Management of Corrosive Esophageal Stricture with Fistula
Patients with corrosive esophageal stricture complicated by fistula require immediate surgical intervention with esophagectomy and fistula repair, as endoscopic dilation is contraindicated in the presence of a fistula. 1
Immediate Assessment and Stabilization
Obtain contrast-enhanced CT immediately to define the extent of esophageal necrosis, map the fistula tract anatomy, and assess the degree of mediastinal or pleural contamination. 1 This imaging modality is superior to endoscopy for detecting transmural injuries and predicting complications. 2
Perform preoperative tracheobronchial endoscopy to assess the extent of airway involvement and precisely identify the fistula site, particularly if a bronchopleural or tracheoesophageal fistula is suspected. 1
Secure the airway early if there is severe upper airway edema, respiratory distress from vapor aspiration, or need for airway protection—tracheostomy may be life-saving in these scenarios. 2
Surgical Management Strategy
The definitive treatment is stripping esophagectomy performed through a combined abdominal and cervical approach with complete resection of all necrotic esophageal tissue. 1 This approach is necessary because:
- The presence of a fistula indicates transmural injury that cannot be managed conservatively 1
- Attempting endoscopic dilation when a fistula is present risks catastrophic complications including mediastinitis, empyema, and death 1
- Partial resections lead to worse outcomes due to ongoing necrosis 3
Address the fistula tract directly during the operation:
- For bronchopleural fistulas, perform pulmonary patch repair through right thoracotomy 1
- For tracheoesophageal fistulas, repair the airway defect with viable tissue 1
- Resect all obviously necrotic tissue during the initial procedure 3
Preserve the stomach if possible unless transmural gastric necrosis is present, as it may serve as a future conduit for reconstruction. 1
Create a feeding jejunostomy at the end of the operation for long-term nutritional support, as oral feeding will not be possible for many months. 3, 1
Critical Surgical Principles
Do not attempt immediate esophageal reconstruction at the emergency operation, as subsequent stricture formation can compromise functional outcomes and mortality risk is unacceptably high. 3, 1 Reconstruction should be delayed 6-12 months until inflammation has completely resolved. 1
Be prepared for extended resections if adjacent organs (stomach, colon, bronchi) show concomitant necrosis—all necrotic tissue must be removed during the initial operation. 3, 1
Reoperation should be undertaken promptly if ongoing necrosis is suspected postoperatively based on clinical deterioration or laboratory abnormalities. 3
Common Pitfalls to Avoid
Never delay surgical intervention when transmural necrosis with fistula is present—without appropriate surgical management, mortality approaches 100%. 1 The standard mortality ratio for patients operated for caustic necrosis is 21.5 compared to the general population, but this is vastly superior to non-operative management in the presence of transmural injury. 3, 1
Never attempt endoscopic dilation of a corrosive stricture when a fistula is present, as this will worsen contamination of the mediastinum, pleural space, or airway. 1
Never perform partial gastric resections when complete resection is indicated—ongoing necrosis will compromise survival. 3
Do not attempt primary esophageal reconstruction at the emergency operation, as this significantly increases morbidity and mortality. 1
Post-Operative Management
Provide long-term nutritional support via the feeding jejunostomy or parenteral nutrition for 6-12 months until delayed reconstruction can be performed. 3, 1
Plan for delayed esophageal reconstruction after 6-12 months when inflammation has resolved, typically using colonic interposition or gastric pull-up depending on what tissue remains viable. 1, 4
Mandatory psychiatric evaluation must be conducted before hospital discharge, as most corrosive ingestions are intentional, and long-term control of psychiatric disease is essential to prevent recurrence. 3, 1
When Fistula is NOT Present (Stricture Only)
If the patient has a corrosive stricture without fistula formation and no transmural necrosis:
Endoscopic dilation is first-line treatment for patients with few (<3) short (<5 cm) esophageal strictures, initiated 3-6 weeks after the acute injury. 3, 2
- Perform dilations at 1-3 week intervals 3
- Expect 3-5 sessions to provide satisfactory results 3
- Consider reconstructive esophageal surgery after 5-7 failed dilation attempts 3
Avoid dilation between 1-3 weeks post-ingestion due to significantly higher perforation risk during the healing phase. 2