Ожог пищевода у ребенка форум

UpToDate

Stricture formation All patients with significant esophageal burns (grade 2A or higher) should be evaluated with a barium esophagogram to assess for stricture formation. The study should be performed two to three weeks after the ingestion, or sooner if the patient develops dysphagia (difficulty swallowing), which suggests esophageal obstruction.

Stricture formation is the primary complication of caustic injury, occurring in 3 to 57 percent of ingestions with documented esophageal burns, and in virtually all patients with severe circumferential burns (grade 2B or 3 in the scheme outlined above) [4-6,16]. More superficial or non-circumferential burns (grade 1 or 2A) are less likely to result in strictures [50], although one report found that half of the children with non-circumferential transmucosal burns (grade 2A) went on to develop esophageal stricture [66]. A few older reports described patients with apparently normal endoscopic findings who went on to develop strictures [6], but it seems likely that a burn was present but was missed because the endoscopy was performed with a rigid endoscope.

Most patients who develop a stricture will have obstructive symptoms within two months. In patients with the most severe burns, there may be complete obstruction within three weeks [67]. At six weeks, the esophagram shows a long constriction (image 1). Patients with severe strictures commonly have recurrent symptoms after two years, despite repeated dilation.

Once a stricture is confirmed radiologically, esophageal dilatation usually is required to maintain or reestablish normal swallowing. For patients who develop strictures, the optimal time for beginning dilation has not been established. Most clinicians wait three to six weeks after the initial injury before beginning dilation because there is some evidence that performing earlier dilation will increase the risk of perforation [68-70]. However, two retrospective series in children suggest that strictures were less likely to be recurrent if they were treated with early dilation (7 to 28 days after the injury) versus later dilation (beginning 4 weeks or more after the injury) [71,72].

A variety of dilators can be used, including balloon dilators, silicone or tungsten bougies, Maloney antegrade dilators, or Tucker dilators (used for retrograde dilatation); some dilators can be passed over a string or guide wire. Because caustic strictures appear to perforate easily, retrograde dilatation has been considered the safest method, although this method requires a gastrostomy and a string for guidance [59]. The risk of perforation probably depends on many factors, including the cause of the stricture (perforation appears to be more common in caustic strictures as compared with those due to esophageal atresia), interval of time since injury, length and diameter of the stricture, total number of previous dilations, and operative technique (operator experience and selection of maximal dilation) (see “Complications of endoscopic esophageal stricture dilation”, section on ‘Esophageal perforation’). The techniques used for children are similar to those for adults, except that the maximal dilation of the esophagus is smaller for a child. (See “Management of benign esophageal strictures”.)

Balloon dilators under endoscopic control are commonly used in children and are our preferred approach [73-75]. In theory, perforation should be less likely with balloon dilation because only radially directed force is exerted, as compared with use of a bougie, in which there is also a longitudinal shearing force. The reported rates of esophageal perforation for balloon dilation range from 1.6 to 13 percent per procedure [71,73,76-79], as compared with 5.6 percent for bougienage [78]. Balloons come in a variety of sizes and lengths. The size of the balloon dilator is selected using an estimate of the esophageal lumen diameter. One group selects a balloon catheter with a diameter equal to the interpeduncular distance of the childs thoracic spine, as measured on a pre-procedure radiograph [78]. Dilation balloons are available as small as 2 mm (these are designed for biliary dilation), and these can be used for the tightest strictures. For strictures narrower than 2 to 3 mm, dilation balloons with a wire guide may prevent creating a false-track in which the balloon may pass through damaged tissue along the mucosal surfaces rather than through the esophageal lumen.

The use of fluoroscopy varies widely among institutions. This technique may be of greatest benefit for patients with small diameter lumen or near-complete occlusion; in patients where there is a high concern of perforation based on endoscopic findings; or in those with a prior history of perforation.

Although esophageal dilatation may be beneficial initially, repeated dilatations usually are needed. Only 33 to 48 percent of patients with caustic strictures have long-term success with repeated dilatations [5,16]. The remaining patients, who often have long strictures, have increasing difficulty in swallowing because of progressive obstruction. Many of these patients have extensive strictures that ultimately require esophagectomy with colon interposition within two years following the ingestion [5,16]. Although colon interposition can be successful, many patients have persistent difficulty swallowing. Complications of colon interposition surgery include anastomotic strictures that may require periodic dilatation and gastrocolic ulceration caused by reflux of gastric contents into the neoesophagus [80,81].

Preliminary data suggests that mitomycin C, an inhibitor of fibroblast proliferation, helps to prevent recurrent stricture formation in patients with severe caustic esophageal injury [82-86]. Mitomycin C is applied topically to the strictured area of the esophagus at the end of a dilation session [87]. In a randomized trial in 40 patients with localized caustic esophageal strictures (<3 cm in length), treatment with mitomycin C was associated with a reduced need for repeated dilation (3.85 versus 6.9 dilation sessions), and higher rates of complete resolution during the six-month follow-up period (80 versus 35 percent resolution), as compared with placebo [85]. Similar results were seen in an international retrospective case series in which topical mitomycin C was successful in eliminating or reducing the need for repeated dilatations in 82 percent of the patients [84].

Esophageal stenting has been described in limited series for use in management of refractory caustic esophageal strictures [88,89]. Stents have also been used in children after surgery for congenital strictures and esophageal injury from batteries, with mixed success [88,90]. Most data is from studies of fully covered nitinol self-expanding plastic in adults, but other nonmetal stents continue to be developed. The use of expandable uncovered metal stents for benign esophageal strictures is not recommended because of a high incidence of complications and difficulty in removal. The use of biodegradable stents has been reported in adults with caustic ingestion, but has not been studied in children [91]. (See “Management of benign esophageal strictures”, section on ‘Nonmetal stents’.)