Esophageal Injuries

Abstract

Injuries to the esophagus in children are often due to accidental ingestions or traumatic injuries as young children have a tendency to explore the world with their hands and mouth. Childhood curiosity, lack of complete dentition, limited oromotor control, and immature judgment or carelessness each contribute to foreign body or caustic ingestion. Although ingestion of foreign bodies, batteries, coins, and drugs are accidental in most instances, child abuse, psychiatric illness, suicide, or Munchausen by proxy should be considered. Once having passed through the esophagus, most ingested foreign bodies, including sharp or pointed objects, will pass spontaneously through the alimentary tract.

Appendices

Summary Points

Although ingestion of foreign bodies are usually accidental, child abuse, psychiatric illness, suicide, or Munchausen by proxy should be considered.

Retrosternal chest pain, dysphagia, hypersalivation, stridor, and retching are typical symptoms of esophageal injuries in older children, but in young children, symptoms are not always obvious.

If the patient is asymptomatic, an esophageal foreign body in the lower esophagus should be removed within 12–24 h of ingestion, in which case radiographic confirmation should be repeated immediately prior to endoscopy.

The main anatomic locations for esophageal foreign body retention are the cricopharyngeus, the aortic arch, left main stem bronchus, and the lower esophageal sphincter.

Following the ingestion of either acid or alkali, hemorrhage, thrombosis, and a marked inflammatory response with significant edema are present within the first 24 h after ingestion (early acute phase).

Serious esophageal burn, including perforation, can occur in the absence of oropharyngeal burns or abdominal pain, and burns to the mouth do not provide evidence of an esophageal burn.

After caustic ingestion, most recommend the judicious use of broad-spectrum antibiotics, but corticosteroids probably have little benefit in most cases.

Caustic esophageal burns are regarded as pre-malignant (squamous cell carcinoma).

Editor’s Comment

Esophageal foreign bodies can remain in place for a surprisingly long time before coming to the attention of a clinician. By then, the object can become deeply embedded in the wall of the esophagus, often surrounded by a considerable mass of granulation tissue and phlegmonous reaction. Some will have partially eroded through the wall and into adjacent ­tissues, usually walled off by several layers of inflammation. A pediatric thoracic surgeon will be asked in these situations to remove the foreign body at thoracotomy, although in some cases thoracoscopy might also be a reasonable option. A preoperative CT scan helps with planning the approach and anticipating complications. The key elements of such an operation, as always, include: wide exposure, protection of adjacent structures (especially nerves and vessels), primary repair of the esophagus and, most importantly, adequate drainage. The wall of the esophagus itself is rarely able to be identified; rather, suture repair simply involves approximating layers of inflammatory tissue, arguably with little actual benefit. Most esophageal injuries will heal spontaneously if adequate drainage is achieved, essentially creating a controlled fistula. This means a large sump-type nasogastric tube to continuous suction in addition to a well-placed chest tube. Placement of a second suction catheter in the upper esophagus more proximal to the injury is unlikely to function as desired and adds significantly to the discomfort of the patient. Antibiotics that cover oral flora should be continued until the fistula has closed completely. After five to 7 days of nil per os, a contrast esophagram should be obtained and, if no leak is identified, the patient may resume oral intake. A leak will usually heal after another week or so of fasting. A cervical esophagostomy should almost never be required, except perhaps in the extremely rare case of uncontrolled mediastinal soiling and life-threatening sepsis.

Children with esophageal atresia and tracheo-esophageal fistula are at life-long risk of esophageal foreign body and food impaction due to either an actual stricture or an area of relative narrowing created by an inelastic ring of scar. Many pediatric surgeons will therefore continue to follow these patients into adulthood and prefer to perform foreign body removal and esophageal dilatation themselves.

Caustic injuries of the esophagus have thankfully become rare in most developed countries but remain a huge public health dilemma in the third world. The worst offenders are sodium hydroxide-based drain cleaners, as they are viscous and strangely palatable to young children. All patients, regardless of symptoms or severity of clinical presentation should undergo a careful esophagoscopy by an experienced endoscopist, who should conclude the examination as soon as a severe injury is identified. Nearly every patient should receive a gastrostomy tube, which should be placed in a location on the stomach that does not preclude the use of the stomach as a replacement, should this option eventually become necessary.

The very rare full-thickness esophageal injury with mediastinal extension is associated with a high risk of death and therefore mandates urgent esophagectomy. Nearly all other injuries can be observed and allowed to heal, which can take up to 4–6 weeks. Superficial injuries will usually heal without sequelae, while deeper burns inevitably result in ­strictures. Corticosteroids should be administered with caution, if at all, while antibiotics are probably of some benefit. All ­esophageal replacement operations are huge undertakings with a very high incidence of early complications and long-term problems; thus the adage that retaining a damaged native esophagus is almost always preferable to reconstructing the esophagus. For isolated strictures of the esophagus, balloon dilation under radiographic guidance is the safest and most effective technique. For long or multiple strictures, bougienage using tapered dilators passed over a wire or heavy suture that loops into the nose and out through a gastrostomy is still probably the best approach.

Esophageal replacement operations are chosen mostly on the basis of the surgeon’s experience. Colonic interposition is the easiest, safest, and most popular operation; however the problem of long-term redundancy and stasis remains an unresolved issue – nearly every patient will develop recurrent symptoms and require multiple surgical revisions as an adult. Gastric pull-up and gastric tube operations are popular in some centers, but are also fraught with complications and the need for further surgery in the long term. The most anatomic replacement in terms of size and function appears to be the jejunum, but issues related to the blood supply of the graft and the relatively high risk of ischemia make it another less-than-perfect choice. Self-expanding wire stents have been tried but are associated with life-threatening complications (septic mediastinitis, esophago-aortic fistula) and are extremely difficult to remove once they become incorporated into the soft tissue of the esophageal wall. Their use outside of a carefully designed study and truly extreme circumstances should be condemned.

Differential Diagnosis

Foreign body impaction

Esophageal perforation

Caustic ingestion

Diagnostic Studies

Plain radiographs (chest X-ray)

Contrast esophagram

Flexible esophagoscopy

Rigid esophagoscopy

Preoperative Preparation

Prophylactic antibiotics

Repeat radiograph prior to endoscopic retrieval of foreign body

For surgical intervention, wide sterile preparation (neck, chest, abdomen)

Parental Preparation

With endoscopy, there is a very small risk of esophageal perforation.

There is no ideal surgical replacement for the esophagus so we will make every attempt to preserve the native esophagus, even if it is damaged.

With foreign bodies that have become embedded in the wall of the esophagus, it is sometimes necessary to retrieve them by thoracotomy.

Technical Points

Both rigid and flexible esophagoscopy are effective methods for removing foreign bodies.

Urgent endoscopic intervention is required when a sharp object or disc battery is lodged in the esophagus, if an object is located in the upper third of the esophagus, if there is a high-grade obstruction, or if the child is unable to manage secretions.

Esophageal mucosal burns have been noted within 1 h of caustic ingestion, with involvement of all layers within 4 h after ingestion, and perforation as soon as 6 h.

Early endoscopy is the gold standard for the evaluation of caustic injuries and should occur within the first 12–24 h.

Early identification of patients with full-thickness injury is critical for immediate resection of devitalized tissue and limiting further extension of the corrosive injury.