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Corrosive Ingestion and Oesophageal Replacement 327

and 51.10) A feeding jejunostomy rarely is required for caustic injuries.
Reported complications from Great Ormond Street Children’s Hospital
25
in London are as follows: Mortality, 5.2%; anastamotic leaks, 12%;
oesophageal strictures, 38%. All leaks but one closed spontaneously,
and all strictures except three responded to dilatation. Transient dump-
ing syndrome and delayed gastric emptying were also noted. Results
were excellent in 90% of patients with minimal impact on growth,
development, and respiratory function.
Jejunal Substitution
The jejunum is more commonly used in adults. It is used mainly as a
free graft with microvascular anastamosis. Due to the popular use of
the colon or stomach as replacement organs with good results, jejunal
substitution is used less in the paediatric population.
Surgical Technique
The most critical point in the planning of the operation is the selection
of the site for proximal anastomosis. The site of the upper anastomosis
depends on the extent of the pharyngeal and cervical oesophageal dam-
age. When the cervical oesophagus is destroyed and a pyriform sinus
remains open, the anastomosis can be made to the hypopharynx. When Figure 51.8: Retrosternal colonic graft.
the pyriform sinus is completely stenosed, a transglottic approach is
used to perform an anastomosis to the posterior oropharyngeal wall.
Recovery is long and difficult and may require several endoscopic
dilatations and, often, reoperations. Sleeve resections of short strictures
are not successful because the extent of damage to the wall of the
oesophagus can be greater than realised, and almost invariably the gastrostomy
anastomosis is carried out in a diseased area. The management of oesophageal stump
a bypassed damaged oesophagus after injury is problematic. The
extensive dissection necessary to remove the oesophagus, particularly in
the presence of marked perioesophagitis, is associated with significant
morbidity. Leaving the oesophagus in place preserves the function of
the vagus nerves and, in turn, the function of the stomach. Leaving a
damaged oesophagus in place, however, can result in multiple blind
sacs and subsequent development of mediastinal abscesses years
later. Most experienced surgeons recommend that the oesophagus be
removed unless the operative risk is unduly high. 5
Antral stenosis may develop rapidly 3 to 6 weeks after the injury, pyloromyotomy
but in some cases it may appear only after several years. Therefore,
26
long-term follow-up is required even though the initial symptoms
26
of the patients are minimal. Some surgeons perform a Billroth
I procedure for severely injured mucosa with complete pyloric
obstruction, and pyloroplasty for moderate mucosa injury associated
with partially obstructed but still viable pylorus. However, distal
27
gastric resection is usually recommended. Although many patients Figure 51.9: Gastric interposition.
are initially achlorhydric, vagotomy is usually performed because
acid production may return. With extensive injury, subtotal or total
gastrectomy or partial oesophagectomy may be necessary.
A strong association exists between caustic injury and squamous
cell carcinoma of the oesophagus. From 1% to 7% of patients with
carcinoma of the oesophagus have a history of caustic ingestion.
A 1000- to 3000-fold increase has been estimated in the expected
incidence of oesophageal carcinoma after caustic ingestion. Because
3–7
of the markedly increased incidence of cancer in these patients, many
authors have recommended yearly endoscopic surveillance beginning
20 years following caustic oesophageal injury. 7

Figure 51.10: Contrast of gastric interposition.