Prevention and treatment of post-burn strictures of the esophagus in children

The dissertation is devoted to an urgent problem of pediatric surgery — the prevention and treatment of post-burn esophageal strictures in children using the drug «Kuriozin» and an original device for restoring esophageal patency. The relevance of the study is determined by the high incidence of chemical burns of the esophagus in childhood, which ranks first among esophageal diseases in children, the absence of a tendency toward a decrease in morbidity, as well as the imperfection of existing methods for the prevention and treatment of this pathology. The purpose of the work was the development of a comprehensive method for treating children with chemical burns and post-burn esophageal strictures using the drug «Kuriozin» and a device for restoring esophageal patency, allowing for the improvement of treatment outcomes in this category of patients. The study addressed objectives of experimental substantiation of the effectiveness of the drug «Kuriozin», development of a technique for the prevention and treatment of cicatricial esophageal strictures of grade III, comparative evaluation of the clinical effectiveness of the developed method, and analysis of its economic feasibility.

Significance of the Problem

Despite advances in the treatment of chemical burns of the esophagus in children, the problem remains relevant, due to the absence of a tendency toward a decrease in the number of children with this pathology. Chemical burns rank first among esophageal diseases in children. Most frequently, chemical trauma of the esophagus affects children aged one to three years, constituting 75% of all children with esophageal burns.

In the Russian Federation to date, poisoning by caustic substances in children accounts for a sufficiently large proportion, ranging from 9.5 to 14.1% of the total number of poisonings. The hospitalization rate in Russia is 1.1 per 1000 population. Thus, annually in France, 15,000 to 20,000 poisonings by chemical substances are recorded; in the USA, more than 5,000 children annually sustain esophageal burns from alkaline products and acids, resulting in esophageal stenosis in 20–30% of children.

Despite advances in the treatment of chemical burns of the esophagus, mortality from poisoning by acids and alkalis among the adult population ranges from 20 to 50%, while among children this figure is much lower, ranging from 2 to 15%.

The development of the pathological process in chemical burns of the esophagus in children is reflected in the works of E.N. Vantsyan and R.A. Toshchakov. Upon contact of a chemical agent with tissues, their damage occurs. As the contact period increases, damage to the organ walls worsens. Here, not only the action of corrosive substances plays a significant role, but also reflex vasospasm.

To date, children with esophageal burn disease undergo prolonged and not always effective treatment, resulting in the development of esophageal stenosis of varying severity.

The diagnosis of esophageal burn can be reliably established or excluded using fibroesophagoscopy. Here, esophageal burns of grade II and III are differentiated in the acute period according to developed endoscopic criteria, which in a number of cases allows for the abandonment of preventive esophageal bougienage.

Grade III esophageal burns lead to cicatricial stenosis of the lumen in 100% of cases, requiring the implementation of preventive and therapeutic bougienage.

Currently, the primary method for the treatment and prevention of cicatricial esophageal stenosis is early bougienage, developed and introduced into practice by Salzer in 1920 and currently used in various modifications. Most researchers engaged in preventive bougienage indicate the danger of esophageal perforation and frequently ensuing mediastinitis. Additionally, the disadvantages of early bougienage include traumatism, risk of esophageal perforation, and delayed reparative processes.

When using the blind bougienage technique, the risk of esophageal perforation development reaches 30%. This circumstance served as the basis for the development and introduction into the practice of treatment of post-burn esophageal strictures of bougienage over a guide wire, which has significantly reduced the number of esophageal perforations.

In the complex of conservative local treatment of chemical burns of the esophagus, a wide range of medications is used. Treatment with adrenal cortex preparations has received the greatest distribution. The positive role of corticosteroids during burn shock has been proven by many clinics. At the same time, there are highly contradictory literature data on the results of local hormone administration in the treatment of chemical burns of the esophagus during the scarring period.

The use of new treatment methods involving intramural lidase administration, hyperbaric oxygenation promoting the formation of loose scarring, and endoscopic laser therapy has not fundamentally resolved the problem of prevention and treatment of post-burn esophageal stenoses in children.

Both preventive and therapeutic bougienage at present is the most common, although not always effective, method of non-surgical elimination of cicatricial esophageal strictures in children.

The necessity becomes clear for developing simple and, at the same time, effective methods for the prevention and treatment of chemical burns and post-burn esophageal strictures in children that promote the restoration of esophageal patency. The imperfection of most treatment techniques used in the prevention and treatment of esophageal burns in children served as the motivation for the execution of this work.

Purpose of the Work

To improve the results of treatment of children with chemical burns and post-burn esophageal strictures based on a comprehensive treatment method using the drug «Kuriozin» and a device for restoring esophageal patency.

Objectives of the Research

1. To experimentally substantiate the effectiveness of the application of the drug «Kuriozin» for the treatment of chemical burns of the esophagus.

2. To develop a technique for the prevention and treatment of cicatricial esophageal strictures in children with grade III chemical burns.

3. To evaluate the clinical effectiveness of the developed method for the treatment of children with grade III chemical burns of the esophagus and post-burn strictures in comparison with blind bougienage and bougienage over a guide wire techniques.

4. To evaluate the economic effect of the application of the developed technique for the treatment of chemical burns and post-burn esophageal strictures in children.

Scientific Novelty

For the first time, the high effectiveness of the drug «Kuriozin» application has been demonstrated in an animal experiment and clinical study in the treatment of children with chemical burns of the esophagus.

The developed device for the prevention and treatment of post-burn esophageal strictures introduced into clinical practice is protectable.

The developed comprehensive treatment technique based on the patented device «Device for Restoring Esophageal Patency» and the drug «Kuriozin», allowing for the effective treatment of chemical burns and post-burn esophageal strictures in children, possesses priority novelty.

Practical Significance

The proposed method of local application of the drug «Kuriozin» and the device for restoring esophageal patency (Russian Federation patent for invention No. 2225229) allows for the restoration of esophageal patency in cases of chemical burn and post-burn esophageal stricture in children.

The application of this treatment method ensures the prevention of post-burn esophageal stricture formation in children.

The developed comprehensive treatment promotes the recovery of children with chemical burns of the esophagus and post-burn strictures, reducing the duration of their stay in a medical institution by 47.8 ± 8.8%, and decreases material costs for treatment from 67,165 rubles to 32,704 rubles.

The economic effect per patient is 34,461 rubles.

Implementation of Results in Public Health Practice

The developed practical recommendations have been used in the treatment of children with chemical burns of the esophagus in the departments of general surgery of the Irkutsk State Regional Children's Clinical Hospital, the Ivanovo-Matreninskaya City Children's Clinical Hospital, and the Emergency Hospital of Ulan-Ude. The principles of treatment of children with grade III chemical burns of the esophagus are set forth in methodological manuals and are used in the training of cadets at the Department of Pediatric Surgery of the Irkutsk State Institute of Physicians' Advanced Training.

Publications on the Dissertation Topic

Seven printed works have been published on the dissertation topic, including the Russian Federation patent for invention No. 2225229 «Device for Restoring Esophageal Patency».

Work Approval

The dissertation materials were presented at the conference of pediatric surgeons of Irkutsk Oblast (Angarsk, May 2000), at the interregional scientific and practical conference of young scientists of Siberia «Current Problems of Clinical and Experimental Medicine» (Irkutsk, November 2003), at the congress of the Association of Surgeons of Irkutsk Oblast (Irkutsk, May 2004), and at the exhibition «Sibhealthcare-2004» (Irkutsk).

Scope and Structure of the Dissertation

The dissertation consists of an introduction, 6 chapters, a conclusion, conclusions, and practical recommendations.