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Aggressive conservative treatment of esophageal perforations in children
L Martinez1, S Rivas, F Hernández
1Department of Pediatric Surgery, Hospital Universitario La Paz, Madrid, Spain.
Insights
Nonoperative management of pediatric esophageal perforation (EP) is effective, leading to survival and organ preservation in most cases. This approach remains the preferred initial treatment for children with EP.
Area of Science:
- Pediatric Surgery
- Gastroenterology
- Thoracic Surgery
Background:
- Esophageal perforation (EP) in children is typically managed nonoperatively, unlike in adults where surgical closure is standard.
- This study evaluates the long-term efficacy of nonoperative treatment for pediatric EP.
Purpose of the Study:
- To assess the effectiveness and outcomes of nonoperative management for esophageal perforations in pediatric patients.
- To determine if the traditional nonoperative approach for pediatric EP remains a viable and successful strategy over time.
Main Methods:
- Retrospective chart review of 17 pediatric patients (mean age 5.3 years) treated for EP between 1991 and 2001.
- Analysis of perforation causes, nonoperative treatment strategies, and patient outcomes, including survival and esophageal function.
Main Results:
- 19 episodes of EP were analyzed, with causes including stricture dilation, foreign body extraction, blunt trauma, and variceal sclerosis.
- Nonoperative closure was achieved in 18 of 19 episodes, with all patients surviving and recovering esophageal function.
- Two patients with severe lye strictures required esophageal replacement; one patient with esophageal necrosis underwent organ loss and reconstruction.
Conclusions:
- Prompt, aggressive nonoperative treatment for pediatric esophageal perforation leads to high survival rates and organ conservation.
- Nonoperative management is confirmed as the primary and preferred therapeutic choice for esophageal perforations in children.
Background/Purpose:
In contrast with adult patients in whom surgical closure of the defect is preferred, nonoperative treatment has been the usual approach for esophageal perforation (EP) in children. This report aims to assess whether this strategy stands the passage of time.
Methods:
We reviewed retrospectively the charts of 17 patients aged 5.3 +/- 0.9 years (mean +/- SD) treated at our institution for EP between 1991 and 2001.
Results:
Nineteen episodes of EP were caused by stricture dilation in 9 cases, foreign body extraction in 3, and blunt trauma and sclerosis of varices in 2 cases each. The remaining child had multiple gastrointestinal perforations in the course of chemotherapy for leukemia. Vigorous treatment, consisting of nasopharyngeal aspiration, wide spectrum antibiotics, prompt drainage of effusions and either parenteral or infraesophageal nutritition, was implemented immediately after diagnosis. Perforations were closed without direct surgery in 18 of 19 episodes (16 of 17 children). One or more pleural drains were inserted in 12 cases, and pericardial drainage was required once. Seven gastrostomies, 2 jejunostomies, and one esophagostomy were performed. Several major abdominal operations were necessary to repair concomitant lesions in a child who sustained severe blunt abdominal trauma and in the patient with leukemic perforations. All patients survived, and all recovered esophageal function. However, 2 with intractable lye strictures ultimately required esophageal replacement. The only patient in whom a direct approach for esophageal necrosis due to variceal endosclerosis was unavoidable, lost her organ and had a retrosternal colonic interposition after a successful portosystemic shunt. Excluding patients with other concomitant lesions and the patient who underwent surgery, median length of stay was 11 days (range, 6 to 47).
Conclusions:
Prompt and aggressive nonoperative treatment of esophageal perforations in children allows survival with conservation of the organ in most cases and remains, in the authors' hands, the first therapeutic choice at this age.