Experience with esophageal stenting for caustic burns in children

Utilization of chest tube as an esophagus stent in pediatric caustic injuries: A retrospective study

BACKGROUND

The management of caustic esophageal burns in the pediatric population has changed over the years, while the most optimal management with regards to effectiveness, availability, and cost-beneficent stays controvertible.

AIM

To describe how to utilize a chest tube for esophageal stenting in pediatrics.

METHODS

Data regarding the etiology, treatment, and complications of caustic injury in pediatrics over 10 years was collected retrospectively. Furthermore, data regarding the patient's follow-up who underwent esophageal chest tube (ECT) were collected. The ECT was prepared by carving a narrowed section in the chest tube while maintaining the radiopaque section. The ECT will then be positioned from the cricopharyngeal and exited through the nostril and fixed on the patient's cheek.

RESULTS

During the period of our study, data from 57 patients with an average age of 2.5 years (range 1-12; SD = 1.7) were obtained. The results showed that 89% of esophageal injury was due to alkaline and 9.4% were caused by acidic agents. The treatment methods showed that 29 patients (50.8%) recovered with dilatation alone. In 16 patients (28.06%), the esophageal repair was performed by using the colon, and in 5 patients (8.7%), other surgical methods were used and in 7 patients (12.2%), the ECT stents were used. ECT was inserted in 7 cases with a mean age of 2 (range: 1.5-3) years who were classified as grade IIB or III. Grading was performed by endoscopy assessment on the first day. Antibiotics and corticosteroids were administrated as initial medical management for all patients. ECT implantation was done during the first 8 d for 5 out of 7 cases (mean: 3.8 d). For the 2 patients, ECT was used after 27 (patient 6) d and 83 (patient 7) d. The reason for late stenting in these patients was a postponed referral to our center, in which patient 7 even received 4 dilation episodes before visiting our center. ECT was removed after an average of 44 d in the first 5 patients, while in the other 2 patients (6 and 7) was 2 and 1 wk, respectively. There was no complication related to, or failure of, stent placement. It is worth mentioning that none of the 7 ECT cases required gastrostomy or jejunostomy.

CONCLUSION

The ECT method introduced in our study can be used as a broadly available, economic, and easy-use facility for esophageal stenting, particularly in developing countries and emergency departments which have limited access to modern equipment. Further multicenter studies with higher volume patients are required for further deployment of this method.

Self-expanding esophageal stents for the management of benign refractory esophageal strictures in children: A systematic review and review of outcomes at a single center

BACKGROUND

This study aimed to evaluate our outcomes and complication rate following placement of self-expanding esophageal stents in children for the management of refractory esophageal strictures and comparing these to the existing literature.

METHODS

Outcomes following placement of stents in consecutive patients under 18 years at a single center from 2003 to 2018 were reviewed. A PRISMA-guided systematic review was conducted identifying studies with 5 or more children evaluating self-expanding stents published from 1975 to 2018. Endpoints for both the retrospective and systematic reviews were the requirement for further intervention and stent-associated complications.

RESULTS

25 patients received 65 stents. There were 12 caustic injury-related strictures (48%), 9 anastomotic strictures (36%), and 4 esophagitis-related strictures (16%). Four patients were lost to follow-up. 19/21 patients (90%) required further intervention, and 8/21 (38%) had esophageal replacement. Nine studies, all case series, were included in the systematic review. 97 patients received 160 stents for esophageal strictures and/or perforation. 36 out of 69 patients (52%) with strictures required no further treatment post-stenting, and 22/29 (76%) of esophageal perforations closed with stenting.

CONCLUSIONS

Esophageal stents may have a role as a bridge to definitive surgery and for the management of esophageal leaks, but complete stricture resolution post-stenting is unlikely.

TYPE OF STUDY

Treatment Study (Case Series with no Comparison Group) LEVEL OF EVIDENCE: Level IV.

A Novel Method of Esophageal Remodeling: Thinking Outside the Box

Caustic esophageal strictures are complex strictures with high rates of recurrence and complications. Management of these strictures requires a multipronged approach including endoscopic dilation and complex surgeries. Even with these modalities, treatment of each patient has to be individualized because it requires high clinical discretion. We present a 38-year-old female woman who had required esophagostomy and total gastrectomy in the acute phase after caustic ingestion. The definitive surgical procedure was deferred because of cicatrization of the proximal esophageal remnant. We remodeled scarred esophagus using a novel technique, which facilitated definitive surgery.

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.

Treatment of persistent esophageal leaks in children with removable, covered stents

Removable, fully covered, expandable metal esophageal stents are routinely used in adults for both malignant and benign esophageal disease. Several case reports have demonstrated the use of these stents in the management of caustic esophageal strictures in children. Most iatrogenic esophageal perforations and esophageal anastomotic leaks in children may be expected to heal with nonoperative treatment, although, in a small percentage, the leak may persist. We report 3 patients with complicated esophageal perforations refractory to nonoperative therapy who were successfully managed using covered esophageal stents.

Esophageal stents for severe strictures in young children: experience, benefits, and risk

The use of esophageal stents has been commonplace in adults for many years and for a variety of indications, including palliative care for malignant lesions involving the esophagus. The use of esophageal stents in the pediatric population, however, was limited by the inability to remove them and the implications this has for the growing child, especially for primarily benign esophageal lesions. With the advent of removable, covered stents, the potential uses for stents in children expanded to include treatment of a wide variety of congenital and acquired esophageal strictures. Stenting offers tremendous potential advantage over more traditional pneumatic or bougie dilation in its ability to provide continuous, radially oriented dilation pressure sustained over a period of time. This review examines the published pediatric literature on stents, discusses the indications for their use, outlines the types of stents available, offers technical guidance for proper placement, and reviews subsequent management and complications.

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.

Ingestion of caustic substances by adults

Caustic products are responsible for the most serious cases of poisoning, which are always emergency cases. In this paper, we review demographic features and endoscopic results of the patients admitted to a university emergency department with a history of caustic substance ingestion between January 2000 and June 2003. Thirty-seven patients were included in this study. Twenty-one of the patients were female and 16 were male. The mean age of the patients was 30.9 +/- 14.7 years. The agents included sodium hypochlorite in 24 patients and hydrochloric acid in 13 patients. All the patients ingested these agents orally. The mean interval time of admission to emergency department after ingestion of caustic agent was 5.4 +/- 5.6 hours. Endoscopy was attempted in 37 patients. Endoscopic results were as follows: grade 0 in 8 (21.6%) patients, grade 1 in 17 (45.9%) patients, grade 2a in 5 (13.5%) patients, and grade 2b in 7 (18.9%) patients. We believe that early signs and symptoms after caustic substance ingestion are not consistent with the extent of damage, and endoscopy is the only reliable method to assess injury. It is important that efforts should be made to educate the public about the dangers of caustic substances so that their threat may be diminished.

Vagal-sparing esophagectomy: a more physiologic alternative

OBJECTIVE

To evaluate the function of the vagal nerves and the gastric reservoir after vagal-sparing esophagectomy.

SUMMARY BACKGROUND DATA

Esophagectomy as currently performed includes division of the vagal nerves and surgical alteration of the stomach, with attendant postoperative dumping, diarrhea, reduced meal capacity, and weight loss. Vagal-sparing esophagectomy has been introduced as a technique for removal of the esophagus while preserving the vagal nerves and gastric reservoir. The procedure is touted as having a low morbidity and is applicable to patients with end-stage benign or early malignant disease.

METHODS

A random sample of 15 patients at a median of 20 months after a vagal-sparing esophagectomy was compared to 23 asymptomatic normal subjects; 10 randomly selected patients, 29 months after esophagogastrectomy with colon interposition; and 10 randomly selected patients, 47 months after standard esophagectomy with gastric pull-up. Gastric mucosal acidification was tested with Congo red staining. Vagal secretory function was measured by gastric acid output and pancreatic polypeptide response to sham feeding. Vagal motor function was assessed by a technetium gastric emptying scan and a questionnaire to evaluate dumping and diarrhea. Gastric reservoir function was evaluated by measuring meal capacity and postoperative changes in body mass index.

RESULTS

Vagal-sparing esophagectomy preserved the function of the vagi, as evident by an increase in gastric acid output, a rise in serum pancreatic polypeptide following sham feeding, and preservation of normal postoperative gastric emptying in 70% of the patients. After vagal-sparing esophagectomy, patients were free of dumping and diarrhea and were analogous to normal subjects in meal capacity but had a slight reduction in the speed of eating.

CONCLUSIONS

Vagal-sparing esophagectomy preserves gastric secretory, motor, and reservoir function. Postoperatively, patients have normal alimentation, bowel regulation, and no weight loss. It is an ideal procedure for patients with end-stage benign disease, Barrett's esophagus with high-grade dysplasia, or esophageal carcinoma limited to the lamina propria.

Accidental caustic ingestion in children: is endoscopy always mandatory?

BACKGROUND

Patients who have experienced severe caustic injury to the gastrointestinal tract are at high risk of esophageal strictures. Early endoscopy is usually recommended systematically in children after caustic ingestion to assess the severity of the initial digestive lesions. The aim of this study was to determine the predictive value of clinical symptoms and ingested-substance types as markers of severe esophagogastric lesions and to define indications for endoscopy.

METHODS

Ingested-product types, clinical symptoms, endoscopic data and outcome were prospectively recorded in 85 children admitted after accidental caustic ingestion.

RESULTS

Forty-eight children (57%) had no symptoms; the others presented with vomiting, hematemesis, drooling, respiratory distress, and/or oropharyngeal lesions. Endoscopy showed no or minimal lesions in 63 cases (74%). None of the children developed digestive sequelae. Severe esophagogastric lesions were present in 22 cases (26%), mostly caused by lye ingestion (14 of 22) but also by strong acids (4 of 22); 9 of the 22 children (41%) developed esophageal stenosis. Vomiting, drooling, and oropharyngeal lesions did not predict severe endoscopic lesions. Hematemesis, respiratory distress, or presence of at least three of the symptoms was associated with severe lesions (positive predictive value = 1). The absence of symptoms was always associated with no or minimal lesions (negative predictive value = 1).

CONCLUSIONS

In conclusion, endoscopy is not recommended for children living in developed countries who are asymptomatic after accidental caustic ingestion.

Corrosive esophagitis in children: a 30-year review

Caustic ingestion with resultant corrosive esophagitis in the pediatric population comprises a heterogeneous group in terms of offending agent, location of burn and the degree of damage. Consequently, the treatment of these injuries has also varied over the years and the optimal management remains controversial. Another area of concern that is seldom reported in the otolaryngology literature is the socioeconomic impact of such injuries both on the child and on the family. We report a 30-year retrospective review of aerodigestive tract caustic injuries at The Hospital for Sick Children. Eighty patients were identified with an age range from 1 month to 16 years. Early and late complications are reviewed including 23 patients (29%) that developed medical complications and 16 patients (20%) that developed severe esophageal strictures. Five of these children required repeat prograde dilatation, while 11 children required gastrostomy and stringing with subsequent retrograde dilatation. All the 11 children required esophageal replacement surgery. The economic and social consequences to the child and family were also noted with particular attention to hospital costs, parental absenteeism from work, and the need for job relocation. A partial cost analysis using a child with a severe injury is presented as an example. Psychological aspects such as attempted murder, jail terms and attempted suicides are also documented. We also present an analysis of those children requiring esophageal replacement surgery, and examine the possible role of esophageal stents in recalcitrant strictures.

Reactive oxygen radical levels in caustic esophageal burns

PURPOSE

This study was designed to determine the tissue levels of reactive oxygen radicals in caustic esophageal burns in a rat model.

METHODS

Forty rats were divided into four groups of 10 animals each. The control rats were uninjured in group A, and the others were injured rats in groups B, C, and D. Through a median laparatomy incision, a 1.5-cm abdominal esophageal segment was isolated and tied with 2-0 chromic sutures in all groups as described by Gehanno. One milliliter of 10% sodium hydroxide solution in groups B, C, and D and 0.9% saline solution in group A were instilled through the isolated segment via a no. 24 cannula for 3 minutes, then the esophagus was rinsed for 1 minute with distilled water. The studied 1.5 cm of the abdominal esophagus was removed from each animal 24 hours after caustic injury in group B, 48 hours after in group C, and 72 hours after in group D. In group A, studied uninjured segments were removed for biochemical investigation. Tissue malondialdehyde (MDA) and glutathione (GSH) levels were determined for each group.

RESULTS

The mean MDA levels in esophageal tissue were significantly higher in groups B, C, and D than in group A (P < .05). Moreover, the mean GSH levels in the same esophageal tissues were significantly lower in groups C and D than in groups A and B (P < .05).

CONCLUSION

The reactive oxygen radicals may be play an important role in early phase of caustic esophageal burns by increasing the tissue damage.

[Severity of ingestion of caustic substance in children]

BACKGROUND

Caustic ingestion is frequent in children, sometimes leading to esophageal stricture.

PATIENTS AND METHODS

Between 1988 and 1994, esogastroscopy was performed in 65 children after caustic ingestion. The children were classified in three groups: no lesion (group A), minimal lesions (group B) and severe lesions (group C). Nature of the caustic substance, clinical signs and evolution were compared in the three groups.

RESULTS

Median age was 2 years for the 65 children (24 girls, 41 boys). Ingestion occurred at home (94%) during meal periods. Substances were dishwater detergents (n = 14), oven cleaner (n = 10), bleach (n = 9), washing powder (n = 4), others (n = 20), more often in a liquid form (n = 37) than solid (n = 28). Children had no symptoms (57%), presented emesis (n = 20) or abdominal pain (n = 10) not correlated to endoscopic findings, and hematemesis (n = 3) or respiratory distress (n = 4), both symptoms seen only in group C. Buccal lesions (41%) were not correlated to endoscopic findings. After endoscopy, 28 children (43%) were classified into group A and 20 children (31%) in group B. Among the 17 children (26%) of the group C, eight developed an esophageal stricture: seven long strictures requiring replacement of the esophagus, one short stricture requiring repeated dilations.

CONCLUSION

Esophageal stricture is still a severe complication after caustic ingestion. These data stress the interest of controlled studies to confirm the preventive role of high dose corticosteroids, and the importance of the prevention of accidental caustic ingestions in children.

Treatment of corrosive esophageal strictures by long-term stenting

From 1975 through 1992, 932 patients with caustic esophageal burns were admitted to the author's institution. Deep circumferential burns were diagnosed esophagoscopically in 241 children within the first 48 hours postburn. Initial treatment consisted of periodic anterograde and/or retrograde dilations of the injured and scarring esophagus (n = 172). In 1989, a long-term stenting technique was introduced, and a total of 69 patients have been treated in this manner. The healing rates of patients treated with traditional therapy were compared with those of patients who had stenting, and a significant difference was noted (33% v 68%; P <.01). Failure among the stented group was attributable to poor patient compliance and to gastroesophageal reflux resulting from shortening of the esophagus during scar formation.

Effect of intermittent acid and pepsin exposure on burned esophageal mucosa

PURPOSE

To determine if gastroesophageal reflux affects the healing of esophageal mucosa damaged by alkaline substances.

MATERIALS AND METHODS

In a rabbit model, the effects of intermittent acid and pepsin exposure (thereby mimicking gastroesophageal reflux) on post-caustic-burn esophageal mucosa were examined. Exposures were group I (n = 9), sodium hydroxide exposure alone; group II (n = 9), daily acid and pepsin exposure; and group III (n = 8), sodium hydroxide, then daily acid and pepsin exposure. After 3 weeks, the animals were killed and their esophagi examined.

RESULTS

Grossly, specimens in group II appeared normal; specimens in groups I and III were abnormal, displaying some scar tissue, but were not significantly different. Histologically, the differences between groups I and III approached significance. Increased numbers of intraepithelial eosinophils were seen in those specimens exposed to reflux.

CONCLUSIONS

Gastroesophageal reflux may retard the healing of injured esophageal mucosa and should be studied further in an effort to improve the care of patients who sustain alkaline esophageal burns.

Ingestion of caustic cosmetic products

Twelve children over a 6-year period (1985 to 1991) underwent aerodigestive tract endoscopy after ingestion of lye-containing cosmetic products. All children were less than 2 years of age and had facial and/or oral cavity burns. Eleven of these patients ingested alkaline hair products such as "activators" or "relaxers." Endoscopy revealed pharyngeal burns in five patients but no laryngeal or esophageal burns in any patient. Erythema of the esophageal mucosa was seen in one patient. One patient ingested a solution used in fingernail decorating. This patient sustained extensive superficial burns of the pharynx, larynx, and esophagus and required intubation and admission to the intensive care unit. No long-term sequelae developed. Cosmetic products containing caustic chemicals represent a significant health risk to small children, especially because child-proof packaging is not standard for these products.

Battery acid burns of the upper gastro-intestinal tract

Strong acid ingestion produces distinctly different injuries from alkali burns. Alkali burns are well described but the lack of literature on the diagnosis and management of acid burns is apparent. This retrospective review of 18 patients with battery acid (30% sulphuric acid) ingestion showed no correlation between the severity of the symptomatology and the degree of injury. The quantity of acid needed to cause a significant upper GIT burn was more than 200 ml. Previous reports that acid spared the oesophagus due to rapid transit were disproved, since oesophageal involvement was found in 55% (10/18). Deep burns rather than circumferential burns resulted in stricture formation. The major injury site was the gastric antrum with 4 patients (23%) requiring surgical intervention to restore function.

The role of fiberoptic endoscopy in the management of corrosive ingestion and modified endoscopic classification of burns

We prospectively evaluated the role of fiberoptic esophagogastroduodenoscopy in the management of 81 patients with corrosive ingestion. A total of 381 endoscopic examinations were performed: 88 within 96 hours following corrosive ingestion, 108 between the third and ninth week, and 185 during the period of follow-up after bougie dilation of esophageal strictures. The customary endoscopic classification of burns (grades 0 to 3) was modified by subdividing grade 2 burns into 2a and 2b, and grade 3 burns into 3a and 3b for prognostic and therapeutic implications. There was no significant correlation between oropharyngeal and upper gastrointestinal tract injury. Early major complications and deaths were confined to patients with grade 3 burns. All patients with grade 0, 1, and 2a burns recovered without sequelae. The majority of patients (71.4%) with grade 2b injury and all survivors with grade 3 injury developed esophageal or gastric cicatrization, or both, which needed endoscopic or surgical treatment. There were no complications related to endoscopy. We conclude that early endoscopy is not only a safe, reliable, and accurate diagnostic tool in such patients, but also is of crucial importance in management and prognosis.