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A Journal on Cardiac, Vascular and Thoracic Surgery

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The Journal of Cardiovascular Surgery 1998 June;39(3):373-7

language: English

Esoph­a­geal per­fo­ra­tions encoun­tered ­during the dila­tion of ­caustic esoph­a­geal stric­tures

Karnak I., Tanyel F. C., Buyukpamukcu N., Hicsonmez A.

From the Depart­ment of Pedi­atric Sur­gery Hacet­tepe Uni­ver­sity ­Faculty of Med­i­cine, ­Ankara, ­Turkey


Back­ground. The ­most ­common ­cause of esoph­a­geal stric­ture in chil­dren is the acci­dental inges­tion of ­strong alka­lies and the ­life-threat­ening com­pli­ca­tion of dila­tions for ­treating ­caustic esoph­a­geal stric­tures is esoph­a­geal per­fo­ra­tion.
­Methods. ­During a 25-­year ­period ­between 1971 and 1996, 195 ­patients ­with ­caustic esoph­a­geal stric­tures under­went ­repeated dila­tions pro­gram and 34 had 36 com­pli­cating per­fo­ra­tions (17.4%) at the Hacet­tepe ­Children’s Hos­pital Depart­ment of Pedi­atric Sur­gery. A ret­ro­spec­tive clin­ical ­study was per­formed to eval­uate the ­risks, ­results and out­come of esoph­a­geal per­fo­ra­tions encoun­tered ­among stric­tured eso­pha­guses. ­Thirty-­four ­patients, of ­whom 19 ­were ­male (56%) and 15 ­female (44%) ­with 25 (74%) ­being ­younger ­than 5 ­years of age, ­were eval­u­ated ret­ro­spec­tively.
­Results. ­There was no rela­tion ­between the ­type of ­therapy ­against stric­ture for­ma­tion and per­fo­ra­tion of the esoph­agus. Sev­enty-­five per­cent of per­fo­ra­tions ­occurred ­during ante­grade dila­tions ­with ­stiff ­woven ­dilator and ­most per­fo­ra­tions (69.4%) ­occurred in the ­first, ­second or ­third dila­tions. Esoph­a­geal per­fo­ra­tion was sus­pected ­during dila­tion pro­ce­dure in 7 per­fo­ra­tions ­while the ­remaining 29 ­were diag­nosed fol­lowing a sug­ges­tive clin­ical ­course. The diag­nosis of per­fo­ra­tion was con­firmed by ­chest X-ray, esoph­a­gog­raphy, and eso­pha­gos­copy in 30, 5, and 1 per­fo­ra­tions respec­tively. The treat­ments ­included anti­bi­o­tics, ­digoxin and ­drainage ­through gas­tros­tomy ­among 13 ­patients, and addi­tion­ally ­chest ­tube ­drainage ­among 12 ­patients, and addi­tion­ally ­feeding jej­u­nos­tomy ­among 7 ­patients ­while ­three ­patients under­went ­only ­feeding jej­u­nos­tomy in addi­tion to anti­bi­o­tics, ­digoxin and ­drainage ­through gas­tros­tomy. Six ­patients (18%) ­died, 6 ­patients (18%) ­required esoph­a­geal replace­ment for pre­vious cer­vical esoph­a­gos­tomy or per­sisting stric­ture ­that ­impairs swal­lowing. Esoph­a­geal stric­tures in 22 ­patients (64%) ­have ­been ­treated by dila­tions. Red­i­la­tion ­therapy ­started ­within 3 ­months fol­lowing per­fo­ra­tion and 68% of ­patients ­required 2 to 3 ­years of ­chronic dila­tions to be ­accepted as ­normal swal­lowers.
Con­clu­sions. The esoph­a­geal per­fo­ra­tions encoun­tered ­during ­dilating ­caustic esoph­a­geal stric­tures ­present a spec­trum ­from a min­imal per­i­-esoph­a­geal ­leakage to mas­sive rup­ture ­with pneu­moth­orax ­causing med­i­as­tinal ­shift and ­sudden ­death. The diag­nostic and ther­a­peutic ­approaches ­should be indi­vi­du­al­ised ­according to the ­place of the ­patient in ­this spec­trum.

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