There are three main types of chemicals that cause chemical burns in the esophagus: acids, bases, and other chemicals. In children it is mostly accidental, in adults, it can be accidental, but also swallowed by mental disorders or attempted suicide. With esophageal chemical burns, late complications include esophageal stricture, malnutrition, pulmonary lesions (pneumonia, lung abscess, bronchiectasis and esophageal tracheal or bronchial fistula), perforation, hiatal hernia and carcinoma. Among them, esophageal stricture and esophageal tracheal or bronchial fistula are more common in clinical practice, and have their own special and difficult treatment. There are many treatment methods, but there is no uniform and effective means yet, which is a difficult point of treatment in general thoracic surgery.
After accidental administration of chemical corrosive agents, the scope of burns includes the mouth, pharynx, larynx, esophagus, stomach, and duodenum. Esophageal chemical corrosive agent burns can be classified into three degrees.
I mucosal congestion and edema, which heals within about 7-8 days.
II necrosis and ulceration of the mucosa and muscular layer, with proliferation of granulation tissue and replacement of normal tissue by fibrous tissue within 3-6 weeks, followed by formation of strictures due to scarring.
Ⅲ ulcer reaches deep into the surrounding tissues of the esophagus, invading the mediastinum, pleura or peritoneum, leading to esophageal perforation and mediastinitis, secondary infection, shock or death due to toxin absorption and poisoning.
1.Early treatment.
1.1 Keep the airway open, maintain circulatory function and hemodynamic stability, maintain water and electrolyte balance; clean the trauma, use neutralizing drugs, weak acids (neutralize strong bases), weak bases (neutralize strong acids), saline, water, milk, and 10% C02 gas aspiration; place a nasogastric tube; use antibiotics and hormones, etc.
1.2 Surgical treatment should be based on the pathological and progressive characteristics of the patient to decide whether to perform surgery and what kind of surgery to perform. Principles: The aim should be to save the patient’s life, to minimize the scope of surgery, to protect organs or tissues that may be saved or preserved, to avoid blind removal of the stomach or esophagus, to use drainage such as abdominal drainage, gastrostomy, and to maintain nutrition such as jejunostomy as much as possible.
1.3 Early dilation: In patients with esophageal burns, it is controversial whether early dilation is possible. After chemically corrosive esophageal burns, esophageal strictures of different degrees are formed later, regardless of whether early dilation occurs. Early dilation cannot stop the pathological change process of esophageal burns because in esophageal burns, there is inevitably esophageal mucosal damage. In some patients, the corroded esophageal mucosa is vomited out in strips or discharged with the stool about a week after the burn, and the esophageal muscle layer is adhered to form the so-called esophageal self-truncation, so early dilation is ineffective in such patients, and substitution esophageal surgery should be performed after the esophageal stricture stops progressing.
2. Late treatment: After the inflammatory edema subsides and the painful dysphagia is relieved, a series of treatments for the gradual emergence of esophageal stricture and dysphagia are performed.
2.1 Esophageal dilatation: 7-10 days after burn for degree I-II esophageal burns, and 3 weeks after burn for degree III esophageal burns, with dilatation starting once a week and changing to once a month after 6 weeks, for a total of 6 months-1 year.
2.2 Microwave therapy: Microwave is an electromagnetic wave with a wavelength of lmm-1m, and its frequency is 300 MHz-300 GHz, so it is also called ultra-high frequency electromagnetic wave. Using the thermogenic effect of microwaves can treat the scar stenosis after chemical burns of the esophagus, and the effect is sure.
2.3 Memory alloy esophageal stent: Currently, there are two types of memory alloy esophageal stents, domestic and imported, for the treatment of scar stenosis <10 cm in length after esophageal burns. There are various structures and shapes of stents: dumbbell-shaped, spiral-shaped, grid-shaped, and grid-shaped memory alloy esophageal stents with grasping nails at both ends, as well as memory alloy esophageal stents with membranes.
2.4 Silicone tube holder in the lumen of the esophagus: its shape is tube-shaped with a funnel-shaped upper end to prevent it from sliding down and a chamfered projection on the lower, thinner outer wall to prevent it from sliding upward. The silicone tube is left in place for more than 3 weeks to keep the lumen open, promote epithelial proliferation, and prevent the formation of mucosal adhesions and strictures.
2.5 Surgical treatment: Surgery can be considered after the esophageal stricture segment is too long or after the above treatments have failed. The main purpose of surgery is to replace the esophagus and repair the fistula. The organs to replace the esophagus are stomach, colon or jejunum, and duct. Repair materials include intercostal muscle flaps, etc.
The treatment of scarred esophageal strictures after chemical burns of the esophagus is mainly described below and can be divided into esophageal dilatation, internal tube or internal stent in the lumen of the esophagus and esophageal reconstruction.
1.Dilatation therapy: This group uses hard polyethylene esophageal dilators, which are simple to operate, less dangerous, less painful to patients and reliable. It is mainly suitable for patients with mild stenosis.
2.Internal stent therapy: The cases collected from the interventional department and the microscopy department of our hospital were treated with memory alloy esophageal stent and intra-luminal silicone tube stent, which can keep the lumen open, promote epithelial proliferation and prevent mucosal adhesions and stenosis formation.
3.Surgical treatment
There are many surgical methods for the treatment of benign esophageal strictures, except for gastrostomy or jejunostomy, which can be summarized as resection and reconstruction of the stenosed esophagus and simple diversion esophageal bypass to preserve the stenosed esophagus. At present, the retrosternal colonic substitution for the esophagus seems to be the safest surgical method.
3.1 Colonic substitution of the esophagus: The colon is by far the most commonly used replacement organ for benign esophageal strictures. It is suitable for stenosis at any site, especially for stenosis in the upper thoracic segment or in the low neck. The advantage of this method is that the colonic mesentery is wide and the marginal vessels are thick, which can maintain a good blood supply to the colonic. In addition, the colon can be lifted behind the sternum or subcutaneously to the pharynx without entering the chest, which is less traumatic and safer for surgery. Both the right and left colon can be replaced, but the literature reports that the left colon is superior to the right colon. This is because the left colon (1) has a smaller diameter, similar to the caliber of the esophagus; (2) has a more fixed and reliable blood supply; (3) is long enough to replace the entire esophagus; and (4) has better peristaltic force. Patients with corrosive esophageal burns have higher postoperative complications than other benign esophageal diseases, with 60% of patients having proximal anastomotic stenosis and 20% having poor swallowing function. Therefore, it is advocated that patients with corrosive esophageal burns should choose alternative organs other than the colon, such as: stomach, jejunum, etc.
3.2 Gastric substitution for esophagus: It is more ideal to use stomach for esophageal reconstruction. Its advantages are: (1) esophagogastric anastomosis restores the continuity of the digestive tract; (2) simple operation with one anastomosis and few complications; (3) good blood flow and sufficient length for anastomosis in all planes; (4) little intraoperative contamination and no intestinal preparation; (5) no bad breath; (6) can lesion the esophagus to prevent long-term complications; (7) can prevent food reflux; (8) normal gastric emptying time in the long term and does not affect growth and development. In addition, chemical injuries to the esophagus are often accompanied by burns and contractures of the stomach, which affect its replacement.
3.3 jejunal substitution of esophagus: free jejunum or jejunal graft with vascular tip has good results for esophageal reconstruction of benign esophageal strictures. The disadvantages are
The technical requirements are high. We do not perform this technique.
3.4 Ductal-jejunal substitution of esophagus: In the mid-1950s, we successfully performed ductal-jejunal substitution of esophagus and created a miracle in medical history of 45 years of high quality survival after surgery.
3.5 Treatment of esophagotracheal or bronchial fistula: Our group has successfully applied tipped intercostal muscles to repair both tracheal defects and esophageal defects. The use of intercostal muscle flap as a material for repairing esophageal respiratory fistula has many advantages: (1) it is easy to take the material and can be performed with either left- or right-sided open chest without a separate incision; (2) the vascular distribution of intercostal muscle is regular, and the production of tipped muscle flap is simple and easy to survive; (3) compared with other repair materials, intercostal muscle flap has strong resistance to infection, good elasticity, easy to close suture with the tissue around the fistula, and strong regenerative ability; (4) it can be used according to the size of the fistula. (4) the corresponding height of intercostal muscle can be used as repair material according to the level of the fistula. The method is worthy of reference and promotion.
Conclusions: (1) Esophageal dilatation is used to get relief by mechanical expansion, while the expansion treatment of corrosive esophageal strictures, in terms of timing, is currently considered: dilatation is better at about 3 weeks after injury, and both are gradually expanded from fine to coarse dilators, which have obvious effects on lighter or limited lighter circumferential esophageal strictures.
(2) Interventional treatment has led to the emergence of a new and effective treatment for corrosive esophageal strictures and esophagotracheal fistulas with memory alloy esophageal stents for the treatment of scarred strictures <10 cm in length after esophageal burns. Intraluminal silicone tube stent for esophagus, which can keep the lumen open and promote epithelial proliferation to prevent mucosal adhesions and stricture formation.
(3) In comparing the advantages and disadvantages of various treatment methods for esophageal strictures, the importance of colonic and gastric substitutes and gastrostomy or jejunostomy in the treatment was confirmed. The ductal-jejunal substitution of the esophagus set a record of 45 years of high quality survival after surgery. The successful simultaneous repair of tracheal defects and esophageal defects with tipped intercostal muscles is an ideal solution for the treatment of esophageal respiratory fistulas requiring material repair of the fistula.