Esophageal perforations encountered during the dilation of caustic esophageal strictures

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.

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.

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.

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.