Avoidance of Esophageal Stricture Following Severe Caustic Bums by the Use of an Intraluminal Stent Lawrence J. Mills, M.D., Aaron S. Estrera, M.D., and Melvin R. Platt, M.D.

ABSTRACT The high incidence of stric- ture following conventional therapy for caustic esophageal injuries prompted us to incorporate the esophageal stenting technique of Reyes and col- leagues [3,5, 61 into our protocol for management of such patients. Four adult patients were treated fol- lowing severe esophageal bums caused by the in- gestion of caustic drain cleaner. The severity of the bum was established by early esophagoscopy. Laparotomy and gastrotomy revealed severe but nontransmural gastric bums. The stent was left in place for 21 days. Antibiotics and corticosteroids were also employed. There have been no late stric- tures. One patient required laryngeal dilation for adhesions and another, tracheal dilation for sub- glottic stenosis. Contrast roentgenographic studies and esophageal manometry have revealed nearly normal esophageal function up to 20 months fol- lowing the injury.

Caustic injury to the esophagus produced by the accidental or intentional ingestion of strong alkali remains a difficult management problem and a source of prolonged morbidity. The mild- est burns of the esophagus can be managed by conservative treatment with corticosteroids and antibiotics. The most severe transmural burns, usually produced by highly concentrated liquid products, require emergency resection, with staged reconstruction.

Burns of intermediate severity are a ther- apeutic challenge since stricture formation is a common sequela. Because we had had poor results utilizing corticosteroids, antibiotics, and periodic dilations in patients with such

From the Department of Thoracic Surgery, University of Texas southwestern Medical School, Dallas, TX. Presented at the Twenty-fifth Annual Meeting of the South- em Thoracic Surgical Association, Nov 2-4, 1978, Marco Island, FL. Address reprint requests to Dr. Mills, Department of Sur- gery, 5323 Harry Hines Blvd, Dallas, TX 75235.

burns, we sought to investigate the intralumi- nal stenting technique described by Fell and co-workers [l] in 1966 and further elaborated and refined by Reyes and colleagues [3, 5, 61.

In order to establish criteria for application of this technique, we reevaluated our treatment program for the entire spectrum of caustic in- jury to the upper gastrointestinal tract. Im- pressed by the results reported by Ritter C71, Gago [21, Kirsh [41, and their associates, we also have utilized emergency esophagogastrectomy as the treatment of choice for severe transmural burns. Since transmural gastric injury may not be apparent on physical examination or labo- ratory or radiological tests, we consider explo- ratory laparotomy to be mandatory if severe esophageal burns are present or if the gastric pH is persistently alkaline after gentle saline lavage. This condition indicates that a large dose of caustic material has reached the stomach. The protocol for management of caus- tic ingestion is depicted in Figure 1.

Method The intraluminal stent is employed in patients who have second- and third-degree esopha- geal burns as established by esophagoscopy. Barium swallow is not used routinely since the interpretation is rarely definitive and does not alter the need for esophagoscopy. The esophagoscope is advanced until an area of ul- ceration or eschar formation is encountered. Even if first-degree burns are found, the ex- amination is continued since we have observed that the burn is often most severe in the distal esophagus. If second- or third-degree burns are visualized, an exploratory laparotomy is routinely performed through a midline incision to assess gastric viability. It is important to enter the lesser sac since transmural injury is more likely in the dependent portion of the stomach. If the stomach is judged to be viable

60 0003-4975/79/070060-06$01.25 @ 1978 by Lawrence J. Mills

61 Mills, Estrera, and Platt: Esophageal Stricture and Intraluminal Stent

AU Patients with History of Caustic

Ingestion I I

Acid Gastric pH Gastric pH

I

t

No Bum 2"3' Esophageal 1" Esophageal Bum Bum

w *

Antibiotics Oral Bums

Full Thickness Gastric Necrosis Gastric Bum

ESOPHAGOG ASTRECTOMY INTRALUMINAL STENT

Fig 7 . Protocol for management of caustic ingestion. Gastric p H and findings of esophagoscopy determine the course of treatment. In our experience, severe trans- mural gastric burns a lways indicate full-thickness esophageal necrosis.

on external inspection, it is opened with the GIA autostapler. In each of our patients, the severe esophageal bums appreciated by endos- copy were accompanied by severe mucosal burns in the stomach characterized by edema and a grayish black pseudomembrane covering the entire mucosal surface. In spite of a severe mucosal insult, the stomach will recover as long as the serosal surface remains intact.

The adult stent is constructed from a 40 cm length of medical grade silicone tubing (Dow- Corning) 15.9 mm (5/8 inch) in outside diameter and 9.5 mm (3/8 inch) in inside diameter (Fig 2). A slit latex drain is affixed to the distal end to prevent reflux. An 18F Salem sump is passed through the nares and brought out through the gastrotomy. The end of the sump is placed in the proximal end of the stent and sutured in place. The stent is then pulled into the esoph- agus and positioned with the proximal end just through the cricopharyngeal junction and the distal end just through the esophagogastric junction. Position is maintained by secure tape fixation at the nares (Fig 3) . Radiopaque clips attached at either end of the stent allow

Fig 2 . Detail of construction of the intraluminal stent illustrating the method of attachment of the latex "valve" and nasogastric sump catheter.

monitoring of position by serial chest roent- genograms. The stomach is closed with the TA stapler and a feeding jejunostomy is performed.

Postoperatively, the patient is maintained in a semi-Fowler position to minimize reflux. Feeding is accomplished through the jejunos- tomy. This route of feeding reduces the possi- bility of reflux.

62 The Annals of Thoracic Surgery Vol 28 No 1 July 1979

Fig 3 . Correct position of the intraluminal stent. The only point of fixation is the attachment of the sump tube a t the nares.

Fig 4 . (Patient 4 . ) Barium swallow done 21 days after operation and just prior to removal of the stent. Note the free passage v f the barium around the stent and the normal mucosal pattern.

A cephalosporin is administered intrave- nously for 10 days. Methylprednisolone (1 mg per kilogram of body weight) is given daily for 21 days and then is tapered. On the twenty-first day a barium swallow is obtained. In each pa- tient the roentgenogram revealed a mildly di-

lated esophagus with the stent suspended freely in the lumen (Fig 4). Removal of the stent is performed in the operating room under gen- eral anesthesia to permit esophagoscopy for evaluation of the degree of healing.

Since mid-l976,4 patients have met our crite- ria and have been treated with the intraluminal stent. The case reports follow.

Case Reports Patient 2 A 20-year-old man was admitted to the emergency room of Parkland Hospital on January 16, 1977, a few hours after swallowing three to five Darvon (propoxyphene hydro- chloride) capsules that had been filled with granular Drano. Physical examination showed severe oral burns. The lungs were clear. The abdomen was tender to palpation, with mild rebound tenderness. All laboratory tests were within normal limits, except for a white blood cell count of 12,000/mm3. Chest roentgenogram was normal.

The patient was placed on a regimen of ste- roids and antibiotics. Esophagoscopy showed deep second-degree burns of the proximal esophagus. Laparotomy did not show trans- mural gastric necrosis, but inspection of the opened stomach revealed the mucosal surface to be gray to black in color and extremely edema- tous. The esophageal stent was inserted, and a feeding jejunostomy was performed. A second operation was done forty-eight hours later, which confirmed gastric viability. The patient’s

63 Mills, Estrera, and Platt: Esophageal Stricture and Intraluminal Stent

subsequent course was benign. Barium swal- low on the twenty-first postoperative day showed a patent esophagus with the stent floating in the lumen. When the stent was re- moved, the esophageal mucosa was normal without residual changes of the lye burn.

Patient 2 A 17-year-old boy inadvertently drank liquid Drano. He was admitted to the emergency room of Parkland Hospital. Vital signs were normal. Physical examination revealed burns on the lips and buccal mucosa. The condition of the abdo- men was benign. The gastric aspirate had a pH of 8. The white blood cell count was 13,6001 mm”. Esophagoscopy showed severe burns with friable tissue, mucosal desquamation, and ulceration in the proximal esophagus. Laparotomy revealed a pale stomach without full-thickness necrosis. Gastrotomy showed at least deep second-degree burns of the stomach and distal esophagus. The stent was inserted and a jejunostomy was performed. The pa- tient’s subsequent course was benign. A barium swallow on the twenty-first postopera- tive day revealed findings similar to those in Patient 1. Esophagoscopy showed only scat- tered areas of mild inflammation.

Patient 3 A 43-year-old woman was admitted to Park- land Hospital after ingesting liquid Drano, Tide detergent, and liquid bleach. She vomited re- peatedly and experienced severe chest pain. Physical examination revealed severe oral burns. The chest was clear and the abdominal examination, normal. Laboratory tests and chest roentgenogram were normal. The gastric aspirate had a pH of 8.0. Laryngoscopy showed severe laryngeal burns. Esophagoscopy showed severe ulcerations and inflammatory exudates. Laparotomy revealed a grossly edematous stomach without full-thickness necrosis. Gas- trotomy shohed severe mucosal burns. The stent was inserted, and jejunostomy and tracheostomy were performed. Steroid therapy was omitted in this patient.

The subsequent course was benign. A bar- ium swallow on the twenty-first day and en- doscopic findings were similar to those in the

first 2 patients. A laryngeal stricture devel- oped, which responded to dilation.

Patient 4 A 43-year-old man with organic brain syn- drome was admitted twelve hours after ingest- ing an unknown quantity of powdered caustic dissolved in water. Physical examination re- vealed abdominal tenderness. The white blood cell count was 25,000/mm3, and the hematocrit was 59%. Chest roentgenogram was normal. Abdominal roentgenogram showed a dilated transverse colon and air-filled loops of small bowel. Esophagoscopy revealed burns starting at the cricopharyngeal junction that progressed in severity as the esophagoscope was advanced to the midesophagus, where there was eschar formation, deep ulcers, and marked friability. Laparotomy revealed serosanguineous ascitic fluid, marked edema of the greater and lesser omentum, but no gastric perforation. Gas- trotomy showed severe burns with eschar for- mation. The stent was placed and jejunostomy was performed. The postoperative course and studies were similar to those in the previous patients.

Three weeks following discharge, the patient was readmitted with stridor secondary to sub- glottic narrowing. This responded to temporary tracheostomy and dilations.

FOIIOW-UP Three of the 4 patients have undergone detailed follow-up at periods of four weeks to 20 months following injury. A careful dietary history, physical examination, barium swallow, and esophageal manometry were obtained for each. Manometry was performed using a standard triple-lumen perfused catheter technique, with recordings made at each centimeter proximal to the distal high-pressure zone.

The patient examined at four weeks (Patient 4) had a normal barium swallow with some dila- tation of the esophagus. The motility testing re- vealed a normal upper esophagus with tertiary contractions in the lower third. The distal high-pressure zone was normal and relaxed ap- propriately with swallowing.

Of the 2 patients examined at the longest intervals (17 and 20 months), 1 had a normal

64 The Annals of Thoracic Surgery Vol 28 No 1 July 1979

barium swallow (Fig 5) and manometry (Patient 2), while the other demonstrated radiographic evidence of reflux (Fig 6 ) and borderline low pressure at the lower esophageal sphincter (Pa- tient l).

All 3 patients were asymptomatic and were eating a regular diet at the time of writing. Pa- tient l specifically denied reflux symptoms but was placed on a medical regimen of antacids and had the head of his bed elevated as a prophylactic measure. The fourth patient (Pa- tient 3) was asymptomatic when last seen 6 months after the burn.

Comment The experimental foundation for the stent treatment of caustic esophageal bums was established by Fell and colleagues 111 and was later confirmed by Reyes and Hill [5]. These investigators showed that splinting of the burned esophagus during the period of granulation tissue formation and reepitheliza-

Fig 5. (Patient 2 . ) Normal barium swallow done 27 months followina iniuru.

" / _ I

tion avoided stricture formation. The mecha- nism of this effect seems to be the prevention of intraluminal adhesions between adjacent areas of healing esophageal wall.

Also, in well-controlled experiments in cats, Reyes and Hill [51 demonstrated that the length of time that the stent is employed is critical to the final outcome. Splinting for only two weeks did not produce satisfactory results. Three weeks of splinting allowed almost complete epithelization to occur, with subsequent satis- factory complete healing without stricture. It is postulated that the nonreactive silicone stent produces a flat, thin bed of granulation tissue that is highly favorable to epithelial prolifera- tion and that reduces the acute inflammation that leads to extensive fibrosis of the deeper layers of the esophagus and eventual stricture formation. The excellent functional outcome in our patients, who had retum to near normal motility, confirms in humans the results ob- tained in the feline studies.

Webb and associates [8] showed that prompt treatment with corticosteroids and antibiotics has a favorable influence on the frequency of

reason, we generally employ these agents con-

Fig 6 . (Patient 1 .) Barium swallow done 20 months fol- lowing injury. Mild esophageal dilatation and evidence of esophagogastric reflux are present.

strictures burns. For that

65 Mills, Estrera, and Platt: Esophageal Stricture and Intraluminal Stent

comitantly with the intraluminal stent. We achieved a good result, however, in Patient 3 in whom steroids were omitted because of the fear of masking signs of esophageal necrosis and mediastinitis.

We plan to continue the use of the intralumi- nal esophageal stent in patients satisfying the criteria of severe esophageal burns without full-thickness necrosis. The stent device is in- expensive and constructed of readily available components. The procedure can be easily and rapidly performed, is well tolerated even by depressed or mentally disturbed patients, and appears to restore near normal function to the severely burned esophagus. Utilizing this ther- apy we hope to eliminate the need for esophageal reconstruction except in patients who demonstrate full-thickness necrosis from the outset.

References 1. Fell SC, Denize A, Becker MH, et al: The effect of

intraluminal splinting in the prevention of caustic

stricture of the esophagus. J Thorac Cardiovasc Surg 52:675, 1966

2. Gago 0, Ritter FN, Martel W, et al: Aggressive surgical treatment for caustic injury of the esophagus and stomach. Ann Thorac Surg 13:243, 1972

3. Hill JL, Norberg HP, Smith MD, et al: Clinical technique and success of the esophageal stent to prevent corrosive stricture. J Pediatr Surg 11:443, 1976

4. Kirsh MM, Ritter F: Caustic ingestion and sub- sequent damage to the oropharyngeal and diges- tive passages (current review). Ann Thorac Surg 21:74, 1976

5. Reyes HM, Hill JL: Experimental treatment of cor- rosive esophageal burns. J Pediatr Surg 9:317, 1974

6. Reyes HM, Hill JL: Modification of the experi- mental stent technique for esophageal bums. J Surg Res 20:65, 1976

7. Ritter FN, Gago 0, Kirsh MM, et al: The rationale of emergency esophagogastrectomy in the treat- ment of liquid caustic bums of the esophagus and stomach. Ann Otol Rhino1 Laryngol 80:513, 1971

8. Webb WR, Koutras P, Ecker RR, et al: An evalua- tion of steroids and antibiotics in caustic bums of the esophagus. Ann Thorac Surg 9:95, 1970

Notice from the American Board of Thoracic Surgery

The American Board of Thoracic Surgery now requires that candidates pass both the written and oral portions of the certifying examination.

In 1979 only, the two parts of the examination were given together. The time and place was March 22-24, 1979, in Chicago, IL, and the closing date for registration was August 1,1978.

In 1980 and thereafter, a written examination will be given prior to the oral examination. It

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Please address all communications to the American Board of Thoracic Surgery, 14640 E Seven Mile Road, Detroit, MI 48205.