IATROGENIC ESOPHAGEAL-PERFORATION IN CHILDREN - PATTERNS OF INJURY, PRESENTATION, MANAGEMENT, AND OUTCOME

latrogenic esophageal perforations in children are rare. To evaluate p atterns of injury, clinical presentation, and treatment options for su ch patients, the authors reviewed the case records of 11 children who had sustained transmural injury to the esophagus during a dilatation p rocedure at their institution between 1967 and 1994. Strictures requir ing dilatation were attributable to caustic ingestion in eight, esopha geal atresia repair in two, and congenital stenosis in one. Eight were penetrating injuries, and three were disruptions. Two involved the ce rvical esophagus; and nine involved the thoracic esophagus. Pain, pyre xia, and tachycardia were early signs. Proximal thoracic perforations led to signs in the left chest region (effusion/pneumothorax); with di stal perforation the signs were on the right side. Treatment along con ventional lines (local drainage, gastrostomy, primary repair after ear ly recognition, and antibiotic therapy) was successful, with two major complications, both empyemas. The most recent case, a disruption of a tracheoesophageal fistula stricture, was successfully treated with or al water irrigation and antibiotics only. Six had colonic interpositio n (all caustic ingestion), one required endoesophageal resection of a distal stricture, and four had resolution of the stricture, three with out additional dilatation. The majority of children with iatrogenic in juries of the esophagus can be managed successfully by conservative me asures and pleural drainage, with surgical procedures reserved for lar ge disruptions of the esophagus, intraabdominal perforations, and case s that do not respond to appropriate conservative measures. Patients w ith caustic injury to the esophagus have a greater risk for the develo pment of penetrating injury, and this may be one indicator of the seve rity of scarring. There are distinct clinical patterns of presentation , which depend on the level at which the esophagus is perforated. Dila tation disruption of a localized stricture has a good long-term progno sis for the esophagus and may even cure the stricture. The role of ora l irrigation still must be fully evaluated where disruption has occurr ed as distinct from a penetrating injury. Copyright (C) 1996 by W.B. S aunders Company