Caustic Esophageal Strictures Research Articles

Outcomes of pneumatic dilation in pediatric caustic esophageal strictures: a descriptive and analytic study from a developing country.

Corrosive substance ingestion in children represents a significant public health issue due to its long-term health sequelae. Esophageal stricture, main complication of this dangerous condition, is treated by pneumatic dilation and eventually by esophageal replacement. We aimed, through this study, to report the outcomes of esophageal pneumatic dilation complicating corrosive substance ingestion in children in a developing country. This cross-sectional study was performed on the population of pediatric patients with caustic esophageal stenosis between January 2005 and December 2020. All patients underwent pneumatic balloon dilation. A logistic regression model was built to predict the probability of the occurrence of the event (success/failure) of the dilation. The ROC curve is used to evaluate the performance of the logistic regression model to discriminate between positive and negative values of the dependent variable. The success rate of pneumatic balloon dilation was 80.4%. The median duration of overall management was 11months. The severity of caustic stricture observed during endoscopy was significantly linked to worse outcomes (p = 0.001). Multivariate analysis indicated that the severity of stenosis and the number of dilation sessions were independent risk factors for failure of dilation. ROC curve analysis showed that the area under the curve was 71.7%. A Cut-Off point value of 7 provided the best sensitivity and specificity. Pneumatic balloon dilation has been proven to be efficacious in infants with caustic esophageal stricture. Pediatric surgeons should take into account factors to promptly switch to replacement surgery and avoid unnecessary and time-consuming serial dilations.

Endoscopic dilation with bougies versus balloons in caustic esophageal strictures: 17-year experience from a tertiary care center.

Endoscopic dilation is the preferred management strategy for caustic esophageal strictures (CES). However, the differences in outcome for different dilators are not clear. We compared the outcome of CES using bougie and balloon dilators. Between January 2000 and December 2016, the following data of all the patients with CES were collected: demographic parameters, substance ingestion, number of strictures, number of dilations required to achieve ≥ 14mm dilation, post-dilation recurrence, and total dilations. Patients were divided into two groups for the type of dilator, i.e., bougie or balloon. The two groups were compared for baseline parameter, technical success, short- and long-term clinical success, refractory strictures, recurrence rates, and major complications. Of the 189 patients (mean age 32.17 ± 12.12years) studied, 119 (62.9%) were males. 122 (64.5%) patients underwent bougie dilation and 67 (35.5%) received balloon dilation. Technical success (90.1% vs. 68.7%, p < 0.001), short-term clinical success (65.6% vs. 46.3%, p value 0.01), and long-term clinical success (86.9% vs. 64.2%, p < 0.01) were higher for bougie dilators compared to balloon dilators. Twenty-four (12.7%) patients developed adverse events which were similar for two groups. On multivariate analysis, use of bougie dilators (aOR 4.868, 95% CI 1.027-23.079), short-term clinical success (aOR 5.785, 95% CI 1.203-27.825), and refractory strictures (aOR 0.151, 95% CI 0.033-0.690) were independent predictors of long-term clinical success. Use of bougie dilators is associated with better clinical success in patients with CES compared to balloon dilators with similar rates of adverse events.

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The cover image is based on the Case Report Caustic esophageal stenosis: A case report of endoscopic dilatation with nasogastric tubes by Esau Ogei et al.,https://doi.org/10.1002/ccr3.7208

Caustic oesophageal stricture treated by instrumental dilatation: A review of 6 years of practice at the pediatric university hospital charles de gaulle of Ouagadougou.

Oesophageal stricture is one of the most important and redoubtable complications following caustic ingestions in children. Instrumental dilatation is usually considered the first line of treatment. This study aims to evaluate the outcomes of caustic stenosis treatment when using Lerut dilatators. This is a descriptive retrospective study from May 2014 to April 2020. All children under 15 years hospitalised in our department for caustic oesophageal stricture and had a gastrostomy and oesophageal dilatation with insertion of an endless wire were included. A total of 83 patients were included. The sex ratio was 2.2. The mean age was 4 years. The mean time from caustic ingestion to presentation was 90 days. Oesophageal stricture was mostly caused by caustic soda (n = 41) and potash (n = 15). We performed in total 469 dilatations and had only three oesophageal perforations. After a mean follow-up of 17 months, we had 60.2% good results (n = 50) and 7.2% (n = 6) failures. The mortality rate was 13.2% (n = 11). The results of the dilations by Lerut dilatators give encouraging results in our department. It is easy to perform and its complications remain rare. Mortality could be reduced by adequate nutritional support.

EP-601 Biodegradable stents for benign oesophageal strictures- a single centre experience

Abstract Biodegradable (BD) stents have been used for the management of various oesophageal strictures (ES). The present study aim to evaluate our experience and efficacy of BD stents in benign ES at the endoscopic unit at the James Cook University Hospital, Middlesbrough, UK. Methods A retrospective review of case notes of 9 patients who have undergone endoscopically placement of BD stent for benign ES between March 2010 and November 2020. All 9 patients underwent successful stent placement. None of the patients had previous surgery for their condition. All patients, prior to stenting had oesophageal dilatations, some multiple times. Results Stent placement was successful in all 9 patients. Some patients had stent migration and subsequent re stenting. All patients had benign ES as the cause of dysphagia. One patient had caustic oesophageal stricture, remaining eight had peptic ulceration and GORD as the cause of dysphagia. The median number of dilatations prior to stent placement was 4 (IQR 7), more than the median number of dilatations post stent placement which was 2.0 (IQR: 3.5). Conclusion BD stents offers prolonged dilatation-free interval and reduces the number dilatations in patients with benign oesophageal strictures.

Predictive factors for the success of endoscopic dilation of esophageal caustic stricture: the experience of a French tertiary reference center.

Predictors of the efficacy of endoscopic dilation for caustic esophageal stricture have been poorly studied. All patients undergoing an endoscopic dilation for an esophageal caustic stricture between 1990 and 2015 in a French national reference center were included. Success of dilation was defined by self-food autonomy without the need for reconstructive esophageal surgery. During the study period, 894 patients were admitted after caustic ingestion. Among them, 101 patients developed esophageal stricture and 92 patients were eligible for analysis (missing data in 8 cases, 1 patient died before endoscopic dilation). In this cohort (median age 42years, women 53%, strong alkali 74%, suicide attempt 77%, hydrostatic balloon use 93%), the overall success rate of dilation was 57% with a median number of 3 dilation sessions (274 sessions, range 1-17). Factors predicting the success of the procedure were: non-inflammatory stricture or non-inflammatory intercalated mucosa between stricture (88% vs 47%, p = 0.001), a single stricture versus 2 or more strictures (69% vs 47% vs 33%, respectively, p = 0.04), a stricture of less than 5cm (70% vs 27%, p < 0.001) and the existence of mild/ moderately tight or very tight stricture (70% vs 21% of success, p < 0.001). Perforation rate was 6.5% (18/274) requiring emergency surgery in 2 cases. Several characteristics of caustic esophageal strictures are significantly associated with the success rate of endoscopic dilation. Our data may be useful for customizing treatment strategies in patients with a caustic stricture.

Caustic Esophageal Strictures in Children: Diagnosis, Treatment and Evolution in the City of Douala

Caustic Esophageal Strictures in Children: Diagnosis, Treatment and Evolution in the City of Douala

Caustic and Toxic Ingestions

Ingestion of caustic substances remains a potentially fatal public health concern with extensive morbidity and the possibility of long-term sequelae. The management strategies of these complex injuries continue to be extensively studied in the literature. Areas of interest include the most efficacious treatment of caustic esophageal stricture to preserve the native esophagus, use of steroids, and use of esophageal stents. Prevention of accidental ingestion through strategies to limit the availability of caustic substances is a key factor in reducing the incidence of injury, but there continues to be a high rate of accidental ingestion in developing countries with less rigorous manufacturing standards. Initial evaluation includes endoscopic evaluation of the esophagus and tracheobronchial tree. Optimal treatment strategies, including the use of proton pump inhibitors to reduce gastroesophageal reflux, steroid use to prevent stricture formation, and use of stents for management of strictures, continue to be debated. Initial surgical management includes esophagectomy for full-thickness injury with abdominal exploration. Multiple surgical options exist for both restoration of gastrointestinal continuity after esophagectomy and the management of strictures refractory to medical management, including reverse gastric tube, colonic interposition, and gastric advancement. Numerous small studies have evaluated the efficacy of these interventions, but there continues to be a need for larger prospective studies to develop a worldwide consensus opinion on best practices. We provide a review of the recent literature and practice recommendations for the management of injuries due to caustic ingestion. This review contains 7 figures, 10 tables, and 51 references. Key words: caustic ingestion, endoscopic management, stricture, surgical management

Caustic and Toxic Ingestions

Ingestion of caustic substances remains a potentially fatal public health concern with extensive morbidity and the possibility of long-term sequelae. The management strategies of these complex injuries continue to be extensively studied in the literature. Areas of interest include the most efficacious treatment of caustic esophageal stricture to preserve the native esophagus, use of steroids, and use of esophageal stents. Prevention of accidental ingestion through strategies to limit the availability of caustic substances is a key factor in reducing the incidence of injury, but there continues to be a high rate of accidental ingestion in developing countries with less rigorous manufacturing standards. Initial evaluation includes endoscopic evaluation of the esophagus and tracheobronchial tree. Optimal treatment strategies, including the use of proton pump inhibitors to reduce gastroesophageal reflux, steroid use to prevent stricture formation, and use of stents for management of strictures, continue to be debated. Initial surgical management includes esophagectomy for full-thickness injury with abdominal exploration. Multiple surgical options exist for both restoration of gastrointestinal continuity after esophagectomy and the management of strictures refractory to medical management, including reverse gastric tube, colonic interposition, and gastric advancement. Numerous small studies have evaluated the efficacy of these interventions, but there continues to be a need for larger prospective studies to develop a worldwide consensus opinion on best practices. We provide a review of the recent literature and practice recommendations for the management of injuries due to caustic ingestion. This review contains 7 figures, 10 tables, and 51 references. Key words: caustic ingestion, endoscopic management, stricture, surgical management

EFFICACY OF ENDOSCOPIC TOPICAL MITOMYCIN C APPLICATION IN CAUSTIC ESOPHAGEAL STRICTURES IN THE PEDIATRIC POPULATION: A SYSTEMATIC REVIEW AND META-ANALYSIS OF RANDOMIZED CONTROLLED TRIALS.

Caustic ingestion and development of esophageal strictures are recognized major public health problems in childhood. Different therapeutic methods have been proposed in the management of such strictures. To evaluate efficacy and risk of endoscopic topical application of mitomycin C in the treatment of caustic esophageal strictures. We searched MEDLINE, EMBASE, Central Cochrane, and LILACS databases. The outcomes evaluated were dysphagia resolution rate, number of dilations performed in resolved cases, and the number of dilations performed in all patients. Three randomized clinical trials were included for final analysis with a total of 190 patients. Topical mitomycin C application group showed a significant increase in dysphagia resolution rate, corresponding to a 42% higher dysphagia resolution as compared to endoscopic dilation alone, with statistical significance between the two groups (RD: 0.42 - [CI: 0.29-0.56]; P-value <0.00001). The mean number of dilations performed in resolved cases were significantly less in the topical mitomycin C application group, compared to endoscopic dilations alone, with statistical significance between the two groups (MD: 2.84 [CI: 1.98-3.69]; P-value <0.00001). When comparing the number of dilations in all patients, there was no statistical difference between the two groups (MD: 1.46 [CI: -1.53-4.44]; P-value =0.34). Application of topical mitomycin C with endoscopic dilations in caustic esophageal strictures was more effective in dysphagia resolution than endoscopic therapy alone in the pediatric population. Moreover, topical mitomycin C application also reduced the number of dilation sessions needed to alleviate dysphagia without rising morbidity.

The Effectiveness of Combined Balloon and Bougie Dilatation Technique in Children with Impassable Esophageal Stricture.

Background: Impassable caustic esophageal strictures (CES) can be rendered passable through sophisticated dilatation techniques, hence avoiding the esophageal replacement surgery and its complications. Patients and Method: Patients with impassable CES who were presented to our hospital between January 2015 and April 2020 underwent a combined balloon and bougie dilatation. This technique aims at doing an initial partial dilatation of the proximal segment of the stricture, using a balloon catheter to pave the way for the endoscope to be advanced more distally. Therefore, a guide wire could be passed down to the stomach to complete the dilatation session using bougie dilators. Results: Seven patients out of 138 patients who underwent endoscopic dilatation for CES at the pediatric surgery department were enrolled in this study. Their ages ranged from 2.5 to 6 years. This technique was successful in 6 patients indicating technique reproducibility of 85.7%. These 6 patients continued their next dilatation sessions using bougie dilator only, whereas 4 patients were completely cured from dysphagia indicating technique efficiency of 57%, 1 is still on dilatation, and 1 patient had a resistant stricture. The dilatation through the proposed technique failed in 1 patient, who was referred for a replacement surgery. Conclusion: Combined dilatation is safe and effective to preserve the native esophagus in some difficult CES.

The feared postdilation complication in caustic esophageal stenosis: combined endoscopic and surgical treatment.

The feared postdilation complication in caustic esophageal stenosis: combined endoscopic and surgical treatment.

Caustic Esophageal Stenosis: Epidemiological, Clinical, Endoscopic and Therapeutic Aspects at the Gabriel Tour&amp;#233; University Hospital in Bamako

Voluntary or accidental ingestion of a caustic product is increasingly encountered in our country. Caustic esophageal stenosis is the most common sequel. Its treatment involves instrumental dilation and/or surgery which is particularly heavy. The aim of this study was to study the epidemiological, clinical and therapeutic aspects of caustic esophageal strictures in our context. The retrospective study took place from December 2013 to December 2017 in the Hepato-Gastroenterology department of the Gabriel Toure university hospital in Bamako. We included patients with caustic esophageal stenosis referred to the gastrointestinal endoscopy unit for dilation. 67 patients admitted for caustic stenosis were included. The mean age of our patients was 20.76 ± 19.9 years with extremes of 1 and 70 years and a sex ratio of 1.9. In 50.7% of cases, the product ingested was basic in nature. The clinical symptomatology was dominated by dysphagia (100%), vomiting (100%), the emaciated (60%) and cough (40%). In 59 (88%) patients, the stenosis was unique and multiple in 8 (12%). The KILLIAN mouth as the sole site of the stenosis was found in 40.3% of patients. The number of sessions was ≤ 3 in 16.4% and >3 in 83.6% with a mean of 4.59 ± 1.57 sessions. The evolution was favorable in 95.5% of our patients. However, we recorded three (3) cases of death all following a perforation. Conclusion: Caustic esophageal stenosis, a consequence of ingestion of caustics, is increasingly observed in our context. Endoscopic dilation occupies an important place in its management.

S0395 Outcomes of Benign Corrosive Esophageal Stricture Dilation—Single Center Experience

INTRODUCTION: The strictures secondary to caustic ingestion is a debilitating condition causing long-term nutritional challenges. This retrospective study investigates the outcomes of endoscopic dilation in patients with benign esophageal strictures secondary to corrosive ingestion. METHODS: A retrospective study that included patients with esophageal strictures due to caustic injury under follow-up was performed at a tertiary care center. These patients at the centre underwent endoscopic dilation by both Endoscopic Balloon Dilation (EBD) and Gilliard Savary (GS) dilators based on endoscopist comfort (P.K.). Symptomatic relief within 2 months of intervention was considered a successful response. RESULTS: The study included 39 patients including 31 patients with acid ingestion and 8 with alkali ingestion (Figure 1). Of patients with acid ingestion, 32.3% (10/31) underwent EBD and 67.7% (21/39) underwent GSD with only 50% (5/10) and 38.1% (8/21) respectively having symptom relief. Of patients with alkali ingestion, 50% (4/8) underwent EBD and 50% (4/8) underwent GSD with 75% (3/4) and 50% (2/4) respectively having symptom relief. Irrespective of caustic etiology, the composite success for EBD and GSD sub-groups were 61.5% and 38.5% respectively. Short stricture length was associated with successful outcomes among patients with acid ingestion (P = .003) but not among patients with alkali ingestion. Patients with failed outcomes had higher percentages of grade 2B and 3 mucosal injury at time of initial caustic exposure and warranted repeated endoscopic dilations for symptom management. This however did not reach significance in patients with either alkali (P = 0.19) or acid ingestion (likelihood ratio; P = 0.14). In the study population, seven patients had concomitant stomach involvement with three (7.7%) developing gastric outlet obstruction (GOO), all of whom underwent surgical intervention. Other than GOO, no other sequelae like achlorhydria, mucosal metaplasia, carcinoma or protein losing enteropathy were diagnosed during follow up. CONCLUSION: Overall success of endoscopic dilation for caustic esophageal stricture is limited and newer modalities like stent placement or endoscopic incision therapy may play a role in management of refractory strictures. Primary prevention of such injuries should be the preferred approach in managing this public health issue.Figure 1.: Flow diagram describing the endoscopic dilations among the patients with benign strictures.

Predictors of successful endoscopic management of caustic esophageal strictures in children: When to stop the dilatations?

BackgroundCaustic esophageal strictures are mainly managed by endoscopic dilatations. Cases that do not respond to the dilatations eventually require an esophageal replacement. The aim of our study was to identify factors that could allow us to predict if the dilatations will be successful or not. MethodsWe retrospectively reviewed the chart of 100 patients with caustic esophageal injuries treated at our center between 2012 and 2019. Collected data included age, gender, type of caustic substance, duration of the dilatations, length and extent of the strictures, number and time interval between dilatations, presence of gastroesophageal reflux, occurrence of esophageal perforation, and outcome of the dilatation program. ResultsThe patient ages ranged from 1 to 8 years old. The overall success rate was 98.2% for patients with short strictures and 81.8% for patients with long strictures (>3 cm). A long stricture, a pharyngeal extension of the stricture, the occurrence of an esophageal perforation, and the presence of gastroesophageal reflux were strong predictors of the failure of the dilatation program. The median treatment time for the patients to achieve a cure was 5 months in cases of short strictures and 17 months in cases of long strictures. Within the subgroup of patients with long strictures, a dysphagia-free period within the first year of management of 8 weeks was associated with the success of the dilatation program. ConclusionA length of more than 3 cm, pharyngeal involvement, the occurrence of esophageal perforation, and the presence of gastroesophageal reflux are predictors of failure of dilatations for the management of caustic esophageal strictures. A dysphagia-free period of 8 weeks or more within the first year of dilatations is considered a predictor of success of dilatations in patients with long strictures. Level of EvidenceLevel II.

Caustic esophageal stricture from diagnosis untill cure

Background: The diagnosis of esophageal stricture after caustic ingestion is based on clinical symptoms of dysphagia, regurgitation and chocking that is evident initially in the acute stage. These symptoms may ameliorate by time or proceed to evident stricture due to fibrosis. This will need either dye esophagogram or Esophagoscopy which is better to be done not before the lapse of at least 6 weeks from injury. Esophageal dilatation using wire-guided dilators is the cornerstone of treatment. The frequency of dilatation is based on recurrence of dysphagia and in multiple strictures, repeated sessions with multi-level injection of steroids and graded dilatation is needed. Failure of dilatation or occurrence of complications may necessitate esophageal replacement and usually we prefer the transverse colon based on the left colic vessels in retrosternal position to treat the condition. We aimed to review the management of caustic esophageal strictures based on what is known and adding our experience in this aspect. Methods: We reviewed the articles discussing management of caustic esophageal strictures in the last twenty years. We added our experience of more than forty years managing an average of thirty new cases every year. Results: Management of caustic esophageal strictures has changed in the last years. Advanced endoscopic techniques of dilatation reduced the need for esophageal replacement. Conclusions: Caustic esophageal strictures could be managed successfully with advanced techniques of endoscopic dilatation. Keywords: Caustic stricture; esophageal dilatation; esophagoscopy; esophageal replacement

Iatrogenic esophageal perforation caused by endoscopic dilatation of caustic stricture: Current management and possibility of esophageal salvage

BackgroundIatrogenic esophageal perforation (EP) is an undesirable complication of endoscopic dilatation of caustic esophageal stricture. We reported our current management protocol with possibility of continuing the dilatation program. Patients and methodsFrom January 2009 to January 2020 medical records were reviewed for patients presented with iatrogenic EP. Management according to each case condition was reported. Results24 patients were enrolled, aged from 1.5 to 6 years old. Perforation was cervical in one case, abdominal in two cases, and thoracic in 21 cases. Immediate surgical repair was performed in the abdominal cases. Conservative management was chosen in 22 cases; two cases didn't respond and underwent esophageal diversion, and one of them died owing to severe sepsis. Three patients refused another trial of dilatation. Two cases failed to be redilated. 17 patients continued a dilatation program. Time passed between perforation and redilatation ranged from 35 days to 7 months. 15 patients were cured completely from dysphagia, one patient had marked improvement of his dysphagia, and one case with a resistant stricture was referred for esophageal replacement. ConclusionPreserving the native esophagus is possible after iatrogenic EP of caustic esophageal stricture. A conservative approach should be attempted with caution not to endanger patient's life.Level IV of evidence

Accuracy of contrast swallow study in assessment of caustic esophageal stricture length in children: Agreement study

BackgroundCaustic esophageal stricture length assessment is essential for planning endoscopic management and predicting its prognosis. We aimed to assess the accuracy of contrast swallow study (CSS) in measuring stricture length in comparison to endoscopy (definitive investigation for actual length measurement). MethodMedical records of caustic esophageal strictures between 2010 and 2020 were retrospectively reviewed. Reliability study was done to compare between radiological and endoscopic measurement of stricture length. Result124 CSSs for 91 patients were analyzed. Six studies showed no stricture, single stricture was reported in 101 studies, double strictures were reported in 16 studies, triple strictures were reported in one study (136 radiological stricture). Endoscopy revealed 133 true strictures. Number of the strictures was consistent between CSS and endoscopy in 112 studies (90.3%) and different in 12 studies (9.7%). Eight endoscopies revealed strictures not reported in CSS (5.5% false negative strictures), while 10 CSSs reported 11 strictures that were not detected during the endoscopy (7.6% false positive strictures). Reliability analysis revealed interclass correlation coefficient = 0.6 (95% CI 0.5 to 0.7) indicating moderate reliability. ConclusionCSS is not accurate in assessing caustic esophageal stricture length. Combination of CSS and endoscopic investigation is better for proper evaluation of these patients.Level III of evidence

Corticosteroid injection of impassable caustic esophageal strictures without dilatation: Does it pave the way to interval endoscopic dilatation?

Background/PurposeEndoscopic dilatation of caustic esophageal stricture is the mainstay of therapy. The need for esophageal replacement has decreased over the past decades owing to advancement in techniques of dilatation. In this study, we aimed to assess our results of four-quadrant corticosteroid injection of impassable caustic esophageal strictures followed by a trial endoscopic dilatation. MethodsDuring the period from June 2003 to May 2017, in 340 patients in whom a trial of endoscopic dilatation after corrosive ingestion failed, corticosteroid was injected in 4 quadrants at the site of the stricture in the same setting. After 2 weeks, another trial of endoscopic dilatation was done. ResultsOut of the 340 patients with failed first trial of endoscopic dilatation followed by four-quadrant corticosteroid injection, the second trial of endoscopic dilatation, after 2 weeks, was possible in 255 patients (75%). In the remaining 85 patients (25%), the endoscope could not pass and they were candidate for esophageal replacement. ConclusionsFour-quadrant corticosteroid injection of impassable caustic esophageal stricture followed by endoscopic dilatation is a minor procedure which decreased the need of a major procedure to replace the injured esophagus. Type of the studyClinical research paper. Level of evidenceLevel III.

Intralesional Mitomycin C Injection in Management of Caustic Esophageal Stricture in Children

Abstract Background Corrosive ingestion is a devastating event that induces significant burdens on modern health systems worldwide. The management of resulting esophageal strictures is challenging where endoscopic dilatation is the first line of management with varying rate of success. Aim of the Work We aimed at this work to study the feasibility and safety of intralesional Mitomycin C injection in patients with caustic localized esophageal stricture. Patients and Methods This study has been conducted at Pediatric Surgery Department, Pediatric Hospital, Ain Shams University Hospitals on eight pediatric patients with caustic esophageal stricture with variable degrees of dysphagia. We evaluated the clinical improvement of the dysphagia, as well as the intra and postoperative complications of Mitomycin C injection. Results Eight patients with short caustic esophageal stricture were managed with intralesional Mitomycin C injection adjuvant to endoscopic dilatation. Seven patients were completely cured from dysphagia with at least 6 months dysphagia free period. No intraoperative complications were documented while there were two cases who reported GIT side effect postoperative in the form of colics and non-bilious vomiting that resolved by medical treatment. Conclusion Intralesional Mitomycin C injection could be a good adjuvant therapy with endoscopic dilatation for caustic esophageal stricture. However, long-term observations are mandatory on a large scale of patients.