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

Copyright © 2000 EDIZIONI MINERVA MEDICA

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


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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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