What is the next step in managing a patient with severe oesophageal (esophageal) strictures due to unintentional corrosive ingestion, who has been undergoing regular endoscopic dilatation for 3 months with a feeding jejunostomy in place?

Management of Severe Corrosive Esophageal Strictures

For a patient with severe esophageal strictures due to corrosive ingestion who has been undergoing regular dilatation for 3 months with a feeding jejunostomy in place, continuing endoscopic dilatation is the most appropriate next step in management.

Assessment of Current Management

Endoscopic dilatation remains the first-line treatment for corrosive esophageal strictures. The current 3-month duration of treatment is still within the expected timeframe for successful management, as:

• Endoscopic dilatation should be the upfront treatment of esophageal strictures, typically started 3-6 weeks after ingestion 1
• Most patients require multiple dilatation sessions before achieving symptom resolution 1
• Weekly or two-weekly dilatation sessions are recommended until easy passage of a ≥15 mm dilator is achieved along with symptomatic improvement 1

Recommended Management Plan

Continue Endoscopic Dilatation

1. Frequency of dilatation:

   • Consider a time interval between dilatations of less than 2 weeks 1, 2
   • Weekly dilatation until easy passage of a greater than 14 mm dilator is a common strategy 1

2. Technique considerations:

   • Use fluoroscopic guidance during dilatation of refractory strictures 1
   • Either bougie or balloon dilators can be used, with the decision based on the nature (length, location, cause) of the stricture 1
   • Aim for a graded stepwise approach to dilatation between 13-20 mm 1, 2

3. Adjunctive therapy:

   • Consider intralesional steroid therapy combined with dilatation if there is evidence of inflammation 1
   • Use steroid injections (0.5 mL aliquots of triamcinolone 40 mg/mL to the four quadrants) to potentially reduce the frequency of repeat dilatations 1

When to Consider Alternative Approaches

Surgical intervention (options B and D in the question) should only be considered after failure of endoscopic management:

• Reconstructive esophageal surgery (including esophageal resection or bypass) should be considered only after recurrent failure of endoscopic dilatation, typically after 5-7 failed attempts 1, 2
• Stent placement (option C) should be considered as an intermediate step before surgery when dilatation fails 3, 4

Monitoring and Complications

• Monitor for perforation, which is more common in corrosive strictures (reported rates of 0.4% to 32% per procedure) 1, 2
• Suspect perforation if the patient develops pain, breathlessness, fever, or tachycardia 1
• Perform a contrast study or CT scan if perforation is suspected 1

Prognostic Factors

Factors that may predict poor response to dilatation include:

• Stricture length greater than 6 cm 5
• Non-peptic causes of stricture (such as corrosive injury) 1
• Fibrous strictures 1
• Maximum dilator size less than 14 mm 1

Long-term Considerations

• Endoscopic dilatation has been shown to be successful in achieving persistent symptom relief in approximately 70% of patients with corrosive strictures 5
• Patients with corrosive strictures typically require more dilatation sessions (median of five) compared to those with peptic strictures (median of three) 6
• Carefully selected patients with recurrent benign strictures may be taught self-dilatation 1

By continuing with endoscopic dilatation at this stage, you provide the patient with the best chance of avoiding more invasive surgical procedures while addressing the dysphagia and working toward restoration of normal esophageal function.