Iatrogenic esophageal perforation caused by endoscopic dilatation of caustic stricture: Current management and possibility of esophageal salvage

Outcomes of pneumatic dilation in pediatric caustic esophageal strictures: a descriptive and analytic study from a developing country

OBJECTIVES

Corrosive substance ingestion in children represents a significant public health issue due to its long-term health sequelae. Esophageal stricture, main complication of this dangerous condition, is treated by pneumatic dilation and eventually by esophageal replacement. We aimed, through this study, to report the outcomes of esophageal pneumatic dilation complicating corrosive substance ingestion in children in a developing country.

METHODS

This cross-sectional study was performed on the population of pediatric patients with caustic esophageal stenosis between January 2005 and December 2020. All patients underwent pneumatic balloon dilation. A logistic regression model was built to predict the probability of the occurrence of the event (success/failure) of the dilation. The ROC curve is used to evaluate the performance of the logistic regression model to discriminate between positive and negative values of the dependent variable.

RESULTS

The success rate of pneumatic balloon dilation was 80.4%. The median duration of overall management was 11 months. The severity of caustic stricture observed during endoscopy was significantly linked to worse outcomes (p = 0.001). Multivariate analysis indicated that the severity of stenosis and the number of dilation sessions were independent risk factors for failure of dilation. ROC curve analysis showed that the area under the curve was 71.7%. A Cut-Off point value of 7 provided the best sensitivity and specificity.

CONCLUSION

Pneumatic balloon dilation has been proven to be efficacious in infants with caustic esophageal stricture. Pediatric surgeons should take into account factors to promptly switch to replacement surgery and avoid unnecessary and time-consuming serial dilations.

Non-operative management of iatrogenic esophageal perforation in a 6-year-old child

BACKGROUND

Esophageal perforations are rare, the most common encountered esophageal perforation is iatrogenic in origin. It can be life-threatening if not diagnosed and treated early. Medical treatment has been recommended primarily in hemodynamically stable children. Drainage of intrathoracic or periesophageal fluid formation should be reserved to patients with hemodynamic instability. Surgical intervention may seldomly be required, depending on the localization and size of the defect.

CASE REPORT

A 6-year-old male patient was referred to our clinic due to an esophageal perforation whilst removing the foreign body from upper esophagus under direct vision of a rigid esophagoscope. A radiologic appearance similar to esophageal duplication was detected along the esophagus in the esophagogram. A secondary esophagoscopy was carried out by our clinic, laceration at the esophagopharyngeal junction and dissection along the esophagus were observed and the foreign body was propelled into the stomach. The patient, whose clinical condition was stable, was managed medically without the need for a surgical intervention.

CONCLUSIONS

Esophageal perforation is rare, yet perilous if not handled properly. We do not encounter this clinical entity frequently. Despite its rarity it can arise either iatrogenically or while managing a previous complication such as a simple nasogastric tube insertion in an infant or during an endoscopy for an esophageal foreign body. Its management is challenging, and we believe that non-operative treatment is still an important option in childhood esophageal perforations.

Esophageal Perforation into the Pericardium in a 3-Year-Old Child with Esophageal Stricture: A Rare Complication Following Esophageal Dilatation

Perforation of the esophagus during dilatation is a rare complication that might cause mortality. We present the report of a 3-year-old girl who was diagnosed with B cell acute lymphoblastic leukemia at 17 months of age. She experienced a complicated clinical course after chemotherapy was initiated, which included mucositis and acute pericarditis. She later developed an acquired esophageal stricture and tracheoesophageal fistula, which were managed with resection and primary anastomosis when she was in remission. Postoperatively, the patient developed a leak, which was treated conservatively. She subsequently developed a stricture that was treated successfully. On the fourth dilatation attempt and after she was sent home, she presented with persistent vomiting and low-grade fever and became vitally unstable on the same day, after stabilization, upper gastroenterology contrast revealed contrast filling the pericardium. She was managed conservatively with close observation and serial echocardiograms and then discharged home on day 18 in good condition after complete resolution of the pericardial effusion.