© Borgis - New Medicine 3/1999, s. 18-19
Małgorzata Dębska, Mieczysław Chmielik, Iwona Jakubczyk
Treatment of post-burn strictures with internal oesophagotomy
Department of Pediatric Otorhinolaryngology, Medical School, Warsaw
Head: Prof. Mieczysław Chmielik, M.D.
Summary
107 patients with esophagostenosis after chemical burns were examined. Subjective swallowing ability and condition of esophagus in radiological examination were estimated. It was concluded that internal esophagotomy is a valuable method of fixed esophageal stenosis treatment.
Methods of treatment of post-burn strictures of the oesophagus vary from centre to centre. The aim of this paper is to assess, the long-term effects of the treatment of cicatricial strictures with internal oesophagotomy, following chemical injury in children at a developmental age.
Over a period of 45 years (1950-1995) 107 patients with post-burn strictures (95) or atresia (12) of the oesophagus were diagnosed and treated at the Department of Paediatric Otolaryngology, Warsaw. The subjects included 38 girls and 69 boys who had suffered burns of the oesophagus in early childhood (mean age 4.06 years).
Thirty-five subjects were assessed i.e. 35 women and 22 men who came to follow-up after treatment of after-burn oesophageal strictures with internal incision. Out of these, 32 patients had been treated with internal oesophagotomy only, whereas 3 subjects (1 female and 2 males) had undergone intestinal oesophagoplasty. The patients´ ages ranged from 9 to 53 years, the mean age being 33.94 years. The study patients presented at different times on completion of their treatment and the follow-up period was from 4.5 years to 42 years (mean 24.87 years).
A thorough history, study of medical records, and radiological examination of the oesophagus following a barium swallow provided the grounds for the evaluation attempt of the preferred treatment method of oesophageal stricture employed in our Department. The patients´ self-assessment of their ability to swallow food was graded as follows:
I - good, normal swallowing,
II - moderate, all foods are swallowed but are chewed for longer and swallowing require drinking water,
III - dysphagia, swallowing of mashed foods, experiencing episodes of foreign bodies in the oesophagus.
Patients´ self-assessment of food swallowing
Good, normal swallowing ability (I and II) was reported by 29 subjects (90.63%); 3 patients (9.7%) reported normal food ingestion but admitted having difficulty in swallowing (III). Three patients after oesophagoplasty who denied dysphagia were excluded from the self-assessment of their swallowing ability.
Diameter of oesophageal stricture measured with a bougie prior to treatment
In patients with oesophageal stricture the initial size of a constricted lumen of the oesophagus was measured in millimetres using a bougie and was carried out on the first endoscopic examination. One patient presented with atresia; in 4 patients (11.43%) the oesophagus was constricted to 2 mm, in 27 patients (77.14%) the constriction was 3-4 mm, and in 3 patients (8.7%) it was noted to be up to 5 mm. The mean diameter of the stricture was 3.37 mm.
Diameter of oesophageal stricture measured with a bougie following treatment
The final oesophagoscopy carried out after the last successfull internal oesophagotomy permitted to close gastrostomy over a short-term follow-up.
In 1 case atresia was diagnosed; in 14 patients (40%) the oesophageal lumen increased to 7 mm; in 11 patients (31.43%) the lumen reached an 8 mm diameter and in 6 subjects (17.14%) the diameter increased to 9mm. In 2 patients (5.71%) the treatment was completed after obtaining a 6 mm diameter of the oesophageal lumen.
Following the treatment, the mean diameter of the oesophagus at the site of the stricture was 6.57 mm, which shows that improvement had been obtained by an average of 3.20mm (prior to the treatment the oesophageal lumen had been 3.37mm in diameter).
Radiological evaluation of the present diameter of the oesophageal lumen
In 3 patients radiological examination was normal with an oesophageal diameter of 25 mm. The smallest diameter of the oesophagus in patients with strictures was 3 mm. The average oesophageal lumen at the site of stricture was 9.28 mm.
In 20 patients (62.5%) the oesophageal diameter ranged from 7 to 11 mm and in 5 subjects (15.63%) it was more than 11 mm, which totals 25 patients (78.13%) with an oesophageal lumen of more than 7 mm. In 7 patients the oesophageal diameter was smaller than 7 mm including 1 patient with a 3 mm diameter, 2 patients with 5mm and 4 patients with an oesophageal diameter of 6 mm.
Present oesophageal diameter vs oesophageal diameter immediately after the treatment
The values of present oesophageal diameters (measured at radiological examination) were compared with those obtained after the treatment, and measured with a bougie.
In 15 patients (46.9%) the diameter was found to be larger than that immediately after the treatment. An average increment of the oesophageal diameter was 61.9% (15 patients). In 6 patients (18.8%) the diameter remained unchanged, and in 11 patients (34.4%) the diameter was decreased in size as compared with the diameter measured immediately after treatment. The average reduction of oesophageal diameter against the values following the treatment of the group of patients accounted for 22.7% (11 patients).
The length of the oesophageal stricture
The length of the oesophageal stricture ranged from 1 mm to 200 mm, averaging 36.78 mm. Evaluation of the condition showed that the largest group (18 subjects) was represented by patients with strictures up to 50 mm. In 11 patients strictures were present at a distance greater than 50 mm.
Dilatation of the oesophagus above the site of stricture
Dilatation of the oesophagus above the site of stricture was found in 5 cases (15.625%) and had developed in patients with an oesophageal lumen less than 8 mm, at the site. In 2 cases a pouch was present in the upper segment of the oesophagus.
Discussion
All patients treated with internal oesophagotomy ingested food normally despite the fact that 3 of them (9.7%) reported dysphagia. Normal swallowing was admitted by 29 patients (90.63%). The results appear acceptable considering the long period since the treatment.
In our material we have proved that the oesophageal lumen obtained well after cessation of the treatment in 21 patients (65.7%) was not reduced. On the contrary, its diameter had increased. In 6 patients the oesophageal diameter did not demonstrate any change and in 11 patients the lumen of the oesophagus had decreased by an average of 22.7%.
It follows that the diameter of the constricted site showed an average increase of 1.94 mm (the average size of the lumen immediately after the treament was 7.34 mm and the average present size was 9.28 mm).
An increasing size of the oesophageal lumen without any additional treament was reported by Jackiewicz (3) and Danielewicz (2). Milewicz also states that due to normal food ingestion the oesophageal lumen, and even that of the stomach, may demonstrate a gradual increase resulting from mechanical action by the food, which may yield a normal status (4). Barbary et al. also noted that eating is a natural way of achieving dilatation (1).
Results of our assessment of the condition of the oesophagus allows us to believe that the treatment of post-burn strictures of the oesophagus in children by means of internal oesophagotomy is an efficient method. There is no need to attempt to obtain an oesophageal lumen of more than 8 mm at the site of stricture because this size is sufficient for normal functioning and, moreover, itmay show a further increase after the treatment.
Conclusions
1. Internal oesophagotomy is an efficient treatment providing satisfactory and permanent long-term effects.
2. The lumen of the oesophagus obtained due to internal oesophagotomy may increase in size spontaneously.
Piśmiennictwo
1. Barbary A.S. et al.: The use of ”indwelling catheter” in the strictures of the esophagus. Laryngoscope, 1966, 76, 9:1562-1571. 2. Danielewicz J., Góralówna M.: Leczenie zwężeń bliznowatych przełyku metodą ezofagotomii wewnętrznej. Otolaryng. Pol., 1955, 9:1,1-10. 3. Jackiewicz Z., Dybicki J.: Wyniki leczenia oparzeń chemicznych górnego odcinka przewodu pokarmowego. Pol. Przegl. Chir., 1985, 57, 9:744-754. 4. Milewicz Z.: Oparzenia truciznami żrącymi górnych dróg pokarmowych w obrazie radiologicznym. Pol. Przegl. Radiol. Med. Nuklear., 1964, 28, 4:295-306.
