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

Esophageal stricture is a major complication after caustic ingestion. When the ingestion is associated with a suicide attempt, the damage is typically worse because a large amount is ingested [1]. Endoscopic dilation is the go-to for initial treatment, with surgical treatment being reserved for refractory cases. The success rate of dilation ranges from 40 % to 90 % [2] [3]. Perforation is a complication with high morbidity and mortality that can occur during the dilation procedure, ranging from 0 to 32 % of cases [4] [5]. We describe a case of esophageal perforation during dilation and how it was treated with a combined endoscopic and surgical procedure.

A 27-year-old man was referred to our department 40 days after ingesting caustic alkali in a suicide attempt. The stricture was identified 25 cm from the incisors ( [Fig.1]). A contrast study showed segmental stricture up to the esophagogastric junction. A flexible guidewire was passed under fluoroscopy and dilation was performed with Savary-Miller bougies up to 8 French (Fr). At the end of the dilation, when the review was performed, an extensive perforation was seen in the distal esophagus with exposure of the abdominal cavity ([Fig. 2]; [Video 1]).

Fig. 1 Fluoroscopic image showing the esophageal stricture and the absence of progression of contrast to the stomach.

Fig. 2 Endoscopic image showing the esophageal perforation into the abdominal cavity.

Video 1 A case of esophageal perforation during dilation and its treatment in the usual way with a combined endoscopic and laparoscopic procedure.

The operation was performed with combined laparoscopic and endoscopic procedures. The perforation was identified ([Fig. 3]) and a gastrotomy was performed on the distal body. The gastroscope (5.4 mm) passed through an abdominal trocar and a retrograde guidewire was passed through the esophagogastric junction and externalized through the mouth. With the guidewire and under laparoscopic vision, dilation was performed using Savary-Miller bougies up to 10 Fr ([Fig. 4]). Another guidewire was passed to the duodenum and a nasoenteral tube was positioned. The esophagus was sutured and covered with an omental patch. Finally, the cavity was drained and the gastrostomy was performed through the gastrotomy orifice.

Fig. 3 Laparoscopic image of the esophageal perforation.

Fig. 4 Intraoperative esophageal dilation with bougies up to 10 Fr.

The patient progressed well, accepting food through the nasoenteral tube, and was discharged after psychiatric evaluation. Follow-up endoscopy was performed after 1 month, showing complete healing of the perforation ([Fig. 5]).

Fig. 5 Follow-up endoscopy was performed after 1 month, showing complete healing of the perforation.

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Competing interests

The authors declare that they have no conflict of interest.

• References

• 1 Arévalo-Silva C, Eliashar R, Wohlgelernter J. et al. Ingestion of caustic substances: a 15-year experience. Laryngoscope 2006; 116: 1422-1426
• 2 Tharavej C, Pungpapong S-U, Chanswangphuvana P. Outcome of dilatation and predictors of failed dilatation in patients with acid-induced corrosive esophageal strictures. Surg Endosc 2018; 32: 900-907
• 3 Josino IR, Madruga-Neto AC, Ribeiro IB. et al. Endoscopic dilation with bougies versus balloon dilation in esophageal benign strictures: systematic review and meta-analysis. Gastroenterol Res Pract 2018; DOI: 10.1155/2018/5874870 .
• 4 Song HY, Han YM, Kim HN. et al. Corrosive esophageal stricture: safety and effectiveness of balloon dilation. Radiology 1992; 184: 373-378
• 5 Poley J-W, Steyerberg EW, Kuipers EJ. et al. Ingestion of acid and alkaline agents: outcome and prognostic value of early upper endoscopy. Gastrointest Endosc 2004; 60: 372-377

Publikationsverlauf

Artikel online veröffentlicht:
27. Januar 2021