What is the next step in managing an adult female patient with severe, refractory corrosive oesophageal strictures who has undergone regular endoscopic dilatation for 3 months with a feeding jejunostomy (jejunal feeding tube)?

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. 1

Rationale for Esophageal Bypass

The management of this case requires careful consideration of several factors:

1. Duration and Response to Current Treatment:

   • The patient has undergone regular dilatation for 3 months without resolution
   • This duration indicates refractory strictures, as suggested by guidelines 1
   • Corrosive strictures are known to be more refractory than peptic or post-surgical strictures 2, 1

2. Severity and Nature of Strictures:

   • Corrosive-induced strictures respond poorly to dilatation compared to other types 2
   • The need for a feeding jejunostomy suggests severe strictures affecting nutritional status
   • Predictors of dilatation failure include strictures longer than 5 cm and severe burns 3

3. Risk of Continued Dilatation:

   • Each additional dilatation attempt increases the cumulative risk of perforation 1
   • Perforation rates are higher in corrosive strictures (up to 18%) 3
   • Continued dilatation may lead to repeated hospital admissions without resolution 3

Treatment Algorithm

Step 1: Evaluate for Refractory Status

• Confirm adequate dilatation technique has been used (graded approach to 13-20 mm) 2
• Ensure optimal frequency of dilatations (intervals of <2 weeks are recommended) 2
• Verify fluoroscopic guidance has been used for these complex strictures 2

Step 2: Consider Less Invasive Options First

• Intralesional Steroid Therapy: Consider if not already attempted, may reduce frequency of dilatations 2
• Temporary Stent Placement: For refractory strictures, but often less effective for corrosive injuries 2

Step 3: Surgical Management

• Esophageal Bypass: Preferred option for extensive, refractory corrosive strictures 1

  • Preserves native esophagus while creating alternative food passage
  • Less morbidity than complete resection
  • Can be performed using colonic or gastric conduit
  • Minimally invasive approaches show favorable outcomes 4

• Esophageal Resection: Generally reserved for cases with malignancy concern or complete destruction 1

Advantages of Bypass Over Other Options

1. Compared to Continued Dilatation (Option A):

   • After 3 months of regular dilatation without resolution, further attempts are unlikely to succeed 1
   • Continued dilatation increases risk of perforation with each attempt 1
   • Studies show only 41% success rate with dilatation alone for corrosive strictures 3

2. Compared to Esophageal Resection (Option B):

   • Resection is more invasive with higher morbidity 1
   • Resection is excessive at this stage without malignancy concern 1

3. Compared to Stent Placement (Option C):

   • Stents are less effective for extensive corrosive strictures 2
   • Stents often migrate and may cause additional complications in these cases

Long-term Considerations

• Esophageal bypass procedures show good long-term results in patients with refractory corrosive strictures 1
• While stricture rate after surgery is approximately 36%, bypass still provides better quality of life than continued dilatation attempts 1
• Long-term follow-up is essential as patients with corrosive injuries have increased risk of esophageal carcinoma 5

Potential Complications to Monitor

• Anastomotic stricture may develop and require endoscopic dilatation 4
• Esophageal motor dysfunction may persist even after successful management 6
• Psychological support is important as psychiatric evaluation is recommended for all patients with corrosive injuries 1