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Stenting for caustic strictures: esophageal replacement replaced
F De Peppo1, A Zaccara, L Dall'Oglio
1Department of Pediatric Surgery, Bambino Gesù Children's Hospital, Rome, Italy.
Insights
Conservative treatment for pediatric caustic esophageal strictures is highly effective. Newer methods involving esophageal stenting with medication and early feeding significantly reduced treatment duration and dilatations needed compared to older methods.
Area of Science:
- Pediatric Gastroenterology
- Otolaryngology
- Surgical Innovation
Background:
- Caustic esophageal strictures in children can lead to significant morbidity.
- Conservative management is the primary approach, but treatment protocols have evolved.
Purpose of the Study:
- To compare the efficacy of different conservative treatment strategies for pediatric caustic esophageal strictures.
- To evaluate the impact of evolving treatment methods on stricture length, treatment duration, and the number of dilatations required.
Main Methods:
- Retrospective analysis of 31 children with caustic esophageal strictures treated between 1983 and 1996.
- Patients were divided into three groups based on treatment: periodic dilatations (Group A), esophageal stenting with dexamethasone and ranitidine (Group B), and esophageal stenting with higher-dose dexamethasone and omeprazole with early feeding (Group C).
Main Results:
- All treatment groups achieved high healing rates (96.5%) with conservative management.
- Group C demonstrated significantly shorter stricture lengths, fewer dilatations, and reduced treatment duration compared to Groups A and B.
- A statistically significant difference (P = .002) was observed in treatment duration and number of dilatations between Group A and C, and between Group B and C (P = .03).
Conclusions:
- Conservative management, particularly esophageal stenting with dexamethasone and early oral feeding, is highly effective for pediatric caustic esophageal strictures.
- Esophageal replacement is reserved for complex cases with tracheoesophageal fistula or refractory strictures.
- Evolving treatment protocols significantly improve outcomes by reducing treatment burden.
Methods:
From 1983 to 1996, 31 children with caustic esophageal strictures were seen at Bambino Gesù Children's Hospital; they were all treated conservatively except for two cases complicated by tracheoesophageal fistula. The remaining 29 patients were divided into three groups depending on the treatment, which was modified over the years. Group A (1983 to 1987) consisted of seven patients treated by periodic dilatations; group B (1988 to 1992) consisted of 10 children treated by 40 days of esophageal stenting plus dexamethasone, 0.5 mg/kg/d plus ranitidine plus no oral feeding for 7 to 10 days; group C (1993 to 1996) consisted of 12 cases treated by 40 days of esophageal stenting plus dexamethasone, 1 mg/kg/d plus omeprazole plus early oral feeding resumption.
Results:
No differences were observed between the three groups of patients with regard to the mean age and to the ingested substance, whereas a significant difference (P = .007) was observed in the mean length of the stricture between group A and C (3.4+/-1.3 and 5.6+/-1.6 cm, respectively). In all but one of the patients (96.5%) complete healing of the stenosis was achieved by conservative treatment, with definitive relief of dysphagia. One patient in group C did not improve after a repeated stenting procedure and was surgically treated. However, in group A, resolution of the stricture was obtained after an average of 19.9+/-14.8 dilatations in a mean period of 25.3+/-17.2 months. In group B, a mean of 12+/-11.3 dilatations were required in a mean period of treatment of 14.1+/-10.6 months. In patients in group C, a mean of 3.5+/-3.2 dilatations were necessary in a mean of 5.8+/-4.8 months. A statistically significant difference was observed both with regard to the number of dilatations and to the duration of treatment, between group A and group C (P = .002) and group B and C (P = .03).
Conclusion:
Esophageal replacement should be considered only in cases complicated by tracheoesophageal fistula or in the rare patients who do not respond to repeated esophageal stenting.
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