From the Guidelines
The next step in managing this patient would be to consider definitive surgical reconstruction, specifically a colonic interposition or gastric pull-up procedure, as endoscopic dilatation has been ongoing for three months without resolution of the strictures. This recommendation is based on the understanding that prolonged dilatation therapy without progression to definitive treatment increases the risk of perforation and fails to address the underlying severe strictures, which are unlikely to resolve with dilatation alone after this duration of treatment 1.
Key Considerations
- Prior to surgery, a comprehensive evaluation including barium swallow studies, CT imaging, and nutritional optimization should be completed.
- The patient should continue jejunostomy feeding to maintain adequate nutrition until reconstruction is complete.
- Proton pump inhibitors (such as omeprazole 40mg daily) should be administered to reduce acid reflux that could worsen strictures.
- While preparing for surgery, dilatation sessions can continue but with gradually increasing intervals between procedures to assess stricture stability.
Post-Surgical Management
- Post-surgical management will include a period of nil-by-mouth, antibiotics (typically a third-generation cephalosporin and metronidazole for 5-7 days), and gradual reintroduction of oral intake after confirming anastomotic integrity.
- The risk of perforation during dilatation is a significant concern, with a reported rate of 2.6% and a mortality of 1% 1.
- The use of a CT-based algorithm to select patients for emergency surgery significantly improved patient outcomes when compared to endoscopy-based management 1.
Evidence-Based Decision
The decision to proceed with surgical reconstruction is supported by the guidelines on the use of oesophageal dilatation in clinical practice, which recommend reconstructive esophageal surgery after recurrent failure of endoscopic dilation 1. The guidelines also emphasize the importance of a comprehensive evaluation and nutritional optimization prior to surgery 1. Overall, the recommendation for surgical reconstruction is based on the most recent and highest quality evidence, with the goal of improving the patient's quality of life and reducing the risk of morbidity and mortality.
From the Research
Next Steps in Management
The patient has been undergoing regular endoscopic dilatation for 3 months with a feeding jejunostomy. Considering the provided evidence, the next steps in management can be outlined as follows:
- Continue Endoscopic Dilatation: According to 2, endoscopic dilation is considered the best treatment for most cases of benign esophageal stricture. The study reports a success rate of 93.5% in achieving adequate dilation.
- Consider Stent Placement: If dilation fails, stent placement should be considered, as suggested by 3 and 4. Stent placement can be an effective option for refractory benign esophageal strictures.
- Other Options: Other endoscopic treatments such as steroid injection, incisional therapy, and stricturotomy may also be considered, as mentioned in 4 and 5.
- Surgical Options: In cases where endoscopic management fails, surgical options such as oesophageal resection or bypass may be considered, as mentioned in 3. However, these options are typically reserved for severe cases.
Key Considerations
When deciding on the next steps in management, the following factors should be considered:
- Stricture Etiology: The underlying cause of the stricture, such as caustic ingestion, can influence the choice of treatment, as noted in 2 and 6.
- Stricture Complexity: The length, location, and diameter of the stricture can affect the choice of treatment, as mentioned in 5.
- Patient Response to Treatment: The patient's response to previous dilatation sessions and any adverse events should be taken into account when deciding on the next steps in management, as discussed in 6.