Caustic Injuries to the Esophagus
- Corrosive injuries are challenging problems that require experience and judgment in management.
- During initial evaluation, equipment for endotracheal intubation and cricothyroidotomy needs to be available in case of severe upper airway edema.
- If intubation is required, orotracheal intubation or fiberoptic-assisted intubation is preferred over blind nasotracheal intubation.
- Endoscopy is performed early; it is most safely performed using a pediatric endoscope with minimal air insufflation and advancement only until the area of the injury is seen. An experienced esophageal surgeon may advance the endoscope farther in an adult, with extreme caution.
- Randomized trials have shown that corticosteroids do not appear to decrease the incidence of strictures.
- For second- and third-degree burns, early dilation starting at 3 to 4 weeks may help decrease the incidence of strictures; dilations can be performed in a retrograde fashion through a gastrostomy or antegrade over a guidewire using fluoroscopic guidance.
- Initial management is guided on endoscopic estimation of the extent of injury. This should be supplemented by CT scans, performed initially, and serially depending upon the clinical condition. In some cases, laparoscopic and thoracoscopic exploration is indicated.
- Key to successful management decisions is constant reassessment of the clinical status of the patient. A deteriorating clinical course may indicate the need for surgical exploration and possible resection, diversion, and drainage.
- If immediate surgery is indicated, almost all patients need to undergo a laparoscopic abdominal exploration with placement of a feeding tube and placement of a gastrostomy tube for potential future retrograde dilation. When not requiring urgent resection, a nonabsorbable suture placed across the esophagus and exiting via the gastrostomy tube may facilitate later endoscopy and safe dilations.
- If resection is being considered, consult with experienced members of the surgical team (thoracic, general surgery, ENT, etc.). Immediate resection of obviously necrotic tissue may be lifesaving. In some patients, drainage and second-look operation within 12 to 24 hours may be necessary.
- If an esophagectomy is performed, preserve as much proximal esophagus as possible. Reconstruction is delayed for several months until the patient has recovered from the initial injury.
- If a stricture does not respond to repeated dilations for a minimum of 6 months, resection may be considered; in this circumstance, remove the native esophagus to prevent the development of a future carcinoma. In cases of severe burns and a severe fibrosing reaction, the esophagus is excluded and a substernal gastric pull-up or colon interposition is performed.
At the beginning of the 20th century, lye products became available for domestic use. This led to a dramatic increase in cases of accidental ingestion of these compounds. Unfortunately, the majority of patients were children. In response, Chevalier Jackson, a leading endoscopist from Pennsylvania who practiced in Pittsburgh and Philadelphia, began a campaign that led to the Federal Caustic Act (1927), which mandated proper labeling of these harmful substances. The rate and severity of corrosive injuries again increased dramatically in the 1960s with the introduction of household cleaners with high alkali concentrations. Subsequently, the Poison Prevention Act of 1970 and the Federal Hazardous Substance Act of 1972 have enforced proper labeling, antidote instructions, concentration restriction, and child-resistant packaging. Nonetheless, corrosive esophageal injuries still remain a significant health hazard, particularly for children.
The controversies that confronted physicians who treated some of the first patients with caustic esophageal injuries remain largely unresolved today. These include the risk and benefit of early endoscopy, methods for preventing and treating esophageal strictures, and the timing and techniques of esophageal resection and replacement. The best treatment remains elusive owing to the relative rarity of this problem, the variable severity of the injury, and the difficulty in objectively assessing a variety of treatment options.
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