we present this retrospective chart review of esophageal injuries / stenosis as it reinforces the need for appropriate management by a team of specialists as per safe protocols . data of 21 children with esophageal injuries ( 18 ) and ces ( 3 ) admitted to the pediatric surgery unit between january 2009 and april 2015 were reviewed retrospectively . there were 21 children with varied presentations ; corrosive stricture ( 7 ) , cervical perforation ( 2 ) , thoracic perforation ( 1 ) , esophageal mucosal injury ( 3 ) trachea esophageal fistula ( tef ) ( 2 ) , retropharyngeal abscess ( 1 ) , pseudo diverticulum ( 1 ) , wall erosion ( 1 ) , ces ( 3 ) [ table 1 ] and [ figures 1 and 2 ] . five children with corrosive strictures presented within 3 weeks of ingestion while the remaining two had ingested more than 3 months back . contrast study and endoscopy revealed single ( 4 ) or multiple strictures ( 3 ) ; varied size ( 5 mm in 2 , 1 cm 2 , 1.5 cm 1 , 5 cm 1 ) , and site ( cricopharynx 2 , middle one - third 2 , lower one - third 5 ) and near complete obstruction ( 2 ) . children with severe stricture ( 2 ) had gastrostomy , followed by retrograde and ante grade dilatation under endoscopic guidance by the gastroenterologist . they had food bolus obstruction on 3 year of follow - up and required re dilation program . this was possible in spite of previous failed colon replacement attempt by a combination of esohagoscopic guidance and approach from a proximal healthy cervical incision . the protocol followed was to dilate to appropriate size for age and then continue at weekly thrice , fortnightly thrice , and taper by monthly thrice to stop . later part of dilations was done blindly without any complications . three ces children presented with dysphagia , nonbilious vomiting , and recurrent respiratory tract infection . contrast study and , endoscopy confirmed stenosis at lower one - third ( 2 ) or middle one - third esophageal segment ( 1 ) . stenotic length was variable ; 1 cm ( 2 ) and 3 cm ( 1 ) . two responded to our calibration protocol and one required resection who later died due to mediastinum leak . alkaline battery complications of esophageal erosions ( endoscopic picture ) , trachea esophageal fistula ( solid arrow ) , pseudodiverticulum ( empty arrow ) and spontaneous closure of trachea esophageal fistula at 4 months neck x - ray showing various sharp foreign bodies clinical data of esophageal injuries and stenosis children six children presented with esophageal perforation ; cervical ( 2 ) , thoracic ( 1 ) , contained pseudodiverticulum ( 1 ) , and tef ( 2 ) . two boys presented with cervical perforations due to impaction and/or retrieval of a 2 cm  3 cm metal flag and dental prosthesis respectively at cricopharynx . both both fb were removed with magill 's forceps under ga in the operation theater ( ot ) . the first patient however had an unsuccessful attempt in fluoroscopy room on an outpatient basis [ figure 2 ] . contrast enhanced computerized tomography ( cect ) and contrast swallow revealed extensive cervical leak in the first boy who required cervical drainage . a 3-month - old , postesophageal atresia repair underwent gastrostomy and retrograde dilatation for anastomotic stricture who later developed thoracic leak requiring immediate intercostal tube drainage . she responded to thoracotomy , debridement , and diversion ( proximal cervical esophagostomy ) and ligation of distal esophagus . five children had alkaline battery impaction at cricopharynx with varied complications including tef ( 2 ) , torticollis and retropharyngeal abscess ( 1 ) , pseudodiverticulum ( 1 ) [ figure 1 ] and cervical erosions . one of the two tef patients was referred to our hospital on ventilatory support after two unsuccessful attempts of removal in local hospital . he was lost to follow - up . other tef healed spontaneously after 4 months . two children presented with open safety pin , one in cricopharynx and another at mid esophagus . they had mild mucosal injury and were retrieved with magill ( 1 ) and endoscopic basket ( 1 ) with sharp end pointing downward in major ot . one - year - old girl had cervical wall erosion due to 2-day - old impacted ear ring and underwent retrieval with magill . all children had good weight gain and asymptomatic at last follow - up , which ranged from 1 to 3 years . vomiting , throat pain , dysphagia , pooling of saliva , stridor , chest pain , fever , and tachypnea are prominent symptoms of esophageal injuries . foreign body impaction , inappropriate modes of retrieval , nonavailability of technical expertise , endoscopy and instrumentation , esophageal dilatation are some of the causes for esophageal perforation . there have been reports of higher complications in academic training / teaching institute , emergency procedure , and institute with low patient volume . though instrumentation is the common cause of esophageal injury , sharp object impaction or retrieval ( 33% ) has the highest complication rate which has been reconfirmed in our series also . esophageal strictures are of varied etiology like corrosive poisoning , anastomotic stricture of esophageal atresia repair or replacement tubes . foreign body ingestion is usually seen in children aged 1 - 3 years , 10 - 20% of which get impacted in the esophagus eight of the ten patients who had foreign body impaction , were < 4 years . fb usually presents earlier following impaction or may have an indolent course and present later with secondary complications . all of our cases were in the impaction stage and was diagnosed correctly by caregivers which are the commonest mode of presentation . alkaline button battery impacted in the esophagus should be considered life - threatening , due to its potential to cause full thick burns leading to perforation , tracheoesophageal fistula , exsanguinations after fistulization of arteries , and airway compromise . the injury depends on size ( > 2 cm ) , duration ( > 2 h ) and area of contact , heat produced and the various electrochemical effects of the battery . battery can cause mucosal damage in 1 h , erosion in 2.5 h , and perforation as early as 5 h. its prompt removal within 2 h of ingestion is mandatory to prevent morbidity and mortality . irregular and sharp fbs should be removed under controlled conditions in the operation theater under ga to prevent complications . protective measures in sharp object retrieval are its engagement to distal end of endoscope , holding and changing directions in stomach and retrograde retrieving with sharp end caudally , and use of basket and protective devices like fb hood protector or over tube . esophageal open safety pin are pushed downwards if open end is pointing upwards and removed after reversing direction or locking pin in stomach . immediate plain x - ray 2 h after any esophageal procedure with potential to cause injury could detect perforation early . contrast study and endoscopy often helps to know site of perforation , extent of leak / damage / resolution , and nature of distal esophagus . postremoval esophagogram is a must before onset of oral feeding in prolonged impaction / delayed diagnosis of fb . electroporation ( joule effect)/sodium hydroxide at the battery cathode end would results in tef and pseudo - diverticulum when it contacts with anterior and posterior esophageal wall respectively . tef have been treated with hyper baric oxygen , conservative management with spontaneous closure but frequently require open surgery with long term sequel . however , our child had spontaneous closure of tef . acute cervical perforations are managed well by controlled adequate drainage with antibiotics or antibiotics only . the 1 time attempted calibration of impassable anastomotic esophageal stricture usually needs early thoracotomy , debridement , and diversion with esophageal replacement later . early recognition of this potentially life - threatening complication is required to prevent a downhill course . delayed presentation of severe corrosive stricture usually were managed initially by gastrostomy and followed with multiple calibrations for successful outcome . success of dilatation depends on age , site , length , number , etiology , expertise of airway management , and response of stricture dilatation . our calibration protocol is safe and effective . with appropriate planning and use of endoscope guidance we managed an orthotopic gastric transposition after native esophagectomy in adolescent girl . close follow - up and barium swallow / endoscopy in scarring period and later follow - up could detect stricture earlier in those with inadequate history and minimal symptoms / or oral lesion on examination . though rare , ces should be considered in recurrent respiratory tract infection and often responds to calibrations in young children . there will be steep learning curve in the fb extraction techniques and complications are more in local hospital / low surgical volume . esophageal replacement has better functional and early good outcome than primary repair / endoscopy procedure in the perforation of obstructive complex esophageal disease . health education of parents and caregivers , keeping things out of reach of children and in secure compartment with lock , active supervision during playing , use of dry run model with reproducible fb , and creation of specialized referral network system could prevent these accidents . esophageal strictures / stenosis should be dilated by appropriate techniques and protocols , by persons with expertise in the same and with fluoroscopic or endoscopic guidance . esophageal perforations should be detected early by expectant monitoring and prompt treatment initiated with an aim at conserving the native esophagus and when not possible esophageal replacement .
aim : to review the patients with esophageal injuries and stenosis with respect to their etiology , clinical course , management , and the lessons learnt from these.materials and methods : retrospective descriptive observation review of children with esophageal injuries and stenosis admitted between january 2009 and april 2015.results:eighteen children with esophageal injuries of varied etiology were managed and included , seven with corrosive injury , five with perforation due to various causes , three with mucosal erosion , two with trachea esophageal fistula ( tef ) , and one wall erosion . the five children who had perforation were due to poststricture dilatation in a child with esophageal atresia and secondary to foreign body impaction or its attempted retrieval in four . 
 alkaline button cell had caused tef in two . 
 three congenital esophageal stenosis ( ces ) had presented with dysphagia and respiratory tract infection . 
 six corrosive stricture and two ces responded to dilatation alone and one each of them required surgery . 
 four of the children with esophageal perforation were detected early and required drainage procedure ( 1 ) , diversion ( 1 ) , and medical management ( 2 ) . 
 pseudo diverticulum was managed expectantly . among tef , 
 one had spontaneous closure and other one was lost to follow - up . 
 all the remaining nineteen children have recovered well except one ces had mortality.conclusion:esophageal injuries though rare can be potentially devastating and life - threatening .