Caustic injury of the oesophagus. Sixteen years experience, and introduction of a new model oesophageal stent

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.

Evaluation of the efficacy of Hypericum perforatum (St. John's wort) oil in the prevention of stricture due to esophageal corrosive burns

BACKGROUND/PURPOSE

The inflammatory response that follows the caustic burns results in fibrosis on the esophageal wall leading to esophageal stricture, dysphagia, and malnutrition. The controversy over the use of corticosteroids warrants alternative therapeutic interventions. We investigated the effect of extracts from St. John's wort (SJW) with known wound-healing activity on stricture formation in rat esophageal injury models.

METHODS

Five experimental groups were involved: sham group with no injury, control group with injury without treatment, and three different treatment groups (methylprednisolone, SJW extract, and combination of the two). Histopathological examination of esophageal damage and collagen accumulation, stenosis index, and tissue hydroxyproline levels were used to assess stricture and the effect of treatments.

RESULTS

There was a significant weight loss in all groups except for those without injury and those treated with SJW extract, the latter gained weight albeit not significant. Stenosis index was increased in all groups compared to sham but not significantly in those treated with SJW extract. Histopathological and biochemical analyses produced mixed results.

CONCLUSIONS

Some of the experimental indicators such as weight gain and stenosis index suggested the treatment of esophageal injury models using extracts of St. John's wort effective while other histopathological indicators show no significant benefit.

Effect of polaprezinc on experimental corrosive esophageal burns in rats

Unconsciously caustic ingestion is one of the most common causes of serious esophageal strictures in children. The aim of this study is to determine the efficiency of polaprezinc in preventing stricture formation after corrosive esophageal burns (CEB); this was the first time it has been used to treat experimental CEB in rats. Twenty-four rats were divided into four groups, three of which received CEB by the instillation of 1 mL of 10% NaOH solution into their isolated esophageal segments for three minutes. Group C (control) was uninjured and untreated. Group B (esophageal burn) received CEB but were left untreated. Groups PT1 and PT2 had CEB and received 100 mg/kg/day and 200 mg/kg/day, respectively, of intraperitoneal polaprezinc treatment (PT) for the first two weeks, then oral PT for another two weeks. We assessed the treatment's efficiency of the treatment after the fourth week by evaluating the stenosis index (SI) and the histopathological damage score, determining tissue hydroxyproline content (HP), and measuring the weight of the rats before and after the experiment. Mean SI was statistically lower in the groups PT1 and PT2 when compared with Group B (p = 0.006, 0.004, respectively). HP levels were highest in Group B, but it was insignificant (P> 0.05). In terms of histopathological damage score, treatment groups demonstrated less collagen deposition, mucosal, and submucosal damage than both Group B (p = 0.01) and Group C (p = 0.02). Group PT1 and Group PT2 (P> 0.05) showed similar results, indicating the treatment's effectiveness was independent of dosage. Outside of Group C, weight gain was detected only in Group PT2, though it was statistically insignificant. In Group PT1, weight loss was lower than in Group B. Polaprezinc, with its antifibrotic, antioxidant, anti-inflammatory, wound-healing and antiapoptotic effects, was efficient in reducing stricture formation by decreasing HP levels and histopathologic damage, preventing stenosis, and weight gain in higher dosages in the treatment group.

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 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.

Dynamic esophageal stents

Esophageal stenting represents a new strategy in the treatment of resistant or recurrent stenosis that obviates the need for multiple dilations. Our custom dynamic stent (DS) improves esophageal motility unlike the widespread self-expandable plastic or metallic esophageal stents. The DS allows food and secretions to pass in the space between the esophageal wall and the stent wall. This contrasts with the other types of stent, in which food passes into the stent that presses into the esophageal wall. Until the stent patent is complete, we use slices of silicon drains overlapped with each other to fashion the stent to the desired length and diameter (7-, 9-, or 12.7-mm external diameter). It is built coaxially on a nasogastric tube that guarantees the correct position. The two ends are tailored to allow an easy introduction and food passage between stent and esophageal wall. The stent is inserted after stricture dilations (Savary-Gilliard dilators) under fluoroscopic guidance. All patients who underwent stenting were treated with dexamethasone (2 mg/kg/day) for 3 days and proton pump inhibitors (omeprazole or lansoprazole, 1-2 mg/kg/day). From 1992 to 2012, 387 patients (mean age 38.6 months; range 3-125 months) with post-surgical esophageal stricture because of esophageal atresia correction were enrolled in this study. Twenty-six of 387 patients (6.7%) underwent custom DS placement for recurrent stricture instead of a program of serial dilations. The stent was left in place for at least 40 days and was effective in 21 (80.7%) of 26 patients. There were two stent-related major complications (subclavian-esophageal fistula). Our custom stent represents an effective and safe option in the treatment of severe and recurrent post-surgical esophageal strictures. Surgery with stricture resection, and reanastomosis or jeunoplasty represents the rescue strategy.

Unwitnessed lithium ion disc battery ingestion: case report and review of best practice management of an increasing clinical concern

Objective:

To describe a case of unwitnessed lithium ion disc battery ingestion, with a review of radiology findings and current best practice management.

Case report:

A three-year-old girl presented following ingestion of a foreign body, which her four-year-old brother claimed was a one pound coin. The patient was managed non-urgently and transferred for specialist ENT assessment 6 hours following the initial ingestion, with no evidence of airway compromise. A corroded battery was removed from the level of the cricopharyngeus after 8 hours, with an associated circumferential mucosal burn.

Conclusion:

There is increasing concern regarding the acknowledged rising incidence of lithium ion disc battery ingestion. The lack of a high index of suspicion and the inability to recognise subtleties on imaging may lead to suboptimal management with a higher degree of unnecessary immediate and delayed morbidity. The recently published American Academy of Pediatrics Guidelines may guide the approach to managing battery ingestions.

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.

Battery ingestion in children

INTRODUCTION

Ingestion of batteries by children became more frequent in recent years, due to the increasing accessibility of electronic toys and devices to children. Due to their electrochemical composition, impacted batteries in the esophagus may cause an extensive damage. Following the removal of a battery, the post-esophagoscopy management is still controversial.

CASE PRESENTATION

An otherwise healthy 8 year-old boy presented to the pediatric emergency room 3h after the unintentional swallowing of a lithium battery. On examination, the patient was diaphoretic and tachypneic. Plain PA chest film revealed a 2.5 cm diameter radiopaque round object in the upper esophagus. The patient was scheduled for an urgent rigid esophagoscopy which was performed 2h after admission. Esophagoscopy findings included an impacted lithium battery in an advanced emptying process at a level of 17 cm from the incisor teeth, with a 3rd degree ulcerative esophagitis. It was not possible to visualize either the distal esophagus or the stomach. A nasogastric tube was not inserted because of a significant risk for esophageal perforation if bluntly passed. Post-operative medical therapy included fasting, administration of intravenous antibiotic therapy, antacids, and steroids. Flexible esophagoscopy superior to the level of the mucosal injury performed one day later, revealed erosive esophagitis, without evidence of perforation. Upper digestive tract gastrografin swallow test performed 2 days after esophagoscopy did not demonstrate a leak from the esophagus, and oral feeding was carefully re-initiated. Treatment was discontinued the following day. Follow up on days 10 and 14 revealed a healthy child with normal swallowing.

DISCUSSION

Battery ingestion-related injury results from direct pressure necrosis, local electrical currents and alkali leakage. Signs and symptoms of ingested battery are related to impaction duration, size of battery, battery content and peristaltic waves of the esophagus. Appropriate imaging studies should be performed to maximize identification of the foreign body before esophagoscopy. Esophageal stenting and adjuvant medical therapy (steroid therapy, antibiotic therapy and anti-reflux therapy) have a low evidence level of clinical benefit following caustic injuries from impacted batteries and spillage of their content to the esophagus. A judicious management should be tailored in each patient. Increased public and health personnel awareness is necessary to diminish the incidence of battery ingestion.

Mitomycin C decreases the rate of stricture formation in caustic esophageal burns in rats

BACKGROUND

Although the incidence of caustic ingestion is declining, the management of caustic esophageal strictures remains a challenge. Although many agents have been tried experimentally to treat strictures, few have gained clinical application. The aim of this study was to investigate the influence of mitomycin C (MMC), which inhibits fibroblastic proliferation in treating delayed caustic esophageal strictures.

METHODS

Forty-two rats were allocated into 3 groups. Caustic esophageal burns were created as described by Gehanno. Group A was instilled only with saline. Group B was injured with 10% NaOH and left untreated. Group C was injured and received topical MMC at 0.04% concentration in the fourth week. At 56 days, stenosis index (SI), collagen deposition, and hydroxyproline content (HP) were determined in distal esophageal segments. Statistical analyses were performed.

RESULTS

The mean SI in group B was significantly higher than others (SI: 1.15 +/- 0.37 d/lum, P < .05). Collagen accumulation was highest in group B, followed by groups C and A, respectively. Collagen deposition in group C was statistically lower than group B (P < .018). The mean HP in group B was statistically higher than others (5.07 +/- 1.30 microg/mg tissue, P < .05), and similar between groups A and C (1.20 +/- 0.20, 1.91+/- 0.79, respectively, P = .73).

CONCLUSION

In the current study, MMC treatment ameliorated caustic esophageal stricture as reflected in the significantly lower SI. We conclude that MMC application is effective in the treatment of caustic esophageal strictures.

Prevention of stricture development after corrosive esophageal burn with a modified esophageal stent in dogs

OBJECTIVE

We sought to test the feasibility and technical ease of a newly designed nitinol-based modified esophageal stent and its effects on preventing postcaustic stricture in mongrel dogs and to try to explain the result at the molecular level.

METHODS

Twenty-four dogs were included in this controlled study. Stenosis index (wall thickness/intraluminal diameter), pathologic features, hydroxyproline quantities, esophageal compliance, and biomechanics were compared between the injured but unstented and stented dogs. Transforming growth factor beta1, Sma/Mad (Smad)3, and Smad7 mRNA expression and protein levels in esophageal tissue were detected by means of reverse transcriptase-polymerase chain reaction and Western blotting, respectively.

RESULTS

The modified esophageal stent was able to be placed and retrieved successfully and conveniently and was not only intact but there was also no macroscopic esophageal mucosal injury after the stent removal 4 months later. In comparison with the injured but unstented group, esophageal compliance, biomechanics, and the stenosis index were significantly better in the stented group. Histopathologic study revealed that collagen bundles were thinner and its orientation tended toward a regular and parallel pattern. Transforming growth factor beta1 and Smad3 mRNA expression and protein levels increased and Smad7 mRNA expression and protein levels decreased significantly in esophageal tissue in the stented group. These variables showed no statistically significant difference 2 months after stent removal.

CONCLUSIONS

The modified esophageal stent might be a promising stent in preventing stricture formation after corrosive esophageal burns clinically.

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.

Increasing tendency in caustic esophageal burns and long-term polytetrafluorethylene stenting in severe cases: 10 years experience

In recent years, lye products have come into common household use in Turkey. Unfortunately, we have noted more cases of serious corrosive esophagitis owing to accidental caustic agent ingestion. The aims of this study were to (1) evaluate our experience with these cases and (2) investigate the effects of long-term intraesophageal polytetrafluorethylene stenting on esophageal remodeling and its impact upon the need for esophageal replacement. Between 1997 and 2006, 68 patients (44 males and 22 females) with accidental caustic agent ingestion were admitted to our department, the only tertiary care referral center for the Turkish Army. Once stabilized, esophagoscopy was performed for injury grading (grades 0, 1, 2a, 3b, 3a, or 3b) as described by Millar and Cywes (Pediatric Surgery. 1998;969-979). Esophagogram was performed 3 weeks after injury to assess healing. At presentation, the injury grade for 24, 31, 11, and 1 cases were 0 or 1, 2a, 2b, and 3a, respectively. One case had gastric outlet obstruction. All cases of grade 0 or 1 injuries had a normal esophagogram at 3 weeks postinjury. For the remaining 44 patients, several treatment modalities have been applied, including antegrade and retrograde dilatations in 31 grade 2a patients, intraluminal stenting in 11 grade 2b patients, esophageal reconstruction in 1 grade 3a patient, and gastroenterostomy in 1. Of the 11 patients with esophageal stenting, 8 patients have resumed a normal diet after 9 to 14 months of stenting. Mean follow up duration is 3.5 years (1-6 years) after stent removal. In the remaining 3 cases, treatment is still ongoing. Esophagitis and esophageal structuring because of caustic agent ingestion is a major public health problem in Turkey. Our small uncontrolled pilot series suggests that intraluminal polytetrafluorethylene stenting may be an effective treatment method to reduce the need for major surgical reconstruction of recalcitrant esophageal strictures.

Do corticosteroids prevent oesophageal stricture after corrosive ingestion?

The most serious complication of corrosive damage to the oesophagus besides perforation is stricture formation. The role of corticosteroids in preventing corrosive-induced strictures is controversial. This review evaluates the usefulness of corticosteroid treatment by critically assessing clinical reports published between 1991 and 2004 in the English, German, French and Spanish literature. Inclusion criteria were the presence of second- or third-degree oesophageal injuries documented by endoscopy and management involving either at least an 8-day course of corticosteroids or no steroid therapy. Ten studies with a total of 572 patients fulfilled the inclusion criteria: six studies employed corticosteroids, two studies did not use corticosteroids, and two studies compared the outcome with and without corticosteroid treatment. In those patients with second-degree burns, the incidence of stricture in the corticosteroid-treated patients was 13.8% and in the non-corticosteroid-treated patients was 6.3%. In those patients with third-degree burns, significantly worse results were found in the corticosteroid-treated group (71.0%) than in the non-corticosteroid-treated group (23.1%). As all studies did not separate second- and third-degree burns, re-analysis of the outcome was undertaken. In the 305 patients treated with corticosteroids, 35.1% developed strictures, whereas 33.3% of the 267 non-corticosteroid-treated patients developed strictures. These data suggest that systemic corticosteroids are not beneficial for second- and third-degree corrosive oesophageal burns. Therefore, the use of corticosteroids in the management of corrosive ingestions should be abandoned as they do not prevent the development of strictures and may lead to the development of serious adverse effects.

Miniprobe ultrasonography for determining prognosis in corrosive esophagitis

OBJECTIVE

We evaluated the ability of endoscopic ultrasonography to predict likelihood of stricture formation in patients with corrosive esophagitis.

METHODS

Consecutive patients with esophagitis resulting from alkaline or acid chemical ingestion (n = 11) were evaluated prospectively by endoscopic ultrasonography between hospital days 4 and 12. Findings for the most severe lesion were classified according to the appearance of the muscular layers: distinct muscular layers without thickening (grade 0); distinct muscular layers with thickening (grade I); obscured muscular layers with indistinct margins (grade II); and muscular layers that could not be differentiated (grade III). Findings were also classified according to whether apparent damage to muscular layers in the worst-appearing image involved part of the circumference (type a) or the whole circumference (type b). Implications of these findings for subsequent stricture formation were then evaluated.

RESULTS

Stricture formation did not occur in patients with grade 0 or grade I images; transient stricture formation occurred in a patient showing grade IIa. Stricture requiring repeated bougie dilation occurred in a patient showing grade IIIb.

CONCLUSIONS

Endoscopic ultrasonographic images presumed to reflect the destruction of muscular layers (grades II to III), as opposed to only edema (grade I), may be associated with stricture formation. This modality can accurately visualize deep lesions in corrosive esophagitis, making it prognostically useful.

Corrosive ingestion in adults

Ingestion of a corrosive substance can produce severe injury to the gastrointestinal tract and can even result in death. The degree and extent of damage depends on several factors like the type of substance, the morphologic form of the agent, the quantity, and the intent. In the acute stage, perforation and necrosis may occur. Long-term complications include stricture formation in the esophagus, antral stenosis and the development of esophageal carcinoma. Endoscopy should be attempted and can be safely performed in most cases to assess the extent of damage. Procedure-related perforation is rare. Stricture formation is more common in patients with second and third degree burns. Corticosteroids may help prevent stricture formation. Esophageal carcinoma may develop beginning 30 to 40 years after the time of injury.

Treatment of caustic ingestion: an analysis of 239 cases

The objective of the present study was to analyze a 37-year historical series of patients who had ingested caustic substances, and who were treated in a teaching hospital, to assess the effectiveness of the therapy administered during this period. We studied 239 patients who ingested caustic soda (NaOH) from 1957 to 1994. Data were collected from the medical records of the patients and from interviews with them and analyzed by software and by statistical tests of association. The results showed that more women than men ingested caustic substances (57%, n=153). Ingestion was associated with suicidal intent in 60% of cases and was accidental in 37.2% of cases. The amount of substance ingested ranged from a trace to as much as three tablespoons, with the amount tending to be larger in the suicide attempts. Of the 215 patients for whom information about complications due to ingestion was available, 88.4% (190) presented lesions of the esophagus (73% with stenosis), 1% died during the acute phase, and 10.6% did not present complications. The data revealed that the presence and severity of stenosis were correlated with the amount of caustic substance ingested. The treatment received by the patients in the study sample varied over the years according to the prevailing literature recommendations. Based on our review, we conclude that neither the use of an antidote nor early treatment immediately after ingestion is effective. Treatment with a corticosteroid (1.5-2 mg/kg/day prednisone), an antibiotic, and a high-protein and hypercaloric diet seems to be beneficial for patients who ingest small or medium amounts of caustic soda. When 2-3 tablespoons are ingested, corticosteroids, in addition to being unable to prevent the formation of esophageal stenosis, increase the risk of other complications.