indications for oesophageal dilation were as follows: postoperative strictures in 68 children, oesophageal burns in 17 children, postinflammatory strictures in 14 children, achalasia in 4 children, and strictures caused by a foreign body in 3 children. Rigid guidewire dilators were used in the majority of procedures (271), rigid dilators without a guidewire in 32 procedures, and balloon dilators in 45 procedures. A total of 203 procedures were conducted under fluoroscopic guidance, and 144 without the use of fluoroscopy. The number of dilating sessions performed in individual children varied from 1 to 6 and more.

CONCLUSIONS

Oesophageal dilation constituted a minor proportion of all paediatric endoscopic procedures. The majority of children requiring dilation were patients up to 3 years of age with postoperative oesophageal strictures. In the majority of the centres rigid guidewire dilators were used, and in one third of the procedures these dilators were introduced without fluoroscopic guidance.

Efficiency of upper gastrointestinal endoscopy in pediatric surgical practice

After the introduction of flexible fiber optic endoscopy to pediatric gastroenterology in the 1970s, upper gastrointestinal (UGI) endoscopy can be performed for the diagnosis and treatment of all age groups of children. We review indications, contraindications, preparation of patients for the procedure, and details of diagnostic and therapeutic UGI endoscopy used in pediatric surgery. We also discuss potential complications of endoscopy.

Therapy of caustic ingestion: new treatment considerations

PURPOSE OF REVIEW

This review will focus on therapeutic considerations and recent advances in treatment of caustic ingestion injuries.

RECENT FINDINGS

A retrospective study suggests that it may be safe to advance the endoscope beyond the first circumferential burn to allow for a more complete assessment of extent of injury. A randomized controlled prospective study suggested that a 3-day course of high-dose methylprednisolone might reduce the occurrence of esophageal stricture formation. Balloon dilatation has been shown to be as effective as other bougienage techniques with lower risk of perforations. Recent studies indicate that esophageal dilatation can be safely performed as early as 5-15 days after initial ingestion and may decrease risk for long-term stricture formation. The use of adjunctive treatment, such as topical mitomycin C and esophageal stents, shows promise in reducing the reoccurrence of stricture formation after dilatation.

SUMMARY

Caustic ingestion remains a significant problem in children, despite continued efforts to educate the public about ways to avoid this preventable accident. Because there are few good quality therapeutic trials in children, many of the current recommendations regarding treatment are based on expert opinion. Large, prospective, multicenter, controlled treatment trials are needed to identify the best protocols to prevent serious complications.

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.

Topical mitomycin C can effectively alleviate dysphagia in children with long-segment caustic esophageal strictures

Caustic ingestion in children and the resulting long esophageal strictures are usually difficult to be managed, and eventually, esophageal replacement was required for cases refractory to frequent dilatation sessions. Topical mitomycin C (MMC) application has been used recently to improve the results of endoscopic dilatation for short esophageal strictures. The study aims to assess the role of MMC application in management of long-segment caustic esophageal strictures. From January 2009 to June December 2013, patients presented with long caustic esophageal stricture (>3 cm in length) were included in this study and subjected to topical MMC application after endoscopic esophageal dilatation on multiple sessions. Regular follow-up and re-evaluation were done. A dysphagia score was used for close follow-up clinically; verification was done radiologically and endoscopically. During the specified follow-up period, 21 patients with long caustic esophageal stricture were subjected to topical MMC application sessions. Clinical, radiological, and endoscopic resolution of strictures occurred in 18 patients (85.7% cure rate). Number of dilatation sessions to achieve resolution of dysphagia was (n = 14.3 ± 5.7) with application of mitomycin two to six times. There was no recurrence in short- and mid-term follow-up. No complications were encountered related to topical MMC application. MMC is a promising agent in management of long-segment caustic esophageal strictures. Long-term follow-up is needed to prove its efficacy and to evaluate potential long-term side-effects of MMC application.

Endoscopic balloon dilatation of benign esophageal strictures in childhood: a 15-year experience

The study aims to evaluate the effectiveness and safety of endoscopic balloon dilatation (EBD) in childhood benign esophageal strictures. The medical records of 38 patients who underwent EBD from 1999 to 2013 were retrospectively reviewed. Demographic features, diagnoses, features of strictures, frequency and number of EBD, complications, outcome, and recurrence data were recorded. Median age was 1.5 years (0-14), and female/male ratio was 17/21 (n = 38). Primary diagnoses were corrosive esophageal stricture (n = 19) and esophageal atresia (n = 19). The length of strictures were less than 5 cm in 78.9% (n = 30). No complication was seen in 86.8% (n = 33). Perforation was seen in 10.5% (n = 4), and recurrent fistula was seen in 2.7% (n = 1). Total treatment lasted for 1 year (1-11). Dysphagia was relieved in 60.5% (n = 23). Recurrence was seen in 31.6% (n = 12). Treatment effectiveness was higher, and complication rates were lower in strictures shorter than 5 cm compared with longer ones (70% vs. 25%, P < 0.05, and 3.4% vs. 37.5%, P < 0.05). Although there was no statistical difference, treatment effectiveness rates were lower and complication and recurrence rates were higher in corrosive strictures compared with anastomotic ones (P > 0.05). EBD is a safe and efficient treatment choice in esophageal strictures, especially in strictures shorter than 5 cm and anastomotic strictures.

Stents for benign and malignant esophageal strictures

This paper presents commentaries on endotherapy for esophageal perforation/leaks; treatment of esophageal perforation; whether esophageal stents should be used for treating benign esophageal strictures; what determines the optimal stenting period in benign esophageal strictures/leaks; how to choose an esophageal stent; how a new fistula secondary to an esophageal stent should be treated; which strategy should be adopted when a fistula of a cervical anastomosis occurs; intralesional steroids for refractory esophageal strictures; balloon and bougie dilators for esophageal strictures and predictors of response to dilation; whether refractory strictures from different etiologies respond differently to endotherapy; surgical therapy of benign esophageal strictures; and whether stenoses following severe esophageal burns should be treated by esophageal resection or esophageal bypass.

Indwelling esophageal balloon catheter for benign esophageal stenosis in infants and children

BACKGROUND

Balloon dilatation of benign esophageal strictures is an established mode of therapy in adults and children. There remains a group of patients with refractory stenosis despite dilatation at regular intervals. An indwelling balloon catheter may offer an alternative.

METHODS

This is a retrospective study of 19 children who underwent esophagoscopy between 2004 and 2012 with placement of an indwelling balloon catheter for refractory esophageal stenosis. Total number of endoscopies, number of endoscopies with indwelling balloon catheter, as well as complications, reoperations, and mortality due to use of the balloon catheter were studied.

RESULTS

Patient age ranged from 4 weeks to 15 years. The indwelling balloon catheter was used to treat refractory stenosis after corrective surgery of long gap esophageal atresia (n = 5), esophageal atresia with distal fistula (n = 2), refractory esophageal stenosis due to caustic esophageal burns (n = 7), reflux (n = 2), and stenosis of unknown cause (n = 3). With the indwelling balloon catheter in place, the mean number of endoscopies equalled four. Complications were restenosis after a symptom-free period for which a new indwelling balloon catheter was necessary (n = 3). Two others needed two to five additional dilations: balloon leakage requiring replacement (n = 7 in 5 patients), sputum retention (n = 1), and dislodgement (n = 5 in 4 patients). More importantly, there was no mortality or the need for any patient to undergo a surgical resection.

CONCLUSIONS

The indwelling balloon catheter is safe to use and can be used by parents at home. More importantly it obviates the need for rethoracotomy/-scopy or esophageal replacement.

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 mitomycin C application is effective in management of localized caustic esophageal stricture: a double-blinded, randomized, placebo-controlled trial

BACKGROUND

Frequent sessions of endoscopic dilatation are usually required in the management of benign esophageal strictures, especially caustic induced ones. Topical mitomycin C (MMC) has been recently used in the management of resistant strictures. This study evaluated the efficacy of MMC application in prevention of stricture recurrence after endoscopic dilatation.

PATIENTS AND METHODS

This double-blind, randomized, placebo-controlled trial included forty patients with caustic esophageal strictures dating from January 2008 to October 2010. Patients were randomized into 2 groups to undergo endoscopic dilatation with application of either MMC versus placebo on stricture site. Regular follow up and re-evaluation were done after 6 months of management. The number of dilatation sessions needed for resolution of dysphagia in each group was our primary outcome.

RESULTS

During the specified follow up period, 80 % of strictures in the MMC group got completely resolved compared to only 35% in the placebo group. The mean number of dilatation sessions needed in the MMC group was n = 3.85 ± 2.08 compared to n = 6.9 ± 2.12 in the placebo group which was statistically significant (p < 0.001).

CONCLUSION

Mitomycin C application significantly reduced the number of dilatation sessions needed to alleviate dysphagia in patients with caustic esophageal strictures.

Esophageal endoscopic dilations

OBJECTIVE

Esophageal strictures in children are serious and require specialized care. Peptic stricture is most common in our context, whereas caustic and congenital strictures are rare. The present study reports our experience in esophageal endoscopic dilation while specifying the causes of esophageal strictures as well as their response to endoscopic treatment.

METHODS

This is a case study during a period of 7 years, in which 60 cases of esophageal stricture were treated with endoscopic dilation by Savary-Gilliard bougies. Our patients were divided into 3 groups: group A for peptic strictures (52 patients), group B for caustic strictures (4 patients), and group C for strictures subsequent to esophageal atresia surgery (4 patients). The age of patients was between 10 months and 17 years. Dysphagia was the main symptom and was the major reason for consultation. Two hundred forty-seven dilation sessions were performed, with an average of 4 sessions per patient ranging from 1 to 15 sessions. The maximum score was observed in group B (50%). Expansion was performed under deep sedation.

RESULTS

We had 2 esophageal perforations: 1 in group A and 1 in group B. A good response was obtained in group A (70%) and B (50%). The patients in group C still required repeated sessions.

CONCLUSIONS

Esophagus endoscopic dilation is an effective technique, especially in peptic stricture, with no need of surgery in some cases. In addition, perforation was rare in this group.

Predictability of outcome of caustic ingestion by esophagogastroduodenoscopy in children

AIM: To assess the necessity of esophagogastroduodenoscopy (EGD) to predict the outcome of caustic ingestion in children.

METHODS: The study included 206 children who underwent EGD because of ingestion of caustic substances between January 2005 and August 2010. Retrospective analysis of data of the patients was performed.

RESULTS: The male/female ratio was 1.6 and mean age was 38.1 ± 28.8 mo. The caustic substances were acidic in 72 (34.9%) cases, alkaline in 56 (27.2%), liquid household bleach in 62 (30.1%), and unknown in 16 (7.8%). Fifty-seven (27.7%) patients were symptom-free. Significant clinical findings were observed in 149 (72.3%) patients. Upper gastrointestinal endoscopy findings of esophageal injury were grade 0 in 86 (41.7%) patients, grade 1 in 49 (23.8%), grade 2a in 42 (20.4%), grade 2b in 28 (13.6%), and grade 3a in 1 (0.5%) patient. 35 patients with grade 2a, 2b, and 3a injuries underwent esophageal dilation at second week of ingestion. Esophageal stricture, which necessitated a regular dilation program developed in 13 of the aforementioned 35 patients. There is no statistically significant difference in the rate of development of esophageal stricture between the patients who ingested acidic (15.3%) and alkaline (8.9%) substances (P = 0.32). Severe gastric injury was detected in 38 (18.5%) patients. The rate of development of gastric injury was significantly higher in the acidic group (14%) than in the alkaline group (2.9%) (P = 0.001). Out of 149 patients with clinical findings, 49 (32.9%) patients had no esophageal injury and 117 (78.5%) patients had no gastric lesion. Esophageal and severe gastric injuries were detected in 20 (35.1%) and 8 (14%) of patients with no clinical findings respectively. Pyloric stenosis developed in 6 patients. Pyloric obstruction improved with balloon dilation in 2 patients. Mean hospitalization time were 1.2 ± 0.5 d for grade 0 and 2.3 ± 5 d for grade 1 and 6.3 ± 6.2 d for grade 2a and 15.8 ± 18.6 d for grade 2b. It was significantly longer for patients with grade 2a and 2b injuries (P = 0.000).

CONCLUSION: Endoscopy is an effective technique for determining the presence of esophageal and gastric damage and to avoid unnecessary treatment in patients with no or mild injury.

Endoscopic balloon dilatation of esophageal strictures in children

AIM OF THE STUDY

To assess the efficacy and safety of endoscopic balloon dilatation of esophageal strictures in children.

DESIGN

retrospective case series; population: 49 patients under 18 years of age referred to our center for esophageal strictures; treatment: endoscopic balloon dilatation; outcome parameters: residual dysphagia, weight gain, iatrogenic esophageal perforation, assessment of the esophageal lumen by endoscopy or esophagogram.

RESULTS

The three main etiologies were esophageal atresia (49%; n=24), corrosive injury (25%; n=12), and epidermolysis bullosa (14%; n=7), followed by a heterogeneous group of rarer causes (12%; n=6). The number of dilatations ranged from 1 to 8 sessions per patient (median ± SEM: 2 ± 0.3). The length of the follow-up period ranged from 20 to 109 months (median ± SEM: 40 ± 4 months). Treatment was successful in 86% of cases (n=42). Twelve percent of patients (n=6) had a residual stenosis requiring surgery, and a further one still experienced swallowing difficulties requiring enteral nutrition via gastrostomy in spite of the absence of significant residual stricture. Results were less satisfactory in cases of corrosive injury than with other etiologies. Three esophageal perforations were observed (6% of patients; 2% of procedures). All were medically treated.

CONCLUSIONS

Endoscopic balloon dilatation is a simple, safe and efficacious treatment of esophageal strictures in children.