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To review the patients with esophageal injuries and stenosis with respect to their etiology, clinical course, management, and the lessons learnt from these.
Retrospective descriptive observation review of children with esophageal injuries and stenosis admitted between January 2009 and April 2015.
Eighteen children with esophageal injuries of varied etiology were managed and included, seven with corrosive injury, five with perforation due to various causes, three with mucosal erosion, two with trachea esophageal fistula (TEF), and one wall erosion. The five children who had perforation were due to poststricture dilatation in a child with esophageal atresia and secondary to foreign body impaction or its attempted retrieval in four. Alkaline button cell had caused TEF in two. Three congenital esophageal stenosis (CES) had presented with dysphagia and respiratory tract infection. Six corrosive stricture and two CES responded to dilatation alone and one each of them required surgery. Four of the children with esophageal perforation were detected early and required drainage procedure (1), diversion (1), and medical management (2). Pseudo diverticulum was managed expectantly. Among TEF, one had spontaneous closure and other one was lost to follow-up. All the remaining nineteen children have recovered well except one CES had mortality.
Esophageal injuries though rare can be potentially devastating and life-threatening.
Esophageal foreign bodies (FBs) are seen in all ages. Endoscopic removal under general anesthesia (GA) is the common mode of retrieval of sharp, irregular, and impacted FBs by a team of pediatric surgeon, anesthetist, and pediatric gastroenterologist. Magill forceps removal under GA is the method for cricopharyngeal impacted smooth FBs. Improper extraction techniques could cause perforation.[1,2,3] Congenital esophageal stenosis (CES) is a rare disorder.
We present this retrospective chart review of esophageal injuries/stenosis as it reinforces the need for appropriate management by a team of specialists as per safe protocols.
Data of 21 children with esophageal injuries (18) and CES (3) admitted to the pediatric surgery unit between January 2009 and April 2015 were reviewed retrospectively. Clinical features, etiology, and their management were analyzed.
Age at presentation varied from 3 months to 12 years. There were 21 children with varied presentations; corrosive stricture (7), cervical perforation (2), thoracic perforation (1), esophageal mucosal injury (3) trachea esophageal fistula (TEF) (2), retropharyngeal abscess (1), pseudo diverticulum (1), wall erosion (1), CES (3) [Table 1] and [Figures [Figures11 and and2].2]. Five children with corrosive strictures presented within 3 weeks of ingestion while the remaining two had ingested more than 3 months back. Contrast study and endoscopy revealed single (4) or multiple strictures (3); varied size (5 mm in 2, 1 cm 2, 1.5 cm 1, 5 cm 1), and site (cricopharynx 2, middle one-third 2, lower one-third 5) and near complete obstruction (2). Children with severe stricture (2) had gastrostomy, followed by retrograde and ante grade dilatation under endoscopic guidance by the gastroenterologist. They had food bolus obstruction on 3rd year of follow-up and required re dilation program. Adolescent girl underwent transhiatal native esophagectomy and orthotopic gastric transposition. This was possible in spite of previous failed colon replacement attempt by a combination of esohagoscopic guidance and approach from a proximal healthy cervical incision. She had symptomatic anastomotic stricture at 11 months and required re dilatation program. The remaining four corrosive strictures responded well to antegrade dilatation using Savory Gillard dilators. The protocol followed was to dilate to appropriate size for age and then continue at weekly thrice, fortnightly thrice, and taper by monthly thrice to stop. Later part of dilations was done blindly without any complications.
Three CES children presented with dysphagia, nonbilious vomiting, and recurrent respiratory tract infection. Contrast study and, endoscopy confirmed stenosis at lower one-third (2) or middle one-third esophageal segment (1). Stenotic length was variable; 1 cm (2) and 3 cm (1). Two responded to our calibration protocol and one required resection who later died due to mediastinum leak.
Six children presented with esophageal perforation; cervical (2), thoracic (1), contained pseudodiverticulum (1), and TEF (2). Two boys presented with cervical perforations due to impaction and/or retrieval of a 2 cm × 3 cm metal flag and dental prosthesis respectively at cricopharynx. Both had drooling of saliva and dysphagia. Both FB were removed with Magill's forceps under GA in the operation theater (OT). The first patient however had an unsuccessful attempt in fluoroscopy room on an outpatient basis [Figure 2]. Contrast enhanced computerized tomography (CECT) and contrast swallow revealed extensive cervical leak in the first boy who required cervical drainage. Fistula healed after 2 months. Other boy responded to antibiotics.
A 3-month-old, postesophageal atresia repair underwent gastrostomy and retrograde dilatation for anastomotic stricture who later developed thoracic leak requiring immediate intercostal tube drainage. She responded to thoracotomy, debridement, and diversion (proximal cervical esophagostomy) and ligation of distal esophagus. Anastomotic stricture of gastric transposition responded to dilatation.
Five children had alkaline battery impaction at cricopharynx with varied complications including TEF (2), torticollis and retropharyngeal abscess (1), pseudodiverticulum (1) [Figure 1] and cervical erosions. FB were retrieved with magill (4) or basket (1). One of the two TEF patients was referred to our hospital on ventilatory support after two unsuccessful attempts of removal in local hospital. He was lost to follow-up. Other TEF healed spontaneously after 4 months. Rest were managed conservatively.
Two children presented with open safety pin, one in cricopharynx and another at mid esophagus. They had mild mucosal injury and were retrieved with magill (1) and endoscopic basket (1) with sharp end pointing downward in major OT. One-year-old girl had cervical wall erosion due to 2-day-old impacted ear ring and underwent retrieval with magill. All children had good weight gain and asymptomatic at last follow-up, which ranged from 1 to 3 years.
Vomiting, throat pain, dysphagia, pooling of saliva, stridor, chest pain, fever, and tachypnea are prominent symptoms of esophageal injuries. Foreign body impaction, inappropriate modes of retrieval, nonavailability of technical expertise, endoscopy and instrumentation, esophageal dilatation are some of the causes for esophageal perforation.[3,4] There have been reports of higher complications in academic training/teaching institute, emergency procedure, and institute with low patient volume.[2,3,5] Though instrumentation is the common cause of esophageal injury, sharp object impaction or retrieval (33%) has the highest complication rate which has been reconfirmed in our series also.[1,4] Site of perforation may be anywhere from cervical to abdominal esophagus. Esophageal strictures are of varied etiology like corrosive poisoning, anastomotic stricture of esophageal atresia repair or replacement tubes.[6,7]
Foreign body ingestion is usually seen in children aged 1-3 years, 10-20% of which get impacted in the esophagus. Two percent of FBs in the esophagus are alkaline button batteries.[8,9,10,11] Eight of the ten patients who had foreign body impaction, were <4 years. FB usually presents earlier following impaction or may have an indolent course and present later with secondary complications. All of our cases were in the impaction stage and was diagnosed correctly by caregivers which are the commonest mode of presentation. Alkaline button battery impacted in the esophagus should be considered life-threatening, due to its potential to cause full thick burns leading to perforation, tracheoesophageal fistula, exsanguinations after fistulization of arteries, and airway compromise.[8,9] The injury depends on size (>2 cm), duration (>2 h) and area of contact, heat produced and the various electrochemical effects of the battery.[8,9] Battery can cause mucosal damage in 1 h, erosion in 2.5 h, and perforation as early as 5 h.[8,9,10] Its prompt removal within 2 h of ingestion is mandatory to prevent morbidity and mortality.[8,11] Ingestions are usually accidental but often not considered for specialized treatment services. Irregular and sharp FBs should be removed under controlled conditions in the operation theater under GA to prevent complications.[4,8] Protective measures in sharp object retrieval are its engagement to distal end of endoscope, holding and changing directions in stomach and retrograde retrieving with sharp end caudally, and use of basket and protective devices like FB hood protector or over tube. Our study also emphasized above findings. Battery is retrieved easily with Magill forceps or retrieval net in OT. Ferric oxides with blackish-brown deposits are seen on battery after electrolysis. Clinician awareness of level I trauma care for battery could prevent its lethal complication. Esophageal open safety pin are pushed downwards if open end is pointing upwards and removed after reversing direction or locking pin in stomach.
Immediate plain X-ray 2 h after any esophageal procedure with potential to cause injury could detect perforation early.[12,13,14,15] Contrast study and endoscopy often helps to know site of perforation, extent of leak/damage/resolution, and nature of distal esophagus.[16,17,18] Postremoval esophagogram is a must before onset of oral feeding in prolonged impaction/delayed diagnosis of FB. Electroporation (joule effect)/sodium hydroxide at the battery cathode end would results in TEF and pseudo-diverticulum when it contacts with anterior and posterior esophageal wall respectively.[11,17] TEF have been treated with hyper baric oxygen, conservative management with spontaneous closure but frequently require open surgery with long term sequel. However, our child had spontaneous closure of TEF. Cervical perforation has subtle presentation due to deep cervical fascia of neck. CECT scan in deteriorating patients gives additional information. Acute cervical perforations are managed well by controlled adequate drainage with antibiotics or antibiotics only. Thoracic perforation following the 1st time attempted calibration of impassable anastomotic esophageal stricture usually needs early thoracotomy, debridement, and diversion with esophageal replacement later.[13,14] Early recognition of this potentially life-threatening complication is required to prevent a downhill course.
Acquired esophageal stricture is benign. Delayed presentation of severe corrosive stricture usually were managed initially by gastrostomy and followed with multiple calibrations for successful outcome.[7,8,9] Incidence of postcalibration perforation is 1.5-2%.[7,12] Balloon and savory dilatations are safe and effective in the hands of respective experts.[6,7] Retrograde and string running dilatations are useful in severe stricture. Success of dilatation depends on age, site, length, number, etiology, expertise of airway management, and response of stricture dilatation.[6,7,12] Dilatations are used before or after surgery as alternative or complementary. Our calibration protocol is safe and effective. With appropriate planning and use of endoscope guidance we managed an orthotopic gastric transposition after native esophagectomy in adolescent girl. Close follow-up and barium swallow/endoscopy in scarring period and later follow-up could detect stricture earlier in those with inadequate history and minimal symptoms/or oral lesion on examination. Though rare, CES should be considered in recurrent respiratory tract infection and often responds to calibrations in young children.
There will be steep learning curve in the FB extraction techniques and complications are more in local hospital/low surgical volume. Esophageal replacement has better functional and early good outcome than primary repair/endoscopy procedure in the perforation of obstructive complex esophageal disease.[12,15] Health education of parents and caregivers, keeping things out of reach of children and in secure compartment with lock, active supervision during playing, use of dry run model with reproducible FB, and creation of specialized referral network system could prevent these accidents.[6,16,17] Primary prevention is always better than improved treatment option.
Irregular and sharp FBs and alkaline battery requires tertiary level care. Esophageal strictures/stenosis should be dilated by appropriate techniques and protocols, by persons with expertise in the same and with fluoroscopic or endoscopic guidance. Esophageal perforations should be detected early by expectant monitoring and prompt treatment initiated with an aim at conserving the native esophagus and when not possible esophageal replacement. Esophageal strictures require a long-term follow-up. CES responds to calibrations and TEF can be managed conservatively.
There are no conflicts of interest.