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• W2041536518 abstract "Children who ingest a caustic product with resultant corrosive esophagitis comprise a heterogeneous group of patients in terms of the offending agent, the location of the burn, and the degree of damage. Today, there is no optimal standardized approach. We report a case of successful treatment of a child with an esophageal stenosis after caustic ingestion with a self-expanding and biodegradable esophageal stent. CASE REPORT A 10-year-old healthy boy with normal psychomotor development ingested by accident several full swallows of a drain cleaner, a 15% NaOH solution with a pH of 12.5. The house was being redecorated and a family member had put a plastic mineral water bottle containing the drain cleaner in the door of the fridge. The boy was thirsty, saw the bottle, and started to drink from the bottle. He immediately vomited and started complaining of dysphagia and retrosternal pain. His vital parameters (blood pressure, heart, and respiratory rate) were normal and stable. Severe buccal ulcerations were present. The abdominal examination was normal. Because the patient was stable and had no signs of perforation, an upper endoscopy was performed 15 hours after the ingestion. Major circumferential ulcerations over the whole length of the esophagus were present: grade IIb according to Zargar et al (1). There was no perforation, and the stomach was normal. During the first couple of days there was an obvious excessive production of saliva, and he complained of retrosternal pain. Analgesics, parenteral nutrition, intravenous omperazole (2 mg · kg−1 · day−1), and high-dose intravenous corticosteroids (1 g/1.73 m2) were administered. A large nasogastric tube was put in place to prevent the development of esophageal stenosis. Preventive antibiotics and antifungal medication were started because of the high-dose corticosteroids. After 4 days, enteral tube feeding was started. The mouth lesions disappeared after about 10 days, and oral feeding was started after 10 days; also the endoscopic appearance of the esophagus had significantly improved, and the corticosteroids were switched to oral administration; after 3 weeks, they were decreased gradually. The thick nasogastric tube was removed after 16 days. After 3 weeks, he was discharged with an oral proton pump inhibitor and corticosteroids in a decreasing dose. Control endoscopy before discharge still showed an active corrosive circular esophagitis at the mid-esophagus. Sloughing of necrotic areas was present as well as areas of granulation tissue. A control endoscopy 2 weeks after discharge still showed ulcerations, sloughing, and granulomatous tissue, but also, and for the first time, a developing stenosis at the mid-esophagus. A gastroscope (Olympus GIF-Q180, with an external diameter of 8.8 mm; Olympus, Hamburg, Germany) no longer passed the mid-esophagus; the neonatal endoscope (Olympus GIF-N180, external diameter of 4.9 mm) passed without any problem. The stenosis in the middle of the esophagus had a length of about 1 to 2 cm. At that time, there was no distal stenosis. The patient complained at that time of dysphagia for solids. A self-expandable biodegradable SX-ELLA esophageal stent was inserted under general anesthesia 6 weeks after the accidental ingestion. The stent had a body diameter of 25 mm and a length of 80 mm; insertion was uneventful (Fig. 1). During the first days after the insertion, he complained of retrosternal pain and dysphagia. He also had nausea and vomited several times per day, for which he was treated with alizapride. Two weeks after the insertion of the stent, he was discharged because he had been asymptomatic for several days. Oral omeprazole (20 mg/day) was continued.FIG. 1: View of the stent immediately after esophageal insertion.The stent remained in place, although a control endoscopy after 3 weeks showed that the distal end had extended into the stomach (Fig. 2). Because, to our knowledge, this was one of the first stents of this type placed in a child with corrosive stenosing esophagitis, a control endoscopy was performed every 2 to 3 weeks. About 12 weeks after insertion, the stent had degraded about 50%. At that time, esophageal mucosa had healed. Although the patient remained symptom free during the 4 months, he developed a severe distal esophageal stenosis more than 4 cm about 10 months after the initial ingestion and 6 months after the stent placement. The stenosis in the middle of the esophagus remained visible, but passage of the Olympus GIF-Q180, with external diameter of 8.8 mm, remained easy. Esophageal pH monitoring showed a reflux index of 15% in the lower esophagus; histology was compatible with a “reflux esophagitis.” Repeated history and low gastrin levels confirmed noncompliance to the omeprazole treatment. After 4 balloon dilatations and with careful control of the proton pump inhibitor intake (omeprazole 40 mg/day), the distal esophageal stenosis did no longer relapse. Histology of the distal esophageal biopsies is normal. Gastroplasty or colic interposition has not been necessary. The child now has normal eating habits.FIG. 2: Retrograde view of the stent protruding into the stomach after 3 weeks.DISCUSSION Ingestion of caustic agents, especially strong alkali, causes burns of the esophagus. In the short term, it provokes pain, dysphagia, odynophagia, vomiting, hematemesis, and in severe cases acute perforation of the esophagus, mediastinitis, sepsis, and shock. Esophageal stricture is a long-term complication of corrosive esophagitis grade IIB and grade III. The long-term consequences of these strictures are serious, not only medically (esophageal replacement surgery) but also socioeconomically (2). Strictures typically develop during the phase of proliferation of esophageal fibroblasts with deposition of collagen. This usually occurs 1 to 3 months after the injury, but may not develop until 1 year later. Such strictures may develop in up to one third of these patients. Prevention and treatment of caustic injury–induced stenosis is difficult and frequently unsuccessful. Systemic high doses of methylprednisolone (1 g/1.73 m2) have been advocated to reduce the number and the severity of the strictures by inhibition of granulation and fibroblastic tissue reaction (3,4). However, early treatment (within 24 hours after ingestion of the caustic product) versus delayed treatment, or short versus long treatment (less than or more than 21 days), was reported not to make any difference (5). High-dose corticosteroids may obscure evidence of mediastinitis and may increase the risk of infection. Local infection may, in turn, increase the risk of stricture formation. Therefore, we concurrently treated our patient with antibiotics. Early esophageal dilatation has been advocated by some authors to prevent stricture formation. However, there are no controlled data to support this approach and early dilatation could increase the risk of perforation, a life-threatening complication in these patients. Alternatively, the insertion of a large nasogastric tube, which is less aggressive than dilatation, has been proposed. Although the risk of perforation is lower, it could theoretically increase local inflammation and collagen deposition, and it could increase reflux of gastric content and acid into the esophagus. However, the tube can be used for enteral feeding and prevents total occlusion of the lumen. Temporary esophageal stenting for severe caustic esophageal injury in children has been performed for more than 20 years (6). It was shown that stenting should be continued until complete esophageal healing to prevent stricture formation. Other favorable results have been published. In a controlled Turkish trial, stenting provided a much better outcome, leading to a healing in 68% of the patients compared with 33% with the “classic” therapy (dilatations) (7). Poor patient compliance and gastroesophageal reflux resulting from esophageal shortening of the esophagus during scar formation were the most important reasons for failure of the stenting (7). Another Turkish series reported a series of 11 patients with esophageal stents in 10 years time. Eight patients had a normal feeding pattern, also after stent removal, with a mean follow-up of 3.5 years after stent removal (8). Long-term stenting was suggested to decrease the need for surgical reconstruction and to decrease esophageal stricture incidence (8). The Turkish experience is regarding “closed stents,” which means that the food needs to pass between the esophageal mucosa and the stent, which is comparable with the nasogastric tube that was also placed in our patient. Open stents have a larger diameter and allow the food to pass through the stent. A recent Chinese series of 33 patients suggests laparotomy to bring the esophageal stent in place 2 to 3 weeks after ingestion or even immediately in case of esophageal perforation (9). More recently, self-expanding covered stents have become available. These stents are introduced more easily, and in contrast to uncovered stents, they can be removed endoscopically. A wide range of benign stenosing disorders of the esophagus can be treated safely with a self-expanding plastic stent (10). The most common complications of these stents are chest pain, dysphagia, nausea, and vomiting (11). A recent evolution is the development of biodegradable stents (Figs. 3 and 4). This type of stent is made of degradable synthetic material. The stent integrity and radial force are maintained for a period of 6 to 8 weeks following implantation. The stent disintegration occurs 11 to 12 weeks after insertion. Dual flared ends reduce the risk for migration. The biomaterials (synthetic and natural) are intended to interface with the biological systems to preserve the normal esophageal function. The degradable and absorbable stent contains magnesium alloys, polymers—polylactic or polyglycolic acids or their copolymers, polydioxanon. Stents with a length of 6, 8, 9, 11.5, and 13.5 cm exist. The diameter at the flared end is 30 mm (over a length of 15 mm), whereas the diameter of the shaft is 25 mm. A radioopaque marker has been inserted at both ends of the shaft. The stent must be loaded just before the implantation. To our knowledge, this is one of the first reports on the use of an SX-ELLA biodegradable esophageal stent in a child with a severe corrosive esophagitis developing a stenosis. The first 2 cases of successful implantation of this BD Stent (ELLA-CS, Hradec-Kralove, Czech Republic) in children with caustic esophageal stricture were performed in Minsk, Byelorussia, in 2006. The implanting team works at the Children Surgery Center of 1st City Clinical Hospital in Minsk. However, this experience was not reported in the international literature. A short description of our case was published in Endoscopy(12). The fact that after 3 weeks the stent was visible in retrovision in the stomach may be caused by a small migration, and/or by esophageal shortening caused by the healing process, and/or because of the fact that a stent of 80 mm is too long for children. Shorter stents (∼40–50 mm length—only 1 length [80 mm] is available now) are likely to be more appropriate for children. Major advantages of this stent are that it remains in place for 6 to 12 weeks and that it must not be removed endoscopically. As with other self-expanding stents, we observed chest pain, dysphagia, nausea, and vomiting in our patient. Because mucosal healing was present and we did not observe any stricture recurrence within 3 months after stent degradation, it is unlikely that a second stent will be necessary in this patient.FIG. 3: Schematic drawing of the stent.FIG. 4: View of an open stent.In conclusion, we report the favorable outcome of this pediatric case in which an SX-ELLA esophageal degradable BD Stent was implanted. The procedure is easy to perform. Given the high failure rate of the treatment options suggested in the literature, biodegradable esophageal stents should be evaluated as the first-choice intervention in patients developing a corrosive esophageal stenosis." @default.
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• W2041536518 title "A Biodegradable Esophageal Stent in the Treatment of a Corrosive Esophageal Stenosis in a Child" @default.
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