Emergency surgical management of a case with severe esophageal burns.

Sir,

Alkaline esophageal burn (EB) is a debilitating injury and common in the southern rural areas of our country where the air conditioning systems are cleaned by alkaline liquids which are accidentally ingested by children. These agents usually result in strictures. However, the high concentration of alkaline liquid sometimes causes severe complications like fistula between gastrointestinal and tracheobronchial or major arteries, esophageal perforation, and air way obstruction, unless treated emergently.[12]

A 3-year-old girl was seen in our pediatric department with history of unknown amount of aluminum hydroxide powder ingestion by accident. She underwent flexible pediatric endoscopy by a gastroenterologist on arrival, which showed severe burns of oral cavity and esophagus (Gllb).[34] The patient was given anti-secretory agent (ranitidine 5 mg/kg/d), antibiotics clindamicin (30 mg/kg/d) + ceftriaxone (50 mg/kg/d), and hydrocortisone (1 mg/kg/dose, q8 h).[4]

She complained of dyspnea, abdominal distension, and drooling after 4 days when a surgeon was consulted. Her chest and abdominal X-rays showed signs of diffuse infiltration of lung and gaseous distensions of stomach. She needed a rigid bronchoscopy and esophagoscopy for diagnosis of complications and treatment.

Esophagoscopy findings were ulcerated oral cavity associated with narrowed and burned esophagus (GIIb) from which anesthetic gas leaked. There were severe inflammation, thick secretions, and large tracheoesophageal fistula near the origin of left main bronchus on bronchoscopy.

We had to use the esophagus as a reinforcing patch for severely damaged trachea. Therefore, we were supposed to perform cervical esophagostomy to divert the saliva; but on exploration, the two organs were found fused and damaged, making end esophagostomy impossible.We devised a pharyngostomy tube in right side of her neck by number 32 mushroom catheter and the esophagus was closed by a prolene mesh plug which completely was filled with cyanoacrylate glue (Glubran II, Virgilio, Italy) to prevent swallowing of saliva.[5]

Through bronchoscopic intervention, the carinal fistula was closed with small pieces of prolene mesh which were embedded in the fistula tract and covered with Clubman II, accompanied by insertion of a tracheostomy tube for prevention of tracheal stenosis [Figure 1].

Figure 1

Closure of fistula with mesh and Glubran II through bronchoscope

We needed to insert a gastrostomy tube to prevent the upward reflux of the gastric contents and a jejunostomy tube for enteral nutrition.

The patient was transferred to surgical ICU for respiratory care and she also received antibiotics, anti-secretory agent, and steroid. She underwent repeated bronchoscopy for evaluation of healing fistula. She could be transferred to normal ward after 1 week and discharged to home care setting.

The perforation rate was reported to be 0.47–32% in many studies, and White et al. reported five out of eight deaths because of complications during the treatment course in their series.[6] But our patient became so compromised that keeping her alive needed extraordinary planning of treatment.

Our plan was to save the respiratory tract by sacrificing the esophagus, so we plugged the esophagus and carinal fistula with a combination of synthetic mesh and bioglue (Glubran II), which have never been used before. However, it required regular bronchoscopic evaluation to recheck the developing complications and for proper management.

Based on our experience, we recommend that complicated EBs should be managed by an experienced surgeon in this field who knows how to use all the available means. This case also demonstrates the efficacy of bioglue in treating esophagobronchial fistula.