Caustic Stricture Research Articles

639. WHICH FACTORS LEAD PATIENTS WITH BENIGN ESOPHAGEAL STRICTURES FOR SURGICAL TREATMENT BESIDES ENDOSCOPIC TREATMENT?

Abstract Background This work proposes to evaluate patients with benign esophageal strictures, excluding caustic strictures, about their etiologies and poor prognostic factors for the success of endoscopic treatment. Methods It was evaluated in our service 38 patients, from 1992 to 2023, with benign esophageal strictures not related to caustic strictures. We could follow-up 24 patients from 7 months and 384 months (average of 136 months). Four died during the follow- up. We could analyze these following outcomes: clinical symptoms, surgical indications, age, gender, alcohol abuse, smoking, length of stricture, number of endoscopic dilation and stricture etiology. Results Concerning the 24 patients with follow-up, 4 had esophagectomy; 10 underwent endoscopic treatment with fundoplication and 10 were treated with endoscopic and medical treatment. Both groups, endoscopic and medical treatment, and endoscopic treatment with fundoplication had 4 patients that continued symptomatic (40%). The number of endoscopic dilations range from 1 to 101 (average 18) in each patient. The etiology of 38 patients with benign esophageal strictures were: 35 gastroesophageal reflux disease (13 Barrett´s esophagus); one with infectious esophagitis; one eosinophilic esophagitis and another due to esophageal varicose sclerosis. The prognostic factors to surgical treatment will be analyzed by statistical analysis. Conclusion From our data, it is possible to conclude that the endoscopic treatment is effective to manage the majority of benign esophageal strictures, even in association with fundoplication. Moreover, the main etiology was gastroesophageal reflux disease. Only few patients have developed indication to esophagectomy.

Outcomes of Colonic and Gastric Tube Transplants after Caustic Esophageal Burn in Children: A 33-Year Review.

Introduction: Accidental caustic burns of the esophagus in children represent a significant global health challenge, often necessitating esophageal reconstruction. The aim of this study is to compare the efficacy and morbidity related to esophagus replacement with colonic and gastric tube transplants in a pediatric population followed for caustic stenosis. Methods: This retrospective study was conducted at a tertiary pediatric surgery unit for children treated from January 1989 to December 2022. We compared colonic and gastric tube esophageal replacement. Short term (within 30 days) and mid-term outcomes and complications were reviewed. Statistical evaluation was considered using a Chi-square test for categorical data analysis. Results: A total of 124 children with caustic esophageal burns were included. Among them, 23 (18.5%) had a gastric tube transplant for esophagus replacement and 101 (81.5%) a colonic transplant. During surgical intervention, we found a significantly higher risk of complications when using a colonic transplant (34%, p < 0.001). There was no significant statistical difference in postoperative short term and mid-term complications between the two techniques. Twenty-six (26%) of the children required a reoperation, with a higher risk in the gastric tube transplant group (p < 0.001). Endoscopic dilatation after surgery was also performed on a higher number of children who had received a gastric tube transplant (p = 0.005). Overall, 97.6% recovered full normal oral feeding. Conclusions: We found that colonic and gastric tube replacement are both good options for pediatric esophageal replacement after a caustic injury and show effectiveness over time. Gastric tube transplants carried a slightly higher risk of reoperations and a higher number of dilatations post-surgery. However, our groups are not really comparable, due to the much higher number of colonic transplants. Both surgical options have to be considered during surgery, and the choice depends on the anatomy of the patient. Our future research will focus on assessing long term quality of life and the potential risk of neoplastic complications.

Dilation of benign esophageal strictures with balloon/bougie; a single center experience

Objective: Narrowing in the esophagus caused by benign conditions such as peptic injury, surgical anastomosis, radiation therapy, Schatzki rings, esophageal webs, erosive injury and eosinophilic esophagitis are called benign esophageal strictures. In the treatment of benign esophageal stricture, endoscopic dilation with balloon or bougie is the first priority. Method: The study included a total of 96 patients who were diagnosed with a benign stricture at the gastroenterology clinic of our university from May 2009 to October 2023. All patients were symptomatic, and their main complaint was dysphagia. The benign stricture was diagnosed through clinical examination, radiological imaging and endoscopy. Patient data were scanned retrospectively. The dilation method (bougie, balloon), the number of times the procedure was permormed and any potential complications were recorded. Stents were applied to patients who did not provide adequate dilatation. Results: A total of 96 patients were included in the study. 47 (49%) of them were women and 49 (51%) were men. The average age was 48±17 years (the youngest was 18, the oldest was 81). A total of 198 dilation procedures were performed on 96 patients. The average follow-up period was 79±54 (1-179) months. Srictures were divided into 4 groups according to etiology as anastomotic stricture, peptic stricture, caustic stricture and post-radiotherapy stricture. Of the cases with stricture, 76 (79.2%) underwent bougie dilation, 26 (27.1%) underwent balloon dilation, 5 (5.2%) underwent bougie and then balloon dilation, and in 5 (5.2%) cases, metallic stent was placed due to failed dilations. Conclusion: This study shows the effectiveness of bougie and/or balloon dilation in treating most of the patients with benign esophageal strictures, with a low complication rate. It is less invasive, comfortable and cost-effective than the alternative surgical approach.

Esophageal replacement in children - 27 years of experience in a University Hospital.

esophageal replacement in children is indicated when it is impossible to maintain the native esophagus, which in the pediatric population includes patients with esophageal atresia and esophageal caustic stenosis. The objective of this communication is to report the experience of a university service with two techniques of esophageal replacement. this is a retrospective study based on the revision of hospital files. The study population consisted of patients who underwent esophageal replacement from 1995 to 2022, at the Hospital de Clínicas of the State University of Campinas. The analyzed data were age, sex, underlying disease, technical aspects, complications, and long-term results. during the study period, 30 patients underwent esophageal replacement. The most common underlying diseases were esophageal atresia (73.33%) and caustic stenosis (26.67%). Twenty-one patients underwent gastric transposition (70%), and nine underwent esophagocoloplasty (30%). The most frequent postoperative complication was fistula of the proximal anastomosis, which occurred in 14 patients. Most of the patients with fistulas had a spontaneous recovery. There were three deaths. Of the 27 survivors, 24 can feed exclusively by mouth. esophageal replacement in children is a procedure with high morbidity and mortality. Esophagocoloplasty and gastric transposition have similar results and complications, with the exception of proximal anastomotic fistulas, which are generally self-resolving and are more common in esophagocoloplasty. The choice of the best surgical technique must be individualized according to the patients characteristics and the surgeons experience, as both techniques offer the ability to feed orally in the short or medium term.

The presence of adenocarcinoma of the right colon and polyp in colonic graft in a female patient with colon interposition due to caustic stricture of the esophagus in childhood

Introduction. Colon interposition is considered an effective option for esophageal replacement in children, particularly in cases of caustic esophageal stricture. The use of colonic tissue grafts for esophageal replacement can lead to late complications, including the development of precancerous lesions and malignant tumors. The aim of the paper is to describe a female patient who was diagnosed with adenocarcinoma of the right colon at the age of 71, 60 years after surgery for benign esophageal stricture. Case outline. A 71-year-old female presented to our clinic in January 2023 with symptoms of abdominal pain. At the age of 11, the patient had bypass esophagocoloplasty with retrosternal esophagogastrocolonic anastomosis due to esophageal stricture after accidental caustic ingestion. CT imaging revealed tumor of the ascending colon, estimated stage T4aN1M0. An upper digestive endoscopic examination revealed one polyp while a lower digestive endoscopic examination confirmed the presence of a stenotic tumor in the ascending colon. Furthermore, a polypoid alteration was identified in the descending colon. CT angiography revealed that the tumor was found to receive its vascular supply through the middle colic artery, while the colonic transplant received its vascular supply through the right colic artery. Conclusion. It is recommended to implement lifelong endoscopic surveillance for patients who have undergone colon interposition. In cases such as this, it is crucial to establish a comprehensive treatment plan and employ effective diagnostic measures to ensure the preservation of the integrity and vascularization of the colonic graft.

From Caustic Stenosis to Esophageal Cancer, a Challenging Evolution - Narrative Review.

Caustic ingestion remains a complex public health problem worldwide, both in adults and children. The consequences of caustic ingestion depend on the severity of the injuries, the general condition of the patient at presentation and the promptness of medical management. Long-term complications include strictures or stenoses, resulting in dysphagia. In addition to metabolic and hydroelectrolytic disorders, consequences of dysphagia, there are distant cases of esophageal cancer based on esophageal stenosis. The ingestion of caustic products is a risk factor for the occurrence of esophageal cancer, and the specialized literature reports the occurrence of the disease, approximately 30 to 40 years after the accident, with the determination mainly of squamous carcinoma. The pathophysiological mechanism of esophageal cancer related to caustic ingestion is not fully understood. The diagnosis of esophageal cancer on post caustic scar is based on two important pillars: the change of the clinic by the appearance or change of the characters of dysphagia and the endoscopic examination of the lesion. Obviously, the information needs to be completed by complex imaging explorations, both for the certification of the diagnosis and for the purpose of a complete oncological assessment. The principles and methods of treatment for "esophageal scar cancer" are the same as for any other esophageal cancer: early detection, complete oncological assessment and surgical resection associated with oncological therapy are the main pillars for cure. Due to the complexity of these cases, a series of discussions and recommendations appear as necessary in their management.

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.

Colon interposition in the management of post-corrosive strictures

: Stricture of the esophagus is the most frequent late sequelae of the ingestion of caustic agents. It is disabling, lead to chronic pain and malnutrition. Endoscopic dilatation still remains the first-line management but cannot be effective in all patients. When surgery is indicated, only selected patients can be submitted to an esophago-gastroplasty. Colon interposition for esophageal replacement is more frequently performed for treatment of caustic burns, but many questions still remain about colonic tract to be used (right or left), route of transposition and timing of the operation. Surgeon’s experience is the most important factor to choose the right colonic tract as esophageal substitute. Age, psychiatric disorders, massive ingestion, emergency tracheotomy, extended visceral resections, short delays in reconstruction, and pharyngeal involvement worsen surgical outcomes, therefore surgery should be performed in high-volume centers. Follow-up of these patients should not tend only to verify the patency of the transit and weight maintenance, but it should identify any lesion of the graft and any metabolic alteration referring to an altered permeability of the transposed colic segment. In this review, we present the main step of preoperative, intraoperative and postoperative pathway of esophageal reconstruction for caustic strictures with a colonic graft, critically exposed according to our experience.

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.

In a Setting of Esophageal Replacement, Total Gastric Pull-Up has Fewer Complications than Partial Gastric Pull-Up

AimThe main indications for an esophageal replacement (ER) are unresolved complex esophageal atresia (EA) and caustic strictures (CS). The use of different organs for replacement has been described. When the stomach is chosen, there are two ways to do a gastric pull-up: a partial (PGP) or a total pull-up (TGP). Few studies have been published comparing the different techniques. The aim of this study was to compare the outcomes of patients who underwent ER by PGP or by TGT. MethodsThe medical records of all patients who underwent gastric pull-up for ER in the last 18 years at the National Pediatric Hospital Prof. Dr. Juan P. Garrahan were reviewed. The study is comparative, retro-prospective and longitudinal. Patients were divided in two groups according to the ER technique (PGP or TGP). We compared the following outcomes: duration of the operation, days of hospitalization in the intensive care unit (ICU), days of total hospitalization, time to initiation of oral feedings and rate of anastomosis dehiscence, incidence of anastomotic stenosis, need for re-operations, incidence of gastroesophageal reflux disease (GERD), incidence of tracheo-esophageal fistulas (TEF), incidence of dumping syndrome, incidence of gastric necrosis and mortality. ResultsThere were 92 patients included in the study: 70 in the PGP group (76%) and 26 in the TGP group (24%). The two groups were demographically equivalent. Patients in the TGP group had a statistically significant lower incidence of anastomotic dehiscence (22,7% versus 54,3%; p = 0.01) and dumping syndrome (13,6% versus 37,1%; p = 0.038). Patients in the TGP had lower incidence of anastomotic stenosis, although the difference was not statistically significant. There were no statistically significant differences between the groups in terms of duration of the operation, postoperative days in the ICU, time to oral feedings, GERD, TEF or overall hospital stay. There were no cases of gastric necrosis. There were 3 deaths in the PGP group and one in the TGP group. ConclusionsWe observed benefits in the TGP group versus the PGP approach in terms of anastomotic dehiscence and dumping syndrome, as well as a trend toward a lower incidence of anastomotic stenosis. Based on this experience, we recommend the TGP approach for patients who need an esophageal replacement by a gastric pull-up. Levels of evidenceAccording to the Journal of Pediatric Surgery this research corresponds to type of study level III for retrospective comparative study.

Phagophobia in A 6-Year-Old Child : Case Report

Introduction: Photophobia or swallowing phobia is a rarely studied clinical entity. Classified as a specific phobia by the DSM-V. Through our clinical case, we highlight the diagnosis difficulty of this clinical entity and the interest of early therapeutic management appropriate to the age of the child. Clinical observation: A 6-year-old female patient was hospitalized in pediatric surgery for esophageal caustic stenosis that required esophageal replacement. Thereafter, the persistence of swallowing disorders was observed while the organic etiological assessment was negative. Manifestations of phobic anxiety were identified starting the first psychiatric consultation. These manifestations were found to be linked to the memory of traumatic events that the patient experienced during the gastro esophageal fibro copy. The diagnosis of phobic disorder was retained and the treatment was essentially based on behavioral therapy. The evolution was globally favorable. Discussion: Photophobia, or swallowing phobia, is an uncommon phobic disorder listed in the 11th edition of the International Classification of Mental Disorders and the DSM-5. The important question before diagnosing this disorder is to determine its psychogenic basis. In most cases, the onset of the disorder follows a swallowing accident, which leads to swallowing phobia, which in turn is considered a particular form of post-traumatic stress disorder. It can also be associated with separation anxiety in children as in our case. Conclusion: Swallowing phobia is considered a specific, non-developmental phobia. Swallowing phobia and other childhood anxiety disorders are closely correlated. Cognitive behavioural therapies have shown favourable responses in most cases.

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.

Long term outcome of a subcutaneous colonic interposition after pharyngo-laryngectomy for strictures of the larynx and hypopharynx resulting from caustic ingestion: A case report.

IntroductionCaustic agents, also called corrosive agents, could be acids or alkali in nature. If ingested, these agents can injure any part of the aerodigestive tree. Extent of injury depends on the type, concentration, duration of exposure and volume of caustic agent ingested. Serious complications after caustic agent ingestion can occur both in the short term such as hollow viscus perforation and death and in the long term such as stricture formation causing obstruction and lifetime risk of development of carcinoma.Presentation of a caseThis is a case of a 25-year-old female who ingested an unknown substance resulting to a severe stricture of the larynx, hypopharynx, esophagus and pyloroantral region of the stomach. Six months after her tracheostomy and tube jejunostomy, she sought further medical attention in our institution due to inability to swallow food and saliva. She underwent pharyngolaryngectomy (PL) with the strictured esophagus and stomach left in-situ due to extensive adhesions. The subcutaneous colonic interposition reestablished the alimentary continuity by providing enough length for tension-free anastomosis and a more direct route for cervical anastomosis.DiscussionStricture formation is one of the most challenging late complication of corrosive injury. It results from scar formation in response to inflammation of the aerodigestive tract. Key factors in managing caustic strictures include safety of strictured segment resection, choice of replacement organ for reconstruction and route of conduit.ConclusionTiming of surgery and proper selection the surgical procedure for complications of caustic ingestion can result in excellent long term outcomes.

Benign Stenosis of Oesophagus: About 101 Cases in the Digestive Endoscopy Department of the General Idrissa Pouye Hospital (Dakar, Senegal)

Introduction: Benign oesophageal strictures are defined as narrowing of the oesophageal lumen not related to neoplastic pathology. They are frequently encountered during endoscopic practice and are often responsible for a reduction in the quality of life of patients due to the appearance of dysphagia. In sub-Saharan Africa, little data are available on these benign esophageal strictures. The objective of our study was to determine the sociodemographic, diagnostic and therapeutic aspects of benign oesophageal strictures in a digestive endoscopy centre in Senegal. Patients and Methods: This was a retrospective, descriptive study analysing reports of upper GI endoscopies performed between January 2015 and December 2017 in a hospital in Senegal. Reports that concluded to have non-neoplastic oesophageal stenosis were collated. Sociodemographic data, indications for and results of endoscopy, and therapeutic modalities were collected. These data were analysed using the Sphinx version 5 software. Results: We collected 101 cases of benign oesophageal stenosis, representing a prevalence of 2.1% in the endoscopy centre. The mean age of the patients was 34 years (range 2 and 83 years) with a median of 37.9 years. There was a female predominance with a sex ratio of 0.38 (73 females). Dysphagia, the main symptom, was present in 87 patients (86.1% of cases) with a Dysphagia score greater than or equal to 2 in 51 patients (50.5%). The average duration of this dysphagia, excluding caustic stenosis, was 4 years (extremes 1 and 15 years). Endoscopy revealed simple stenosis in 76 cases (75.2% of cases). A membranous ring of the cervical oesophagus, suggestive of the Plummer-Vinson syndrome ring, was found in 60 patients (59.4% of cases) and was the primary cause; other aetiologies were dominated by caustic stenosis (19 cases), Schatzki rings (8 cases) and peptic stenosis (4 cases). Endoscopic dilatation was performed in 90 patients (89.1% of cases) with Savary Gilliard bougies (87 cases) and hydrostatic balloons (3 cases). The average number of dilatation sessions was 1.69. In 10 patients (11.1%), refractory stenosis was observed. This stenosis could be resolved after further dilatation in 8 cases before the 8th session. In 2 patients, dilatation failed. Conclusion: Benign oesophageal strictures in our digestive endoscopy centre in Senegal mainly affect young adults, with a predominance of women. Diagnosis is often late. Cervical oesophageal rings in the context of Plummer-Vinson syndrome are the main cause. Oesophageal dilatation with bougies is of great therapeutic value.

Seventy Cases of Partial Gastric Pull-Up According to the Schärli Technique for Esophageal Replacement in Pediatrics

Introduction Esophageal replacement (ER) is indicated in patients with long gap esophageal atresia (LGEA) or failure of the primary anastomosis. Also, severe caustic or peptic strictures, resistant to conservative treatment with medication and dilations, may require an ER. Numerous techniques with different organs and routes have been described, all with satisfactory results. Objective Our objective is to describe the experience obtained with partial gastric pull-up according to the Schärli principles (SGPA). Materials and Methods Medical records of patients who required a SGPA between October 1995 to June 2018 were reviewed. The analysis was observational, longitudinal, retro-prospective and descriptive. Epidemiological data, surgical aspects and postoperative complications of the patients were considered. Results Seventy ER were performed with SGPA. The indication was esophageal atresia (EA) in 58 cases (44 long gap and 14 failure of the anastomosis), 10 caustic strictures, one peptic stricture resistant to conservative treatment and the other due to a retained foreign body. The age of the ER was on average 2-years and 9-months. The route was: posterior mediastinal (35), retrosternal (29) and transpleural (6); without a thoracic approach in 59 patients. The duration of the procedure was 4.7-hours on average. There were 13 cases of intraoperative complications, 8 cases of pneumothorax, 5 bleeding injuries (3 in the spleen, 1 liver and 1 cervical), and one injury to the cervical trachea. Anastomotic dehiscence was observed in 37 patients (52%), which closed spontaneously after an average of 17.8-days in all except one patient. Thirty-one patients (44%) developed anastomotic stenosis, requiring redo anastomosis in 6 cases; 37% developed dumping and 23% gastroesophageal reflux disease. There were 3 deaths (4.2%): all in EA patients with associated malformations, following a morbid postoperative period with infectious complications in intensive care at 10-days, 7 and 8-months after ER. Follow-up was an average of 8-years. All 67 living patients are currently tolerating oral feeding. Conclusion In our experience with ER using SGPA, we observed a high incidence of complications, generating a longer post-operative evolution and with greater morbidity than that described in other techniques. Given these results, we changed our strategy to complete gastric transposition, in order to reduce morbidity and improve the evolution of this complex group of patients.

S2071 Refractory Benign Esophageal Stricture - Management Dilemma

Introduction: Benign esophageal strictures can result from long-standing GERD, ablative or radiation therapy, caustic ingestion and etc. Management of strictures could be very challenging. We describe a case of a refractory esophageal stricture with aim to focus on management challenges. Case Description/Methods: A 36-year-old Indian female with a history of esophageal strictures secondary to caustic ingestion present to our GI clinic with complaints of worsening dysphagia to solids. She underwent multiple serial endoscopies with dilatation at an outside facility and subsequently was performing self-dilatation with bougie dilators, until no further relief of her symptoms. An esophagram revealed a narrow caliber mid and distal esophagus with 3 prominent stricture points. The proximal stricture could not be traversed on initial endoscopy with 9.9 mm gastroscope, therefore a 4.9 mm bronchoscope was used to assess the size and location of the 3 esophageal strictures which were noted at 25 cm, 30 cm and 35 cm from incisors. Serial dilations were performed with a CRE balloon dilator and triamcinolone injection at the refractory stricture site post dilation. The esophageal strictures were able to be dilated with serial dilatations and the gastroscope was able to traverse all 3 strictures without difficulty and patient experienced symptomatic relief. Patient was counseled regarding high risk of perforation with subsequent dilatation and given surgical consultations for second opinion and alternative management options. Discussion: Late management of caustic strictures makes dilatation more complex owing to fibrosis in esophageal wall. Perforation rates for caustic strictures is higher than standard benign stricture dilatation with anything from 0.4 up to 32% recorded in the literature. Refractory strictures are more common in caustic ingestion and the management has been reported with intralesional steroid injection or topical mitomycin C at the time of dilatation, and temporary stent placement. Prior to dilatation one must consider the following prior to endoscopically dilating such as etiology of stricture, degree of patient’s dysphagia, length, tortuosity and luminal diameter of the stricture. Our patient’s strictures were refractory to dilatation and intralesional steroid use. Stent placement is technically not feasible given different size and diameter of strictures as it enhances risk of perforation. Surgery although a high-risk approach but remains as curative resort for such cases.

Efficacy and Safety of Endoscopic Esophageal Dilatation in Pediatric Patients with Esophageal Strictures.

Materials and Methods In this retrospective cross-sectional single center study, records of patients with esophageal strictures presented to the pediatric department, Salmaniya Medical Complex, Bahrain, in the period between 1995 and 2019 were reviewed. Demographic data, indications of endoscopic dilatations, the procedure success rate, and possible complications were assessed. Results Forty-six children were found to have esophageal strictures. Twenty-five (54.3%) patients were males. Most patients presented during infancy (86.5%, 32/37 patients). Twenty-six (56.5%) patients required 88 dilatation sessions, while the remaining 20 (43.5%) patients did not require dilatations. The median number of dilatation sessions per patient was three (interquartile range = 2–5). Savary-Gilliard bougienages were the main dilators used (80.8%, 21/26 patients). Anastomotic stricture (post esophageal atresia/tracheoesophageal fistula repair) was the main cause of esophageal strictures and was found in 35 (76.1%) patients. Patients with nonanastomotic strictures had more frequent dilatations compared to those with anastomotic strictures (P = 0.007). The procedure success rate was 98.8%. Yet, it was operator dependent (P = 0.047). Complete response to dilatation was found in 18 (69.2%) patients, satisfactory in seven (26.9%), and an inadequate response in one (3.9%). Those with satisfactory responses still require ongoing dilatations based on their symptoms and radiological and endoscopic findings. No perforation or mortality was reported. Patients with dilatations had more recurrent hospitalization (P < 0.0001), more dysphagia (P = 0.001), but shorter hospital stay (P = 0.046) compared to those without dilatations. Surgical intervention was required in one patient with caustic strictures. The median follow-up period was six years (interquartile range = 2.25–9.0). Conclusions Endoscopic esophageal dilatation in children with esophageal strictures is effective and safe. Yet, it was operator dependent. Nonanastomotic strictures require more dilatations compared to anastomotic strictures. Findings of this study are comparable to those reported worldwide.

Double caustic, esophagic and pyloric stenosis post-ingestion of soda: Rare case

The ingestion of caustic soda is frequently a source of complications. Esophageal stenosis remains among them the most frequent complication and by far the most formidable. Pyloric stenosis remains rare following ingestion of soda. We report through this clinical case, a cicatricial pyloric stenosis after ingestion of caustic soda associated with a stenosis of the esophagus having caused vomiting with the onset of severe malnutrition. The diagnosis was confirmed by the oeso-gastro-duodenal transit (OGDT) and the child underwent under general anesthesia an enlargement pyloroplasty according to Mikulicz initially and an esophageal dilation secondly to the candle of SAVARY. The postoperative follow-up was favorable with an improvement of the signs and a progressive postoperative weight gain after a follow-up of 06 months. The evolution was favorable after the monthly dilation sessions with a good resumption of transit.

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.

Pedicled jejunal interposition as esophageal substitute in pediatric patients. Technical considerations and long-term results

The current study reports the surgical technique and the clinical long term results of pediatric esophageal substitution with a pedicled jejunal loop in two patients with long gap esophageal atresia and one patient with severe esophageal stenosis due to a caustic lesions. Postoperative course was uneventful in all patients. At a long term follow-up of 29 and 43 years for the patients with esophageal atresia and 21 for the one with caustic stenosis, no feeding troubles were reported due to malfunction of the esophageal replacement nor to loss of its original functions and the patients referred a highly satisfying quality of life. Pedicled jejunal interposition confirms as a good substitute of the esophagus in pediatric age with the advantage to maintain good performances for very long time. Although these patients do not share the same risks of illness as other patients still harboring their native pathologic esophagus, a far sighted surveillance is recommended due to long term potential morbility risk.