A Biodegradable Esophageal Stent in the Treatment of a Corrosive Esophageal Stenosis in a Child

Abstract

Children who ingest a caustic product with resultant corrosive esophagitis comprise a heterogeneous group of patients in terms of the offending agent, the location of the burn, and the degree of damage. Today, there is no optimal standardized approach. We report a case of successful treatment of a child with an esophageal stenosis after caustic ingestion with a self-expanding and biodegradable esophageal stent. CASE REPORT A 10-year-old healthy boy with normal psychomotor development ingested by accident several full swallows of a drain cleaner, a 15% NaOH solution with a pH of 12.5. The house was being redecorated and a family member had put a plastic mineral water bottle containing the drain cleaner in the door of the fridge. The boy was thirsty, saw the bottle, and started to drink from the bottle. He immediately vomited and started complaining of dysphagia and retrosternal pain. His vital parameters (blood pressure, heart, and respiratory rate) were normal and stable. Severe buccal ulcerations were present. The abdominal examination was normal. Because the patient was stable and had no signs of perforation, an upper endoscopy was performed 15 hours after the ingestion. Major circumferential ulcerations over the whole length of the esophagus were present: grade IIb according to Zargar et al (1). There was no perforation, and the stomach was normal. During the first couple of days there was an obvious excessive production of saliva, and he complained of retrosternal pain. Analgesics, parenteral nutrition, intravenous omperazole (2 mg · kg−1 · day−1), and high-dose intravenous corticosteroids (1 g/1.73 m2) were administered. A large nasogastric tube was put in place to prevent the development of esophageal stenosis. Preventive antibiotics and antifungal medication were started because of the high-dose corticosteroids. After 4 days, enteral tube feeding was started. The mouth lesions disappeared after about 10 days, and oral feeding was started after 10 days; also the endoscopic appearance of the esophagus had significantly improved, and the corticosteroids were switched to oral administration; after 3 weeks, they were decreased gradually. The thick nasogastric tube was removed after 16 days. After 3 weeks, he was discharged with an oral proton pump inhibitor and corticosteroids in a decreasing dose. Control endoscopy before discharge still showed an active corrosive circular esophagitis at the mid-esophagus. Sloughing of necrotic areas was present as well as areas of granulation tissue. A control endoscopy 2 weeks after discharge still showed ulcerations, sloughing, and granulomatous tissue, but also, and for the first time, a developing stenosis at the mid-esophagus. A gastroscope (Olympus GIF-Q180, with an external diameter of 8.8 mm; Olympus, Hamburg, Germany) no longer passed the mid-esophagus; the neonatal endoscope (Olympus GIF-N180, external diameter of 4.9 mm) passed without any problem. The stenosis in the middle of the esophagus had a length of about 1 to 2 cm. At that time, there was no distal stenosis. The patient complained at that time of dysphagia for solids. A self-expandable biodegradable SX-ELLA esophageal stent was inserted under general anesthesia 6 weeks after the accidental ingestion. The stent had a body diameter of 25 mm and a length of 80 mm; insertion was uneventful (Fig. 1). During the first days after the insertion, he complained of retrosternal pain and dysphagia. He also had nausea and vomited several times per day, for which he was treated with alizapride. Two weeks after the insertion of the stent, he was discharged because he had been asymptomatic for several days. Oral omeprazole (20 mg/day) was continued.FIG. 1: View of the stent immediately after esophageal insertion.The stent remained in place, although a control endoscopy after 3 weeks showed that the distal end had extended into the stomach (Fig. 2). Because, to our knowledge, this was one of the first stents of this type placed in a child with corrosive stenosing esophagitis, a control endoscopy was performed every 2 to 3 weeks. About 12 weeks after insertion, the stent had degraded about 50%. At that time, esophageal mucosa had healed. Although the patient remained symptom free during the 4 months, he developed a severe distal esophageal stenosis more than 4 cm about 10 months after the initial ingestion and 6 months after the stent placement. The stenosis in the middle of the esophagus remained visible, but passage of the Olympus GIF-Q180, with external diameter of 8.8 mm, remained easy. Esophageal pH monitoring showed a reflux index of 15% in the lower esophagus; histology was compatible with a “reflux esophagitis.” Repeated history and low gastrin levels confirmed noncompliance to the omeprazole treatment. After 4 balloon dilatations and with careful control of the proton pump inhibitor intake (omeprazole 40 mg/day), the distal esophageal stenosis did no longer relapse. Histology of the distal esophageal biopsies