Surgical management of esophageal strictures after caustic burns: A 30 years of experience

Evaluation of effects of curcumin on acute esophagitis in the corrosive esophagitis model in rats

Ingestion of a corrosive substance may cause corrosive esophagitis. Curcumin has anti-inflammatory and mucosal protective effects. In this study, the effects of curcumin on the acute phase of corrosive esophagitis were investigated. Twenty-seven Wistar Albino rats were divided into four groups; sham (group I), control (group II), and experiment groups (group III, 100 mg/kg curcumin; group IV, 200 mg/kg curcumin). Forty percent sodium hydroxide solution was used to erode the esophagi of rats in groups other than the sham group. Curcumin was applied to animals in the experiment groups 10 min after the corrosion. After 24 h, animals were sacrificed, and esophagus samples were collected. According to the histopathological examination, the muscularis mucosa damage was regressed from 100% in group II to 71.4% in group III and 50% in group IV. Mild level of damage and collagen deposition in the tunica muscularis regressed from 66.7% of the animals in the control group to 42.9% in group III and to none in group IV. Further, an increase in submucosal collagen was present in all samples from groups II and III, while 83.3% of samples had an increase in submucosal collagen in group IV. There was a significant difference in the histopathological total score between the control group and group IV (p=0.02). The results showed that the administration of curcumin in a dose-dependent manner can relieve the acute phase of corrosive esophagitis.

Colonic transposition using mid colon for corrosive oesophageal strictures

Purpose

To evaluate mid colon as a viable alternative for reconstruction in diffuse corrosive oesophageal stricture compared to other modes.

Methods

This is a prospective observational study of surgical management of corrosive oesophageal stricture using the colonic interposition graft. Eight patients were included for a period of 4 years from January 2017 to December 2020 and followed up for a mean period of 32 months (range of 24 to 46 months). The results in these eight patients are discussed.

Results

A total of 8 patients underwent retrosternal oesophagocoloplasty and gastrojejunostomy. There was no intraoperative or hospital death. Postoperative complications included one patient each having aspiration pneumonia and anastomotic leak.

Conclusion

A successful reconstruction can be done by securing the correct vascular pedicle and a technique of good anastomosis. From our experience, colonic transposition using mid colon as conduit can be considered as a viable alternative in patients with long segment oesophageal stricture.

Changing trends in the minimally invasive surgery for corrosive esophagogastric stricture

Esophagogastric stricture is the troublesome long-term complication of corrosive ingestion with a significant adverse impact on the quality of life. Surgery remains the mainstay of therapy in patients where endoscopic treatment is not feasible or fails to dilate the stricture. Conventional surgical management of esophageal stricture is open esophageal bypass using gastric or colon conduit. Colon is the commonly used esophageal substitute, particularly in those with high pharyngoesophageal strictures and in patients with accompanying gastric strictures. Traditionally colon bypass is performed using an open technique that requires a long midline incision from the xiphisternum to the suprapubic area, with adverse cosmetic outcomes and long-term complications like an incisional hernia. As most of the affected patients are in the second or third decade of life minimally invasive approach is an attractive proposition. However, minimally invasive surgery for corrosive esophagogastric stricture is slow to evolve due to the complex nature of the surgical procedure. With advancements in laparoscopic skills and instrumentation, the feasibility and safety of minimally invasive surgery in corrosive esophagogastric stricture have been documented. Initial series have mainly used a laparoscopic-assisted approach, whereas more recent studies have shown the safety of a total laparoscopic approach. The changing trend from laparoscopic assisted procedure to a totally minimally invasive technique for corrosive esophagogastric stricture should be carefully disseminated to preclude adverse long-term outcomes. Also, well-designed trials with long-term follow-ups are required to document the superiority of minimally invasive surgery for corrosive esophagogastric stricture. The present review focuses on the challenges and changing trends in the minimally invasive treatment of corrosive esophagogastric stricture.

Minimally invasive esophagectomy in the semi-prone position for corrosive esophagitis: a case report

Treatment strategies for corrosive esophagitis include conservative treatment, such as balloon dilatation at the stenosis site, and surgical treatment. Esophagectomy for corrosive esophagitis is usually performed through the transthoracic or transhiatal approaches. Herein, we report a case of corrosive esophagitis treated with thoracoscopic esophagectomy with the patient in the semi-prone position. The patient was a 48-year-old woman who developed corrosive esophagitis due to accidental ingestion of an alkaline agent. Surgical intervention was required for esophageal stenosis. Therefore, thoracoscopic esophagectomy was performed with the patient in the semi-prone position with bilateral pulmonary ventilation. In our hospital, good operative outcomes have been obtained using thoracoscopic esophagectomy for esophageal cancer with the patient in the semi-prone position with bilateral pulmonary ventilation. This technique is also considered effective for the treatment of corrosive esophagitis.

Outcomes of Gastric Conduit in Corrosive Esophageal Stricture: a Systematic Review and Meta-analysis

BACKGROUND

Gastric conduit has emerged as the preferred treatment option for both esophageal bypass and replacement for corrosive stricture of the esophagus. There is a lack of consensus and a dearth of published literature regarding the short- and long-term complications of using a gastric conduit. This meta-analysis aims to evaluate the outcomes, morbidity, and complications associated with it.

METHODS

MEDLINE, Cochrane Library, and Google Scholar (January 1960 to May 2020) were systematically searched for all studies reporting short- and/or long-term outcomes and complications following the use of a gastric conduit for corrosive esophageal stricture.

RESULTS

Seven observational studies involving 489 patients (53.2% males, mean age ranging from 22.1 to 41 years) who had ingested a corrosive substance (acid in 74.8%, alkali in 20.7%, and unknown in the rest) were analyzed. Gastric pull-up was performed in 56.03% (274/489) of patients. Median blood loss in the procedure was 187.5 ml with a mean operative duration of 298.75 ± 55.73 min. The overall pooled prevalence rate of anastomotic leak was 14.4% [95% CI (6.2-24.0); p < 0.05, I² = 67.38], and anastomotic stricture was 27.2% [95% CI (13-42.8); p < 0.001, I² = 80.11]. Recurrent dysphagia according to pooled prevalence estimates occurred in 14.4% patients [95% CI (5.4-25.1); p < 0.05, I² = 69.1] and 90-day mortality in 4.8% patients [95% CI (1.5-9.1%); I² = 31.1, p = 0.202]. The dreaded complication of conduit necrosis had a pooled prevalence of 1.3% [95% CI (0.1-3.4%); I² = 0, p = 0.734].

CONCLUSION

The stomach can be safely used as the conduit of choice in corrosive strictures with an acceptable rate of complications, postoperative morbidity, and mortality.

Surgical management of esophageal stenosis due to ingestion of corrosive substances

BACKGROUND

Corrosive ingestion is a significant challenge for healthcare systems. Limited data are available regarding the best treatments, and there remains a lack of consensus about the optimal surgical approach and its outcomes. This study aims to review the current literature and show a single institution's experience regarding the surgical treatment of esophageal stenosis due to corrosive substance ingestion.

METHODS

A retrospective review that accounted for demographics, psychiatric profiles, surgical procedures, and outcomes was performed. A systematic review of the literature was performed using PubMed.

RESULTS

In total, 27 surgical procedures for esophageal stenosis due to corrosive substance ingestion were performed from 2010 to 2019. Depression and drug abuse were diagnosed in 30% and 22% of the included patients, respectively. Esophagectomies and esophageal bypasses were performed in 13 and 14 patients, respectively. No 30-day mortality was recorded.

CONCLUSION

Surgical intervention either by esophagectomy or esophageal bypass results in durable relief from dysphagia. However, successful clinical outcomes depend on a high-quality multidisciplinary network of esophageal and thoracic surgeons, intensivists, psychologists, psychiatrists, and nutritional teams.

Assessing the Degree of Acute Esophageal Injury Secondary to Corrosive Intake: Insights From a Public Sector Hospitals of a Developing Country

Background

Caustic ingestion continues to be a significant problem worldwide especially in developing countries and particularly in the age group of under six years. Ingestion of caustic substances is a medical emergency in both the adult and pediatric population and is associated with high morbidity and mortality. The ingestion of caustic substances induces an extensive spectrum of injuries to the aerodigestive tract, which includes extensive necrosis and perforation of the esophagus and stomach.

Objectives

The main aims were to determine upper and lower esophageal injuries associated with corrosive intake and to compare esophageal injury with age and gender.

Rationale

Once we’ll find the extent and severity of esophageal injury associated with corrosive intake within 24 hours, we’ll be able to manage the case timely and to limit further complications and disabilities.

Materials and Methods

This descriptive cross-sectional study was conducted on 150 patients who presented with corrosive ingestion and underwent urgent endoscopic evaluation. Data were collected using self-designed pro forma. Endoscopic findings were classified according to the Zargar classification. A descriptive analysis of study variables was performed using SPSS v.21.0 (IBM Corp., Armonk, NY, USA). The chi-square test was used, and a p-value of less than 0.05 was considered statistically significant.

Results

Out of 150 patients under study, 103 (68.7%) were females and 47 (31.3%) were males. The most prevalent age group presenting with corrosive intake was found to be between 21 and 34 years of age (43.3%) in both genders. The most common part of the esophagus prone to corrosive insult is the upper esophagus (99.3%), whereas, regarding severity, the lower esophagus has more severe injuries (predominant being stage 2B, i.e., 32%). There are no statistically significant differences in esophageal injuries in different age groups (upper esophageal injury: 0.319; lower esophageal injury: 0.696) and genders (upper esophageal injury: 0.769; lower esophageal injury: 0.752).

 Conclusions

Most of the patients under study belong to the female gender and teen and younger age group. The predominant upper esophageal injury as a result of corrosive intake is stage 0 injury, and the least common is found to be stage 1 injury. The predominant lower esophageal injury as a result of corrosive intake is stage 2B injury, whereas the least common is found to be stage 4 injury.

Minimally Invasive Retrosternal Esophageal Bypass Using a Mid-Colon Esophagocoloplasty for Corrosive-Induced Esophageal Stricture

INTRODUCTION

Colonic bypass for corrosive-induced esophageal stricture is traditionally performed using an open approach. The laparoscopic mid-colon retrosternal esophageal bypass has not been previously reported. The present study is aimed to report the feasibility of laparoscopic mid-colon esophagocoloplasty and to compare the short- and medium-term outcomes with the open approach.

MATERIALS AND METHODS

Patients who underwent surgery for corrosive esophageal stricture between August 2016 and August 2019 were retrospectively analyzed. Laparoscopic procedure was preferred in patients with stricture starting at or below the level of cricopharynx and without prior laparotomy. The perioperative and medium-term outcomes of patients who underwent open and laparoscopic mid-colon bypass were compared.

RESULTS

Of the 15 patients, seven patients underwent laparoscopic mid-colon bypass, and eight patients underwent the open procedure. The duration of surgery was less in the laparoscopic group, but the difference was not significant (440 vs. 510 min, P = 0.93). Intraoperative blood loss (median) and postoperative analgesic requirement (median days) were significantly lower in laparoscopic group (200 mL vs. 350 mL, P = 0.03 & 3 vs. 5, P = 0.02). There was no significant difference in the postoperative complications, ICU and hospital stay between the two groups. At a median (range) follow-up of 14 (7-42) months, all patients in the minimally invasive colon bypass group were euphagic to regular Indian diet. Two patients in the open group developed anastomotic stricture requiring endoscopic dilatation.

CONCLUSION

Minimally invasive mid-colon esophageal bypass is a feasible procedure for selected patients with corrosive esophageal stricture with favorable short-term and comparable medium-term outcomes.

Factors affecting the outcome of endoscopic dilatation in refractory post-corrosive oesophageal stricture in Egyptian children: a single-centre study

BACKGROUND

An important complication of corrosive ingestion is oesophageal stricture. Improvements in endoscopes and accessories have supported an increase in the number of patients who are conservatively treated with endoscopic dilations. In this study, we aimed to detect factors affecting the outcome of endoscopic dilatation for refractory post-corrosive oesophageal stricture.

METHODS

This study was carried out in the Paediatric Endoscopy Unit in the Children's Hospital and included 100 children older than 2 years of age of both sexes who had an established diagnosis of post-corrosive oesophageal stricture on repeated endoscopic dilatation sessions. The duration of the condition was more than 6 months, and dilatation failed to achieve a diameter of 14 mm during the first five sessions at 2-week intervals (refractory), excluding other causes of oesophageal stricture.

RESULTS

Males represented 63% of patients. The mean age of enrolled children was 5.9 ± 2.6 years; 90% of patients ingested an alkaline corrosive substance (potash). The total number of dilatation sessions ranged from 16 to 100, with a mean number of sessions ranging from 37.2 ± 14.9. Fifty-four patients (54%) were well controlled by regular endoscopic dilatation with good clinical and endoscopic outcomes, and no more dilatations were needed.

CONCLUSION

Endoscopic dilation is an effective method for managing refractory post-corrosive oesophageal strictures that require a long follow-up period. There are a lot of factors affecting the outcome.

Spontaneous Perforation of a Malignified Corrosive Stricture of the Esophagus and Subsequent Perforation of a Giant Duodenal Stress ULCUS

Surgical interventions for corrosive stricture of the esophagus are extremely difficult and technically challenging. In this manuscript, we present a patient with esophagectomy due to perforation of a corrosive stricture of the esophagus that underwent malignant transformation and subsequent perforation of a giant duodenal stress ulcus, which occurred 12 days after the intervention. We performed a total esophagectomy, pharyngo- and gastrostomy, suture of the duodenal perforation but the postoperative period was challenging and despite our efforts, the patient died on the 50th postoperative day due to respiratory and renal failure.

A case of corrosive esophagitis causing extensive cicatricial esophageal stenosis treated by esophageal bypass with supercharged pedicled jejunal pull-up

•

Swallowing corrosive substances leads to gastrointestinal stenosis due to scarification.

•

Bypass surgery was performed as adhesions posed risk of injury to adjacent organs.

•

Esophageal bypass with a “supercharged” pedicled jejunal flap was performed.

•

The technique creates anastomoses between jejunal and internal thoracic vessels.

•

It is an optimal technique for treatment of stenosis caused by corrosive esophagitis.

Introduction

Swallowing a corrosive substance causes delayed gastrointestinal stenosis due to scar formation. Here, we report on our use of esophageal bypass using a supercharged pedicled jejunal flap to treat cicatricial esophageal stenosis caused by corrosive esophagitis.

Presentation of case

Nineteen years before presentation, a 57-year-old man had swallowed a chemical cleaning agent, which caused extensive corrosive cicatricial stenosis from the thoracic upper esophagus to the gastric fornix. An enterostomy had been created, and the patient had since been subsisting on enteral nutrition. However, he wanted to be able to eat through his mouth again and was referred to our department for treatment. With the exception of the cervical esophagus, circumferential cicatricial stenosis was present throughout the esophagus and gastric fornix, with severe adhesions to the surrounding tissue. It was decided not to perform esophagectomy but to perform esophageal bypass surgery using a supercharged pedicled jejunal flap.

Discussion

Despite the extremely high risk of cancer in the stenotic esophagus due by corrosive esophagitis, indicating that esophagectomy should be performed if possible, we chose to perform bypass surgery because the severe adhesions posed a high risk of early injury to the surrounding organs.

Conclusion

We suggest that esophageal bypass using pedicled jejunal pull-up “supercharging” by creating anastomoses between the jejunal and internal thoracic vessels is the optimal procedure for patients with extensive cicatricial esophageal stenosis caused by corrosive esophagitis.

Colonic Interposition After Adult Oesophagectomy: Systematic Review and Meta-analysis of Conduit Choice and Outcome

BACKGROUND

Colonic interposition is a second-line option after oesophagectomy when a gastric neo-oesophagus is not viable. There is no consensus on the optimum anatomical colonic conduit (right or left), or route of placement (posterior mediastinal, retrosternal or subcutaneous). The aim of this review was to determine the optimum site and route of neo-oesophageal conduit after adult oesophagectomy.

METHODS

PubMed, MEDLINE, and the Cochrane Library (January 1985 to January 2017) were systematically searched for studies which reported outcomes following colonic interposition in adults. The outcome measures were overall morbidity and mortality.

RESULTS

Twenty-seven observational studies involving 1849 patients [1177 males; median age (range) 60.5 (18-84) years] undergoing colonic interposition for malignant (n = 697) and benign (n = 1152) pathology were analysed. Overall pooled morbidity of left vs. right colonic conduit was 15.7% [95% CI (11.93-19.46), p < 0.001] and 18.7% [95% CI (15.58-21.82), p < 0.001] respectively. Overall pooled mortality of left vs. right colonic conduit was 6.5% [95% CI (4.55-8.51), p < 0.001] and 10.1% [95% CI (7.35-12.82), p < 0.001] respectively. Retrosternal route placement was associated with the lowest overall pooled morbidity and mortality of 9.2% [95% CI (6.48-11.99), p < 0.001] and 4.8% [95% CI (3.74-5.89), p < 0.001] respectively.

CONCLUSION

Left colonic conduits placed retrosternally were safest.

Esophagectomy with gastric conduit reconstruction for benign disease: extreme but important

Esophagectomy is usually performed to resect esophageal cancer. However, there are numerous other indications for esophagectomy, including Barrett's esophagus with high-grade dysplasia (HGD) and some benign diseases such as obstruction, end-stage achalasia, esophagus perforation or disruption, benign neoplasm, and severe caustic injury. For these patients, esophagectomy could relieve their symptom obviously. However, esophagectomy causes huge trauma, induces quite high morbidity and mortality, and may decreases patients' quality of life obviously due to postoperative reflux, dumping, anastomotic stricture and other complications. Accordingly, the considerations of a surgery must be carefully deliberated, including the underlying disorder, lesions localization, extent of disease, and options for esophageal replacement. For patients received esophagectomy and alimentary tract reconstruction, gastric conduit is the most common used replacement organ, then colon and jejunum. This review demonstrated the importance and technical experience of esophagectomy with gastric conduit reconstruction for benign diseases.

Use of self-expanding nitinol stents in the pediatric management of refractory esophageal caustic stenosis

BACKGROUND

The treatment of recurrent esophageal stricture secondary to the ingestion of a caustic agent is an arduous task. Self-expanding esophageal stents may be an alternative to repeated endoscopic esophageal dilations.

CASE REPORT

We present the case of a two-year-old male with a severe and long esophageal stricture successfully treated by the combination of dilations and stent placement. After five months of serial pneumatic dilations, three self-expanding nitinol stents internally coated with silicone were introduced through a gastrostomy, covering the entire esophagus. The procedure was performed under endoscopic and radiological guidance. Three months later, the treatment was repeated with a single stent. A new stenosis in the proximal esophagus required surgical resection, and anastomosis followed by two pneumatic dilations for five months resulted in longer intervals where the patient was asymptomatic.

DISCUSSION

The results obtained were satisfactory, allowing the patient to conserve and use his own esophagus. However, this is a unique case and the optimal maintenance time and withdrawal time of the stent must be determined.

Caustic ingestion

Corrosive ingestion is a rare but potentially devastating event and, despite the availability of effective preventive public health strategies, injuries continue to occur. Most clinicians have limited personal experience and rely on guidelines; however, uncertainty persists about best clinical practice. Ingestions range from mild cases with no injury to severe cases with full thickness necrosis of the oesophagus and stomach. CT scan is superior to traditional endoscopy for stratification of patients to emergency resection or observation. Oesophageal stricture is a common consequence of ingestion and newer stents show some promise; however, the place of endoscopic stenting for corrosive strictures is yet to be defined. We summarise the evidence to provide a plan for managing these potentially life-threatening injuries and discuss the areas where further research is required to improve outcomes.

Minimally invasive substernal colonic transposition for corrosive strictures of the upper aerodigestive tract

Corrosive upper aerodigestive tract strictures are conventionally treated by open surgery. Surgical advancements permit these strictures to be addressed with minimal invasion. Corrosive strictures treated minimally invasively over a 2-year period (2014-2015) were audited. Colonic mobilization and retrosternal tunneling were performed laparoscopically. The left colic vessel-based isoperistaltic colonic/ileocolonic segment was transposed substernally into the neck, aided by miniceliotomy. Proximal anastomosis was side-to-side esophagocolic in all patients except those who underwent pharyngolaryngectomy or partial laryngectomy, where pharyngocolic/pyriform fossa-ileal anastomosis was employed. Distal anastomoses were colo-jejunal and colocolic/ileocolic in all the patients. Enteral nutrition and ambulation were commenced on the first postoperative day. Oral nutrition was commenced following a normal contrast swallow on the seventh postoperative day. Patients were followed up on an outpatient basis. Ten adults, aged between 19 and 40 years, were treated for acid-induced strictures. Esophagus and stomach were multiply strictured in all patients. Additionally, duodenum was involved in two patients while pharynx and larynx were strictured in three patients. Two patients underwent pharyngolaryngectomy. One patient underwent partial laryngectomy. The average operative time was 240 minutes (range: 210-300 minutes). The mean blood loss was 150 mL (range: 100-200 mL). One patient (10%) had cervical anastomotic leak on the ninth postoperative day, which was resolved spontaneously. One patient (10%) had proximal anastomotic stricture, requiring dilatation thrice. One patient (10%) had the transient left recurrent laryngeal nerve paresis, which was resolved spontaneously. All the patients are on oral solid diet. The followup ranged from 5 months to 2 years. Minimal access substernal colonic transposition is feasible and efficacious in restoring alimentary continuity in corrosive strictures.

NUTRITIONAL THERAPY IN THE TREATMENT OF ACUTE CORROSIVE INTOXICATION IN ADULTS

INTRODUCTION

Acute intoxications with corrosive substances can cause severe chemical injuries of the upper gastrointestinal tract, most often located in the mouth, pharynx, esophagus, stomach and duodenum. If a patient survives the acute phase of intoxication, regenerative response may result in esophageal and/or gastric stenosis, and increased risk of esophageal and gastric cancer. Such intoxication may be fatal due to perforation or tracheal necrosis. Enteral nutrition is a nutritional method when nutritional substances are administered through specially designed tubing placed through the nose or percutaneously, directly into the GIT.

AIM

The aim of this study is to describe the methods of artificial nutrition in patients with acute corrosive intoxications and the importance of nutritional support in the treatment of these intoxications.

DISCUSSION

Nutrition in the treatment of acute corrosive intoxications is one of the most important therapeutic processes that largely contribute to faster recovery of the post-corrosive injuries of upper GIT, stabilization of biologic, immunologic and metabolic parameters, and reduction of length of stay in hospital Aim of the treatment of acute corrosive intoxications is to prevent perforation and progressive fibrosis, and esophageal and gastric stenosis. There are different and often conflicting positions, on the conservative treatment of acute corrosive intoxications in adults. Such treatment mainly consists of anti-secretory treatment, antibiotics and intensive hyper-alimentation, aiming to prevent late post-corrosive intoxications.

CONCLUSION

It is considered that nutritional support plays a major role in maintenance of metabolic processes and prevention of severe metabolic complications that could additionally aggravate the condition and impair the treatment.

Caustic soda ingestion in children under-5 years presenting for fluoroscopic examinations in an Academic Hospital in Ghana

Background

Disastrous effects and lifelong complications, ranging from respiratory and gastrointestinal burns to death can result from caustic soda ingestion. Accidental and non-accidental ingestions occur in different age groups. However, it is very troubling to find ingestion of caustic soda a very common occurrence among children below 5 years since they do not have the developmental level required to independently weigh up risks and are also under parental and societal protections. This study was therefore planned to investigate the ingestions of caustic soda by these children for purposes of proposing measures to curb the problem.

Methods

Descriptive survey was employed for this study. A 14-item, semi-structure questionnaire was purposively issued to 57 parents/guardians whose wards had ingested caustic soda. Data was analysed with SPSS V.20.

Results

Twenty-seven (47.4 %) children got access to the soda at storage, 1 (1.86 %) was administered accidentally by a sibling while 29 (50.9 %) ingested during soap preparation. In respect of the former, the majority got access because it was stored in soft drink and water bottles in their parents/guardians rooms or kitchen. For the later, the children got access to the left-over soda because the soap-makers failed to adhere to good storage and disposal practices.

Conclusion

Storage of caustic soda in soft drink and water bottles in accessible places, and training of children to drink directly from bottles influence caustic soda ingestion in children under five. Non-compliance to good practices of storage and disposal of caustic soda during soap preparation increases exposure and access of children to caustic soda ingestion.

Foregut caustic injuries: results of the world society of emergency surgery consensus conference

INTRODUCTION

Lesions of the upper digestive tract due to ingestion of caustic agents still represent a major medical and surgical emergency worldwide. The work-up of these patients is poorly defined and no clear therapeutic guidelines are available.

PURPOSE OF THE STUDY

The aim of this study was to provide an evidence-based international consensus on primary and secondary prevention, diagnosis, staging, and treatment of this life-threatening and potentially disabling condition.

METHODS

An extensive literature search was performed by an international panel of experts under the auspices of the World Society of Emergency Surgery (WSES). The level of evidence of the screened publications was graded using the Oxford 2011 criteria. The level of evidence of the literature and the main topics regarding foregut caustic injuries were discussed during a dedicated meeting in Milan, Italy (April 2015), and during the 3rd Annual Congress of the World Society of Emergency Surgery in Jerusalem, Israel (July 2015).

RESULTS

One-hundred-forty-seven full papers which addressed the relevant clinical questions of the research were admitted to the consensus conference. There was an unanimous consensus on the fact that the current literature on foregut caustic injuries lacks homogeneous classification systems and prospective methodology. Moreover, the non-standardized definition of technical and clinical success precludes any accurate comparison of therapeutic modalities. Key recommendations and algorithms based on expert opinions, retrospective studies and literature reviews were proposed and approved during the final consensus conference. The clinical practice guidelines resulting from the consensus conference were approved by the WSES council.

CONCLUSIONS

The recommendations emerging from this consensus conference, although based on a low level of evidence, have important clinical implications. A world registry of foregut caustic injuries could be useful to collect a homogeneous data-base for prospective clinical studies that may help improving the current clinical practice guidelines.

Topical mitomycin C can effectively alleviate dysphagia in children with long-segment caustic esophageal strictures

Caustic ingestion in children and the resulting long esophageal strictures are usually difficult to be managed, and eventually, esophageal replacement was required for cases refractory to frequent dilatation sessions. Topical mitomycin C (MMC) application has been used recently to improve the results of endoscopic dilatation for short esophageal strictures. The study aims to assess the role of MMC application in management of long-segment caustic esophageal strictures. From January 2009 to June December 2013, patients presented with long caustic esophageal stricture (>3 cm in length) were included in this study and subjected to topical MMC application after endoscopic esophageal dilatation on multiple sessions. Regular follow-up and re-evaluation were done. A dysphagia score was used for close follow-up clinically; verification was done radiologically and endoscopically. During the specified follow-up period, 21 patients with long caustic esophageal stricture were subjected to topical MMC application sessions. Clinical, radiological, and endoscopic resolution of strictures occurred in 18 patients (85.7% cure rate). Number of dilatation sessions to achieve resolution of dysphagia was (n = 14.3 ± 5.7) with application of mitomycin two to six times. There was no recurrence in short- and mid-term follow-up. No complications were encountered related to topical MMC application. MMC is a promising agent in management of long-segment caustic esophageal strictures. Long-term follow-up is needed to prove its efficacy and to evaluate potential long-term side-effects of MMC application.

Gastro-intestinal stromal tumor (GIST) complicating a colonic interposition: a novel case report

Background

Gastrointestinal stromal tumor (GIST) is a rare tumor comprising 0.1-0.3% of all gastrointestinal (GI) malignancies. Stomach followed by small intestine is the most common sites of involvement, implicated in 95% of the cases. We present a case of GIST complicating a colonic interposition. To the best of the author's knowledge, this is the first reported case of GIST complicating a colonic interposition.

Case presentation

A 47 year old African American male presented to the emergency department with intermittent, severe chest pain. Past medical history was significant for alkali (NaOH) ingestion during 1980 for which esophageal resection and a colonic pull-through was performed. A CXR revealed a widened mediastinum and CT scan chest revealed showed a large (11.4 × 8.3 × 12.1 cm) vascular mediastinal mass. At endoscopy, a large, ulcerated, cratered and friable mass was found at 29cm extending to 36cm at which point the lower anastomosis of the colonic pull through was present. Multiple endoscopic biopsies were obtained which showed that the tumor was immunoreactive with CD117, CD34 and DOG1 while markers of carcinoma, melanoma and lymphoma were negative. In light of the pathology report, the immunohistochemistry and the CT scans, the tumor was classified as a stage 4 GIST of colonic interposition.

Conclusions

GIST can complicate unusual locations such as colonic interposition and should be kept in the differential diagnosis of such unusual presentations.

Efficacy of keratinocyte growth factor (palifermin) for the treatment of caustic esophageal burns

Current treatment strategies against the development of corrosive esophageal strictures remain unsatisfactory. Thus, the aim of the present study was to investigate the efficacy of keratinocyte growth factor, in the form of palifermin, for the prevention of stricture development following esophageal caustic injuries in a rat model. A total of 32 female Wistar albino rats were divided into four groups, which included the control (C), burn (B), steroid (S) and steroid plus palifermin (S/P) groups. An experimental corrosive esophageal burn model was established in the B, S and S/P groups. Weight gain was recorded and histopathological evaluation was performed for each group. Weight gain in the S and B groups was compared with the control group and statistically significant differences were observed. In addition, statistically significant differences in weight gain were observed between the S/P group and the B group. Histopathologically, statistically significant differences were identified with regard to submucosal collagen deposition, muscularis mucosa and tunica muscularis damage when comparing the B group with the C group. In addition, statistically significant differences were observed when comparing the S and S/P groups with the B group. Furthermore, significant submucosal collagen deposition and tunica muscularis damage were observed in the S group when compared with the S/P group. The stenosis indexes in the C and S groups were significantly lower compared with the B group. In addition, the stenosis index in the S/P group was significantly lower compared with the S group. To the best of our knowledge, the present study is the first to investigate the effect of palifermin on corrosive esophageal burns. The addition of palifermin to the corrosive esophageal burn standard treatment regimen was found to reduce the degree of fibrosis and ameliorate histopathological damage in an experimental model of corrosive esophagitis in rats.

Corrosive oesophageal injuries: a preventable menace

Introduction

Potentially catastrophic presentations and lifelong complications resulting from corrosive ingestions in humans is one of the most challenging situations encountered in clinical medical practice. This study reviewed pattern, mechanisms and associated socio-medical challenges with ingestion of corrosive agents as seen in a tertiary health institution in South-western Nigeria.

Methods

A retrospective review of all patients that were managed for corrosive ingestion at Ladoke Akintola University of Technology Teaching Hospital, Osogbo, Osun State, Nigeria, over a seven year period.

Results

A total of 28 patients M:F: 1.6:1. There were 7 children and 21 adults. Majority (78.6%) of the patients ingested alkaline substances. Accidental ingestion occurred in 28.6% while 71.4% resulted from deliberate self harm especially among adults (66.7%). Almost two thirds (64.3%) of the patients presented after 48hrs of ingestion. Patients who presented early were managed conservatively. Most patients (64.3%) who presented late had nutritional and fluid rehabilitation. Two patients died from oesophageal perforation and resulting septicaemia. Psychiatric evaluation revealed that seven adults (25%) had psychotic illness while (42.9%) of the patients developed oesophageal strictures. Short segment strictures were managed with oesophageal dilatation with good outcome while long and multiple segment strictures were referred to cardiothoracic surgeons for management.

Conclusion

Corrosive oesophageal injuries remain a prevalent and preventable condition in the developing countries. Preventive strategies should include regulation and packaging of corrosive substances, organization of psychiatric services, and education of the population on corrosive ingestion.

Acute therapy with intravenous omeprazole on caustic esophageal injury: a prospective case series

The ingestion of caustic substances may result in significant esophageal injury. There is no standard treatment protocol for esophageal injury and most patients are treated with a proton pump inhibitor or H2 antagonist. However, there is no clinical study evaluating the efficacy of omeprazole for caustic esophageal injury. A prospective study of 13 adult patients (>18 years of age) who were admitted to our hospital for caustic ingestion between May 2010 and June 2010 was conducted. Mucosal damage was graded using a modified endoscopic classification described by Zargar et al. Patients were treated with a proton pump inhibitor and maintained without oral intake until their condition was considered stable. Patients received omeprazole 80 mg in bolus IV, followed by continuous infusion of 8 mg/hour for 72 hours. A control endoscopy was performed 72 hours after admission. There was significant difference regarding endoscopic healing between the before and after omeprazole infusion (P = 0.004). There was no hospital mortality at the follow-up. Omeprazole may effectively be used in the acute phase treatment of caustic esophagus injuries.

Antesternal colonic interposition for corrosive esophageal stricture

Restoration of swallowing in a patient with dysphagia due to nondilatable corrosive stricture of esophagus remains a surgical challenge. Organs available for replacement are stomach, jejunum, or colon. Jejunum is useful to replace a small segment, whereas stomach and colon are required for a long-segment replacement. In cases where the stomach is also injured, colon remains the only option. The route of colonic interposition has also been a subject of debate over the years. Antesternal, retrosternal, or esophageal bed passage are the routes described. In the present series, the data of antesternal colonic interposition (ACI) performed for nondilatable benign esophageal strictures in 32 patients (1988-2011) have been retrospectively analyzed. The results indicate that ACI for corrosive strictures is a quick and simple procedure. Thoracotomy is avoided and anastomosis is easily performed in the neck, and mortality rate due to anastomotic failure or graft failure is diminished. This retrospective analysis discusses the ease, effectiveness, quality of life, morbidity, and mortality of ACI and compares the pros and cons of ACI with other procedures described in the literature.

Surgical management and outcomes of severe gastrointestinal injuries due to corrosive ingestion

AIM: To report our experience in the surgical management of severe injuries of the gastrointestinal tract due to corrosive ingestion.

METHODS: A retrospective review of patients who underwent emergency surgery for severe gastrointestinal injuries following corrosive ingestion between 1983 and 2010 was carried out. Data was extracted from a prospectively maintained esophageal disease database. Severe corrosive injuries were defined as full thickness necrosis with perforation of the esophagus or the stomach (with or without involvement of the adjacent viscera) with resultant mediastinitis or peritonitis.

RESULTS: Between 1983 and 2010, 209 patients with corrosive injury of the esophagus were managed. Of these, 13 (6.2%) patients underwent emergency surgery for severe corrosive injury. The median age of the patients was 22 years and the median interval between ingestion of the corrosive substance and surgery was 24 h. The surgical procedures done included esophagogastrectomy alone (n = 6), esophagogastrectomy with duodenectomy (n = 4), esophagogastrectomy with pancreaticoduodenectomy (n = 1), esophagogastrectomy with splenectomy (n = 1) and distal gastrectomy with duodenectomy (n = 1). Two patients died in the postoperative period and one after discharge awaiting the second surgery. The factors significantly predictive of mortality following such an injury included renal failure at the time of initial presentation, presence of metabolic acidosis, delay of more than 24 h between corrosive ingestion and surgery, and corrosive induced adjacent organ injury (pancreatic) (P < 0.001, 0.02, 0.005 and 0.015 respectively). Ten patients underwent subsequent surgery for restoration of the alimentary tract continuity with a colonic pull-up (n = 8) and gastrojejunostomy (n = 1). In one patient, the attempted colon pull-up failed due to extensive scarring of the mesocolon. The median follow up (following restoration of continuity of the gastrointestinal tract) was 36.5 mo. One patient developed dysphagia due to a stricture at the anastomotic site, which was successfully managed by dilatation. Another patient developed severe aspiration, necessitating laryngeal inlet closure and permanent tracheostomy, and 3 patients complained of occasional regurgitation.

CONCLUSION: Management of severe corrosive injury involves prompt resuscitation and urgent surgical debridement. Although the subsequent restoration of continuity may be complicated and may not always be possible, long term outcomes are acceptable in the majority.

Effects of sodium hydroxide exposure on esophageal epithelial cells in an in vitro ovine model: implications for esophagus tissue engineering

BACKGROUND

Esophagus tissue engineering holds promises for esophageal replacement after severe caustic injuries. The aim of this study was to determine whether viable esophageal epithelial cells could be isolated from an esophagus exposed to varying concentrations of alkali with regard to number, viability, and morphology during in vitro culture.

METHODS

Ovine esophagi were exposed to phosphate-buffered saline 2.5%, 15%, or 25% sodium hydroxide (NaOH). The effect of NaOH concentrations on epithelial damage was assessed histologically. Esophageal epithelial cells were then isolated, and cell count and viability were investigated. Finally, cell number, viability, and morphology of esophageal epithelial cells were determined for 24 days of in vitro culture.

RESULTS

Histologic analysis showed a progressive destruction of the epithelium proportional to increasing NaOH concentrations. Esophagi treated with phosphate-buffered saline and 2.5% NaOH showed significantly higher viable cell counts after isolation and culture in comparison with those treated with 15% to 5% NaOH.

CONCLUSION

The evidence presented in this study indicates that epithelial biopsies from an esophagus exposed to low concentrations (2.5%) of NaOH will still yield large numbers of viable cells suitable for tissue engineering applications. In cases of exposure to higher concentrations (15%-25%), alternative cell sources for epithelial regeneration, such as stem cells, will be necessary for tissue engineering applications.

Outcome following surgical management of corrosive strictures of the esophagus

OBJECTIVE

To analyze the short- and long-term outcomes following surgical treatment for corrosive stricture of the esophagus.

BACKGROUND

Surgery is a well-established treatment for corrosive strictures of the esophagus and involves either resection or bypass of the damaged esophagus and replacement by a conduit. The need for resection and the choice of the ideal conduit for esophageal replacement in these patients continues to be debated and there are only a few studies reporting on the long-term outcome following the surgical treatment.

METHODS

This was a retrospective analysis of patients with corrosive stricture of the esophagus who were managed surgically between 1983 and 2009. The type of surgery performed (resection or bypass), the conduit used, the short- and long-term outcomes were assessed.

RESULTS

One hundred seventy-six corrosive strictures of the esophagus were managed surgically (resection: 64, bypass: 112). A transhiatal resection could be accomplished in 59 of 62 patients in whom it was attempted. Stomach conduits were used in 107 patients and colonic conduits in 69. The mean operating time was 4.3 ± 1.5 hours and the mean estimated blood loss 592 ± 386 mL. Cervical anastomotic leak occurred in 22 patients (12.5%). Follow up of more than 10 years was available for 78 patients (44.3%) and more than 15 years for 54 patients (30.7%). Recurrent dysphagia developed in 33 patients (18.7%). There were no differences in the short- or long-term outcomes in patients who underwent resection or bypass. The mean duration of surgery, intraoperative blood loss, incidence of conduit necrosis, and in-hospital mortality was significantly lower in patients with stomach conduits as compared with colonic conduits. There was a higher incidence of recurrent laryngeal nerve palsy, recurrent dysphagia, and aspiration after surgery in patients with strictures involving the upper end of the esophagus at or near the hypopharynx.

CONCLUSIONS

Satisfactory outcomes are achieved after surgery for corrosive strictures of the esophagus. Resection of scarred esophagus may be done without a substantial increase in the morbidity and mortality; however, the outcomes are not significantly different from bypass. Stomach is a good conduit and the colon should be reserved for cases where the stomach is not available. Long-term outcomes in patients with hypopharyngeal strictures, however, continue to be poor.

Therapeutic options for management of pharyngoesophageal corrosive strictures

INTRODUCTION

Pharyngoesophageal strictures due to corrosive injury raise difficult therapeutic problems due to the site of stricture, the possible association with laryngeal injury and the presence of downstream esophageal strictures. We present here our approach to management of 51 consecutive patients with pharyngoesophageal strictures seen over a 30-year period.

METHODS

Patients (51) with PES were managed by one of several options depending on the individual case, viz. dilatation alone, dilatation followed by esophagocoloplasty, dilatation after cervical esophagostomy with or without an esophagocoloplasty, pectoralis major or sternocleidomastoid myocutaneous flap inlays with or without esophagocoloplasty, pharyngocoloplasty with tracheostomy, and neck exploration followed by esophagocoloplasty if a lumen was found in the cervical esophagus.

RESULTS

The overall results were excellent with satisfactory swallowing restored in 45 out 51 patients (88.2%). There was one death and three incidences of complications, two patients with temporary cervical salivary fistula, and one patient in whom swallowing could not be restored because of lack of suitable conduit. The mean dysphagia score was improved from a pre-operative value of 3.6 to 1.5 post-operatively.

CONCLUSION

In conclusion, pharyngoesophageal strictures require considerable expertise in management, and one should be aware of various options for this purpose. The choice of procedure depends on site of stricture, time of presentation after the corrosive injury, relationship of the stricture to the laryngeal inlet, status of the larynx and the airway, length of the stricture, presence or absence of a lumen distal to the stricture in the cervical esophagus, and presence or absence of strictures further downstream. With proper treatment, mortality is negligible and morbidity minimal and is usually restricted to temporary salivary fistula.

Reflux esophageal stricture--a review of 30 years' experience in children

PURPOSE

Strictures of the esophagus in children may have multiple etiologies including congenital, inflammatory, infectious, caustic ingestion, and gastroesophageal reflux (peptic stricture [PS]). Current literature lacks good data documenting long-term outcomes in children. This makes it difficult to counsel some patients about realistic treatment expectations. The objective of this study is to evaluate our institutional experience and define the natural history and treatment outcomes.

METHODS

A retrospective review of clinical data obtained from children who underwent dilation for PS was performed.

RESULTS

Over the past 30 years, 114 children and adolescents received 486 dilations. The most common indications for stricture dilation were PS (42%) and esophageal atresia (38%). Other lesser indications included congenital, foreign body, corrosive, cancer, radiation, allergic, and infectious. This review focuses on the 48 children with PS. Of the children with PS, a congenital anomaly was identified in 23 children; and 12 had neurologic impairment. Average age at presentation was 10.2 years (range, 0.5-18.3 years). Most patients had had symptoms for many months before diagnosis. Peptic stricture was most common in the lower esophagus (n = 39). However, middle (n = 8) and upper (n = 1) strictures were occasionally identified. Noncompliance with medical therapy was a challenge in 12% (n = 5) of children. Children with a PS received a median of 3 dilations, but a subset of 5 patients with severe strictures underwent up to 48 dilations (range, 1-48). Repeated dilations were required for a median of 20 months (range, 1-242 months). Among patients receiving esophageal dilation for PS, 94% required an antireflux procedure (19% required a second antireflux surgery). A subgroup of patients (n = 10) was identified who required extended dilations, multiple surgeries, and esophageal resection. This subgroup had a significantly longer period of symptomatic disease and increased risk of esophageal resection compared with those patients requiring fewer dilations. Surgical resection of the esophageal stricture was ultimately required in 3 children with PS after failure of more conservative measures.

CONCLUSION

Children and adolescents presenting with reflux esophageal stricture (PS) frequently require antireflux surgery, redo antireflux surgery, and multiple dilations for recurrent symptoms. We hope that these data will be of use to the clinician attempting to counsel patients and parents about treatment expectations in this challenging patient population.

Colopharyngoplasty for intractable caustic pharyngoesophageal strictures in an indigenous African community--adverse impact of concomitant tracheostomy on outcome

OBJECTIVES

Surgical management of caustic strictures of the upper digestive tract poses difficult challenges. This is because reconstruction above the cricopharyngeal junction interferes with the mechanisms of swallowing and respiration. This report reviews the outcome of colopharyngeal reconstruction of severe diffuse pharyngoesophageal caustic strictures in an indigenous African community.

METHOD

The medical records of patients who underwent colopharyngoplasty from January 2006 to December 2008 were retrospectively reviewed to obtain information on patients' demographics, surgical technique and outcome.

RESULTS

In the study period, 20 patients underwent reconstruction for caustic esophageal strictures; in five (three males, two females) colopharyngoplasty was required. Their ages ranged from four to 56 years (mean 25 years). Follow-up ranged from 23 to 94 months (mean 33 months). Colopharyngoplasty using left colon tunneled retrosternally was performed in all patients. Rehabilitative training for deglutition was required for 0.5-5.0 months postoperatively to restore near-normal swallowing in all patients. However, tracheostomy complications caused two deaths (one early, one late) and varicella encephalitis caused another late death.

CONCLUSION

In this African community, colopharyngoplasty provided an effective mean of restoration of upper digestive tract continuity in patients with severe caustic pharyngoesophageal strictures. Tracheostomy in this setting portends a significant long-term mortality risk.

Protective effects of ibuprofen against caustic esophageal burn injury in rats

PURPOSE

The aim of this study was to investigate the efficacy of ibuprofen on the healing of esophagus and the prevention of stricture development after esophageal caustic injuries in rats.

MATERIALS AND METHODS

Rats were divided into three groups as: group 1(sham), group 2(esophageal burn injury), group 3(injury + ibuprofen). In groups 2 and 3, a standard esophageal burn injury was created by applying 10% NaOH solution to distal esophagus of about 3 cm. To rats in the sham group, isotonic solution was given instead of NaOH. Ibuprofen (90 mg/kg/day) was given via oral route to group 3 rats. Normal saline as placebo was given via the same route to rats in groups 1 and 2. 28 days later, all the live rats were killed. The distal esophageal segments of all rats were removed and divided into two equal parts for biochemical and histopathologic examination. In the tissue samples, biochemically hydroxyproline and histopathologically collagen content and stenosis indices were evaluated for efficacy of treatment.

RESULTS

The hydroxyproline level (microg/mg wet tissue) in the groups was 1.54 +/- 0.08, 4.82 +/- 0.60, and 3.28 +/- 0.27, respectively. The hydroxyproline level increased significantly in group 2 compared with group 1 (P < 0.01). Although the hydroxyproline level was significantly increased in group 3 compared with group 1, it decreased significantly in group 3 compared with group 2 (P < 0.05) by treatment of ibuprofen. In group 3, the collagen content score (1.50 +/- 0.26) was significantly lower than in group 2 (2.62 +/- 0.37) (P < 0.05). The stenosis index was found as 0.37 +/- 0.02 in group 1, 0.84 +/- 0.02 in group 2, and 0.67 +/- 0.03 in group 3. The stenosis index in group 2 was significantly higher than group 1 and group 3 (P < 0.01). Although the stenosis index was significantly higher than in group 1, a significant decrease in stenosis index was found in group 3 compared with group 2, by ibuprofen treatment (P < 0.01).

CONCLUSION

Based on these results, we concluded that the treatment with ibuprofen in acute phase esophageal burn injury has beneficial effects on healing of esophagus and may decrease the stricture formation. For these reasons, ibuprofen may effectively be used in the acute phase treatment of caustic esophagus injury and after esophageal dilatation procedures.

Anatomically based comparison of the different transthoracic routes for colon ascension after total esogastrectomy

Colon interposition is the method of choice to restore the digestive tract after esogastrectomy. The aim of this study was to compare the length of the four available routes for colon transposition (posterior mediastinum route, transpleural route, substernal route and subcutaneous route) and to achieve a specific evaluation of the transpleural route. Our study was conducted with anatomical (dissection) and radiological (2D CT scan reconstructions) protocols. For both, the posterior mediastinum route was always the shortest way and the subcutaneous route was always the longest. For the anatomical results, the transpleural route and the substernal route were similar in terms of length and for the radiological study, the transpleural route was shorter than the substernal route (P < 0.001) and shorter than the subcutaneous route (P < 0.001). We demonstrated that the transpleural route was acceptable for colon transposition in term of length, and could be an alternative when the substernal route is unavailable.

A single center experience of self-bougienage on stricture recurrence after surgery for corrosive esophageal strictures in children

PURPOSE

This study was undertaken to evaluate the long-term treatment of esophageal strictures in children with corrosive esophagitis and to determine the effect of self-bougienage on recurrent strictures.

MATERIALS AND METHODS

We reviewed the medical records of nine children that were treated for corrosive esophageal strictures from May 2000 to May 2008. Six males and three females were included and their average age was 30 months. Six patients had ingested acids, two patents had ingested alkali, and one ingested an unknown agent.

RESULTS

The interval between caustic ingestion and esophageal stricture ranged from one to eight weeks. The average length of the esophageal strictures was 3.8 cm (range, 1 to 9.2 cm). Four patients had a long segment stricture (longer than 5 cm) and one patient had multiple strictures. The most common site of involvement was the upper third followed by the mid third of the esophagus. Eight patients received repeated dilatation using a balloon catheter or bougie dilator. Among the eight patients, two patients had complete resolution of symptoms and six patients required surgery. Among five patients that developed restenosis of the esophageal anastomosis site, three patients had improved symptoms after self-bougienage and two patients had improved symptoms with repeated balloon dilatation or endoscopic bougienage. There were no complications in these patients.

CONCLUSION

Although a small number of patients were studied, self-bougienage was safe, less invasive, and effective for the management of esophageal restenosis in patients who required frequent dilation after surgery.

Prevention and management of complications after colon interposition for corrosive esophageal burns

We present our experience in the management of complications after a colon interposition for corrosive esophageal burns. From April 1976 to December 2006, 85 patients with caustic esophageal burns were included in this study. The superior belly median incision with an anterior border incision of the left sternocleidomastoid was used. Anastomosis between the colon and the cervical esophagus was performed in 68 and between the colon and pharyngeal portion in 14 patients. An esophageal scar part resection and gastric-esophageal anastomosis was performed in one patient who had been given an unsuccessful colon and jejunum interposition at another institute. An anastomotic modeling operation was performed in one patient with anastomotic stricture who had been managed with colon interposition at another institute. Exploratory thoracotomy and gastrostomy was performed in one patient who had an unsuccessful colon interposition at another institute. Seven of 14 patients (8.5% of 17.1%) died with serious complications such as aspirated pneumonia, interposition colon necrosis, abdominal wound dehiscence and degradation of swallowing and concordance function. However, others with such serious complications survived and were discharged for rehabilitation after corresponding treatment. The 25 patients (30.1%) with other mild complications were discharged for rehabilitation and corresponding management. Two patients from other institutes were discharged for rehabilitation and one was lost to follow-up. The most dangerous complication of this procedure is colon necrosis, and the stomach is the best organ for re-operation. Otherwise, aspiration in infants due to hypoplasia and degradation of swallowing co-ordination needs attention. Peri-operative management is very important, including the control of mediastinal and pulmonary infection and systemic nutritional support to avoid abdominal wound dehiscence. The platysma flap is an excellent method for the treatment of anastomotic stricture.

Laparoscopically assisted transhiatal esophagectomy with esophagogastroplasty for post-corrosive esophageal stricture treatment in children

A tight post-corrosive esophageal stricture in a child poses significant surgical challenges. Many studies have described minimally invasive esophagectomy in adults, but very few reports have described this technique in children. Minimally invasive esophagectomy represents a new alternative to conventional open esophagectomy. This retrospective study evaluated the safety and efficacy of laparoscopically assisted transhiatal esophagectomy and gastric transposition for post-corrosive esophageal stricture treatment. Twenty-seven children with post-corrosive esophageal stricture were subjected to this technique. Their ages ranged from 3 to 13.5 years (mean 5.6 years). Fourteen were females and thirteen were males. None of the procedures needed to be converted to an open approach, and there were neither intra-operative complications nor increased blood loss. Left-sided pneumothorax occurred in one case only (3.7%). The mean operating time was 160 min (range 120-180). Three patients were admitted postoperatively to intensive care unit for a period of 48 h for assisted ventilation. Mean hospital stay was 4 days (range 3-7 days). Anastomotic leakage occurred in three patients (11.1%), while anastomotic stricture occurred in four patients (14.8%). About 93.5% of our cases have achieved excellent results. Post-operative nutritional status was satisfactory and accepted. Laparoscopically assisted transhiatal esophagectomy and gastric transposition for post-corrosive esophageal stricture treatment in children is safe, visible, effective, and an accepted operative technique. The cosmetic result is excellent.

The acute management and surgical reconstruction following failed esophagectomy in malignant disease of the esophagus

The stomach is the favored organ for reconstruction following esophageal resection for malignant disease, but has a 2% failure rate relating to ischemia. This event is associated with a high mortality, although appropriate surgical management with removal of the conduit can be life-saving. Further reconstruction is very challenging. We discuss the management options and surgical techniques for these patients. We reviewed of the surgical management of seven patients referred to a tertiary center over a 2-year period with failure of their primary esophageal reconstruction. Four patients had reconstruction with jejunum (2 free transfers and 2 'supercharged' pedicles with microanastomosis in the neck), and three with left colon. The route of reconstruction was substernal in four patients, subcutaneous in two, and through the left pleural cavity in one. There was 0% mortality, and 57% morbidity. The median intensive care unit stay was 2 days (mean 8, range 1-42). All patients tolerated full enteral nutrition, and had a satisfactory functional outcome. Failure of the conduit post-esophagectomy is a rare but serious complication, and these patients require complex surgical reconstruction. The surgical techniques described require a specialist multidisciplinary approach, but good clinical and functional outcomes are possible, even in patients with an underlying malignancy.

Methamphetamine Exposure Presenting as Caustic Ingestions in Children

With the growing prevalence of methamphetamine use and production in home laboratories, children are at risk for injuries resulting from living in a drug-endangered environment. Although the ingestion of household cleaners is usually accidental and not a result of illicit drug use or production, medical providers must be aware of the chemicals associated with methamphetamine and illicit drug production to identify patients harmed in this environment. We present the first reported cases of children harmed by ingesting caustic substances used in the production of methamphetamine in the home.

Esophageal reconstruction with intraoperative dilatation of the hypopharynx for the management of chronic corrosive esophageal strictures. A technical tip

Chronic corrosive strictures of the upper cervical esophagus and hypopharynx resulting from ingestion of caustic substances are a challenging surgical entity when repeated endoscopic dilatations fail to yield satisfactory results. Restoring the continuity of the upper digestive tract by esophageal substitution at healthy tissue margins not only compromises the integrity of the swallowing mechanism, but also often requires the performance of a tracheostomy in order to ensure avoidance of recurrent aspirations. We describe three cases of corrosive upper cervical esophageal strictures treated with intraoperative dilatation of the proximal hypopharyngeal stump and concurrent 'stenting' of the pharyngeal anastomosis with the conduit replacing the esophagus. All patients tolerated the procedure well. Avoidance of both impairment of deglutition and respiratory complications, as well as restoration of normal esophageal function, was successfully accomplished.

Corrosive injury to upper gastrointestinal tract: Still a major surgical dilemma

In the developed and developing countries, corrosive injury to the gastrointestinal system as a consequence of either accidental ingestion or as a result of self-harm has become a less common phenomenon compared to decades ago. This could partly be attributed to the tighter legislation imposed by the government in these countries on detergents and other corrosive products and general public awareness. Most busy upper gastrointestinal surgical units in these countries, especially in the developed countries will only encounter a small number of cases per year. Up to date knowledge on the best management approach is lacking. In this article, we present our experience of two contrasting cases of corrosive injury to the upper gastrointestinal tract in our thoracic unit in the last 2 years and an up-to-date Medline literature search has been carried out to highlight the areas of controversies in the management of corrosive injuries of the upper gastrointestinal tract. We concluded that the main principle in managing such patients requires a good understanding of the pathophysiology of corrosive injury in order to plan both acute and future management. Each patient must be evaluated individually as the clinical picture varies widely. Signs and symptoms alone are an unreliable guide to injury.

Successful Management of Esophageal Perforation Diagnosed 3 Days After Injury Caused by an Explosion in the Workplace: Report of a Case

We report a case of esophageal perforation caused by an explosion, but which was not diagnosed until 3 days after the injury. A 53-year-old worker sustained superficial dermal burns to his trachea, face, neck, and legs during an explosion. The burns were treated conservatively at a local hospital, but he was transferred to our hospital 3 days after the injury, when mediastinal emphysema and bilateral pleural effusion became evident. An esophagogram followed by computed tomography showed an esophageal perforation caused by the blast injury, and we performed an esophagectomy with recontruction of the gastric tube. After the operation, an X-ray showed a foreign body in the lower abdomen, which we found in the upper thoracic esophagus on the day of injury. We surmised that the patient had inadvertently swallowed a foreign body, which had been heated and scattered by the explosion, and it had melted the upper thoracic esophagus.