Conservative treatment of caustic esophageal injuries in children: 20 years of experience

The authors present their experience in the medical treatment of 1,296 caustic esophageal injuries in children over the last 20 years in two study groups, one comprising the period up to 1989 and the other 1990 to 1996, comparing the different treatments used in each group. The treatment was based fundamentally on dilatations with anterograde mercury bougies, Savary bougies, or retrograde thread-guided bougies with gastrostomy. Pneumatic balloons or stenting procedures have also been employed in the last 3 years. Early fiberendoscopy was used systematically in the second group, which provides a more accurate evaluation of the esophageal lesions. Antibiotic coverage was done systematically during the first 10 days in all serious cases, while steroids were employed routinely only in the last 3 years. The results were similar in both groups, with a dilatation average of 32 in the first and 30 in the second group and an initial dilatation interval of 3 to 4 weeks in both. Using updated exploration and dilatation techniques, we drastically reduced the number of gastrostomies needed for retrograde thread-guided dilatations from 51 in the first group to 5 in the second, consequently improving the patients' life quality. There was no mortality and only five esophageal perforations, which did not require surgical treatment. Accepted: 5 January 1999     

Indomethacin for prevention of stricture formation due to alkali-induced corrosive esophageal burns in the rat

The aim of this study was to investigate the therapeutic effect of indomethacin on corrosive esophageal strictures. Esophageal burns were produced in 40 of 50 Sprague-Dawley rats by 10.7% NaOH and were then grouped as pure esophageal burns, esophageal burns treated with indomethacin, and controls. All of the animals were killed on the 28th day of the experiment and hydroxyproline levels in esophageal tissue were determined for each rat. Hydroxyproline levels were significantly lower in the indomethacin-treated group than in the other two groups. Based on our results, we suggest that indomethacin inhibited collagen synthesis and thus alkali-induced esophageal stricture formation. Offprint requests to: M. Pul     

Biochemical and histopathologic effects of omeprazole and vitamin E in rats with corrosive esophageal burns

The aim of the study reported here was to evaluate the biochemical and histopathologic effects of omeprazole and vitamin E in rats with corrosive esophageal burns. A total of 144 Wistar Albino rats were divided into 12 experimental groups (12 rats per group) and used in an animal study. Group I rats were given a laparotomy and received no treatment (control group), while groups II, III and IV received a laparotomy and were treated with omeprazole, vitamin E or omeprazole/vitamin E, respectively. Groups V-XII rats received a laparotomy and were given a caustic acid burn through acid instillation (1 ml caustic 10% sulphuric acid; groups V–VIII) or alkali instillation (corrosive 10% sodium hydroxide solution; groups IX–XII) into the isolated esophageal segment via a 22-Fr cannula for 2 min. Each group of rats subjected to caustic burn received either no treatment (groups V and IX) or were treated with omeprazole, vitamin E or omeprazole/vitamin E, respectively (remaining six groups). Omeprazole (20 mg/kg) or vitamin E (10 mg/kg) was administered to the rats intraperitoneally or intramuscularly, respectively. Seventy-two rats (50% of each group, n = 6) were killed immediately after the experimental treatment (acute phase). The remaining rats were kept under standard conditions for 21 days (late phase) before being killed. The distal esophageal segments were harvested from all animal and used in histopathologic and biochemical analyses. Compared to the controls (no caustic burn), rats receiving only the acid or alkali installation (and no subsequent treatment) had the highest mean malondialdehyde (16.9 and 15.8 μmol MDA/g protein, respectively) and hydroxyproline (5.9 and 5.7; mg HP/g wet tissue) levels of all groups. In comparison, rats treated with acid + omeprazole and/or vitamin E had relatively lower MDA (12.9 and 11.6 μmol/g protein, respectively) and HP levels (4.3 and 4.08 mg/g wet tissue, respectively). Similarly, rats treated with alkali + omeprazole and/or vitamin E had low levels of MDA (13.9 and 11.7 μmol/g protein, respectively) and HP (4.3 and 4.4 mg/g wet tissue, respectively). The glutathione (GSH) levels of acid-only- or alkali-only-treated rats were lower than those found in omeprazole- and/or vitamin E-treated rats. Based on these results, we conclude that vitamin E and omeprazole affect the biochemical and histopathologic parameters in rats receiving corrosive esophageal burn from acid and alkali. The effect of both substances was slightly greater in the acid-treated groups.     

Brain abscess: an unusual complication of multiple esophageal dilatations

Lye ingestion in children continues to be a problem and may result in severe esophageal strictures. Esophageal dilatations to treat these strictures usually result in bacteremia. A case of 13-year-old boy who developed a brain abscess after multiple esophageal dilatations is presented and discussed and the literature on the subject is reviewed.     

Caustic ingestion and oesophageal damage in children: Clinical spectrum and feeding practices

Aim: The study aims to evaluate the association of oesophageal damage with clinical data and feeding practices in children who suffered a caustic substance ingestion (CSI). Methods: Cross‐sectional design was used in this study. The setting was at a paediatric referral hospital in 2006. Ninety‐four children with CSI were used as study samples, with mean age of 38.4 months, and 37.2% were females. The independent variable was oesophageal damage; the dependent variables were clinical data and feeding practices. Results: Main symptoms included salivation, oropharyngeal burns and vomiting. On endoscopy, 84.6% had second‐ or third‐degree burns. Oesophageal stricture occurred in 48.9%. Severe burns were associated with oesophageal stricture and ingestion of alkaline products; dysphagia was associated with oesophageal stricture. In about one fourth of the cases, a nutritional intervention with complete and balanced liquid diets was required to maintain the adequate daily recommended intake (DRI). Conclusions: Alkali ingestion was associated with severe burns and oesophageal stricture. The presence of oesophageal strictures and dysphagia required changes in the feeding practices in order to maintain an adequate nutritional status and/or to complete their DRI.     

儿童食管化学性烧伤后狭窄的外科治疗

对儿童食管化学性烧伤后狭窄行胸骨后结肠代食管术１０例，均取得良好效果，无手术死亡。结肠有足够长度，血运良好，基础代谢率低，体积小，易游离，且使胃保持正常生理位置之特点。重点介绍避免损伤喉返神经以及如何预防吻合口瘘发生的具体经验和体会，并阐明了不切除病变食管的利弊关系。     

A novel approach for preventing esophageal stricture formation: sphingosylphosphorylcholine-enhanced tissue remodeling

Using a new class of intracellular 2nd messengers to prevent stricture formation after caustic ingestion, sphingosylphosphorylcholine (SPC) has a wide spectrum of activity in cell growth regulation and signal transduction. Caustic esophageal burns were created with 15% NaOH in an experimental rat model. Control group animals (n=10) had esophageal burns with no treatment, whereas the SPC group (n=10) had esophageal burns gavaged with SPC for 7 days. Efficacy of treatment was assessed in 28 days by contrast esophagograms, histopathologic evaluation, and biochemically by tissue hydroxyproline (OHP) content. Contrast esophagograms demonstrated that SPC significantly prevented stricture formation. Obvious collagen deposition was present in submucosa, muscularis mucosa, and muscular layers in the control group compared with the SPC group. The damage to the esophageal wall on histopathologic examination was significantly lower in the SPC group (p<0.05). Tissue OHP contents were significantly lower in the SPC-treated group (3.0±0.1 g/mg) compared with the control group (4.3±0.2 g/mg) (p<0.05). We conclude that SPC improves healing following caustic esophageal burns. Furthermore, SPC is effective in preventing caustic esophageal strictures. These effects of SPC occur through its proliferative and specifically its remodeling effects on wound healing.     

胃镜直视下球囊扩张术治疗小儿食管狭窄

目的 探讨胃镜直视下球囊扩张治疗小儿食管狭窄的安全性和有效性.方法 12例食管狭窄患儿,其中食管闭锁术后吻合口狭窄7例、先天性食管狭窄3例、腐蚀性炎性狭窄2例,年龄5～59个月,在静脉复合麻醉和气管插管下,通过胃镜直视用控制辐射状扩张(CRE)三级扩张球囊行食管狭窄扩张.观察术后腹痛、黑便、呕吐的发生,同时随访术后3～12个月恢复饮食种类,狭窄口大小、营养情况.结果 12例共进行22次扩张,19次成功,3次术后出现并发症,扩张成功率为86%.12例中,3例扩张失败,9例扩张成功、症状改善,有效率为75%.扩张前狭窄口直径2～8 nun,3～12个月后复查胃镜和随访,狭窄口直径9～13mm,8例可进食固体食物、营养状况改善.结论 CRE三级食管球囊行食管狭窄扩张治疗,操作简单、效果确切,食道闭锁术后吻合口狭窄的扩张效果较好.     

Gastric outlet obstruction due to corrosive ingestion: incidence and outcome

A retrospective clinical study was performed to determine the incidence, management, and outcome of gastric outlet obstruction (GOO) caused by caustic ingestion in children. Of 220 patients who sustained caustic substance ingestion and were treated at our unit between 1976 and 1996, 168 ingested alkaline substances; of these, 9 children (5.3%) developed GOO in addition to esophageal strictures. The remaining 52 patients ingested acid agents, and 2 of them (3.8%) presented with GOO without esophageal strictures. The overall incidence of corrosive GOO was 5% (n = 11). The mean age of the patients with GOO was 5.7 ± 2.8 years (range 2–14) with a female:male ratio of 6:5. Sodium hydroxide (n = 6), potassium hydroxide (n = 3), and hydrochloric acid (n = 2) were the ingested caustic agents. The patients were subdivided into two groups according to serial endoscopic and radiologic findings: group I: moderate (dense superficial and spotty ulcerations with intact mucosa) mucosal injury with partial pyloric obstruction; and group II: severe (deep ulcerations, extreme hemorrhagic erosions, eschar formation with white plaques) mucosal injury with complete pyloric obstruction. Group I consisted of 5 patients who ingested alkali agents while group II included 6 who presented with ingestion of alkaline (n = 4) and acid (n = 2) agents. Surgical treatment included Billroth I (n = 6) operations performed in group II and Finney (n = 3) and Heineke-Mikulicz (n = 2) pyloroplasty procedures done in group I. All patients are alive without any complaints. Fiberoptic endoscopy should be the preferred method of evaluating a patient with ingestion of a corrosive agent. It determines the presence of injury and assesses the extent of damage, establishing the diagnosis and allowing therapy to be instituted immediately. Our experience revealed that substantial damage has occurred early after ingestion, and early surgical intervention has decreased the morbidity and mortality. The extent of the mucosal injury and status of the pylorus and antrum determined the type of surgical treatment. A Billroth I procedure recommended for severely injured mucosa with complete pyloric obstruction, and pyloroplasty for moderate mucosal injury associated with partially obstructed but still viable pylorus. In contrast to the current belief, alkali ingestion also has a high risk of corrosive gastric injury causing GOO, which should be considered during assessment of the injury. We emphasize that a detailed evaluation of radiologic and especially endoscopic findings is very important for determining the timing, necessity, and type of appropriate surgical treatment. Accepted: 17 June 1998     

儿童幽门下消化道异物治疗分析

目的 探讨在儿童不同年龄阶段,对于幽门以下消化道异物处理及预防办法.方法 回顾我院2011年6月到2014年6月间因吞食异物,异物位于幽门管或以下消化道且内镜治疗无效,外科经保守或手术治疗好转的16例患儿(11男5女).结果 16例患儿平均年龄66月龄;手术治疗9例(56％),保守治疗7例(44％);有意吞食异物(年龄＞1岁)为31％(5/16);异物类型包括胃石3例、钢针4例,磁铁2例,温度计碎裂2例,坚果类3例,刀片1例等;腹部X平片及CT阳性率81％ (13/16);病史中可问诊到异物吞食史为75％ (12/16);因消化道穿孔需要急诊手术的5例,穿孔部位以回盲部为主(磁石类引起两处以上穿孔),其中直接入PICU的1例;平均住院时间9.13d.结论 (1)对于磁石类型异物,一旦确诊为双极磁石,建议手术干预为主,已经穿孔的患者,其穿孔数目及肠段应反复探查全肠段后再确定,穿孔部位往往呈跳跃性,无规律性.(2)误食钢针等尖锐异物,除按时评估患儿体征变化外,应间隔6～8h复查腹部平片等检查,及时更改治疗策略.建议＜1岁儿童,不建议喂食坚果核仁类食物.建议使用电子体温计,玻璃水银体温计使用需谨慎.(3)加强儿童心理治疗,特别青春期前的心理健康应注意.     

Epidemiology and prevention of caustic ingestion in children

A total of 102 children less than 16 years of age admitted for caustic ingestion in the period 1976–1991 were registrated. The annual incidence rate of hospitalizatiotl was 10.8:100000 for the city of Aarhus, Denmark. Esophageal burns occurred with a frequency of 5.0:100000 per year. Ninety-four percent of the children were less than 5 years old. For this age group, the incidence rates of admission and esophageal burns were 34.6:100 000 and 15.8:100 000, respectively. All ingestions were accidental. The incidence rates of esophageal burns in children 0–4 years old ( p = 0.019) decreased significantly during the period studied. The cause of this decrease is not clear, but a change in the spectrum of household products and the gradual introduction of child-proof caps are possible explanations. To minimize the frequency of accidents, an information campaign directed specifically at parents of toddlers is recommended. Information material should stress that caustics should always be inaccessible to children and stored separately, and should never be decanted.     

婴幼儿食管瘢痕狭窄的外科治疗

目的：回顾性分析婴幼儿食管良性狭窄30例外科治疗结果。探讨外科治疗各种方法的优劣。方法：30例中男20例，女10例。年龄1岁5个月-5岁，平均29个月。体重5-20kg。除1例为农药烧伤外，余均为误服强酸、碱烧伤。颈段食管完全闭塞3例，基本闭塞5例，余食管造影均见钡剂在食管全长呈不规则线样通过、其中5例伤后曾有时间不等声嘶及吸气性呼吸困难，6例在外院行胃造瘘，全部病例采用保留结肠左动脉升支供血，经胸骨后径路顺蠕动吻合横结肠代食管结肠颈部吻合或结肠咽吻合。结果：手术后颈部吻合口瘘1例，吻合口狭窄1例。术后气管切开1例，经治疗后顺利进食，无手术死亡。经4-20余年随访，患儿发育正常。结论：主张对的食管瘢痕狭窄应积极采取食管重建术。食管替代物中以横结肠为最佳。同期食管瘢痕切除食管的危险性大，手术应以食管旷置为佳。重建平面需在颈部或咽部，不主张任何形式的胸内吻合。     

Rationale for and current status of prenatal cardiac intervention

The idea of prenatal intervention in congenital heart defects was put forward over 20 years ago, arising from the observation that some forms of cardiac malformation progressed in severity as pregnancy advanced. The simultaneous development of minimally invasive catheter techniques in children, led to the concept of treating the foetal heart directly, in an attempt to prevent the changes which had been observed. Early efforts at prenatal valvuloplasty were largely set aside after poor results and the coincidental development of alternative, increasingly successful, postnatal surgical strategies. However, in the last 10 years or so, some centres have revived and extended the interventional techniques, with some success. The application of these techniques is limited to very few conditions, and suitable cases are relatively uncommon. Exploration of these procedures, therefore, should be limited to very few centres and the results should be closely scrutinised before this becomes an accepted management option.     

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??Abstract?? Objective To study balloon dilatation with cryotherapy under bronchoscope for subglottic stenosis in infants and young children??and to explore the efficacy of this new technology??the timing of treatment and safety. MethodFrom July 2009 to May 2014 in 28 SGS cases aged from 1 month to 3 years?? bronchoscopic balloon dilatation treatment with CO2 cryotherapy was performed?? and different types of SGS treated by minimal invasi were assessed regarding efficacy, complications and outcome. Results The infant SGS were divided into ??°~??° by severity?? and soft membrane SGS and scarring SGS by the causes of stenosis. ??° SGS included 16 cases, in which 8 cases soft membrane SGS were treated by balloon dilatation effectively?? 9 cases after combined treatment; in scarring SGS balloon dilatation was effective in 1 case?? 4 cases after combined therapy; ??° SGS included 8 cases?? soft membrane SGS were treated effectively in 2 cases?? 4 cases after combined treatment; in scarring SGS balloon dilatation was effective in 1 case?? 2 cases after combined therapy; ?? °SGS included 4 cases?? 1 case of soft membrane SGS and 1 case of scarring SGS responded well to integrated treatment .Conclusion MSCT and bronchoscopy assessment is used in grading the extent and causes of stratification in infants with subglottic stenosis?? and then we can select the appropriate treatment programs to improve the prognosis of the disease and improve life quality of SGS children.