What is the next step in managing an adult female patient with a history of unintentional corrosive ingestion and severe oesophageal (esophageal) strictures, currently undergoing regular endoscopic dilatation and feeding jejunostomy (a feeding tube inserted into the jejunum) for 3 months?

Management of Severe Corrosive Esophageal Strictures After 3 Months of Dilatation

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

Current Situation Assessment

The patient has:

• History of unintentional corrosive ingestion
• Severe esophageal strictures
• 3 months of regular endoscopic dilatation
• Feeding jejunostomy in place

Decision Algorithm for Management

Why Continued Dilatation Is Not Optimal

• Corrosive strictures are more refractory than other types of benign strictures 1
• Three months of regular dilatation without resolution indicates the refractory nature of these strictures 1
• Continuing with the same approach is unlikely to yield different results
• Each additional dilatation attempt increases the cumulative risk of perforation 1

Why Esophageal Bypass Is Recommended

• Esophageal bypass is recommended for extensive, refractory corrosive strictures 1
• It preserves the native esophagus while creating an alternative food passage
• Has less morbidity than complete resection
• Appropriate after failure of endoscopic dilatation (typically after 5-7 failed attempts) 1
• The British Society of Gastroenterology guidelines suggest that when dilatation fails in refractory strictures, alternative approaches should be considered 2

Why Esophageal Resection Is Not First Choice

• Esophageal resection is usually reserved for cases with:
  • Malignancy concern
  • Complete esophageal destruction
• It is excessive for this clinical scenario at this stage 1
• Has higher morbidity compared to bypass procedures

Why Stent Placement Is Suboptimal

• Temporary stent placement is considered only after failure of other methods 2
• Stents have high migration rates in benign strictures
• May cause additional trauma to already damaged esophageal tissue
• Often requires multiple replacements and can lead to complications

Evidence-Based Considerations

Dilatation Outcomes in Corrosive Strictures

• Success rates for endoscopic dilatation in corrosive strictures range from 70-93% 3
• However, strictures longer than 6 cm are associated with poor outcomes from endoscopic dilatation 3
• The perforation rate is higher in corrosive strictures compared to other benign strictures 2, 1

Surgical Outcomes

• Esophageal bypass procedures show good long-term results in patients with refractory corrosive strictures 3
• Stricture rate after surgery is approximately 36% but still provides better quality of life than continued dilatation attempts 3

Practical Management Recommendations

1. Refer for surgical evaluation for esophageal bypass procedure
2. Continue nutritional support via jejunostomy until definitive management
3. Consider psychiatric evaluation as recommended for all patients with corrosive ingestion 1
4. After bypass surgery, monitor for potential complications:
   • Anastomotic strictures
   • Nutritional deficiencies
   • Reflux symptoms

Pitfalls to Avoid

• Delaying definitive management can lead to:
  • Malnutrition
  • Repeated hospital admissions
  • Increased risk of perforation with multiple dilatations
  • Poor quality of life
• Attempting aggressive dilatation in clearly refractory cases increases perforation risk
• Choosing esophageal resection as first surgical option when bypass may be sufficient

In conclusion, after 3 months of unsuccessful dilatation for severe corrosive esophageal strictures, esophageal bypass represents the most appropriate next step to improve this patient's quality of life, reduce complication risks, and provide a long-term solution to her dysphagia.