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Journal of Current Surgery

Review

Volume 6, Number 2, June 2016, pages 41-45

Surgical Versus Non-Surgical Treatment for Traumatic Esophageal Perforation in Children: A Systematic Review

Esophageal perforation is a rare and potentially life-threatening condition. Early clinical suspicion and imaging is important for case management to achieve a good outcome [1]. Esophageal perforation is most commonly iatrogenic in origin with nasogastric tube insertion, stricture dilation, retrieval of the foreign bodies using esophagoscopy and endotracheal intubation, being the most frequent sources of the injury in infants and children. Clinical presentation depends on whether the cervical, thoracic, or abdominal esophagus is injured. Any patient complaining of chest pain after an upper endoscopy has esophageal perforation until proven otherwise [2]. Catheter interventions in the upper aerodigestive tract, such as the placement of orogastric catheter, nasogastric catheter and the procedure of oro-naso-pharyngeal suction are common medical practices in critically ill patients in the intensive care units that may concurrently have more iatrogenic problems [3]. Ingestion of foreign bodies, mainly button batteries, also contributes to the severe esophageal injury in a group of patients ranged between 6 months and 3 years of age [4]. Signs and symptoms included tachycardia, dysphagia, dyspnea, fever, cyanosis, abdominal pain, chest pain, and subcutaneous emphysema [5].

Several factors, including the difficulty of accessing the esophagus, the lack of a serosal layer, the unusual blood supply of the organ and the proximity of vital structures, all contribute to this condition’s high morbidity and to a mortality rate [6-8]. In addition, the diversity of clinical symptoms and signs combined with a lack of individual experience regarding this particular condition may impede rapid identification of this potentially hazardous situation. Accordingly, delayed diagnostic workup may hinder timely and appropriate treatment with a negative effect on patient outcome [9].

Children with esophageal perforation should receive fluid resuscitation and administration of broad-spectrum antibiotics to cover gram-positive, gram-negative, and anaerobic organisms. Esophageal injuries with ongoing leakage should be repaired as soon as possible, since delay in repair results in increased mortality. Perforations with contained leak in a stable patient on esophagography may be successfully managed non-operatively [10].

The rarity of this emergency makes it difficult for a physician to obtain extensive individual clinical experience; it is also challenging to obtain firm scientific evidence that informs patient management and clinical decision making. Improved attention to non-specific symptoms and signs and early diagnosis based on imaging may translate into better outcomes for pediatric patients.

Despite numerous retrospective serial reports on conservative versus surgical treatment of esophageal perforation in children, there exist no randomized controlled comparisons of clinical efficacy and safety between procedures. In addition, due to the heterogeneity of study designs, inconsistent reporting of complications, and the use of different grading scales for early and delayed diagnosis, it was not possible to perform a meta-analysis using the retrospective studies. Therefore, we endeavored to perform a quantitative systematic review of the current literature published in the recent 10 years to evaluate the clinical efficacy between surgical and non-surgical treatment in pediatric patients with esophageal perforation.

Two clinically relevant questions below were determined and a systematic review of related literature published in the recent 10 years was conducted using MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and Cochrane Database of Abstracts of Reviews of Effects, as well as foreign literature with English translations. Specific clinical questions were as follows: 1) In patients with early diagnosis of esophageal perforation, what are the indications for treatment (surgery versus conservative management) and its impact on prognosis? 2) In patients with delayed diagnosis, what are the indications for treatment (surgery versus conservative management) and its impact on mortality and morbidity rate?

We used the search terms that included “esophag*”, “perforation*”, “child*” and “surg*” to search literature from MEDLINE. The following terms would be contained: “esophagus”, “esophageal”, “perforation”, “child”, “children”, “surgery”, and “surgical”.

Criteria for possible inclusion are as follows: 1) articles published in the recent 10 years, 2) all articles in English or with an English translation, 3) pediatric age group (0 - 14 years old), 4) articles describing surgical treatment of iatrogenic esophageal perforation in children, 5) articles evaluating the conservative management in pediatric patients with esophageal perforation, and 6) articles with non-homogeneous pathology (e.g., trauma and another comorbidity in the same series). Exclusion criteria include the following: 1) spontaneous perforations of the esophagus, and 2) age group above 14 years old.

Studies were reviewed using a standardized data collection form. The type of study (retrospective) was noted. Data including surgery technique, the total number of patients, and mean age were collected. To avoid duplicate records of patients’ data, each group or institution was limited to one study in the systematic review.

The quality of evidence for each article was evaluated as high, moderate, low, or very low. The group then went through decision-making process using a modified Delphi technique to arrive at treatment recommendations related to the key clinical questions. This process and the strength of the recommendation were based on the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) method [11, 12]. These articles were evaluated independently by the authors according to the GRADE criteria.

A total of 66 abstracts were identified using various keywords. All abstracts were screened, and 51 articles were excluded as obviously unrelated. The full texts of 15 papers were screened and nine papers were identified to meet the inclusion criteria, retrospective articles (level III). The details of article selection were presented in Figure 1 and Table 1 [3, 4, 13-18].

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Figure 1. Flow diagram showing identification of studies included in the review.

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Table 1. Characteristics of Included Studies

Non-operative treatment is appropriate for many pediatric patients with iatrogenic perforation, i.e. perforation after dilatation, button battery ingestion, coin ingestion, nasogastric tube placement, insertion of a transesophageal echocardiogram probe and leak after stricture resection (Fig. 2).

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Figure 2. Algorithm of the management of the traumatic esophageal perforation in children.

In infants and children, plain chest films and esophagography, using water soluble contrast may assist in making the diagnosis. Free perforation and hemodynamic lability mandate a more aggressive surgical approach for wide drainage of the mediastinum and pleural spaces [2].

In patients with injury to the esophageal wall and contained leakage without systemic symptoms of infection and compromised circulation, careful observation, nil per mouth, appropriate treatment with intravenous broad-spectrum antibiotics and proton pump inhibitors (PPIs) and nutritional support may be sufficient for successful treatment. Children with esophageal perforation should receive fluid resuscitation and administration of broad-spectrum antibiotics to cover gram-positive, gram-negative, and anaerobic organisms (e.g., piperacillin/tazobactam for patients with penicillin allergy, clindamycin and gentamicin) [10].

Primary repair of esophageal perforation is possible, especially in patients admitted to the hospital within 24 h of the event. Morbidity and mortality are directly related to delays in diagnosis and therapy. Most cases of esophageal perforation in children can be closed primarily and the esophagus salvaged despite delayed presentation. The mortality rate in children with esophageal perforation (4%) is significantly less than that for adults (25-50%) [5].

Incidence of button battery ingestion is increasing in the last years and the early diagnosis, when they become lodged in esophagus, is of capital importance to diminish the risk of potential fatal complications. Endoscopic removal and a close follow-up by a multi-disciplinary group of physicians are essential to deal with both early and late complications [5]. Esophageal perforation is a rare complication of transesophageal echocardiogram probe placement as well. Complications include pneumothorax, pneumomediastinum with associated infection, pseudodiverticulum formation and esophageal obstruction. Non-operative management with broad-spectrum antibiotics and nothing per mouth is a safe and effective treatment strategy for infants with non-complicated perforations resulting from a transesophageal echocardiogram probe [16].

Recent reports emphasize a shift in treatment strategies over the last few decades, with non-operative approaches, such as percutaneous drainage of pleural effusions, collections or abscesses, becoming more common [5]. In addition, there is a growing use of temporary endoscopic esophageal stents to seal esophageal leakage and to recover gastrointestinal continuity [18]. The treatment, being individual to each patient, is mostly based on the time of presentation. Early diagnosed cases have a higher chance of successful primary repair, whereas delayed ones require conservative treatment. The majority of late-presented or late-diagnosed cases can be successfully managed conservatively [19].

In conclusion, non-operative management is recommended for perforations diagnosed within 24 - 48 h in a stable patient with no mediastinitis or empyema. The delay of the diagnosis is associated with a mortality which can oscillate between 4% and 20%. However, it is necessary to perform a controlled study to compare the clinical efficiency between the two methods of treatment.

Competing Interests

The authors declare that they have no competing interests.

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Journal of Current Surgery is published by Elmer Press Inc.