From the Guidelines
The next step in managing this patient would be to consider surgical reconstruction of the esophagus if endoscopic dilatations have not provided sustainable improvement after 3 months. Specifically, esophageal replacement surgery using either colonic interposition or gastric pull-up should be evaluated, as these procedures can provide a long-term solution for severe strictures that remain refractory to repeated dilatations 1. Prior to surgery, a comprehensive evaluation including barium swallow studies, CT imaging, and nutritional optimization is essential. The patient should continue jejunal feeding to maintain adequate nutrition until oral intake can be safely resumed. Additionally, proton pump inhibitor therapy (such as omeprazole 40mg daily) should be maintained to reduce acid reflux that could worsen strictures. For pain management, a multimodal approach using non-opioid analgesics is recommended. The timing of surgery is critical - waiting at least 6 months after the initial injury allows for stabilization of tissue inflammation, but prolonged delays may lead to further complications including malnutrition and psychological distress. Surgical reconstruction is justified because severe corrosive strictures often do not respond adequately to endoscopic management alone, and restoring normal swallowing function is essential for quality of life and long-term nutritional independence. Some key points to consider in the management of this patient include:
- The role of endoscopy in the management of corrosive esophageal strictures, including the use of endoscopic dilation and stenting 1
- The importance of comprehensive evaluation and nutritional optimization prior to surgery 1
- The potential risks and benefits of surgical reconstruction, including the risk of complications and the potential for improved quality of life and long-term nutritional independence 1
From the Research
Management of Oesophageal Strictures
The patient in question has a history of unintentional corrosive ingestion, which has led to severe oesophageal strictures. She is currently undergoing regular endoscopic dilatation and feeding jejunostomy for 3 months. The next steps in managing her condition can be considered based on the available evidence:
- Continuation of Endoscopic Dilatation: Studies have shown that endoscopic dilatation is an effective method for managing benign oesophageal strictures, including those caused by corrosive ingestion 2, 3, 4. The patient's current treatment plan includes regular endoscopic dilatation, which can be continued to achieve and maintain a luminal diameter of ≥14 mm and to keep the patient dysphagia-free with minimal re-interventions.
- Adjustment of Dilatation Intervals: Research suggests that weekly endoscopic dilations as the initial approach can be effective in managing complex benign esophageal strictures 5. The patient's dilatation intervals can be adjusted based on her response to treatment.
- Consideration of Other Endoscopic Treatments: If the patient's strictures are refractory to dilatation, other endoscopic treatments such as steroid injection, incisional therapy, and stent placement can be considered 2, 4.
- Monitoring and Follow-up: Regular monitoring and follow-up are crucial in managing oesophageal strictures. The patient's condition should be closely monitored, and adjustments made to her treatment plan as needed.
Factors Affecting Outcome
Several factors can affect the outcome of endoscopic dilatation in refractory post-corrosive oesophageal stricture, including:
- Duration of the condition
- Number of dilatation sessions
- Type of corrosive substance ingested
- Patient's age and sex
- Presence of other causes of oesophageal stricture 6
Treatment Options
The treatment options for the patient can be summarized as follows:
- A. Continue endoscopic dilatation: This is a viable option, given the patient's current treatment plan and the effectiveness of endoscopic dilatation in managing benign oesophageal strictures.
- B. Oesophageal resection: This is a more invasive option and may not be necessary at this stage, given the patient's response to endoscopic dilatation.
- C. Stent placement: This can be considered if the patient's strictures are refractory to dilatation.
- D. Oesophageal bypass: This is a more invasive option and may not be necessary at this stage, given the patient's response to endoscopic dilatation.