Topical mitomycin C versus intralesional triamcinolone in the management of esophageal stricture due to caustic ingestion

Corrosive upper gastrointestinal strictures in children: Difficulties and dilemmas

Children constitute 80% of all corrosive ingestion cases. The majority of this burden is contributed by developing countries. Accidental ingestion is common in younger children (< 5 years) while suicidal ingestion is more common in adolescents. The severity of injury depends on nature of corrosive (alkali or acid), pH, amount of ingestion and site of exposure. There are multiple doubts and dilemmas which exist in management of both acute ingestion and chronic complications. Acute ingestion leads to skin, respiratory tract or upper gastrointestinal damage which may range from trivial to life threatening complications. Esophagogastroduodenoscopy is an important early investigation to decide for further course of management. The use of steroids for prevention of stricture is a debatable issue. Upper gastrointestinal stricture is a common long-term sequelae of severe corrosive injury which usually develops after three weeks of ingestion. The cornerstone of management of esophageal strictures is endoscopic bougie or balloon dilatations. In case of resistant strictures, newer adjunctive therapies like intralesional steroids, mitomycin and stents can be utilized along with endoscopic dilatation. Surgery is the final resort for strictures resistant to endoscopic dilatations and adjunctive therapies. There is no consensus on best esophageal replacement conduit. Pyloric strictures require balloon dilatation , failure of which requires surgery. Patients with post-corrosive strictures should be kept in long term follow-up due to significantly increased risk of carcinoma. Despite all the endoscopic and surgical options available, management of corrosive stricture in children is a daunting task due to high chances of recurrence, perforation and complications related to poor nutrition and surgery.

EFFICACY OF ENDOSCOPIC TOPICAL MITOMYCIN C APPLICATION IN CAUSTIC ESOPHAGEAL STRICTURES IN THE PEDIATRIC POPULATION: A SYSTEMATIC REVIEW AND META-ANALYSIS OF RANDOMIZED CONTROLLED TRIALS

BACKGROUND

Caustic ingestion and development of esophageal strictures are recognized major public health problems in childhood. Different therapeutic methods have been proposed in the management of such strictures.

OBJECTIVE

To evaluate efficacy and risk of endoscopic topical application of mitomycin C in the treatment of caustic esophageal strictures.

METHODS

We searched MEDLINE, EMBASE, Central Cochrane, and LILACS databases. The outcomes evaluated were dysphagia resolution rate, number of dilations performed in resolved cases, and the number of dilations performed in all patients.

RESULTS

Three randomized clinical trials were included for final analysis with a total of 190 patients. Topical mitomycin C application group showed a significant increase in dysphagia resolution rate, corresponding to a 42% higher dysphagia resolution as compared to endoscopic dilation alone, with statistical significance between the two groups (RD: 0.42 - [CI: 0.29-0.56]; P-value <0.00001). The mean number of dilations performed in resolved cases were significantly less in the topical mitomycin C application group, compared to endoscopic dilations alone, with statistical significance between the two groups (MD: 2.84 [CI: 1.98-3.69]; P-value <0.00001). When comparing the number of dilations in all patients, there was no statistical difference between the two groups (MD: 1.46 [CI: -1.53-4.44]; P-value =0.34).

CONCLUSION

Application of topical mitomycin C with endoscopic dilations in caustic esophageal strictures was more effective in dysphagia resolution than endoscopic therapy alone in the pediatric population. Moreover, topical mitomycin C application also reduced the number of dilation sessions needed to alleviate dysphagia without rising morbidity.

Corrosive substances ingestion: a review

Corrosive chemical substance ingestions are a major problem, especially in developing countries, but also in developed countries such as the United States, France, and Belgium. Ingestions may be deliberate as suicide attempts (mostly in adolescents and adults) or accidental (mostly in children). The results can be devastating in terms of individual suffering and disability, but also in terms of resource utilization and costs. In developing countries, outcomes may be worse because of limited medical/surgical resources. Common sequelae include gastrointestinal (GI) tract (esophagus, stomach, pylorus, and duodenum) stricture formation, GI tract perforation, and hemorrhage. Systemic effects may also occur, such as disseminated intravascular coagulation (DIC), multi-organ system failure, and sepsis. Various interventions in the acute phase to reduce the severity of injury have been attempted, but there are no large controlled clinical trials to demonstrate efficacy. Dilation therapy in various forms is commonly used for the treatment of strictures and a variety of surgical procedures including esophagectomy and delayed replacement may be required in severe corrosive injury cases.

Endoscopic Management of Benign Esophageal Strictures

PURPOSE OF REVIEW

This paper presents the author's approach to esophageal dilation. It offers a tailored approach to the application of dilation to specific types of esophageal stenotic lesions.

RECENT FINDINGS

In patients with inflammatory stricture, recent studies confirm the importance of treating the underlying inflammatory condition in order to decrease the rate of recurrence. The paper reviews some of the novel techniques that have been suggested for the treatment of refractory benign esophageal strictures, including incisional therapy, stenting, or the injection steroids or antifibrotic agents. The endoscopist who treats esophageal strictures must be familiar with the tools of the dilation and how they are best applied to specific types of stenotic lesions. If inflammation is present, effective management requires treatment of the inflammatory process in addition to mechanical dilation of the stenotic lesion. Controlled trials of novel approaches to treatment of refractory benign esophageal strictures are limited and will be necessary to determine efficacy.

Management of esophageal caustic injury

Ingestion of caustic substances and its long-term effect on the gastrointestinal system maintain its place as an important public health issue in spite of the multiple efforts to educate the public and contain its growing number. This is due to the ready availability of caustic agents and the loose regulatory control on its production. Substances with extremes of pH are very corrosive and can create severe injury in the upper gastrointestinal tract. The severity of injury depends on several aspects: Concentration of the substance, amount ingested, length of time of tissue contact, and pH of the agent. Solid materials easily adhere to the mouth and pharynx, causing greatest damage to these regions while liquids pass through the mouth and pharynx more quickly consequently producing its maximum damage in the esophagus and stomach. Esophagogastroduodenoscopy is therefore a highly recommended diagnostic tool in the evaluation of caustic injury. It is considered the cornerstone not only in the diagnosis but also in the prognostication and guide to management of caustic ingestions. The degree of esophageal injury at endoscopy is a predictor of systemic complication and death with a 9-fold increase in morbidity and mortality for every increased injury grade. Because of this high rate of complication, prompt evaluation cannot be overemphasized in order to halt development and prevent progression of complications.