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Esophagoplasty for Esophageal Stenosis Due to Caustic Injuries in Children-Personal Experience

G. Aprodu, C. Botez, V. Munteanu
Iasi, Romania

 

Abstract 

Background: In pacients with esophageal stenosis caused by liquid caustic injury, with no response to nonsurgical treatment methods, the esophageal replacement represents the only way for a quasinormal life.

Material and methods: The authors report their experience regarding esophagoplasty for caustic esophageal strictures in 49 cases for a period of twelve years. Two esophagoplasty techniques have been used (reversed gastric tube in 33 cases, colonic conduit in 16 cases). The stripping of the scarred esophagus was accomplished in 29 cases, with the placement of the graft behind the hilum of the lungs (27 gastric and 2 colonic interpositions).

Results: In 36 cases the results were good at a follow-up of up to 12 years. Criteria like physical development, social behaviour, deglutition and contrast studies were noted. In 13 cases, complications occurred and four pacients died.

Conclusion: This study is not intended to be a comparative one; the small number of cases in our series does not allow concluding which technique is the best. Nevertheless, the authors did not notice major differences in the outcome of the patients treated with either of the techniques.

Key words: esophagoplasty, gastric tube replacement, colon replacement, caustic esophageal stenosis.

 

Correspondance 

Gabriel Aprodu MD, PhD,

Department of Paediatric Surgery, University of Medicine and Pharmacy Iasi, Romania. Tel: +040 232 220 727

„Sf. Maria“ Children’s Hospital, 62 Vasile Lupu street, 700309

Iasi, Romania

e-mail: This email address is being protected from spambots. You need JavaScript enabled to view it.  

 

Introduction

Esophageal replacement for postcaustic esophageal strictures is a last option, allowing pacients to have a normal life. The above-mentioned lesions are relatively rare in developed countries. Liquid caustic ingestion is an accident, representing 10% of the intoxication cases in children (15). Alkaline chemicals are the main cause of esophageal injuries, especially home-made lye solutions, dishwasher detergents, drain cleaners. The lesions inflicted by these agents are treated initially in the emergency room (21) and long-term results of most serious caustic lesions can be sometimes prevented (20).

The postcaustic esophageal stenosis is treated in the beginning by bougienage. Disrupting the scar tissue of a circular stricture, dilatation therapy combined with local injection of triamcinolone can be effective (3, 9). In many cases, though, the results are poor and esophageal replacement is necessary. The aim of this article is to present the authors’ experience regarding the cases which required esophagoplasty.

Methods

Between 1992 and 2004, 53 pacients were treated for postcaustic esophageal strictures. Home-made lye solution ingestion was responsible for 49 cases. The bougienage with wire-guided Savary dilators was used in 13 cases for up to nine sessions, with poor results. The rest of 36 cases didn’t receive dilatation therapy. All 49 pacients were operated on, the surgical procedure being esophagoplasty. There were 31 girls and 18 boys, with age ranging from 2 years and 4 months to 12 years old (mean age 5 years and 2 months old). 83% of the patients lived in rural area, where home-made lye is widely used. From the wide variety of surgical techniques described for esophagoplasty (right colon, transverse colon, gastric tube, gastric transposition), the authors employed the most used ones: reversed gastric tube and colonic conduit (Table 1).

Table 1. Esophagoplasty techniques used in our series 

Gastric Tube Colon
Esophagectomy 27 2
Scarred esophagus left in place 6 14
Total 33 16

In 33 cases (67,3%) the reversed gastric tube esophagoplasty was undertaken, without splenectomy, the tube being modeled from greater curvature of the stomach. The transverse colon, nourished by left colic artery, was used in 16 cases (32,6%).

In 29 cases, the esophagoplasty was preceded by blind transthoracic digital esophagectomy, placing the gastric or colonic tube in the scarred esophagus’ place, behind the hilum of the lung. In other 20 pacients the damaged esophagus stripping was impossible, due to intense periesophageal scarring process. In these cases, the new conduit (6 gastric tubes, 14 colonic tubes) was placed substernally. In all procedures suction drainage was used, the drain tube being brought out through an incision in the left laterocervical area. A second drain tube was placed in the vicinity of the removed esophagus in those cases when stripping was possible.

In all cases the gastrostomy was preserved three to four weeks after the esophagoplasty. The pacients with good results were able to feed orally eight days after the surgical intervention when a colonic conduit was used and eleven days postop in cases with gastric tube interposition.

caustic injuries 1

Figure1. Contrast study after gastric tube esophagoplasty.

Results

Postoperatively, all cases evolved well. In 13 cases (26%) complications occurred, early in 9 cases, late in 4 cases. Four pacients died (8,1%). The other 36 patients (73%) had good long-term results for up to 12 years after surgery. At periodical follow-up, certain parameters were recorded: physical status and development, social behaviour, deglutition. All patients underwent a contrast study of the esophageal graft. In all cases, physical development was according to chronological age; patients are going to kindergarten or school. Deglutition was normal in 29 cases (80,5%), seven having incidental choking. The contrast studies with barium sulphate showed normal appearance in 27 cases (75%), in nine cases was described an anastomotic stricture at the level of cervical esophagus-new conduit suture (gastric tube in all these cases). The gastric-new conduit reflux was also scrutinized, with negative results in all 36 cases. Esophageal pH-metry in patients with gastric tube interposition emphasized high acid levels throughout the 24-hour interval (1,14) There were complications in 13 cases (26,5%), summarized in Table 2: Nine cervical fistulas (7 after gastric tube and 2 after colonic tube interposition) were present. In cases with gastric conduit, all fistulas occurred in the fourth postop day and healed spontaneously after 10 to 12 days leaving behind a tight esophageal stricture. The anastomotic stenosis was treated surgically by resecting the narrowed zone and reestablishing the continuity of the neoesophagus by using tissue from dilated proximal portion. The fistulas after colon esophagoplasty had a bad outcome. They appeared in third or fourth postop day and not healed. In one case, after a month during which the fistula persisted, we were forced to give up the colonic conduit.This pacient has esophagostomy and gastrostomy, a new esophagoplasty being necessary. The other pacient contracted a severe sepsis due to necrosis of the tube and died. Both patients had mediastinitis. Other four cases had late complications, four months past surgery: An intestinal obstruction caused by adderential bands, occurred after gastric tube interposition, with good outcome after surgical release of the bowel adhesions. A fistula developed between the gastric tube and trachea, which started with cough, aspiration pneumopathy. The diagnosis was made after four months. The pacient was operated on (esophagostomy and gastrostomy) but recurrent pneumonic episodes led to death, six months after the esophagoplasty. Two gastric perforations; in one case, esophageal replacement was done eight months earlier, and in the other case, one year before.  

Table 2. Complications occured after gastric tube and colon esophagoplasties

Gastric Tube Colon
Early Complications Cervical fistula 7 2

Late Complications

Anastomotic stenosis

Intestinal occlusion

Gastric perforation

Esotracheal fistula 

7

1

2(2deaths)

1(1death)

2(1 death)

0

Peritonitis was the admission diagnosis in both, but symptoms appeared two to three days before admission. Intraoperatively, perforations were found, on the anterior part of the stomach in one case and on the posterior part in the other. Both cases had a bad outcome, demise occurring within first hours after the surgical intervention for peritonitis.

Discussion

Damaged esophagus replacement represents the final step in the treatment of caustic esophageal stenosis. There are several esophagoplasty techniques (17), but the most used ones in pediatric surgery are colon and gastric tube interposition. Variants have been described for each of these two procedures. The colonic conduit can be raised from right colon, transverse colon, transverse and left colon (4, 11, 16). Gastric tube esophagoplasty (10) was employed also by pediatric surgeons for treating caustic lesions (7, 8, 19)

Initially, derivative esophagoplasty was the rule, the corrosive scarred esophagus being left in place. Because of the risk of squamous cell carcinoma, removal has become a necessity (6, 18). The graft’s placement was substernally. Ionescu (13) in 1985 reported a new technique of esophagoplasty with gastric tube with couples blind transthoracic digital esophagectomy, the graft being placed in the scarred esophagus place. The blind transthoracic digital esophagectomy is suitable to pediatric pacient. The relative small dimensions of the thorax make a thoracotomy unnecessary, digital or blunt dissection of the scarred esophagus becoming feasible. The most feared complications of digital esophagectomy are lesions of great vessels and disruption of the posterior tracheal wall (18). The first situation is not encountered in the literature, though, and neither in our practice. The tracheal wall lesion was probably responsible for a tracheoneoesophagus fistula in one of our cases, with late diagnosis.

Bassouny (5) reports 4% mortality after digital esophagectomy in a series of 70 cases which underwent this procedure. The bad results were related with pulmonary lesions. The complications of esophagoplasty are challenging, no matter witch technique is used (2). The most frequent are proximal fistulas at the site of anastomosis of cervical esophagus and the graft. In our series, seven out of nine fistulas occurred with gastric tube, despite the fact that this type of conduit has a rich vascular supply. On the other hand, we had only two cases of fistula in colonic grafts, although the length of the vascular pivot (left colic artery) is big and so the risk of distal ischemia. It is noteworthy that these two cases had a fatal outcome, due to partial or total graft necrosis. The surgical technique by itself led to another group of complications. Blind digital esophagectomy inflicted a fistula between the gastric tube and posterior wall of trachea. Also, two gastric perforations occurred after gastric tube interposition without splenectomy, although the stomach has a rich vascular supply, with very low risk of ischemia.

The results of esophagoplasties are difficult to assess. There are studies on 800 cases (12). Information regarding the life quality in patients that underwent esophagectomy and esophageal replacement for esophageal strictures is scarce. Young (22) in 2000 studied a group of 81 patients operated on for postcaustic strictures of the esophagus. Gastric tube was used in 71% of cases, colonic conduit in 20% and small intestine in 9% of cases. He reported no major outcome differences neither with various techniques of esophageal replacement, nor with age and sex.

Conclusions

The outcome of esophagoplasty as a surgical method of treating postcaustic esophageal stenosis is influenced by a number of factors: the digestive tube segment used for replacement, the anatomical site in which the graft is placed, the type of anastomosis between the conduit and the cervical esophagus or the stomach. Despite the fact that symptoms like disphagia persist no matter what type of esophagoplasty is used, overall, the quality of life and social interaction of patients are good.  

 

 

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