Eur J Cardiothorac Surg 2006;30:207-211
© 2006 Elsevier Science NL
Prevention of stricture with intraluminal stenting through laparotomy after corrosive esophageal burns
Ru-Wen Wang,
Jing-Hai Zhou,
Yao-Guang Jiang*,
Shi-Zhi Fan,
Tai-Qian Gong,
Yun-Ping Zhao,
Qun-You Tan,
Yi-Dan Lin
Department of Thoracic Surgery, Daping Hospital, Third Military Medical University, Chongqing 400042, PR China
Received 8 January 2006;
received in revised form 27 March 2006;
accepted 30 March 2006.
* Corresponding author. Tel.: +86 23 68757261; fax: +86 23 68816736. (Email: gtqlxp{at}cta.cq.cn).
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Abstract
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Objective: We sought to present our experience in preventing esophageal stricture formation using modified intraluminal stenting in patients with caustic burns. Methods: Between April 1976 and June 2005, 33 of 162 patients with corrosive esophageal burns were included in this study. Endoscopy was performed to define the degree of injury in all the patients but one. Among the 33 patients, 31 underwent modified esophageal intraluminal stenting through laparotomy 2–3 weeks after ingestion of corrosive agent and the remaining 2 patients underwent immediately after experiencing esophageal perforation. Results: There was no death in this series. A 1-year-old child had aspiratory pneumonia because of poor compliance. The stent was removed without requiring anesthesia after it had been in situ for 4–6 months in the 33 patients. All the patients had a normal intake of food after removal of the stents, and stricture was not found on barium swallow. However, five patients had esophageal stenosis from 2 to 3 months during follow-up. One of them responded to esophageal bougienage, the remaining four patients required esophageal reconstruction and had a normal diet postoperatively. Twenty-four-hour pH monitoring in five patients showed that there was no gastroesophageal reflux. Conclusion: The modified esophageal intraluminal stent is able to prevent the formation of caustic esophageal stricture.
Key Words: Corrosive esophageal burn • Stent • Esophageal stricture • Prevention
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1. Introduction
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The formation of esophageal stricture after corrosive esophageal burn has been one of the serious late complications [1]. The dense and extensive esophageal strictures require esophageal reconstruction which may be fraught with various complications [2,3]. Therefore, measures to prevent esophageal stricture are indispensable. The current steps include steroids [4,5], insertion of nasogastric tube [6], and early dilation. However, these treatment varieties have the disadvantages of development of side effects, prolonged management time, and less efficacy [7–9].
Esophageal intraluminal stenting has been used to decrease the likelihood of stricture formation in patients with corrosive esophageal burns for several decades [1,10]. Fell and colleagues [11] had established the experimental foundation for the stenting treatment of caustic esophageal burns. Reyes and Hill [12] tried this technique in cats with considerable success. Based on the technique, we modified the esophageal intraluminal stenting. The stent is made of medical silicone tube and is custom-built. Excellent results were achieved in the patients with corrosive esophageal burns. The purpose of this paper was to review our experience of 33 cases to be treated with the modified stenting to prevent the stricture formation in the past 29 years. Especially, we present the procedure for the prevention of stenosis development using the modified intraluminal stenting.
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2. Patients and methods
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2.1 Patients
Between April 1976 and June 2005, 35 patients less than 3 weeks after corrosive agent ingestion were admitted in our hospital. All but one with esophageal perforation underwent esophagoscopy to evaluate the degree of injury. Endoscopy was carried out within 3 days of the injury in 11 patients, between 4 and 7 days in 3 patients, and greater than 7 days in 20 patients. The second- or third-degree of injury was confirmed in all the patients. Two of them swallowed corrosive agent in a suicide attempt and were given a diagnosis of third-degree esophageal injury by means of esophagoscopy, but they declined to undergo operations and died of acute peritonitis and massive hemorrhage on the fourth and sixth days, respectively, after the injury. The remaining 33 patients were included in this study.
There were 21 male and 12 female patients, ranging in age from 1 to 67 years (average, 15.5 years). Eighteen patients (54.5%) were between 1 and 14 years of age. The most common caustic agent was alkali in 26 patients, followed by acids in 6 patients. The remaining 1 patient ingested unknown liquid. Among the 33 patients with caustic agent ingestion, 28 ingestions were accidental and 5 were in an attempt to commit suicide. The quantity of corrosives swallowed was from 2 to 120 ml.
Thirty-one of the 33 patients underwent modified intraluminal stenting 2–3 weeks after ingestion of caustic agent. The remaining two patients underwent stenting immediately after the occurrence of perforation as a result of corrosive agent and rigid endoscope examination, respectively.
2.2 Stenting procedure
The stent was constructed from a medical silicone rubber tube in the range of 40–60 cm in length, 1.0–1.2 cm in inside diameter and 1.4–1.6 cm in outside diameter. A 12F catheter was affixed to the proximal end of the stent with transfixion ligature to suspend the stent. The distal end of the stent was tailored into the shape of a duck's beak and was transfixed with a pair of 10-0 thread to pull the stent (Fig. 1
).
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Fig. 1. Detail of construction of the intralumnnal stent with a 12F catheter being affixed to the proximal end, and the distal end being transfixed with a pair of 10-0 thread.
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A midline laparotomy was carried out after achievement of general anesthesia. The abdominal esophagus, serosal surface of the stomach, and pylorus were evaluated at celiotomy, especially in patients swallowing acidic agents. A pyloroplasty was performed if the pyloric stricture occurred. A gastrotomy at the anterior gastric wall was made. A nasogastric tube was inserted through the guide wire preoperatively. The proximal end of the nasogastric tube was pulled out of the mouth, and its distal end was brought of the stomach through the gastrotomy. If the nasogastric tube was not inserted successfully because of esophageal stricture, esophageal dilation was performed under endoscopy. Two strings of 10-0 filament were tied to the distal end of the nasogastric tube in the abdomen. An assistant pulled up the orogastric tube to bring the knot of the 10-0 filament out of the oral cavity while the other end of the filament was kept in the abdomen. The nasogastric tube was removed. One string of the filament out of the mouth was connected with the thread that tied to the distal end of esophageal stent. The other string of the filament was attached to another nasogastric tube, which was sheathed in the stent earlier to guide the stent and prevent it from diverting. The stent was inserted in an antegrade fashion (Fig. 2
). The nasogastric tube was extracted through the mouth. Then the upper end of the stent was positioned 2 cm below the esophageal orifice by direct laryngoscopy. A side core, the diameter of which is larger than half of the stent's circumference, was cut at the intragastric wall of the stent. Finally, the catheter that suspended the upper end of the stent was fastened through the nostril. Its lower end, used as a feeding gastrostomy, was fixed on the abdominal wall (Fig. 3
).
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Fig. 3. Correct position of the modified intraluminal stent. Catheter that suspended the upper end of the stent is fastened through the nostril, and its lower end, used as a feeding gastrotomy, is fixed on the abdominal wall.
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3. Results
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Three patients associated with gastric injury underwent pyloroplasty concomitantly. There was no death in this series. The esophageal stent was kept in place for 4–6 months because most of the scar was stabilized at that time. The stent was removed without requiring anesthesia. Then the stent was replaced with a piece of thread, from the nostril to the gastrostomy orifice on the abdominal wall, which was kept in place for 2–3 months to dilate the esophagus in case esophageal stricture occurred in the future. Of all the patients included, two patients with esophageal perforation were able to resume oral intake of food. Barium swallow in all the patients showed that there was no esophageal stricture or perforation except for decreased esophageal peristalsis. Esophageal manometric examination in five patients revealed that the lower esophageal sphincter pressure decreased but in normal limit. Twenty-four-hour pH study in these patients demonstrated that DeMeester scores were less than 14.72 and that there was no gastroesophageal reflux [13].
Follow-up was complete in all the 33 patients. A median follow-up period was 36.5 months (range 1–60). Twenty-eight patients had a full diet without dysphagia, and five patients had esophageal stricture 2–3 months after stent removal. Among the latter group, one patient responded to esophageal dilation and the remaining four patients underwent esophageal replacement. The time interval from withdrawal of the stent to esophageal reconstruction ranged from 9 to 44 months (average 18 months). Colon interposition was performed in two patients, and gastric transposition was performed in the other two patients. All four patients have had a normal diet after undergoing esophageal reconstruction.
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4. Discussion
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Alkali is the most common corrosive agent in this series. There has a relation between the lye ingestion with cooking custom of the native people in Chongqing, China. Some food such as bull's stomach is prepared with concentrated alkali (30–50%) before being cooked. This lye is usually held in household bottles which were used to retain alcohol, syrup, or drink. Children often mistake it for syrup or soft drink and adults mistake it for alcohol. This is the reason why the vast majority of our patients including most adults ingested the lye accidentally. Clinical and experimental studies showed that a 22.5% solution of NaOH in contact with the esophagus for 10 s and 30% NaOH for 1 s can produce a full thickness injury [8]. Therefore, most patients in the series had serious esophageal burns.
The management of corrosive esophageal burns depends on the degree of injury, which is only defined by the means of endoscopy. Most authors recommended that endoscopy be performed preferably less than 24 h after the injury [5,6,8]. Mucosal sloughing occurs 4–7 days after the initial injury and collagen deposition may not begin until the second week, the tensile strength of the healing tissue is low during the first 3 weeks. Many people, therefore, advocate avoiding endoscopy between 5 and 15 days after caustic ingestion [14]. However, our institute is a tertiary referring hospital and most patients being admitted had been initially treated in local county- or prefecture-level hospitals. The vast majority of patients in our group from relative remote area referred to our hospital more than 1 week after injury. Even though most patients (75.6%) underwent esophagoscopy more than 24 h, only one patient developed esophageal perforation as a result of rigid endoscope examination at earlier time. Since then, flexible endoscopy was used and there was no such complication. de Jong and colleagues [15] also reported that there were no cases of perforation secondary to endoscopic examination irrespective of time interval relative to the initial injury. Once second- or third-degree of injury was established in the patient who has no indication for emergent operation, the steps should be taken to prevent the formation of esophageal stenosis.
Among the treatment modalities to prevent stricture formation, esophageal dilation and stenting were most common. Prophylactic bougienage may prevent the development of late esophageal stricture, presumably by preventing cross-fusion of adjacent areas of granulation tissue and by disrupting zones of early constriction scar. Nevertheless, esophageal bougienage always produce small fissures upon tearing the esophageal scar and the natural healing of these wounds creates another new stricture within a few weeks [16]. Experimental and clinical evidence shows that scar tissue progressively contracts up to several months even years after the start of the healing process. Therefore, continuous dilatation has to be performed for a long time. The long period of dilation requires the expenditure of time and money to which many Chinese cannot afford. Furthermore, severe deep circumferential burns almost inevitably require esophagoplasty with this management [9,17]. This is because periodic dilations are not effective in conserving the lumen during remodeling of the cicatrized esophagus. If the lumen can be kept open during the remodeling period (6–24 months), further contraction will be prevented. It is logical to accept stent therapy as a ‘continuous dilation’ technique (24 h a day for 365 days) that covers the entire remodeling period of the cicatrix. Conversely, even frequent dilations only amount to stenting for a few minutes each week, which obviously is far less effective than continuous stenting in inducing collagen degradation [17]. In the laboratory, intraluminal splinting of the esophagus by an inert material such as Silastic reduced the amount of inflammation and granulation tissue and minimized scarring. In addition, fusion of mural ulcers and obliteration of the lumen by granulation tissue were prevented during stenting [18].
A variety of stenting has been used to prevent the esophageal stricture formation in the past decades. Reyes and Hill [18] introduced their Silastic tube which the proximal end was attached with a Replogle sump tube to fasten the stent through the nostril and the distal end with a Penrose to serve as a flap valve to prevent reflux through the tube from the stomach. The stent was placed 1.5 cm superior to cricopharyngeus sphincter and 1.5 cm beyond the gastroesophageal junction. This splint was in place for three weeks and prevented stricture effectively. Berkovits and colleagues [19] also reported that their silicone-rubber, silicone oil impregnated, twin-tube allowed greater comfort to the patient and facilitated swallowing of food and drink without causing pressure-induced post-cricoidal ulcers. Recently, Broto and colleagues [16] had used a self-expanding siliconated stent to treat the esophageal stenosis and concluded that stents permitted normal feeding during application, substantially reduced treatment time, and avoided repeated anesthesia sessions for dilatations. We had used a splint which was only suspended by a Replogle sump tube through the nostril based on the technique by Reyes and Hill [18] to treat one patient at early stage. The patient's nostril was indented because of the powerful force of deglutition movement. We decided to modify the stenting. Our modified stent is constructed from medical silicone tube and individualized. This is different from commercially available stents, including Atkinson or Montgomery silicon stents in the developed countries. These stents would have several advantages from the perspective of patient tolerance. First, they do not require the patient wearing a catheter in their nose for the duration of treatment. In addition, an operation can be avoided if Atkinson or Montgomery stents were to be used. However, there was not any commercially available silicone stent in our developing country as far as know. Even though they were available, Atkinson or Montgomery stents would not be used to prevent the stricture formation after corrosive esophageal burns irrespective of their cost. In the light of data on these commercially available stents we have collected, the vast majority of authors used Atkinson stent to palliate inoperable esophageal malignant strictures [20]. Moreover, there was high tube displacement (21%) and esophageal perforation (13%) was associated with Atkinson tube insertion [20]. As for the Montgomery stent, it is to be used to bridge the gap between the pharyngostome and esophagostome following laryngoesophagectomy and first reconstruction of the cervical esophagus. The Montgomery esophageal tube has three functions: (1) it tends to eliminate the problem of profuse salivary leakage of the pharyngostome; (2) it maintains a widely patent pharyngostome and esophagostome; and (3) it creates a trough between pharyngostome and esophagostome facilitating the second stage procedure. All in all, the Montgomery esophageal tube is of use in treating fistulas, strictures and reconstruction of cervical esophagus [21]. It is well known that most of strictures are located at the thoracic esophagus. Therefore, the Montgomery esophageal stent is unsuitable to be used to prevent esophageal stricture after caustic agent ingestion. On the contrary, our homemade stent was able to prevent stricture formation effectively. The modified intraluminal stent can reduce the nose strain allowing the patient to tolerate it for several months through being fastened at both the nostril and the abdominal wall to prevent migration. Besides that, our modified esophageal stenting offers the following advantages: (1) maintaining nutrition through both the oral cavity and a gastrostomy; (2) adjusting the displaced stent readily; (3) decreasing thoracic pollution in patients with a perforated esophagus; (4) removing the stent conveniently; and (5) replacing the removed stent with a thread from the oral cavity to the abdominal orifice of the gastrostomy to perform circulating dilation in case of recurrence of esophageal stricture in the future.
Corrosive esophageal burns may contract in longitudinal orientation and decrease the lower esophageal sphincter pressure resulting in gastroesophageal reflux, which might contribute to the esophageal stricture [22]. This was assumed why the stent introduced by Reyes and Hill [18] had a flap to prevent the reflux. Although our modified stent has not antireflux flap, only a 1-year-old child developed pneumonia as a result of reflux and aspiration because of poor compliance. Five patients who underwent 24 h pH monitoring revealed that there was no gastroesophageal reflux. The following steps were taken to avoid the possible reflux and aspiration: (1) the patients were constantly maintained in semi-Fowler's position (with head and thorax at 45° elevation); (2) the side core at the intragastric part of the stent was large enough to ensure food draining smoothly into the stomach.
In conclusion, alkali is the most common agent responsible for the esophageal burns. The degree of injury is defined by the endoscopy which can better be performed early after corrosive agent ingestion. The measures to prevent stricture formation should be taken in the patients with second- or third-degree of injury. The modified intraluminal esophageal stenting through laparotomy is a treatment of choice in preventing the formation of esophageal stricture in patients with serious corrosive esophageal burns.
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References
|
|---|
- Mills LJ, Estrera AS, Platt MR. Avoidance of esophageal stricture following severe caustic burns by the use of an intraluminal stent. Ann Thorac Surg 1979;28:60-65.[Abstract]
- Zhou JH, Jiang YG, Wang RW, Lin YD, Gong TQ, Zhao YP, Ma Z, Tan QY. Management of corrosive esophageal burns in 149 cases. J Thorac Cardiovasc Surg 2005;130:449-455.[Abstract/Free Full Text]
- Jiang YG, Lin YD, Wang RW, Zhou JH, Gong TQ, Ma Z, Zhao YP, Tan QY. Pharyngocolonic anastomosis for esophageal reconstruction in corrosive esophageal stricture. Ann Thorac Surg 2005;79:1890-1894.[Abstract/Free Full Text]
- Bautista A, Tojo R, Varela R, Estevez E, Villanueva A, Cadranel S. Effects of prednisolone and dexamethasone on alkali burns of the esophagus in rabbit. J Pediatr Gastroenterol Nutr 1996;22:275-283.[CrossRef][Medline]
- Ramasamy K, Gumaste VV. Corrosive ingestion in adults. J Clin Gastroenterol 2003;37:119-124.[CrossRef][Medline]
- Wijburg FA, Beukers MM, Heymans HS, Bartelsman JF, den Hartog Jager FC. Nasogastric intubation as sole treatment of caustic esophageal lesions. Ann Otol Rhinol Laryngol 1985;94:337-341.[Medline]
- Pelclova D, Navratil T. Do corticosteroids prevent oesophageal stricture after corrosive ingestion?. Toxicol Rev 2005;24:125-129.[CrossRef][Medline]
- Gumaste VV, Dave PB. Ingestion of corrosive substances by adults. Am J Gastroenterol 1992;87:1-5.[Medline]
- Karnak I, Tanyel FC, Buyukpamukcu N, Hicsonmez A. Combined use of steroid, antibiotics and early bougienage against stricture formation following caustic esophageal burns. J Cardiovasc Surg (Torino) 1999;40:307-310.
- Estra A, Taylor W, Mills LJ, Platt MR. Corrosive burns of the esophagus and stomach: a recommendation for an aggressive surgical approach. Ann Thorac Surg 1986;41:276-283.[Abstract]
- Fell SC, Denize A, Becker EH. The effect of intraluminal splinting on the prevention of caustic stricture of the esophagus. J Thorac Cardiovasc Surg 1966;52:675-681.[Medline]
- Reyes HM, Hill JL. Experimental treatment of corrosive esophageal burns. J Pediatr Surg 1974;9:317-327.[Medline]
- Khajanchee YS, Hong D, Hansen PD, Swanstrom LL. Outcomes of antireflux surgery in patients with normal preoperative 24-hour pH test results. Am J Surg 2004;187:599-603.[CrossRef][Medline]
- Zargar SA, Kuchhar R, Mehta S, Mehta SK. The role of fibroptic endoscopy in the management of corrosive ingestion and modified endoscopic classification of burns. Gastrointest Endosc 1991;37:165-169.[Medline]
- de Jong AL, Macdonald R, Ein S, Forte V, Turner A. Corrosive esophagitis in children: a 30-year review. Int J Pediatr Otorhinolaryngol 2001;57:203-211.[CrossRef][Medline]
- Broto J, Asensio M, Vernet JM. Results of a new technique in the treatment of severe esophageal stenosis in children: poliflex stents. J Pediatr Gastroenterol Nutr 2003;37:203-206.[CrossRef][Medline]
- Mutaf O. Treatment of corrosive esophageal strictures by long-term stenting. J Pediatr Surg 1996;31:681-685.[CrossRef][Medline]
- Reyes HM, Hill JL. Modification of the experimental stent technique for esophageal burns. J Surg Res 1976;20:65-70.[CrossRef][Medline]
- Berkovits RN, Bos CE, Wijburg FA, Holzki J. Caustic injury of the oesophagus. Sixteen years experience, and introduction of a new model oesophageal stent. J Laryngol Otol 1996;110:1041-1045.[Medline]
- Birch JF, White SA, Berry DP, Veitch PS. A cost-benefit comparison of self-expanding metal stents and Atkinson tubes for the palliation of obstructing esophageal tumors. Dis Esophagus 1998;11:172-176.[Medline]
- Montgomery WW, Montgomery SK. Manual for use of Montgomery laryngeal, tracheal, and esophageal prostheses: update. Ann Otol Rhinol Laryngol Suppl 1990;150:2-28.[Medline]
- Ozcan Z, Ozcan C, Erinc R, Dirlik A, Mutaf O. Scintigraphy in the detection of gastro-oesophageal reflux in children with caustic oesophageal burns: a comparative study with radiography and 24-h pH monitoring. Pediatr Radiol 2001;31:737-741.[CrossRef][Medline]
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Abstract
1. Introduction
