ESOPHAGEAL PERFORATIONS ENCOUNTERED DURING THE DILATION OF CAUSTIC ESOPHAGEAL STRICTURES

Background. The most common cause of esophageal stricture in children is the accidental ingestion of strong alkalies and the Life-threatenin g complication of dilations for treating caustic esophageal strictures is esophageal perforation, Methods. During a 25-year period between 1 971 and 1996, 195 patients with caustic esophageal strictures underwen t repeated dilations program and 34 had 36 complicating perforations ( 17.4%) at the Hacettepe Children's Hospital Department of Pediatric Su rgery. A retrospective clinical study was performed to evaluate the ri sks, 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. Results. There was no relation betwe en the type of therapy against stricture formation and perforation of the esophagus, Seventy-five percent of perforations occurred during an tegrade dilations with stiff woven dilator and most perforations (69.4 %) occurred in the first, second or third dilations. Esophageal perfor ation 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, esophagog raphy, and esophagoscopy in 30, 5, and 1 perforations respectively. Th e treatments included antibiotics, digoxin and drainage through gastro stomy 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 anti biotics, digoxin and drainage through gastrostomy, Six patients (18%) died, 6 patients (18%) required esophageal replacement for previous ce rvical esophagostomy or persisting stricture that impairs swallowing. Esophageal strictures in 22 patients (64%) have been treated by dilati ons. Redilation therapy started within 3 months following perforation and 68% of patients required 2 to 3 years of chronic dilations to be a ccepted as normal swallowers. Conclusions. The esophageal perforations encountered during dilating caustic esophageal strictures present a s pectrum from a minimal peri-esophageal leakage to massive rapture with pneumothorax causing mediastinal shift and sudden death, The diagnost ic and therapeutic approaches should be individualised according to th e place of the patient in this spectrum.