Corrosive stricture of the stomach

Heineke-Mikulicz pyloroplasty for isolated pyloric stricture caused by corrosive ingestion in children

Corrosive ingestion in children is a common problem in low income countries. These agents cause injuries and later strictures of esophagus and stomach. Gastric outlet obstruction is known complication of acids and surgery is the mainstay of treatment. There are multitude of surgical options for these strictures depending on the involved segment of the stomach and experience of the surgeon. Here we present three cases of children who accidentally ingested acid stored in soda bottles and subsequently developed isolated pyloric strictures. These cases presented between August 2018 and April 2019 to our facility, a tertiary care hospital in Karachi, Pakistan. All three patients had an initial latent period of one to two weeks following corrosive ingestion, after which symptoms of gastric outlet obstruction appeared. Intraoperatively, all three had normal esophagus and antrum but scarred and strictured pylorus. Heineke-Mikulicz pyloroplasty was done in these cases without complications and the outcomes were satisfactory.

Laparoscopic Diamond Antroduodenostomy for Postcorrosive Pyloric Cicatrization: A Novel Approach

BACKGROUND

Traditionally, Billroth I procedure or bypass gastrojejunostomy were the recommended approaches for management of postcorrosive complete gastric outlet obstruction (GOO), whereas Heineke Mickulicz pyloroplasty was recommended for moderate mucosal injury with partial cicatrization. In this study, laparoscopic diamond antroduodenostomy was carried out as an alternative minimally invasive approach for cases with pyloric cicatricial obstruction.

PATIENTS AND METHODS

Between January and December 2017, children who were referred to Pediatric Surgery Department, Cairo University Hospital, with GOO as a consequence of caustic liquid ingestions were included in this study. Laparoscopic diamond antroduodenostomy was performed for the presented cases.

RESULTS

Through the year 2017, 5 cases were approached with laparoscopic diamond antroduodenostomy. Isolated pyloric cicatrization was evident in 4 cases, whereas synchronous insult to thoracic esophagus and pylorus was manifest in the fifth case. Laparoscopic feeding jejunostomy completed the procedure for the case with esophageal stricture. Contrast study-24 hour postoperatively-assured no radiological leaks in the presented cases, where enteral feeding was gradually commenced, and patients discharged home a day later. After a mean follow-up of 13.5 months, neither recurrence of obstructive symptoms nor dumping was displayed. Cosmetic outlook inherent to the minimally invasive approach was appreciated by the parents.

CONCLUSION

Laparoscopic diamond antroduodenostomy is a feasible approach for management of postcorrosive pyloric obstruction. It allowed early enteral feeding, with no dumping symptoms, in addition to the fundamental advantages of minimally invasive surgery. A bigger series and longer follow-up is recommended to verify the reported results.

Corrosive injury-induced gastric outlet obstruction: a changing spectrum of agents and treatment

METHODS

During the last 5 years, 61 children were admitted to the authors' hospital because of corrosive substance ingestion, and among them 6 patients were seen with gastric outlet obstruction. Two of them had ingested acid substances, and the other 4 had ingested alkali corrosives. The mean age was 2.9 years (range, 1.5 to 3). Their common complaint was postprandial vomiting, which had begun 3 weeks after the event (range, 1 week to 10 weeks). Endoscopic evaluation and barium contrast radiographies were performed at admission. Four patients had a pyloric stricture, 1 had an antral stricture, and another had an antropyloric stricture. Balloon dilatation of the pylorus (in 1 patient), pyloroplasty (in 3 patients), and Billroth I procedures (in 2 patients) were performed. The mean follow-up period was 22 months (range, 6 weeks to 48 months). One patient, who had undergone a Billroth I procedure, underwent reoperation because of intestinal obstruction 3 months later. On follow-up they are all free of symptoms.

CONCLUSIONS

The treatment of gastric outlet obstruction caused by corrosive ingestion should be treated surgically. Although endoscopic and radiologic evaluation helps to determine the time and necessity, once the diagnosis is confirmed, early definitive surgical intervention should be performed, and the type of the surgery depends mostly on the findings of the surgeon at laparotomy. Endoscopic balloon dilatation of the pylorus maybe attempted in suitable cases. Special care should be given to prevent children from accidental corrosive ingestion.

Acid ingestion: toxicology and treatment

The effects of strong acid ingestion are distinctly different from those of alkali. Strong acids produce superficial injuries to the esophagus and deep injuries to various portions of the stomach. Prevailing early treatment recommendations of simple dilution or weak-base neutralization are inappropriate because of their extraordinary thermal results. Dilution of concentrated sulfuric acid with an equivalent volume of water results in a temperature elevation of approximately 80 C. Neutralization results in even greater heat production. Vigorous gastric aspiration prior to cold fluid lavage is the management of choice in cases treated immediately following acid ingestion.