INDEPENDENT ARTICLES
Conservative Treatment of Caustic Esophageal Strictures in Children By HOlya Z, GOndoejdu, F. Cahit Tanyel, Nebil B0y0kpamukgu, and AkgOn Higs6nmez Ankara, Turkey 9 The most common cause of esophageal stricture in children is the accidental ingestion of strong corrosive agents. During a 13-year period between 1976 and 1989, 202 patients were diagnosed as having caustic esophageal strictures at the Hacettepe University Children's Hospital Department of Pediatric Surgery. A retrospective clinical study was performed to find out the place and predictors of a successful outcome for conservative treatment in children who have caustic esophageal strictures. Two hundred two children, of whom 145 were male (71.7%) and 57 female (28.3%) with 168 (83.2%) being younger than 6 years of age, were evaluated retrospectively. Whereas only 49.3% of patients could be treated within a 12-month period, 50.7% needed more than 1 year, 32.9% needed more than 2 years, 26.7% needed more than 3 years, and 15.4% needed more than 4 years of periodic dilations in order to become swallowers through native esophaguses. The success of conservative treatment has been higher in patients younger than 8 years of age, and in strictures due to caustics other than lye involving upper third portion and less than five cm of an esophageal segment. Most caustic esophageal strictures could have been treated by conservative measures in children.
Copyright 9 1992 by W,B, Saunders Company INDEX WORDS: Esophageal strictures, caustic.
C C I D E N T A L caustic substance ingestion is one of the worldwide common problems among children.1 The most important complication of caustic ingestion is esophageal burn, which may result in severe strictures. 2 Numerous studies attempting prevention of stricture formation following caustic burns have appeared in the literature. 3-6 Despite efforts at prevention, 7% to 15% of children sustaining caustic esophageal burns develop esophageal stricturesY Factors predicting a successful outcome following conservative treatment and the time interval of how long to persist in dilatations have not been evaluated adequately. Additionally, the places of conservative treatment and bypass surgery still remain controversial. A retrospective clinical study was conducted to discuss the place and predictors of a successful outcome for conservative treatment in children who have caustic esophageal strictures. MATERIALS AND METHODS During a 13-year period between 1976 and 1989, 202 patients were diagnosed as having caustic esophageal strictures at the Hacettepe University Children's Hospital Department of Pediatric Surgery. One hundred sixty-eight patients (83.2%) were younger than 6 years of age on admission; of the 202, 145 were male (71.7%) and 57 were female (28.3%).
Journal of Pediatric Surgery, Vol 27, No 6 (June),1992:pp 767-770
All of the patients were referred after the strictures had become complicated. The diagnosis of caustic esophageal stricture was established through esophagographic and esophagoscopic examinations in patients who fail to swallow following caustic substance ingestion. Dilations were planned in every patient who could swallow saliva and had any lumen to dilate. Dilations were carried out under general anesthesia. Anterograde dilations by mercury filled Hurst or stiff woven bougies were initially tried. In the presence of a dilated proximal esophagus and failure to dilate via anterograde route, gastrostomy and retrograde dilations were planned. Dilations were carried out twice weekly in the first month, once weekly in the second month, and once every 2 weeks in the third month. The intervals between dilations were additionally regulated according to the patient's ability to swallow meat and bread, and the radiologic appearance of the esophagus. In patients who could swallow without any difficulty 1 month after dilation, the interval was prolonged to 1V2 months. The intervals were similarly prolonged to 2 and thereafter 3 months. If the patient had no difficulty in swallowing and no deterioration was seen on the esophagogram during a 3-month interval, the interval was prolonged to 6 months. Patients who had no difficulty in swallowing were discharged from the dilation program. The patients were followed for at least 1 year after the cessation of dilations. If the patient showed partial improvement the dilation program was continued using the swallowing factor as our criterion during the 4- to 6-month check ups. Bypass surgery as an initial treatment was only planned in the presence of complete or nearly complete obliteration of the lumen involving an esophageal segment of more than 3 cm in length and causing inability to swallow saliva. Other bypass indications have been difficulties in swallowing meat and bread within a month following the last dilation after the completion of the 1-year treatment period, and difficulties and bleeding during dilating a patient who had previously experienced esophageal perforation. The results of treatment of 202 patients were recorded. The patients whose esophageal strictures were relieved by dilatations were compared with patients for whom bypass surgery was indicated after the initiation of dilatations to find out the predictors of a successful outcome by conservative treatment. Factors that may influence the outcome such as age, ingested caustic, the initial approach at home, treatment against stricture formation, the localization of stricture, length of stricture, and perforation were analyzed. The X2 test was used for statistical analyses and P values less than 0.05 were considered to be significant.
From the Department of Pediatric Surgery, Hacettepe University Children's Hospital, Ankara, Turkey. Date accepted:April 16, 1991. Address reprint requests to Hiilya Z. Giindo~,du, MD, Hacettepe ~ocuk Hastanesi, ~ocuk Cerrahisi Aria Bilirn Dah, Sthhiye, Ankara 06100, Turkey. Copyright 9 1992 by W.B. Saunders Company 0022-3468/92/2706-0024503. O0/ 0 767
GONDO(~DU ET AL
768
RESULTS
Table 2. Total Treatment Time by Dilations
Of the 202 patients admitted with a history of ingested caustics, the causative agents were: lye in 147 patients (72.7%), hydrochloric acid in 30 patients (14.8%), other acids in 14 patients (6.93%), quick lime in 8 patients (3.96%), and other alkalies in 3 patients (1.48%). Of the 202 patients, 133 (65.8%) had difficulties in swallowing solid food, 45 (22.3%) had difficulties in swallowing liquid diets and the remaining 24 (11.9%) had difficulties in swallowing saliva on admission. One hundred sixty-three patients (80.7%) were admitted within 3 months following caustic substance ingestion. The strictures involved the upper third portion of the esophagus in 82 patients (40.6%), middle third portion in 48 patients (23.8%), lower third portion in 47 patients (23.3%), and whole portions in 25 patients (12.4%). The lengths of strictured esophageal segments were between 3 and 5 cm in 72 patients (35.6%), 6 and 9 cm in 84 patients (41.6%), 10 and 14 cm in 43 patients (21.3%), and 15 cm or longer in 3 patients
(1.5%). Seven patients who ingested lye (4), hydrochloric acid (2), and sulphuric acid (1) additionally had accompanying pyloric strictures that necessitated operative relief. Bypass surgery was considered a necessary initial treatment in 23 patients; 179 underwent a chronic dilation program. Dilations began via the anterograde route in 42 patients and via the retrograde route in 137 patients. Forty of the 42 patients who were initially dilated via the anterograde route required additional gastrostomy and retrograde dilations because of esophageal perforations or difficulties in dilating. The most frequent complication during dilations was esaphageal perforations. The other complications included esophageal impaction by a bolus of food in 8 patients (3.96%) and granulation at the Table 1. Results of Treatment in 202 Children Who Have Caustic Esophageal Strictures Results of Treatment Complete success of treatment by dilations Still under dilation program with improvement Bypass surgery initially Bypass surgery after dilations Death Total
Male No.
68
Female No.
29
31 20 21 5
17 3 6 2
145
57
Total Treatment Time (mo)
No. of Patients Treated by Dilations
Percent
1- 12 13-24
48 17
49.4 17.5
25-26
6
6.2
37-48 49-60 60+
11 1 14
11.3 1 14.4
Total
97
gastrostomy site in 7 patients (3.5%). Perforations, which occurred in 34 patients, were most frequent within 3 months of ingestion (94%). All the perforations occurred during esophagoscopy or dilating via anterograde route by still woven bougies. Most of the perforations occurred during initial attempts (38.2%). While 97 patients could have been treated by dilations at the end of study period, 27 patients required bypass surgery after initiation of dilation program (Table 1). Death occurred in 7 of the 202 patients. Six patients died of esophageal perforations during anterograde dilations. One patient died of massive bleeding from the ulcerated transplanted colon. Thirty + 5.14 dilations per patient were required for treatment among 97 patients. Of the 97 patients treated by dilations, strictures have been relieved in a 1-year period in 48 patients (49.4%) but 14 patients (14.4%) required more than 5 years (Table 2). The comparison of 97 patients who were treated by dilations to 27 patients whom necessitated a bypass surgery after the initiation of dilations showed age to be an important determinant of the outcome (Table 3). Patients younger than 8 years of age have a greater chance of being treated by dilations (X2 = 13.031, P < .05). The ingestion of lye lessened the chance of being treated by dilatations (Table 4) (• = 17.808, P < .05). The initial approaches at home, and initial treatments against stricture formation did not influence the outcome (Tables 5 and 6) (• = 4.948, P > .05 and • = 3.287, P > .05, respectively). Table 3. Comparison of Patients Who Were Treated by Dilations and Required Bypass Surgery According to Their Age
Total No. (%)
Results of Treatment Treated Successfully by Dilations
97 (48) 48 23 27 7
(23.7) (11.3) (13.3) (3.4)
202 (100)
100
Age (yr) 0-4 5-8 9+ Total
Unsuccessful
Total No.
No.
(%)
No.
(%)
86 24 14
69 22 6
(80.2) (96.1) (42.8)
17 2 8
(19.8) (8.4) (57.8)
124
97
(78.2)
27
(21,8)
PEDIATRIC CAUSTIC ESOPHAGEAL STRICTURES
769
Table 4. Results of Treatment According to the Ingested Caustic Substance
Table 6. Results of Treatment According to the Initial Treatment Against Stricture Formation
Results of Treatment Treated Successfully by Dilations
Results of Treatment
Unsuccessful
Treated Successfully by Dilations Unsuccessful
Initial Treatments Against Stricture Formation
Caustic Substance
Total No.
No.
(%)
No
(%)
Lye Hydrochloric acid
74 26
52 25
(70.2) (96.1)
22 1
(29,8) (3.9)
Only antibiotic Antibiotic + steroid
20 36
Other acid Quicklime
10 12
10 10
(100) (83.3)
-2
-(16,7)
Antibiotic + steroid + early dilation Other treatments
2
--
Other alkaline Total
124
--
97
(78.2)
2 27
(100)
DISCUSSION
The treatment of caustic esophageal strictures remains controversial. Although some authors advocate bypass surgery as a treatment of choice, s-l~others suggest dilations initially and bypass surgery if the stricture has not been relieved after 3 to 12 months of dilations.2,4,n The individualization of the treatment is generally suggested. However, the criteria to guide the treatment have not clearly been established. Considering that the native esophagus is the best and no substitute can equally replace it, we have initiated dilations whenever there has been a lumen to dilate. Since only 27 of 179 patients who had chronic dilation program required bypass surgery, conservative treatment seems possible even in the presence of a severe stricture. On the other hand, attempts at Table 5. Results of Treatment According to the Initial Approaches at Home
Total No.
No.
(%)
(%)
14 26
(70) (72.2)
6 10
(30) (27.8)
32 36
28 29
(87.5) (80.5)
4 7
(12.5) (19.5)
124
97
(78.2)
27
(21,8)
dilating severe strictures carries a high risk of perforation which was encountered in 34 patients in the present series. The perforations most commonly occurred during esophagoscopy or initial dilation, and within 3 months of ingestion. All perforations occurred during attempts via the anterograde route. It was reported that dilating by pulling instead of pushing obviates the risk of perforation.12 None of the perforations was caused by retrograde dilations among these patients. Therefore, in this department dilating via the retrograde route has been preferred in recent years. 13 This approach eliminated the risk of esophageal perforations. No other complications, such as abscess, were encountered during the study period. Because the required time interval for relief was longer than a 12-month period in 50.7% of the patients whose strictures had been relieved by dilations, planning bypass surgery according to the time interval alone seems inappropriate. The comparison of patients whose strictures were relieved with patients who required bypass surgery after the initiation of chronic dilations program showed the ingested caustic to be one of the important determinants of the outcome. It is known that lye results in more severe strictures. The present series also showed that strictures that develop following lye ingestion are more resistant to dilations. On the other hand, preventive measures against stricture formation either performed at home immediately following ingestion or in
Results of Treatment Treated Successfully by Dilations
Unsuccessful No.
(%)
Localization of the Stricture
Total No.
No.
(%)
No.
(%)
51 26 27 20
47 23 24 3
(92.1) (88,4) (88.8) (15)
4 3 3 17
(7.9) (11.6) (11.2) (85)
124
97
(78.2)
27
(21.8)
Causing vomiting Giving milk Giving yogurt
33 13 18
23 9 15
(69.6) (69.2) (83.3)
10 4 3
(30.4) (30.8) (~6.7}
Other approaches No approach
9 51
9 41
(100) (80.3)
-10
-(19.7)
Upper 1/3 Middle 1/3 Lower 1/3 Whole
124
97
(78.2)
27
(21.8)
Total
Total
No.
Table 7. Results of Treatment According to the Localization of Stricture
Results of Treatment
Initial Approaches at Home
Total
(%)
(21.8)
If the strictures have been located at any one third portion of the esophagus, the chance of benefiting from dilations was higher, but if the strictures involved the whole esophagus the chance was lower (Table 7) (X2= 56.151, P < .01). If the involved segment was less than 5 cm the success rate was higher (Table 8) (• = 22.610, P < .001). Experiencing a perforation lowered the success rate (Table 9) (• = 32.560, P < .001).
Treated Successfully by Dilations
Total No. No.
Unsuccessful
770
GUNDOGDU ET AL
h o s p i t a l following e s o p h o g o s c o p i c c o n f i r m a t i o n has n o t r e s u l t e d in easily d i l a t a b l e strictures. It has p r e v i o u s l y b e e n r e p o r t e d t h a t t r e a t m e n t a g a i n s t strict u r e f o r m a t i o n m a y p r e v e n t s t r i c t u r e a n d m a y also d e c r e a s e t h e severity o f c o m p l i c a t i n g strictures. 7 H o w ever, t h e p r e s e n t series s h o w e d t h a t p r e v e n t i v e m e a sures h a d no effect o n t h e success o f dilations. T h e age at a d m i s s i o n has b e e n f o u n d to influence t h e o u t c o m e . T h e s t r i c t u r e s e n c o u n t e r e d in p a t i e n t s y o u n g e r t h a n 8 y e a r s o f age have b e e n r e l i e v e d m o r e successfully t h a n t h o s e in o l d e r children. T h i s m a y b e d u e to t h e g r e a t e r h e a l i n g c a p a c i t y in y o u n g e r children.
Table 8. Results of Treatment According to the Length of Stricture Results of Treatment Treated Successfully by D i l a t i o n s
Unsuccessful
Length of Stricture
Total No.
No.
(%)
No.
(%)
2-5 cm 6-9 cm 10-14cm 15+ cm
57 40 24 3
52 25 20 --
(91.23) (62.50) (83.33) --
5 15 4 3
(8.77) (37.55) (16.67) (100)
124
97
(78.2)
27
(21.8)
Total
Table 9. Results of Treatment According to the Esophageal Perforation During Treatment Results of Treatment Treated Successfully by Dilations
Unsuccessful
During Treatment
Total No.
No.
(%)
No.
(%)
Esophageal perforation No perforation
20 104
6 91
(30) (87.5)
14 13
(70) (12.5)
Total
124
97
(78.2)
27
(21.8)
T h e o t h e r factors f o u n d to influence t h e success o f conservative treatment have been the region and the l e n g t h o f involved e s o p h a g e a l s e g m e n t s . T h e strict u r e s involving less t h a n 5 c m o f e s o p h a g e a l s e g m e n t a n d l o c a t e d in t h e u p p e r t h i r d p o r t i o n o f e s o p h a g u s have m o r e successfully r e l i e v e d by dilations. O n t h e o t h e r h a n d , success was l i m i t e d in strictures involving m o r e t h a n 9 c m o f e s o p h a g e a l s e g m e n t . Thus, in s u m m a r y , t h e success of conservative t r e a t m e n t is h i g h e r in p a t i e n t s y o u n g e r t h a n 8 y e a r s o f age, a n d in s t r i c t u r e s d u e to caustics o t h e r t h a n lye involving u p p e r t h i r d p o r t i o n a n d less t h a n 5 c m o f an e s o p h a g e a l s e g m e n t . A l t h o u g h a long t i m e interval m a y b e r e q u i r e d , p e r i o d i c d i l a t i o n s u s u a l l y r e s u l t in n o r m a l swallowing t h r o u g h native e s o p h a g i in children.
REFERENCES
1. Buntain WL, Cain WC: Caustic injuries to the esophagus: A pediatric overview. South Med J 74:590-594, 1981 2. Tunell WP: Corrosive strictures of the esophagus, in Welch KJ, Randolph JG, Ravitch MM, et al (eds): Pediatric Surgery. Chicago, IL, Year Book, 1986, pp 698-703 3. Goldman LP, Weigert JM: Corrosive substance ingestion: A review. Am J Gastroentero179:85-90, 1984 4. Fyfe AH, Auldist AW: Corrosive ingestion in children. Z Kinderchir 39:229-230, 1984 5. Marshall F: Caustic burns of the esophagus: Ten-year results of aggressive care. South Med J 72:1236-1237, 1979 6. Tanyel FC, BiJyfikpamukqu N, HiqsOnmez A: The place of steroid antibiotics and early bougienage combination in the treatment of caustic esophageal burns in childhead. Turk J Pediatr 30:253-257, 1988 7. Holler JA, Andrews HG, White JJ, et al: Pathophysiology and managements of acute corrosive burns of the esophagus: Results of treatment in 285 children. J Pediatr Surg 6:578-584, 1971
8. Burfard TH, Webb WR, Ackerman L: Caustic burns of the esaphagus and their surgical management. A clinico-experimental correlation. Ann Surg 138:453-460, 1953 9. Imre J, Kapp M: Arguments against long-term conservative treatment of esophageal strictures due to corrosive burns. Thorax 27:5594-598, 1972 10. Oakes DD, Sherck JP, Mark JBD: Lye ingestion. Clinical patterns and therapeutic implacation. J Thorac Cardiovasc Surg 83:194-204, 1982 11. Symbas PN, Vlasis SE, Hatcher CR Jr: Esophagitis secondary to ingestion of caustic material. Ann Thorac Surg 36:73-77, 1983 12. Tucker GF: Caustic esophageal burns, in Raffensperger JG (ed): Swenson's Pediatric Surgery. New York, NY, AppletonCentry-Crofts, 1980, pp 784-792 13. Tanyel FC, Biiyiikpamuk~u NB, Hiqs6nmez A: An improved stringing method for retrograde dilatations of causic esophageal strictures. Pediatr Surg Int 2:57-58, 1987
Conservative Treatment of Caustic Esophageal Strictures in Children By HOlya Z, GOndoejdu, F. Cahit Tanyel, Nebil B0y0kpamukgu, and AkgOn Higs6nmez Ankara, Turkey 9 The most common cause of esophageal stricture in children is the accidental ingestion of strong corrosive agents. During a 13-year period between 1976 and 1989, 202 patients were diagnosed as having caustic esophageal strictures at the Hacettepe University Children's Hospital Department of Pediatric Surgery. A retrospective clinical study was performed to find out the place and predictors of a successful outcome for conservative treatment in children who have caustic esophageal strictures. Two hundred two children, of whom 145 were male (71.7%) and 57 female (28.3%) with 168 (83.2%) being younger than 6 years of age, were evaluated retrospectively. Whereas only 49.3% of patients could be treated within a 12-month period, 50.7% needed more than 1 year, 32.9% needed more than 2 years, 26.7% needed more than 3 years, and 15.4% needed more than 4 years of periodic dilations in order to become swallowers through native esophaguses. The success of conservative treatment has been higher in patients younger than 8 years of age, and in strictures due to caustics other than lye involving upper third portion and less than five cm of an esophageal segment. Most caustic esophageal strictures could have been treated by conservative measures in children.
Copyright 9 1992 by W,B, Saunders Company INDEX WORDS: Esophageal strictures, caustic.
C C I D E N T A L caustic substance ingestion is one of the worldwide common problems among children.1 The most important complication of caustic ingestion is esophageal burn, which may result in severe strictures. 2 Numerous studies attempting prevention of stricture formation following caustic burns have appeared in the literature. 3-6 Despite efforts at prevention, 7% to 15% of children sustaining caustic esophageal burns develop esophageal stricturesY Factors predicting a successful outcome following conservative treatment and the time interval of how long to persist in dilatations have not been evaluated adequately. Additionally, the places of conservative treatment and bypass surgery still remain controversial. A retrospective clinical study was conducted to discuss the place and predictors of a successful outcome for conservative treatment in children who have caustic esophageal strictures. MATERIALS AND METHODS During a 13-year period between 1976 and 1989, 202 patients were diagnosed as having caustic esophageal strictures at the Hacettepe University Children's Hospital Department of Pediatric Surgery. One hundred sixty-eight patients (83.2%) were younger than 6 years of age on admission; of the 202, 145 were male (71.7%) and 57 were female (28.3%).
Journal of Pediatric Surgery, Vol 27, No 6 (June),1992:pp 767-770
All of the patients were referred after the strictures had become complicated. The diagnosis of caustic esophageal stricture was established through esophagographic and esophagoscopic examinations in patients who fail to swallow following caustic substance ingestion. Dilations were planned in every patient who could swallow saliva and had any lumen to dilate. Dilations were carried out under general anesthesia. Anterograde dilations by mercury filled Hurst or stiff woven bougies were initially tried. In the presence of a dilated proximal esophagus and failure to dilate via anterograde route, gastrostomy and retrograde dilations were planned. Dilations were carried out twice weekly in the first month, once weekly in the second month, and once every 2 weeks in the third month. The intervals between dilations were additionally regulated according to the patient's ability to swallow meat and bread, and the radiologic appearance of the esophagus. In patients who could swallow without any difficulty 1 month after dilation, the interval was prolonged to 1V2 months. The intervals were similarly prolonged to 2 and thereafter 3 months. If the patient had no difficulty in swallowing and no deterioration was seen on the esophagogram during a 3-month interval, the interval was prolonged to 6 months. Patients who had no difficulty in swallowing were discharged from the dilation program. The patients were followed for at least 1 year after the cessation of dilations. If the patient showed partial improvement the dilation program was continued using the swallowing factor as our criterion during the 4- to 6-month check ups. Bypass surgery as an initial treatment was only planned in the presence of complete or nearly complete obliteration of the lumen involving an esophageal segment of more than 3 cm in length and causing inability to swallow saliva. Other bypass indications have been difficulties in swallowing meat and bread within a month following the last dilation after the completion of the 1-year treatment period, and difficulties and bleeding during dilating a patient who had previously experienced esophageal perforation. The results of treatment of 202 patients were recorded. The patients whose esophageal strictures were relieved by dilatations were compared with patients for whom bypass surgery was indicated after the initiation of dilatations to find out the predictors of a successful outcome by conservative treatment. Factors that may influence the outcome such as age, ingested caustic, the initial approach at home, treatment against stricture formation, the localization of stricture, length of stricture, and perforation were analyzed. The X2 test was used for statistical analyses and P values less than 0.05 were considered to be significant.
From the Department of Pediatric Surgery, Hacettepe University Children's Hospital, Ankara, Turkey. Date accepted:April 16, 1991. Address reprint requests to Hiilya Z. Giindo~,du, MD, Hacettepe ~ocuk Hastanesi, ~ocuk Cerrahisi Aria Bilirn Dah, Sthhiye, Ankara 06100, Turkey. Copyright 9 1992 by W.B. Saunders Company 0022-3468/92/2706-0024503. O0/ 0 767
GONDO(~DU ET AL
768
RESULTS
Table 2. Total Treatment Time by Dilations
Of the 202 patients admitted with a history of ingested caustics, the causative agents were: lye in 147 patients (72.7%), hydrochloric acid in 30 patients (14.8%), other acids in 14 patients (6.93%), quick lime in 8 patients (3.96%), and other alkalies in 3 patients (1.48%). Of the 202 patients, 133 (65.8%) had difficulties in swallowing solid food, 45 (22.3%) had difficulties in swallowing liquid diets and the remaining 24 (11.9%) had difficulties in swallowing saliva on admission. One hundred sixty-three patients (80.7%) were admitted within 3 months following caustic substance ingestion. The strictures involved the upper third portion of the esophagus in 82 patients (40.6%), middle third portion in 48 patients (23.8%), lower third portion in 47 patients (23.3%), and whole portions in 25 patients (12.4%). The lengths of strictured esophageal segments were between 3 and 5 cm in 72 patients (35.6%), 6 and 9 cm in 84 patients (41.6%), 10 and 14 cm in 43 patients (21.3%), and 15 cm or longer in 3 patients
(1.5%). Seven patients who ingested lye (4), hydrochloric acid (2), and sulphuric acid (1) additionally had accompanying pyloric strictures that necessitated operative relief. Bypass surgery was considered a necessary initial treatment in 23 patients; 179 underwent a chronic dilation program. Dilations began via the anterograde route in 42 patients and via the retrograde route in 137 patients. Forty of the 42 patients who were initially dilated via the anterograde route required additional gastrostomy and retrograde dilations because of esophageal perforations or difficulties in dilating. The most frequent complication during dilations was esaphageal perforations. The other complications included esophageal impaction by a bolus of food in 8 patients (3.96%) and granulation at the Table 1. Results of Treatment in 202 Children Who Have Caustic Esophageal Strictures Results of Treatment Complete success of treatment by dilations Still under dilation program with improvement Bypass surgery initially Bypass surgery after dilations Death Total
Male No.
68
Female No.
29
31 20 21 5
17 3 6 2
145
57
Total Treatment Time (mo)
No. of Patients Treated by Dilations
Percent
1- 12 13-24
48 17
49.4 17.5
25-26
6
6.2
37-48 49-60 60+
11 1 14
11.3 1 14.4
Total
97
gastrostomy site in 7 patients (3.5%). Perforations, which occurred in 34 patients, were most frequent within 3 months of ingestion (94%). All the perforations occurred during esophagoscopy or dilating via anterograde route by still woven bougies. Most of the perforations occurred during initial attempts (38.2%). While 97 patients could have been treated by dilations at the end of study period, 27 patients required bypass surgery after initiation of dilation program (Table 1). Death occurred in 7 of the 202 patients. Six patients died of esophageal perforations during anterograde dilations. One patient died of massive bleeding from the ulcerated transplanted colon. Thirty + 5.14 dilations per patient were required for treatment among 97 patients. Of the 97 patients treated by dilations, strictures have been relieved in a 1-year period in 48 patients (49.4%) but 14 patients (14.4%) required more than 5 years (Table 2). The comparison of 97 patients who were treated by dilations to 27 patients whom necessitated a bypass surgery after the initiation of dilations showed age to be an important determinant of the outcome (Table 3). Patients younger than 8 years of age have a greater chance of being treated by dilations (X2 = 13.031, P < .05). The ingestion of lye lessened the chance of being treated by dilatations (Table 4) (• = 17.808, P < .05). The initial approaches at home, and initial treatments against stricture formation did not influence the outcome (Tables 5 and 6) (• = 4.948, P > .05 and • = 3.287, P > .05, respectively). Table 3. Comparison of Patients Who Were Treated by Dilations and Required Bypass Surgery According to Their Age
Total No. (%)
Results of Treatment Treated Successfully by Dilations
97 (48) 48 23 27 7
(23.7) (11.3) (13.3) (3.4)
202 (100)
100
Age (yr) 0-4 5-8 9+ Total
Unsuccessful
Total No.
No.
(%)
No.
(%)
86 24 14
69 22 6
(80.2) (96.1) (42.8)
17 2 8
(19.8) (8.4) (57.8)
124
97
(78.2)
27
(21,8)
PEDIATRIC CAUSTIC ESOPHAGEAL STRICTURES
769
Table 4. Results of Treatment According to the Ingested Caustic Substance
Table 6. Results of Treatment According to the Initial Treatment Against Stricture Formation
Results of Treatment Treated Successfully by Dilations
Results of Treatment
Unsuccessful
Treated Successfully by Dilations Unsuccessful
Initial Treatments Against Stricture Formation
Caustic Substance
Total No.
No.
(%)
No
(%)
Lye Hydrochloric acid
74 26
52 25
(70.2) (96.1)
22 1
(29,8) (3.9)
Only antibiotic Antibiotic + steroid
20 36
Other acid Quicklime
10 12
10 10
(100) (83.3)
-2
-(16,7)
Antibiotic + steroid + early dilation Other treatments
2
--
Other alkaline Total
124
--
97
(78.2)
2 27
(100)
DISCUSSION
The treatment of caustic esophageal strictures remains controversial. Although some authors advocate bypass surgery as a treatment of choice, s-l~others suggest dilations initially and bypass surgery if the stricture has not been relieved after 3 to 12 months of dilations.2,4,n The individualization of the treatment is generally suggested. However, the criteria to guide the treatment have not clearly been established. Considering that the native esophagus is the best and no substitute can equally replace it, we have initiated dilations whenever there has been a lumen to dilate. Since only 27 of 179 patients who had chronic dilation program required bypass surgery, conservative treatment seems possible even in the presence of a severe stricture. On the other hand, attempts at Table 5. Results of Treatment According to the Initial Approaches at Home
Total No.
No.
(%)
(%)
14 26
(70) (72.2)
6 10
(30) (27.8)
32 36
28 29
(87.5) (80.5)
4 7
(12.5) (19.5)
124
97
(78.2)
27
(21,8)
dilating severe strictures carries a high risk of perforation which was encountered in 34 patients in the present series. The perforations most commonly occurred during esophagoscopy or initial dilation, and within 3 months of ingestion. All perforations occurred during attempts via the anterograde route. It was reported that dilating by pulling instead of pushing obviates the risk of perforation.12 None of the perforations was caused by retrograde dilations among these patients. Therefore, in this department dilating via the retrograde route has been preferred in recent years. 13 This approach eliminated the risk of esophageal perforations. No other complications, such as abscess, were encountered during the study period. Because the required time interval for relief was longer than a 12-month period in 50.7% of the patients whose strictures had been relieved by dilations, planning bypass surgery according to the time interval alone seems inappropriate. The comparison of patients whose strictures were relieved with patients who required bypass surgery after the initiation of chronic dilations program showed the ingested caustic to be one of the important determinants of the outcome. It is known that lye results in more severe strictures. The present series also showed that strictures that develop following lye ingestion are more resistant to dilations. On the other hand, preventive measures against stricture formation either performed at home immediately following ingestion or in
Results of Treatment Treated Successfully by Dilations
Unsuccessful No.
(%)
Localization of the Stricture
Total No.
No.
(%)
No.
(%)
51 26 27 20
47 23 24 3
(92.1) (88,4) (88.8) (15)
4 3 3 17
(7.9) (11.6) (11.2) (85)
124
97
(78.2)
27
(21.8)
Causing vomiting Giving milk Giving yogurt
33 13 18
23 9 15
(69.6) (69.2) (83.3)
10 4 3
(30.4) (30.8) (~6.7}
Other approaches No approach
9 51
9 41
(100) (80.3)
-10
-(19.7)
Upper 1/3 Middle 1/3 Lower 1/3 Whole
124
97
(78.2)
27
(21.8)
Total
Total
No.
Table 7. Results of Treatment According to the Localization of Stricture
Results of Treatment
Initial Approaches at Home
Total
(%)
(21.8)
If the strictures have been located at any one third portion of the esophagus, the chance of benefiting from dilations was higher, but if the strictures involved the whole esophagus the chance was lower (Table 7) (X2= 56.151, P < .01). If the involved segment was less than 5 cm the success rate was higher (Table 8) (• = 22.610, P < .001). Experiencing a perforation lowered the success rate (Table 9) (• = 32.560, P < .001).
Treated Successfully by Dilations
Total No. No.
Unsuccessful
770
GUNDOGDU ET AL
h o s p i t a l following e s o p h o g o s c o p i c c o n f i r m a t i o n has n o t r e s u l t e d in easily d i l a t a b l e strictures. It has p r e v i o u s l y b e e n r e p o r t e d t h a t t r e a t m e n t a g a i n s t strict u r e f o r m a t i o n m a y p r e v e n t s t r i c t u r e a n d m a y also d e c r e a s e t h e severity o f c o m p l i c a t i n g strictures. 7 H o w ever, t h e p r e s e n t series s h o w e d t h a t p r e v e n t i v e m e a sures h a d no effect o n t h e success o f dilations. T h e age at a d m i s s i o n has b e e n f o u n d to influence t h e o u t c o m e . T h e s t r i c t u r e s e n c o u n t e r e d in p a t i e n t s y o u n g e r t h a n 8 y e a r s o f age have b e e n r e l i e v e d m o r e successfully t h a n t h o s e in o l d e r children. T h i s m a y b e d u e to t h e g r e a t e r h e a l i n g c a p a c i t y in y o u n g e r children.
Table 8. Results of Treatment According to the Length of Stricture Results of Treatment Treated Successfully by D i l a t i o n s
Unsuccessful
Length of Stricture
Total No.
No.
(%)
No.
(%)
2-5 cm 6-9 cm 10-14cm 15+ cm
57 40 24 3
52 25 20 --
(91.23) (62.50) (83.33) --
5 15 4 3
(8.77) (37.55) (16.67) (100)
124
97
(78.2)
27
(21.8)
Total
Table 9. Results of Treatment According to the Esophageal Perforation During Treatment Results of Treatment Treated Successfully by Dilations
Unsuccessful
During Treatment
Total No.
No.
(%)
No.
(%)
Esophageal perforation No perforation
20 104
6 91
(30) (87.5)
14 13
(70) (12.5)
Total
124
97
(78.2)
27
(21.8)
T h e o t h e r factors f o u n d to influence t h e success o f conservative treatment have been the region and the l e n g t h o f involved e s o p h a g e a l s e g m e n t s . T h e strict u r e s involving less t h a n 5 c m o f e s o p h a g e a l s e g m e n t a n d l o c a t e d in t h e u p p e r t h i r d p o r t i o n o f e s o p h a g u s have m o r e successfully r e l i e v e d by dilations. O n t h e o t h e r h a n d , success was l i m i t e d in strictures involving m o r e t h a n 9 c m o f e s o p h a g e a l s e g m e n t . Thus, in s u m m a r y , t h e success of conservative t r e a t m e n t is h i g h e r in p a t i e n t s y o u n g e r t h a n 8 y e a r s o f age, a n d in s t r i c t u r e s d u e to caustics o t h e r t h a n lye involving u p p e r t h i r d p o r t i o n a n d less t h a n 5 c m o f an e s o p h a g e a l s e g m e n t . A l t h o u g h a long t i m e interval m a y b e r e q u i r e d , p e r i o d i c d i l a t i o n s u s u a l l y r e s u l t in n o r m a l swallowing t h r o u g h native e s o p h a g i in children.
REFERENCES
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