Chadin Tharavej, Patpong Navicharern, Supaut Pungpapong, Krit Kittisin, Suthep Udomsaweangsup. Chulalongkorn University
Background: Repeated dilatation is usually recommended as first line treatment in acid-induced corrosive esophageal stricture however outcome, predictors of failure and safety of esophageal dilatation is less known. This study aims to examine the outcome of esophageal dilatations and determine the predictors of failed dilatation for early surgery consideration.
Methods: Patients diagnosed of corrosive esophageal strictures were included. Endoscopic esophageal dilatation with graded Savary-Gillard dilator was performed as first line treatment. Subsequent dilatations had been done when recurrent dysphagia developed. Outcome of dilatation was considered excellent when patients were able to eat solid without extra-nutritional supplementation and no intervention (re-dilatation/surgery) needed at least one year and considered good when re-dilatation needed <3 / year. Patients considered failure of dilatation included complete luminal stenosis, unable to perform safe dilatation, perforation and unable to maintain adequate luminal patency. Colonic interposition was indicated in failed dilatations. Previous emergency esophagogastrectomy, esophageal stent insertion and endoscopic steroid injection were excluded from the study.
Results: There were 55 patients with corrosive esophageal strictures. All patients had strong acid ingestion with suicidal intents. Of 55 patients, 40 had failed esophageal dilatations and underwent substernal colonic interpositions. Thirty-six out 40 patients with substernal colonic interposition had good to excellent swallow outcome. Fifteen (27%) out of 55 patients underwent repeated dilatations with only 2 of them considered cure (excellent outcome). Of 296 sessions of dilatations, 7 (2%) had perforations with 4 patients underwent emergency surgery. There was no mortality. On univariate analysis, concomittant pharyngeal stricture (p = 0.043), long (>10cm) stricture length (P=0.01), number of dilatation > 6 per year (p=0.01) and stricture tightness (unable to pass an 11mm or larger size dilator) (p = 0.046) were more likely to fail dilatation. At the median follow up of 32 months, 13 patients with continue repeated dilatation at median frequency of 4 months can swallow solid food without using feeding enterostomy. Overall good to excellent outcome was 90% after colon interposition and 27% for dilatation (p<0.05).
Conclusion: Majority of patients with acid-induced corrosive esophageal injury were usually refractory to endoscopic dilatation. Esophageal dilatations were ultimately failed in almost 3/4 of patients which surgery provided good results. Moreover, perforation rate was quite high. Concomittant pharyngeal stricture, long stricture length, frequent dilatation needed and stricture tightness were among predictors of failed dilatation. Early surgery should be considered in patients with these factors to avoid prolonged unnecessarily risky procedure.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 80233
Program Number: S073
Presentation Session: Flexible / Therapeutic Endoscopy and NOTES
Presentation Type: Podium