Esophageal Stenting Following Perforation After Balloon Dilatation of Caustic Induced Esophageal Stricture in a 3-year-old Child

Abstract

Purpose: Caustic ingestion in children is relatively common, causing variable injury to aerodigestive tissues. Esophageal strictures (ES) may occur in 20% of these patients. Treatment of ES involves dilatation with balloons, Savary or Eder-Puestow dilators. Such treatment may be complicated by esophageal perforation (EP). In children EP occurs most commonly during the first dilatation. Morbidity and mortality may be high following EP. Treatment of EP includes surgical repair or in selected patients medical treatment. Prognosis is better when EP is recognized early. Placement of esophageal stents has been used in the management of caustic esophagitis and ES both, in children and adults. In adults, placement of expandable, flexible stents has also emerged as effective treatment for EP. However, in North America the use of esophageal stents in pediatrics is a relatively uncommon practice (Curr Gastroenterol Rep 2010,12:203-210. Use of esophageal stents to treat EP in pediatrics is also rare (Endoscopy 2009,41:E325-326). A 3-year-old girl had accidental ingestion of oven cleaner (pH 14.0). Initial endoscopy showed severe, generalized, concentric esophagitis. She was treated with IV antibiotics, steroids, antacids and parenteral nutrition. She was discharged after 3 weeks on oral feedings, prednisone and lanzoprazole. Six weeks later, she reported progressive dysphagia for solids. Barium swallow showed dilatation of the esophagus proximal to the level of T3-T4, with distal esophageal narrowing. Repeat endoscopy revealed a severe stricture at ˜14 cm from dental line. Wire-guided balloon dilatations (6, 7 and 8 mm) were performed. Following the procedure, esophageal contrast injection showed extravasation associated with a pneumothorax. A 10-80 mm Wallflex Rx fully covered biliary stent (Boston Scientific) and chest tubes were immediately placed. She recovered well having occasional episodes of vomiting and was discharged on PO feedings, lanzoprazole and metoclopramide. At endoscopy one month later, she had significant granulation tissue with cobblestone aspect at the proximal and distal ends of the stent. The stent was removed without complications. The esophageal mucosa was still greyish, edematous and friable. Over the next eight months, recurrent dysphagia prompted monthly balloon dilatation of 2 ES at ˜14 and 18 cm. Her esophagitis and dysphagia have progressively improved. She eats solid food but the ES are still present. In our patient, other than formation of granulation tissue, we observed no complications after esophageal stent placement for 4 weeks. The biliary stent treated the EP and improved the segmental ES, but after 8 months, the child still needs esophageal dilatations.