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Caustic Oesophageal Stricture
Paediatric Surgery

Caustic Oesophageal Stricture

20130827_171652   20130827_170953
20121106_101159
20121106_10565420121106_112951
20121106_130834 20121106_122021
20121106_124857 20121106_132635 (2)Caustic soda ( Concentrated NaOH) known by its chemical name as sodium hydroxide  is used by Ghananian women in domestic soap production employing traditional crude methods. The soap is sold to support families and also used for bathing and other domestic chores. This means of revenue generation which is done on a small scale in the houses of parents also expose their children to the ever present risk of accidental ingestion. Children as low as 6months , unattended to,  accidentally ingest the corrosisive sodium hydroxide leading to severe chemical burns with adverse late complications, commonly oesophageal strictures, inability to feed and subsequently severe malnutrion and dehydration. Without intervention most of these children die from chronic starvation and dehydration . This accident usually occurs in  very low income families and puts intense psychosocial burden on parents and the children. There is the attendant financial burden of hospital trips , change of feeding gastrostomy tubes, antibiotics and  ICU care for the those operated . The Paediatric surgery team headed by Dr Nimako Boateng , KATH  Kumasi  has seen several of such cases and successfully operated some leading to improved quality of life. There are few instances where unfortunate mortalities had resulted from post operative   ICU care .
3 year old boy accidentally ingested concentrated caustic soda when he as only 6months old . He later developed oesophageal strictures, cough, fever several months after presentation . A diagnosis of caustic oesophageal stricture and bronchopneumonia were made . Child was treated with antibiotics successfully  . An open surgical placement of feeding gastrostomy tube was done . Child’s parents were able to raise funds to cover posteoperative ICU care and strong antibiotic ( not covered by NHIS) . Child has been treated for bronchopneumonia wich is a common complication of this condition. This results from chronic aspiration of food and pooled secretions in the oropharynx.
Diagnosis: Caustic oesophageal stricture.
Investigations :
FBC, WBC, Grouping and crossmatching
CXR : looks normal
Oesophagoscopy : The oesophagus couldn’t admit the scope
Barium swallow: Note the point of narrowing on image 3 of the contrast study
Surgery : Oesophageal Bypass
Intraoperative Details : Done by two teams . trancervical, tansabdominal . An on table oesophagoscopy is done before starting the surgery . A hockey stick incision is placed on the left side of the neck to mobilise the most proximal part of the oesophagous bearing the stricture . This case proved to be particularly challenging because the level of the stricture was quite high , about 3cm below the hypopharynx making complete excision of the stricture without pharyngoplasty impossble.. The stricture was however found not to involve the whole circumference of the oesophagus so and end to side colo oesophageal anastomosis was decided upon.
The proximal oesophagus was mobilised .The submandibular salivary gland on the left had to be mobilised and displaced upwards in order to gain access to the stricture . The stricture was divided transverselly .   An approriate length of the tranverse colon is divided preserving its blood supply . This length of colon being used as the neo-oesophagus  is tunnelled retrosternally to be anastomosed end to side isoperistalticaly to the oesophagus proximally  and the stomach, distally .The remaining tranverse colon is anastomed end to end
Postoperative state: Child is currently in recovery at the ICU and is stable
Discussion : Though much is known of the dangers associated with domestic use of caustic soda ,it still remains available for purchase and usage.Little has been done in increasing public awareness on such a preventable domestic accident. Most children  suffering caustic oesophageal strictures refuse to attend school for fear of being teased by friends any time they feed through the gastrostomy tubes. The frequent visits to hospital for aspiration pneumonia, kinked, clogged, migrated  tubes, excoriation dermatitis etc, go a long way to disrupt the education of these children. The economic burden of parents are increased as most often such hopsital visits apart from draining the coffers of the parents , also disrupt their work.  Though children are the vulnerable group few adults have fallen victim to their own purchase , mistaking caustic soda for water due to its colourless appearance. The specialised care needed perioperatively does not exist in peripheral health facilities and so much is to gain at employing preventive measures.
Credits :   Prof. Abantanga, Drs Nimako Boateng , Michael Amoah, Abiboye Yifeyeh, Paediatric Surgery KATH ,Kumasi
 

2 COMMENTS

    • Stricture may recur. This case was very demanding. Took about 6hrs. Stricture couldn’t be excised completely. Early complication of anastomosis breakdown, mediastinitis is very real

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