From the Guidelines
The first step in managing this adult female patient with severe esophageal strictures from corrosive ingestion who has been undergoing regular dilatation for 3 months with feeding jejunostomy would be to continue endoscopic dilatation (option A). Before considering more invasive surgical options, it's essential to maximize the benefits of endoscopic therapy, which can be effective for many patients even beyond 3 months. Endoscopic dilatation remains the first-line treatment for esophageal strictures and should be continued as long as the patient shows improvement 1. The management should also include appropriate pain control with analgesics, prophylactic antibiotics to prevent infection after dilatation procedures, and consideration of intralesional corticosteroid injections during dilatation to reduce stricture recurrence.
Some key points to consider in the management of this patient include:
- The use of no more than three successively larger diameter increments in a single session for both bougie and balloon dilators, although this is not strictly evidence-based 1
- The importance of patient education on the possibility of needing several sessions to achieve resolution of dysphagia
- The need for careful monitoring for complications such as perforation, which may require urgent intervention
More invasive options like esophageal resection, stent placement, or bypass surgery would only be considered if dilatation therapy fails after multiple attempts, if the strictures become refractory, or if complications such as perforation occur. Continuing with dilatation provides the best balance of efficacy and safety while avoiding the significant morbidity associated with major surgical interventions. The most recent guidelines support the use of endoscopic dilatation as the primary treatment for esophageal strictures, including those caused by corrosive ingestion 1.
From the Research
Treatment Options for Corrosive Esophageal Strictures
The patient in question has a history of unintentional corrosive ingestion, which has led to severe oesophageal strictures. She has been undergoing regular dilatation for 3 months with feeding jejunostomy. Considering her condition, the next steps can be evaluated based on the available evidence:
- Continue endoscopic dilatation: This approach is supported by studies such as 2, which found that endoscopic dilatation using Savary-Gilliard dilators was successful in achieving persistent symptom relief in 71.8% of patients with corrosive esophageal strictures.
- Oesophageal resection: There is no direct evidence to support this approach as the next step for this patient. However, it may be considered in cases where dilatation therapy fails, as seen in 2.
- Stent placement: Biodegradable stent placement has been shown to reduce the number of repeat dilations and prolong the time to recurrent dysphagia compared to dilation alone, as demonstrated in 3.
- Oesophageal bypass: This option is not directly supported by the provided evidence as a next step for this patient.
Considerations for Treatment
When deciding on the next steps, it is essential to consider the patient's specific condition, including the severity and length of the strictures, as well as any associated complications. The evidence suggests that endoscopic dilatation is a safe and effective first-line therapy for corrosive esophageal strictures, with other options such as stent placement or surgery considered in cases of refractory or recurrent strictures 4, 5, 6.