Dilation of esophageal strictures: comparative morbidity of antegrade and retrograde methods

Corrosive substances ingestion: a review

Corrosive chemical substance ingestions are a major problem, especially in developing countries, but also in developed countries such as the United States, France, and Belgium. Ingestions may be deliberate as suicide attempts (mostly in adolescents and adults) or accidental (mostly in children). The results can be devastating in terms of individual suffering and disability, but also in terms of resource utilization and costs. In developing countries, outcomes may be worse because of limited medical/surgical resources. Common sequelae include gastrointestinal (GI) tract (esophagus, stomach, pylorus, and duodenum) stricture formation, GI tract perforation, and hemorrhage. Systemic effects may also occur, such as disseminated intravascular coagulation (DIC), multi-organ system failure, and sepsis. Various interventions in the acute phase to reduce the severity of injury have been attempted, but there are no large controlled clinical trials to demonstrate efficacy. Dilation therapy in various forms is commonly used for the treatment of strictures and a variety of surgical procedures including esophagectomy and delayed replacement may be required in severe corrosive injury cases.

Caustic injury of the oesophagus

Caustic ingestion continues to be a significant problem world-wide especially in developing countries and particularly in the under 6 years age group. The presence or absence of symptoms or oral lesions does not reliably predict the existence or severity of oesophageal lesions. Upper endoscopy remains the mainstay diagnostic modality for evaluation to define the extent and severity of the injury. The best predictor of morbidity and mortality is the extent of injury as assessed during initial evaluation. Early management strategies for caustic ingestion are well defined. Controversy still surrounds the use of steroids, antibiotics, antacid therapy in the acute phase, and the use of oesophageal stents and the frequency, timing and method of dilatation in the prevention and management of oesophageal strictures. There is a pressing need for non-invasive diagnostic modalities and effective therapeutic options to evaluate and treat the complications associated with caustic ingestion. Indications for definitive surgery or bypass and the type of procedure to use are also subject to ongoing debate.

Paediatric GI emergencies

Paediatric GI emergencies constitute a wide range of gut pathologies ranging from those that are common, easily diagnosed and treated to conditions that are rarer, often more severe and challenging to manage. Among a myriad of ordinary clinical symptoms and signs physicians have to identify the child with a serious, life-threatening pathology and initiate the appropriate diagnostic and therapeutic pathway. The aim of the review is to present and discuss a selection of key paediatric GI emergencies that provide challenges in diagnosis and treatment. These conditions are classified by their presentation or pathogenesis and include inflammatory conditions, those presenting with GI obstruction or haemorrhage and the ingestion of foreign bodies or caustic substances. The most recent advances regarding the management of these entities are discussed along with key areas of clinical practice and future research.

Features and management of esophageal corrosive lesions in children in Sierra Leone: lessons learned from 175 consecutive patients

PURPOSE

This study aims to highlight the peculiar presentation and management of children's corrosive ingestions in developing countries associated with malnutrition, delay in management, lack of technology, and sporadic follow-up.

METHODS

An observational study was carried out since 2005 on all children (<15 years old) admitted for caustic soda ingestion to the "Emergency" Surgical Center in Sierra Leone, either in the acute postinjury phase or for dilatation of esophageal strictures. Complications, mortality, stricture recurrence, and ability to swallow were the main outcome measures. Improvement in nutritional status (ie, gaining weight) and sustained esophageal patency were both considered reference points to successful treatment.

RESULTS

In 4 years (2005-2009), 175 children were admitted, 53.7% at more than 1 month after ingestion. Dilatations were carried out in 77.7%, and a gastrostomy was placed in 64%. Perforations and death rate were 4.5% and 2.8%, respectively. Sixty-two patients (35.4%) required more than 7 dilatations, whereas 15 (8.5%) were unable to maintain a satisfactory luminal diameter. Follow-up (range, 1-36 months; median, 7 months) was possible in 52.7%. Long-term success according to the aforementioned criteria was observed in only 16%.

CONCLUSIONS

Delayed presentations and complex strictures with repeated postdilatation recurrence are characteristics of children's corrosive ingestion in developing countries. Malnutrition is common, and gastrostomy is frequently compulsory. Esophageal patency with improvement in nutritional state is achieved only in a small percentage of patients.

Combined antegrade and retrograde esophageal dilation for head and neck cancer-related complete esophageal stenosis

OBJECTIVES/HYPOTHESIS

Assess the safety and efficacy of combined antegrade and retrograde esophageal dilation (CARD) for complete esophageal stenosis following head and neck cancer (HNC) treatment. Review HNC dysphagia management.

STUDY DESIGN

Retrospective review of all patients undergoing CARD following HNC treatment between May 2001 and September 2008.

METHODS

Forty-five patients were identified for review. Parameters assessed included: ability to obtain intraoperative esophageal patency, complications, number of dilations required, diet, and gastric tube (GT) status. Factors associated with dilation failure were analyzed.

RESULTS

Intraoperative esophageal patency was obtained in 91% of patients. Median number of all dilations per patient was three. Median number of CARDs per patient was one. Resumption of oral intake occurred in 36/45 (80%). Diet results included: regular or soft diet 32/45 (71%), GT removal 27/45 (60%), and GT dependence with nothing by mouth 9/45 (20%). Laryngeal and pharyngeal stenosis, radionecrosis, tracheotomy dependence, and elongated stenosis were associated with dilation failure. Complications occurred in 18/63 (29%) CARD procedures: eight pneumomediastinum, seven GT site problems, two esophageal perforations, and one pharyngeal infection. All complications resolved spontaneously or with minimal interventions.

CONCLUSIONS

CARD was safe and effective. Intraoperative patency was achieved in 91% of patients. Eighty percent resumed oral intake. The majority of patients had their GTs removed and resumed a soft or regular diet. Dilation failure was associated with laryngeal, pharyngeal, and excessively long esophageal stenosis, often resulting from radionecrosis. Complications were minor. CARD should be considered before relegating patients with complete esophageal stenosis to chronic GT dependence or subjecting them to laryngopharyngo esophagectomy.

Conservative management of iatrogenic esophageal perforation in head and neck cancer patients with esophageal stricture

Objective: Evaluate the efficacy of conservative management of iatrogenic esophageal perforation following dilatation of a stricture secondary to the treatment of head and neck cancer.

Study Design: Case series with chart review.

Subjects and Methods: Retrospective chart review of 24 patients with esophageal perforation treated at the Detroit Medical Center from 1999 to 2008. Of these, eight head and neck cancer patients had esophageal stricture and underwent dilatation with subsequent esophageal perforation.

Results: Six patients were managed conservatively; two were managed surgically. All eight patients had radiation, six had chemotherapy, and five had surgery as part of their oncologic treatment. Stricture site was at the cricopharyngeus or neopharynx. Perforation size was estimated at 3 to 7 mm in conservative patients and approximately 10 mm in surgical patients. All patients survived to be discharged from the hospital and diet was tube feeds.

Conclusion: In head and neck cancer patients with post-treatment esophageal stricture, iatrogenic cervical esophageal perforations can often be safely managed conservatively. The criteria are: prompt diagnosis within one hour, small perforation (3–7 mm), penetrating type of perforation with circumferential mucosal contact, proximal or cervical esophageal location, and stabilization and improvement of clinical signs and symptoms for 24 hours after initial ICU management.

Pediatric caustic ingestion: 50 consecutive cases and a review of the literature

Caustic injury to the aerodigestive tract remains a significant medical and social concern despite various efforts to minimize hazards of caustic household products. Agents with a pH less than two or greater than 12 are extremely corrosive, causing damage that can range from mild to extensive, including esophageal perforation leading to mediastinitis and death at the extreme scale. Methods include retrospective case note review of all admissions to the otolaryngology unit with caustic injury that underwent esophagoscopy to the Children's Hospital Westmead between 1990 and 2007. A protocol-based management system with antibiotics and steroids together with esophagoscopy at 48 hours was implemented. A total of 50 admissions were identified with an average follow-up of 5 years. There were a total of 28 males and 22 females with a median age of 22 months. Forty-nine cases (98%) were accidental. Thirty-eight cases (76%) occurred within the interiors of the family home with the kitchen being the common location. Another seven (14%) occurred within the external environment of the home, usually in the garage or pool shed. The causative agents were varied with 37 (74%) being alkali, three cases (6%) being acidic, and other agents, such as chlorine bleach, being the remainder. The most frequently ingested alkalis were dishwashing powder and disinfectants closely followed by degreasers. Twenty-five children (50%) drank directly from a container with the remainder ingesting granules or powder directly. At esophagoscopy, 17 cases (34%) had grade 1 injury and 10 (20%) had grade 2 injury. Fifty percent of patients of grade 2 injury subsequently developed strictures requiring multiple dilatations. Importantly, six cases (12%) had evidence of esophageal injury without oral injury. Caustic injuries continue to be a significant morbidity in the pediatric patient group. Most cases are still happening as a result of accidental ingestion from unmarked containers within reach of children at home. Oral injury is not always a useful marker of more significant distal injury. A protocol-based management can identify children at risk for long-term stricture earlier.

Corrosive esophageal injuries in children. A shortlived experience in Sierra Leone

OBJECTIVE

Children with caustic ingestions in developing countries are often treated at home, sometimes by traditional healers, or are referred, frequently late, to tertiary hospitals, which only seldom offer adequate endoscopic and dilatation facilities. Therefore, when dilatations are performed, the stricture is often already well established, making dilatation more difficult. The aim of this paper is to report our experience in the management of corrosive injuries in a group of children of Sierra Leone, all complaining accidental ingestion of caustic soda, many of them treated months after the ingestion.

METHOD

We considered all children admitted after corrosive ingestion, from November 2001 to November 2005, to the "Emergency" Surgical Center in Goderich-Freetown, Sierra Leone. In December 2005 the hospital was supplied with endoscopes and dilatation devices. The children still followed up clinically were recalled to submit them to an endoscopic follow-up and to a dilatation, if needed.

RESULTS

Forty children were admitted (mean age: 4.5 years): 16 (group A) after an esophageal perforation during dilatation performed elsewhere (death rate: 56%). Twenty-four children (group B) were observed after ingestion, 58% being submitted to a surgical gastrostomy. Death rate after ingestion was nil. The mean interval between ingestion and endoscopy was 8.8 months. Fifty-three dilatations were carried out in 17 children over a 3 months period. We report three perforations (17.6%) and a death rate of 5.8% (1/17). Two patients were lost to follow-up. Three patients (17.6%) did not show any improvement. Four children complained recurrent dysphagia after the first dilatation cycle. Overall, 10 children (58.8%) showed a clear-cut improvement at 6 months.

CONCLUSIONS

The majority of treated strictures were late, therefore difficult to dilate and at higher risk of perforation. Dilatation with Savary bougies seems safer than with balloon catheters. Recurrent strictures and a long-term dilatation treatment should be expected. Retrograde dilatations through gastrostomies should be the preferred method of treatment and surgical gastrostomies should be performed without hesitation. Esophageal replacement is unlikely in these countries, except in very few referral centres. Therefore, any effort should be made to treat caustic strictures by timely dilatation programs.

Evaluation of systemic oxidative status and mononuclear leukocytes DNA damage in children with caustic esophageal stricture

Esophageal stricture (ES) due to accidentally caustic digestions is a common problem in children. Mucosal damage and repeated dilatations lead to chronic inflammation and finally ES. We investigated the oxidative status and DNA damage of children with ES. Five children with ES were compared with the same age- and sex-matched healthy subjects. Oxidative status of plasma was evaluated by measuring myeloperoxidase (MPO) activity, and total peroxide (TP) level. Anti-oxidative status of the plasma was evaluated by measuring catalase (CAT) activity, and total antioxidant response (TAR). We used the Single Cell Gel Electrophoresis (also called Comet Assay) to measure DNA strand break in peripheral blood mononuclear leukocytes. Mean MPO activity and TP levels in the ES group were significantly higher than the control group (0.83 +/- 0.35, 0.09 +/- 0.03 and 0.98 +/- 0.38, 0.34 +/- 0.20, P = 0.009 and P = 0.047 respectively). There was no significant difference in CAT activity and TAR levels between the two groups (P = 0.347). DNA damage in patients with ES was increased compared to control subjects (108.8 +/- 51.2 and 57.6 +/- 31.2 arbitrary units, respectively), but this difference was not significant statistically (P= 0.09). This study shows that systemic oxidative stress and alteration at the nuclear level occur in patients with ES, as a result of multiple dilatations and tissue injury. On the other hand, these results support that patients with ES may benefit from antioxidant treatment.

Iatrogenic esophageal perforation in children: patterns of injury, presentation, management, and outcome

Iatrogenic esophageal perforations in children are rare. To evaluate patterns of injury, clinical presentation, and treatment options for such patients, the authors reviewed the case records of 11 children who had sustained transmural injury to the esophagus during a dilatation procedure at their institution between 1967 and 1994. Strictures requiring dilatation were attributable to caustic ingestion in eight, esophageal atresia repair in two, and congenital stenosis in one. Eight were penetrating injuries, and three were disruptions. Two involved the cervical esophagus; and nine involved the thoracic esophagus. Pain, pyrexia, and tachycardia were early signs. Proximal thoracic perforations led to signs in the left chest region (effusion/pneumothorax); with distal perforation the signs were on the right side. Treatment along conventional lines (local drainage, gastrostomy, primary repair after early recognition, and antibiotic therapy) was successful, with two major complications, both empyemas. The most recent case, a disruption of a tracheoesophageal fistula stricture, was successfully treated with oral water irrigation and antibiotics only. Six had colonic interposition (all caustic ingestion), one required endoesophageal resection of a distal stricture, and four had resolution of the stricture, three without additional dilatation. The majority of children with iatrogenic injuries of the esophagus can be managed successfully by conservative measures and pleural drainage, with surgical procedures reserved for large disruptions of the esophagus, intraabdominal perforations, and cases that do not respond to appropriate conservative measures. Patients with caustic injury to the esophagus have a greater risk for the development of penetrating injury, and this may be one indicator of the severity of scarring. There are distinct clinical patterns of presentation, which depend on the level at which the esophagus is perforated. Dilatation disruption of a localized stricture has a good long-term prognosis for the esophagus and may even cure the stricture. The role of oral irrigation still must be fully evaluated where disruption has occurred as distinct from a penetrating injury.