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Corrosive Ingestion and Oesophageal Replacement 325
Collagen Synthesis Inhibitors
In experimental animals, collagen synthesis inhibitors, such as amino-
proprionitrile, penicillamine, N-acetylcysteine, and colchicine, have been
shown to prevent alkali-induced oesophageal strictures. These compounds
impair synthesis of collagen by interfering with the covalent crosslink.
However, no clinical studies have been performed with these agents. 3
Nutrition
Intravenous (IV) nutrition is essential for patients in whom perforation
has occurred or enteral feeding cannot be maintained. However, in
some African institutions where IV nutrition is not available, patients
may be started on oral alimentation or a nasogastric feeding tube. In
many cases, a feeding gastrostomy or jejunostomy may provide the
Figure 51.3: Balloon dilatation.
patient with the necessary nutritional requirement until surgical correc-
tion can be performed. A feeding gastrostomy can be used as a route
3
for retrograde dilatation. • Patients with complete stenosis, in which all attempts have failed to
Early Oesophageal Dilatation establish a lumen.
Some investigators recommend eosophageal dilatation immediately • Patients with multiple, tortuous, or very long (more than 5 cm) strictures.
after injury. Dilatation is performed at frequent intervals until healing
3
occurs. This approach, however, is controversial in that dilatations can • Patients with severe peri-oesophageal reaction or mediastinitis, and
traumatise the oesophagus, predisposing to bleeding and perforation, in the development of tracheo-oesophageal fistula.
and same data indicate that excessive dilatations cause increased fibro- • Patients who are unwilling or unable to undergo prolonged periods
5
sis. Dilatation is recommended by some only when stricture formation of dilatation.
develops. Others pass a string on the nasogastric tube as part of the
initial therapy to maintain the oesophageal lumen. 3 Treatment Recommendations
Corticosteroids During the acute phase, we give oral feeding as tolerated; otherwise,
Studies by some investigators in animals have shown that corticoste- the patients are kept on IV fluid until oedema subsides; if dysphagia
persists, we prefer to perform gastrostomy to keep the general condition
roids given within 24 hours after alkali injury inhibits granulation and of the patient maintained until an upper endoscopy is performed after
fibroblastic tissue reaction and decreases the incidence of oesophageal 6 weeks. In Egypt, we are performing the gastrostomy by laparoscopy,
3,11
stricture. Others, however, believe that corticosteroids may obscure with better results and fewer adhesions (see Figure 51.4). Our protocol
evidence of peritonitis and mediastinitis and fail to reduce the incidence for oesophageal dilatation starts after 6 weeks and is repeated every 2
of stricture formation. Corticosteroid injections are used in localised weeks for 6 months by using the Savary-Gilliard dilator.
strictures. Intralesional triamcinolone injections augment the effects
of endoscopic dilatation. 12–14 Several studies have shown that local ste-
roids improve and increase the intervals between dilatation but not the
need for replacement.
15
Oesophageal Stents
Some investigators have placed intraluminal silastic stents under
endoscopic guidance in patients with deep circumferential burns.
Unfortunately, the majority of these patients required oesophageal
dilatation later. 3,16
Endoscopic Dilatation
Treatment of strictures is endoscopic dilatation. Gradual dilatation
3
is essential. Dilatation can be done on a weekly or biweekly basis
®
by using Savary-Gilliard bougies, and is considered adequate if the
oesophageal lumen could be dilated to 11 mm with complete relief of
dysphagia. The Savary-Gilliard method is adequate for oesophageal
dilatations in the paediatric population. 17,18,15 Balloon dilatation under
endoscopic guidance and radiological screening of the oesophageal Figure 51.4: Appearance of the stomach after laparoscopic gastrostomy (no
stricture is also successful (see Figure 51.3). The advantages of this adhesions).
method may be that its forces are exerted radially and the procedure
19
may be performed under better control. Perforation, bleeding, sepsis,
and brain abscess may complicate dilatation, however. 3–20 Mitomycin Surgical Interventions
C antibiotic has been recently used with promising results. After endo- The variety of abnormalities seen requires that creativity be used when
scopic dilatation, mitomycin can be applied onto the dilatation wound considering oesophageal reconstruction. Skin tube oesophagoplasties
by using a rigid endoscopy. are now used much less frequently and are mainly of historical inter-
21
An adequate lumen should be reestablished within 6 months to 1 est. Currently, the stomach, jejunum, and colon are the organs used to
year, with progressively longer intervals between dilatations. If, during replace the oesophagus through either the posterior mediastinum or
the course of treatment, an adequate lumen cannot be established or the retrosternal route. A retrosternal route is chosen when there has
maintained, surgery should be considered. Surgical intervention is been a previous oesophagectomy or if there is extensive fibrosis in the
indicated in the following cases: posterior mediastinum. When all factors are considered, the order of
preference for oesophageal substitution depends on the experience of
• Patients with failure to swallow solid food, which may lead to 5
deformities of the mandible, temporomandibular joint, and teeth. the surgeon and the practice in the institution.