Endoscopic and surgical treatment of refractory caustic esophageal strictures

Caustic esophageal stricture is usually refractory to endoscopic dilation. A stepwise endoscopic intervention using various modalities has been recommended, with surgery reserved as a last resort. However, the outcomes of stepwise treatment and the impact of prolonged prior endoscopic interventions on subsequent esophageal reconstruction in caustic refractory benign esophageal stricture (cRBES) are not well understood. This study aims to investigate the long-term outcomes of stepwise endoscopic and surgical treatments for this condition.

Patients diagnosed with cRBES were included. Stepwise endoscopic interventions, including intralesional steroid injections combined with dilations and esophageal stent insertion, were sequentially performed as the initial treatment. Esophageal reconstruction is offered to patients who experience failed sequential endoscopic therapies.

Of the 252 patients with a history of corrosive ingestion, forty-one met the criteria for cRBES. Intralesional steroid injections with dilations and stent insertions were primarily performed. Among the 41 patients, 8 (20%) were successfully treated with endoscopic therapy. The success rate of endoscopic treatment was significantly higher for patients with the recurrent subtype compared to those with the refractory subtype (8/11 vs. 0/30, p < 0.0001). Of these 41 patients, 33 (80%) underwent esophageal reconstruction at a median of 16 months after ingestion. There was one (3%) operative mortality. The prevalence of anastomotic leakage was 10%, and stricture was 12%. At a median follow-up of 32 months, nutritional autonomy was achieved in 91% following reconstruction.

One-fifth of patients with cRBES can be successfully treated with endoscopic interventions. However, 80% of these patients require subsequent esophageal reconstruction. This procedure is safe and effective, achieving favorable long-term outcomes in over 90% of patients who have previously failed various modalities of endoscopic treatments for cRBES. Early surgery should be considered for patients with the refractory subtype, while a stepwise approach can be applied to individuals with the recurrent subclassification.