Abstract
Objectives
Management of caustic ingestion (CI) and esophageal burns are a serious problem which causes a significant burden on the health care services. Since absence of evidence-based guidelines optimal management of CI is still yet to be determined. The study aims to evaluate clinical approach of Turkish pediatric surgeons to caustic esophageal burns.
Materials and Methods
The survey questions were prepared through a literature review for controversial issues. The survey was sent to 450 member of Turkish association of pediatric surgery via Google Forms and 106 of them responded.
Results
There were 46 (43%) participants who do not perform endoscopy in whether symptomatic or asymptomatic patients in the first apply. Sixty (56%) participants preferred to perform endoscopy at the first apply. Thirty-six (34%) of participants perform endoscopy in case of certain ingestion of caustic substance, 14 (13.5%) perform in only symptomatic patients and 10 (9.5%) perform endoscopy in any suspicion of caustic ingestion. Seventy-one (67%) of the participants declared that they do not use antibiotics routinely and forty-six (45%) stated that they do not use steroids with or without esophageal burns.
Conclusion
Although some studies on CI management have been published, a clear algorithm in management of CI has not established yet. Clinicians tend to determine different follow-up and treatment algorithms based on clinical customs and their experience.
Introduction
Management of caustic ingestion (CI) and esophageal burns are a serious problem which causes a significant burden on the health care services (1-3). Initial admission of CI may be only suspicion of ingestion or symptoms such as oropharyngeal or chest pain, dysphagia, vomiting, drooling, stridor, fever and even shock (1, 4). Even though CI and esophageal burns are still relatively common in some countries such as Turkey, due to absence of evidence-based guidelines optimal management is still yet to be determined (5-7). Diagnostic role of endoscopy and its timing, steroid and antibiotic usage, type and timing of dilation of strictures are controversial and all of these vary between centers (1, 2). The management solely depends on the experience of the surgeons and clinical customs.
The study aims to evaluate clinical approach of Turkish pediatric surgeons (PSs) to caustic esophageal burns while emphasizing on endoscopy preference via an online questionnaire.
Materials and Methods
The survey questions were prepared through a literature review for controversial issues. Zargar et al. (8) classification was used to define grade of esophageal injury in the questions and its explained to clinicians in survey (Table 1). There is 21 questions. All participants questioned about their experience. While asking the preferneces of surgeons, it has been checked that they had the all facilities and they prefer one of them. Due to prevent any confusion, it was stated that the questions must be answered for children who was hemodynamically stable and there were no suspected esophageal or gastric perforation. The survey was sent to 450 member of Turkish association of pediatric surgery via Google Forms and 106 of them responded. Ethical approval was obtained from the Human Research Ethics Committee of Ankara University Faculty of Medicine (date: 26.03.2020, decision no.: İ3-182-20). Since the study did not include patients, patient consent was not obtained.
Statistical Analysis
No further statistical study was used. Surgeons’ choices are shown in tables and percentages.
Results
A hundred and six PSs answered the survey. Forty (37.7%) of them had more than 16 years of experience in pediatric surgery. Nearly half of the participants (n=52, 49%) were affiliated with university hospitals, followed by those in education and research hospitals (n=26, 26.5%), state hospitals (n=19, 18%), and private hospitals (n=9, 8.5%). There were 46(43%) participants who do not perform endoscopy in whether symptomatic or asymptomatic patients in the first apply. Sixty (56%) PSs preferred to perform endoscopy at the first apply. Thirty-six (34%) of participants perform endoscopy in case of certain ingestion of caustic substance, 14 (13%) perform in only symptomatic patients and 10 (9%) perform endoscopy in any suspicion of CI (Table 2). Among the participants who performed endoscopy at the first apply, 51 (85%) stated that they perform endoscopy in the first 48 hours, 9 (15%) stated that they performed endoscopy within 48-96 hours after the application. Seventy-one (67%) of the participants declared that they do not use antibiotics routinely. Forty-six PS (45%) stated that they do not use steroids with or without esophageal burns (Figure 1). Sixteen (15%) of participants preferred routine usage of steroid in caustic esophageal burns and 42(40%) stated steroid usage in particular patients. Among PSs who do not perform endoscopy at first admission, 41 (89%) of them preferred endoscopy three weeks later in case of symptomatic esophageal stricture and three (9%) preferred routine endoscopy in all cases.
Sixty-two PSs (68.5%) stated that they perform further examination in follow-up only in symptomatic patients, 22 (20.8%) in patients who had Grade 2B and more serious burns in the first endoscopy. Twenty-two PSs (20.8%) preferred performing further examination in all CI cases. Participants preferred endoscopy (64%), upper gastrointestinal contrast study (UGCS) (11%) and both endoscopy and UGCS (25%) during follow-up. Eighty-five percent of PSs stated that planned examination timing was three weeks.
The participants preferred balloon dilation (57.5%), wire-guided rigid dilator (57.7%) for dilation in esophageal strictures. Detailed information is shown in Table 3. The most common esophageal replacement method was colonic interposition (53%) followed by gastric transposition (30.9%), gastric tube transposition (9.6%).
Discussion
The present study revealed that there are many different approaches in CI among the Turkish PSs. The main debate was in requirement of endoscopic evaluation of esophagus following CI at the admission. Almost half of the participants stated that they do not perform endoscopy in early period after CI even in symptomatic patients.
Despite there are some studies which investigate the effectiveness of computed tomography, endoscopic ultrasound and scintigraphy, upper gastrointestinal tract endoscopy remains the gold standard to evaluate caustic injury of the esophagus (1, 3, 9, 10). Endoscopy is also accepted as an important tool for prediction of prognosis and management and it reduces length of hospital stay in children without esophageal burn (1, 3). Lamireau et al. (11) and Betalli et al. (12) reported that no severe esophageal injury or esophageal stenosis were occurred in asymptomatic children in their series and they argued endoscopy may not be necessary in these patients.
Aforementioned studies suggested performing endoscopy in all symptomatic patients (11, 12). Interestingly, in the present study, 46 participants (43%) stated that they do not perform endoscopy in any patients but only children who has symptomatic esophageal stricture in follow-up period. These participants’ approach was nil by mouth and intravenous fluid replacement until patient’s symptoms such as drooling resolved.
Endoscopy timing is also a controversial issue in CI (1). There are no controlled studies which compare early (within first 24-48 hours) and late (48-96 hours) endoscopy (1). Zargar et al. (8) reported that delayed endoscopy at 48-96 hours after ingestion is safe and they reported no complication. However, current studies suggest that performing endoscopy early in CI is safe and complication concerns such as perforation during endoscopy consist on no scientific reasons (3, 9, 13). Endoscopy also identify patients without esophageal burn who can be discharged, therefore it may prevent prolongation of unnecessary hospitalization (3, 14). Abbas et al. (14) reported that early endoscopy reduces length of hospital stay and treatment cost in a nationwide study (14). In the present study, 51 (85%) of participants who perform endoscopy in the first apply, preferred performing endoscopy first 48 hours.
Prognosis of CI has been found related to findings in endoscopic evaluation (1, 2, 15). Grade 1 and 2A esophageal burns rarely causes esophageal strictures (2, 15). Patients with Grade 2B and Grade 3 esophageal burns develop esophageal stricture formation 70-100% of the cases (1). Additionally, degree of the esophageal injury at endoscopy was found related to systemic complications and these findings may indicate emergency surgery (9).
The routine use of antibiotics is another controversial issue in CI management (1). In the literature, there is no strong evidence suggesting that antibiotic using reduces esophageal stricture formation (1, 3, 16, 17). Hugh and Kelly (3) suggested that broad-spectrum antibiotics should be given all patients with second or third degree esophageal burns (3). In a comprehensive review, Bird et al. (1) recommended using antibiotics for children who are using steroids for airway damage and suspected mediastinal and lung involvement. In this survey, seventy-one (67%) of the participants declared that they do not use antibiotics routinely.
Based on their potential to decrease inflammation and fibrosis; corticosteroids are used for prevention of esophageal stricture development in CI (18). However, steroids have been reported ineffective to prevent stricture formation in several studies (18-20). Steroid usage has been reported to benefit patients with airway involvement, such as larynx edema, and it should be administered in these cases rather than all patients with CI (9, 18, 20). The present study reveal that 16 of participants (15%) use steroids routinely in CI.
Esopageal strictures are the most common late complication after CI (1). Surgical treatment of the esophageal strictures in children has evolved to non-surgical treatments (esophageal bougienage, balloon dilation) by years. (21). There is still no consensus regarding to use of esophageal dilation technique (22). In a meta-analysis, Josino et al. (23) compared esophageal bougienage (Savary dilator) and balloon dilation in benign esophageal strictures and they reported no differences between two techniques in terms of effectivity and complications. In this survey, the most preferred techniques were rigid dilator with guide-wire and balloon dilation. Rigid dilator without guide-wire and stent were preferred by some participants (8.5% and 3.8% respectively).
Local use of corticosteroids such as triamcinolone and betamethasone may be performed in esophageal strictures during the dilation procedure (24-26). Kochhar and Makharia (27) reported outcomes of topical steroid injection in 29 patients who suffer from esophageal strictures due to CI. According to their study, steroid injection reduces number of dilation and improves dysphagia scores (27). Camargo et al. (28) compared saline versus triamcinolone injection in caustic esophagus strictures in their randomized controlled study and found no difference between the groups in dilation number and dysphagia scores. However, larger luminal diameter obtained in steroid group significantly (28). Mitomycin-C (MMC) is another agent that can be used in esophageal strictures based on its property of inhibiting fibroblast proliferation (29). Ghobrial and Eskander (30) reported that MMC application associated with more symptomatic and endoscopic improvement and lower numbers of dilation requirement compared to control group in refractory caustic-induced long segment esophageal strictures . Despite encouraging and promising reports in both triamcinolone and MMC usage in esophageal strictures, definition of the refractory stenosis, patient selection, application doses of both agent, number of applications have been reported differently in the literature (24, 27, 30-32).
Although the main approach is preserving patient’s own esophagus in the management of esophageal strictures, esophageal replacement may be unavoidable in particular patients (33). Esophageal replacement traditionally can be performed by colonic or jejunal interposition, gastric tube interposition, gastric transposition (34, 35). None of these methods are perfect and behave like a native esophagus (34). While colonic interposition is associated with higher risk of redundancy, anastomosis leakage and stricture, gastric transposition has higher respiratory morbidity and delayed gastric emptying (35). In the present study, the most preferred esophageal replacement method was colonic interposition, followed by gastric transposition and gastric tube interposition.
Study Limitations
This study has several limitations. Response bias may significantly influence the results, as the questionnaire was distributed to members of the Turkish Association of Pediatric Surgery, potentially skewing responses toward surgeons who are more engaged in academic meetings. Additionally, the survey was not sent to pediatric gastroenterologists, which represents another limitation.
Conclusion
There are many controversial issues in CI. Although some studies on CI management have been published, a clear algorithm in CI management has not established yet. Clinicians tend to determine different follow-up and treatment algorithms based on customs and their clinical experience as it may be seen in the present study. Prospective controlled studies are required to reach a consensus.
