What is the next step in management for an adult female with a history of unintentional corrosive ingestion resulting in severe esophageal (oesophageal) strictures, who has been undergoing regular endoscopic dilatation for 3 months with a feeding jejunostomy in place?

Management of Severe Corrosive Esophageal Strictures After 3 Months of Dilatation

Esophageal bypass surgery is the most appropriate next step for this adult patient with severe corrosive esophageal strictures who has undergone regular dilatation for 3 months with feeding jejunostomy in place. 1

Rationale for Surgical Intervention

Corrosive esophageal strictures are among the most challenging strictures to manage, with poorer outcomes compared to other types of benign strictures:

• The patient has already undergone 3 months of regular dilatation therapy, which is considered an adequate trial of endoscopic management
• Corrosive strictures typically require a median of 5 dilatation sessions to achieve adequate results 2, 3
• When dilatation fails after multiple attempts (typically 5-7 sessions), surgical intervention becomes necessary 1
• Feeding jejunostomy presence indicates severe nutritional compromise requiring alternative feeding route

Why Endoscopic Dilatation Has Failed

Several factors predict poor response to continued dilatation in this case:

• Corrosive strictures are more refractory than peptic or post-surgical strictures 4
• Non-peptic causes of stricture (like corrosive injury) are predictors of repeated dilatation need 4
• The patient has likely developed fibrous strictures, which respond poorly to dilatation 4
• Three months of regular dilatation without resolution indicates refractory nature of the strictures

Surgical Options Analysis

Among the surgical options:

1. Esophageal bypass (RECOMMENDED):

   • Preserves native esophagus while creating alternative food passage
   • Appropriate for extensive, refractory corrosive strictures
   • Less morbidity than complete resection
   • Allows for nutritional rehabilitation while avoiding continued trauma from dilatation

2. Esophageal resection:

   • More extensive procedure with higher morbidity
   • Usually reserved for cases with malignancy concern or complete esophageal destruction
   • Excessive for this clinical scenario at this stage

3. Stent placement:

   • Not recommended for benign corrosive strictures due to:
     • High migration rates
     • Risk of further tissue injury
     • Poor long-term outcomes in corrosive strictures
   • UK guidelines recommend stents only as temporary measures (4-8 weeks) 4

4. Continued dilatation:

   • Already failed after 3 months of regular attempts
   • Continuing risks perforation (higher in corrosive strictures)
   • Diminishing returns after multiple unsuccessful attempts

Perforation Risk Considerations

The risk of perforation during continued dilatation is significant:

• Overall perforation rate is 2.6% for benign strictures 4
• Risk is higher in complex strictures like those from corrosive injury 4
• Each additional dilatation attempt increases cumulative risk
• Perforation is a medical emergency with significant mortality risk 4

Post-Surgical Management

After esophageal bypass surgery:

• Continue nutritional support via jejunostomy until oral intake is adequate
• Monitor for anastomotic strictures (occur in approximately 36.3% of cases) 3
• Consider psychiatric evaluation before discharge, as recommended for all corrosive injury patients 1
• Long-term follow-up is essential to monitor for complications

Alternative Approaches (If Surgery Contraindicated)

If surgery is absolutely contraindicated:

• Consider combined anterograde and retrograde dilatation (CARD) for completely obstructed esophagus 4
• Aggressive bougie dilatation with intralesional steroids may help in some refractory cases 5
• Self-dilatation could be considered in carefully selected patients for long-term management 6

Esophageal bypass represents the most appropriate next step for this patient with severe corrosive esophageal strictures who has failed 3 months of regular dilatation therapy.