What is the management of esophageal stricture secondary to caustic injury?

Management of Esophageal Stricture Secondary to Caustic Injury

Timely endoscopic dilatation using wire-guided bougie or balloon dilators with fluoroscopic guidance is the cornerstone of managing caustic esophageal strictures, with bougie dilators showing superior clinical success rates in recent comparative studies. 1, 2

Initial Assessment and Timing

Perform upper gastrointestinal endoscopy within 12-48 hours after caustic ingestion to assess injury severity and predict stricture formation, using gentle CO2 insufflation rather than air to minimize complications. 1 Contraindications include radiological evidence of perforation or supraglottic/epiglottic burns. 1

Critical Timing Considerations

• Avoid dilatation during the 1-3 week window after initial injury, as this period carries the highest perforation risk due to active tissue necrosis and inflammation. 1
• Begin dilatation from approximately week 3 onward when scar retraction and stricture formation begin. 1
• Ensure timely initiation of dilatation therapy once the acute phase passes, as delayed management increases complexity due to progressive fibrosis in the esophageal wall. 1

Dilatation Technique and Safety Measures

Dilator Selection

Use wire-guided bougie dilators as the preferred approach for caustic strictures, particularly the Savary-Gilliard type for consolidated and fibrotic strictures. 1 A 2023 comparative study demonstrated that bougie dilators achieved significantly better technical success (90.1% vs 68.7%), short-term clinical success (65.6% vs 46.3%), and long-term clinical success (86.9% vs 64.2%) compared to balloon dilators, with similar complication rates. 2

• Balloon dilators remain an acceptable alternative when bougie dilators are unavailable or unsuitable for specific stricture characteristics. 1
• Never use blind Maloney bougies due to unacceptable safety risks. 1

Fluoroscopic Guidance

Always use fluoroscopic guidance for caustic strictures, as these are classified as high-risk strictures prone to perforation and complex anatomy. 1 Fluoroscopy confirms proper wire passage, prevents wire kinking, demonstrates dilator alignment with the esophageal lumen, and identifies balloon slippage or stricture waist obliteration. 1

Dilatation Protocol

• Perform dilatations at intervals of less than 2 weeks to prevent rapid recurrence and maintain luminal patency. 1
• Target a final diameter of ≥14-15 mm for adequate symptomatic relief. 1, 3
• Expect 3-4 dilatation sessions on average, though significantly more may be required in severe cases. 1
• For very tight strictures, limit initial dilatation to 1-2 size increments (2×1 mm) to enhance safety. 1

Management of Refractory Strictures

Define a stricture as refractory when unable to maintain a luminal diameter ≥14 mm after five sequential dilatation sessions performed 1-2 weeks apart, or inability to maintain target diameter for 4 weeks once achieved. 1, 3 Refractory strictures are particularly common after caustic injury. 1

Advanced Interventions for Refractory Cases

• Consider intralesional steroid injection (0.5 mL aliquots) at the time of dilatation for refractory strictures. 1, 4
• Evaluate topical mitomycin C application during dilatation procedures. 1
• Consider temporary placement of fully covered self-expanding metal stents when repeated dilatations fail to maintain patency. 1, 3
• Biodegradable stents and suspended esophageal silicone prostheses represent emerging options, though evidence remains limited. 1
• Refer to specialized centers with expertise in refractory stricture management for complex cases. 1, 3
• Reserve surgical resection (esophagectomy) for cases where all endoscopic interventions have failed. 1

Complication Management

Perforation Risk and Recognition

Be aware that perforation rates for caustic strictures range from 0.4% to 32%, substantially higher than standard benign stricture dilatation (typically <1%). 1, 3 Complication rates decrease to approximately 4.5% when performed by experienced operators. 1

Suspect perforation immediately if patients develop persistent pain, breathlessness, fever, or tachycardia following dilatation. 1, 5, 3 Transient chest pain is common and not concerning, but persistent pain mandates immediate investigation. 6

Post-Procedure Protocol

• Monitor patients for at least 2 hours in the recovery room. 5, 3
• Ensure patients tolerate water before discharge. 5
• Provide clear written instructions regarding diet progression and warning signs. 5
• Perform immediate repeat endoscopy or contrast injection if perforation is suspected, to consider urgent treatment with fully covered self-expanding metal stents. 1

Adjunctive Medical Management

Optimize proton pump inhibitor therapy to address gastroesophageal reflux, which commonly develops after caustic injury due to impaired lower esophageal sphincter function and can worsen stricture formation. 1, 3 High-dose PPI therapy is essential before labeling any stricture as truly refractory. 1

Patient Counseling

Inform patients about the lack of high-quality evidence for optimal management approaches and the likelihood of requiring multiple dilatation sessions over an extended period (median 15 months for stricture resolution). 1, 7 Set realistic expectations that 3-4 sessions are typical, but some patients require significantly more interventions. 1