Therapeutic Results of Therapeutic Results of Early and LateEarly and Late Endoscopic Endoscopic

DilatationDilatation IN ESOPHAGEAL IN ESOPHAGEAL STRICTURE CAUSED BY STRICTURE CAUSED BY CORROSIVE INGESTIONCORROSIVE INGESTION

Sirikan Yamada, M.D, FRCSTDepartment of SurgeryFaculty of MedicineChiang Mai UniversityThailand

Yamada S, Chakrabandhu T, Sundo T, Ariyakhachorn V

BACKGROUNDBACKGROUND

In Thailand, Esophageal stricture by corrosive In Thailand, Esophageal stricture by corrosive ingestion is one of difficult problems to correct the ingestion is one of difficult problems to correct the result of injury.result of injury.

The strong concentrated alkaline or acid often caused The strong concentrated alkaline or acid often caused the severe damage to the esophagus.the severe damage to the esophagus. Mainly, the esophageal stricture will develop in the Mainly, the esophageal stricture will develop in the cicatrization phase following the ingestion after 2 to 3 cicatrization phase following the ingestion after 2 to 3 weeks.weeks. Esophagogram is preferred to access the Esophagogram is preferred to access the degree of stricturedegree of stricture

Ferguson MK MM.Am J Surg 1989;157: 116-20Ferguson MK MM.Am J Surg 1989;157: 116-20

Corrosive Agent in Thailand(Conc. Acid and Conc. Base)Common in the Depatment store

LIQUID DRANO

•The strong concentrated alkaline or acid often caused the severe damage to both esophagus and stomach.

• Esophageal stricture always occur in concentrate base ingestion and in the case that had repeated episode of injury or NG tube intubation

BACKGROUNDBACKGROUND Esophageal and pyloric stricture were found in grade 2b and grade 3 Esophageal and pyloric stricture were found in grade 2b and grade 3

injuries.injuries. Currently, the controversial issues for Currently, the controversial issues for the proper period to the proper period to perform perform EARLYEARLY endoscopic dilatation was endoscopic dilatation was discussed.discussed.

Grade 0Grade 0 Normal ExaminationNormal Examination Grade 1Grade 1 Edema and hyperemiaEdema and hyperemia Grade 2aGrade 2a Friability, hemorrhage, erosion,blisters,whitish Friability, hemorrhage, erosion,blisters,whitish membrane,exudates and superficial ulcerationmembrane,exudates and superficial ulceration Grade 2bGrade 2b 2a plus deep discrete or circumferential ulceration2a plus deep discrete or circumferential ulceration Grade 3Grade 3 Multiple ulceration and areas of necrosisMultiple ulceration and areas of necrosis

Zargar SA Am J Gastroenterol 1992Zargar SA Am J Gastroenterol 1992

Aim and MethodAim and Method To study the therapeutic results of early and lateTo study the therapeutic results of early and late

endoscopic dilatationendoscopic dilatation in esophageal stricture in esophageal stricture caused by corrosive ingestioncaused by corrosive ingestion

In 5 years, since November 1996 – November 2001, In 5 years, since November 1996 – November 2001, The 44 patients who survived from the attempted suicide by corrosive ingestion or accidental caustic injuries were included in the study at Chiang Mai University hospital.

We critically reviewed endoscopic examination results for the degree of injuries in first 24- 48hrs. after admission and when the esophageal stricture occurred

No steroid therapy in all cases, and antibiotic ( penicillin group) were used in all grade 2-3 injuries

Aim and MethodAim and MethodThere were 15 patients who developed esophageal stricture divided into 2 groups

as the following; 1) early ( 3-6 th week)- 10 patients and 2) late (After 6th week)- 5 patients

endoscopic dilatation were performed by experience endoscopists and surgeons

The failure rate, the improvement of dysphagia in grading, complication, and hospital stay were described.

ResultResultThe nasogastric intubation firmly related to the The nasogastric intubation firmly related to the extent and degree of injury in 75% of cases extent and degree of injury in 75% of cases ((10/15 10/15 ). No difference in both group.). No difference in both group.

4/54/5 in early dilatation group in early dilatation group 6/106/10 in late dilatation group in late dilatation group

All esophageal stricture patients occurred All esophageal stricture patients occurred significantly in second and third degree lesion.significantly in second and third degree lesion. About About 40% (4 /10) 40% (4 /10) failure ratefailure rate occurred in occurred in endoscopic dilatation group after the sixth week endoscopic dilatation group after the sixth week comparing to comparing to 0% (0/ 5)0% (0/ 5) failure ratefailure rate occurred in occurred in early endoscopic dilatation after detection of early endoscopic dilatation after detection of stricture between the third to sixth week. stricture between the third to sixth week.

ResultResult The complication that The complication that needed intervention needed intervention occurred in occurred in

only the only the latelate endoscopic dilatation group endoscopic dilatation group.(3/4).(3/4)

There was no significant difference for recovering of dysThere was no significant difference for recovering of dysphagia phagia grade grade after treatment in both groupsafter treatment in both groups

( Dysphagia are improved in all patients to grade 1-2) ( Dysphagia are improved in all patients to grade 1-2) beside of beside of 11 patient who still develop recurrence stricture patient who still develop recurrence stricture in late treatment group that needed 2- year- follow up in late treatment group that needed 2- year- follow up until now.until now.

However, the late treatment group However, the late treatment group hadhad longer hospital stlonger hospital stayay ((mean 68 daysmean 68 days, , 2.7 times2.7 times of mean hospital stay of mean hospital stay comparing to early dilate group) and comparing to early dilate group) and neededneeded

more frequent repeated endoscopic dilatationmore frequent repeated endoscopic dilatation in this stud in this studyy ( at least 5 times in late dilate group VS 2 times in early ( at least 5 times in late dilate group VS 2 times in early dilate groupdilate group

Early endoscopic dilatationEarly endoscopic dilatationFirst day

Dysphagia grade 4 develop since 10th day without obvious complication from contrast study.Close observation was done and appointed her to perform repeated endoscopic examination at the 2nd week with early dilatation at 6th week since she recover from grade 4 to grade 1 dysphagia

She needed repeated MH dilatation( until Fr 40) in another one time follow up

patient was underwentedLATE Endoscopic Dilatation( 8th- 9th week after ingestoion) who was consulted to Department of Surgery after diagnosis of Esophageal perforation.

2nd degree injury was diagnosed

Gastro jejunostomy was performed previously Thoracotomy was decided to perform and small adhere perforation site was obscured. Mediastinal and pleural cavity were adequate drained.

Large bore tube was used to stent the true lumen of esophagus.

Postoperation of correctedPostoperation of corrected complication complication

TPN therapy was given to improve nutrition for one month after operation.

Stricture developed at cervical esophagus. It was demostrated by barium study at 4th week post operation

Dysphagia grade 3 was improved by 3 times MH dilate (until 4o Fr was passed 2 times) to grade 1 in another 6 week by out patient follow up.

Recurrent stricture Recurrent stricture occuredoccured at the 7 at the 7thth months months after operation / Dysphagia grade 3after operation / Dysphagia grade 3

BW 39 45 kg.

Salvary GuilliardSalvary Guilliard

Guide wire insertionGuide wire insertion

No. selection No. selection

3 Equal to Fr. No of MH dilator

Follow up at the 10Follow up at the 10thth month month

After 2 times SG dilatation and 3 times MH dilatation

BW49 kg

Grade 1

Maloney DilatorMaloney Dilator

Conclusion and DiscussionConclusion and Discussion

We recommend to perform the endoscopic examWe recommend to perform the endoscopic examination and evaluate the extent of injury at first ination and evaluate the extent of injury at first 24-4824-48 hour. hour. At theAt the 3 3rdrd week to the week to the first month, the closed follofirst month, the closed follow w -- up up beforebefore dysphagia developed should be do dysphagia developed should be done ne by barium study and endoscopic examinationby barium study and endoscopic examination. . The early endoscopic dilatation between the thirThe early endoscopic dilatation between the third to the sixth week of injury can be done without d to the sixth week of injury can be done without major complications.major complications.