Topical Mitomycin C Application Is Effective Even in Esophageal Strictures Resistant to Dilatation Therapy in Children. Surg Laparosc Endosc Percutan Tech. 2017;27:e96-e100. [PMID: 28902039 DOI: 10.1097/sle.0000000000000462]

Early topical mitomycin-C prevents stricture formation in children with caustic ingestion

AIM

Stricture formation is the most common remote complication of caustic ingestion. The aim of this study was evaluation of the efficacy of early topical endoscopic application of mitomycin C (MMC) in prevention of stricture formation after corrosive ingestion in children.

METHODS

We enrolled 78 children with a history of caustic ingestion within 48 h in a prospective, randomised-controlled study. Only 61 children completed the study and were classified into two groups: group A and B. After initial stabilisation, patients in group A (n = 30) received topical application of MMC within the initial 48 h while patients in group B (n = 31) only received conventional management. Follow-up endoscopic dilatation was done every 2 weeks to patients in either group until no need for further dilatation.

RESULTS

The barium study, which was done on the third week, revealed that all the patients (100%) on conservative management (group B) had strictures while only nine patients (30%) in group A had strictures (P < 0.001). The median number of dilatations required for patients in group B was 26 (min. = 23 and max. = 32) while in group A, it was 0 (min. = 0 and max. = 7) (P < 0.001). The success of early MMC application was complete response in 26 patients (86.7%), partial response in 3 patients (10%) and no response in 1 patient (3.3%). On the other side, conventional therapy with endoscopic dilatation achieved complete response in 11 patients (35.5%).

CONCLUSION

Early topical MMC application proved its efficacy and safety in prevention of scar and stricture formation in children following caustic ingestion.

Koroziv Madde Alımı Olan Çocukların Uzun Dönem Akciğer Kapasitelerinin Spirometri ile Değerlendirilmesi

Amaç: Bu çalışmada korozif madde alımı sonucu özofagus striktürü gelişen ve mükerrer defa özofagus dilatasyonu işlemi yapılan hastaların uzun dönem akciğer durumlarının spirometri ile değerlendirilmesi amaçlanmıştır. Yöntem: Ocak 2014– Mayıs 2021 tarihleri arasında merkezimize KMA nedeniyle başvuran hastalar retrospektif olarak incelendi. Hastalar; Group 1: Kontrol grubu (n=23) Group 2: Korozif madde alımı sonrası dilatasyon işlemine ihtiyacı olmayan ve kür sağlanmış hastalar (n=9) Grup 3: Korozif madde alımına bağlı özofagus striktürü gelişen ve genel anestezi altında dilatsyon işlemi uygulanan hastalar (n=9) olarak üç gruba ayrıldı. Değerlendirme için; 1. Saniyedeki zorlu ekspiratuar akım hızı (FEV1), zorlu vital kapasite (FVC), FEV1/FVC ve zorlu ekspirasyon ortası akım hızı (FEF 25-75) parametreleri kaydedildi. Bulgular: Yapılan istatistik analizi sonuçlarına göre FEV1, FVC ve FEF 25-75 gibi değerlerin üzerinde dilatasyon işleminin etkisi incelendiğinde Grup 1-2 için FEV1 (p=0,02) ve FVC (p =0,01) değerleri arasındaki fark istatistiksel olarak anlamı, grup1-3 ve grup 2-3 arasında anlamsız (p>0,05) saptandı. FEV1/FVC (p>0,05) ve FEF 25-75 (p>0,05) arasında hiçbir grupta anlamlı fark saptanmadı. Sonuç: Hastalarımızın spirometre ile değerlendirilen akciğer kapasitelerinde uzun dönem olumsuz bir etkilenme tespit edilememiştir.

Predictors of successful endoscopic management of caustic esophageal strictures in children: When to stop the dilatations?

BACKGROUND

Caustic esophageal strictures are mainly managed by endoscopic dilatations. Cases that do not respond to the dilatations eventually require an esophageal replacement. The aim of our study was to identify factors that could allow us to predict if the dilatations will be successful or not.

METHODS

We retrospectively reviewed the chart of 100 patients with caustic esophageal injuries treated at our center between 2012 and 2019. Collected data included age, gender, type of caustic substance, duration of the dilatations, length and extent of the strictures, number and time interval between dilatations, presence of gastroesophageal reflux, occurrence of esophageal perforation, and outcome of the dilatation program.

RESULTS

The patient ages ranged from 1 to 8 years old. The overall success rate was 98.2% for patients with short strictures and 81.8% for patients with long strictures (>3 cm). A long stricture, a pharyngeal extension of the stricture, the occurrence of an esophageal perforation, and the presence of gastroesophageal reflux were strong predictors of the failure of the dilatation program. The median treatment time for the patients to achieve a cure was 5 months in cases of short strictures and 17 months in cases of long strictures. Within the subgroup of patients with long strictures, a dysphagia-free period within the first year of management of 8 weeks was associated with the success of the dilatation program.

CONCLUSION

A length of more than 3 cm, pharyngeal involvement, the occurrence of esophageal perforation, and the presence of gastroesophageal reflux are predictors of failure of dilatations for the management of caustic esophageal strictures. A dysphagia-free period of 8 weeks or more within the first year of dilatations is considered a predictor of success of dilatations in patients with long strictures.

LEVEL OF EVIDENCE

Level II.

The effectiveness of Mitomycin C in Otolaryngology procedures: A systematic review

OBJECTIVE

Many studies have evaluated the effectiveness of topical intraoperative mitomycin (MCC) usage in a wide range of Otolaryngologic procedures with variable conclusions on effectiveness. This systematic review aims to provide a qualitative estimation of mitomycin C's treatment effectiveness in maintaining or preventing stenosis after surgical interventions.

DESIGN AND MAIN OUTCOME MEASURES

Following the PRISMA guideline, a comprehensive systematic search of MEDLINE, EMBASE, and CINAHL databases was performed including hand-searching and cross-reference checking. The search was limited to humans, sample size greater than two, and study designs including a comparative arm.

RESULTS

571 unique abstracts and 109 full articles were reviewed. 77 studies were included in the final analysis. The available evidence ranged from case series to randomized control studies. Meta-analysis was deemed inappropriate due to heterogeneity of study design. 38 studies assessed the effective of MCC in dacryocystorhinostomy, which is reported in a separate meta-analysis. All other studies were categorized into otolaryngologic site and pathology including: choanal atresia (n=5), endoscopic sinus surgery (n=12), airway procedures (n=9), esophageal procedures (n=8), and other (n=2).

CONCLUSIONS

The published literature on the effectiveness of MMC was mixed, but suggested topical MMC improved surgical outcomes in many Otolaryngologic procedures compared to controls. This was the first review to assemble literature on MMC usage for different surgical procedures. Comprehensive interpretation of the data was limited due to heterogeneity in primary outcome, procedure type, and study quality. High quality prospective and randomized controlled studies are required to further confirm the positive effect of MMC use on surgical outcomes.

Role of endoscopy in caustic injury of the esophagus

Caustic injury of the esophagus is a problematic condition challenging endoscopists worldwide. Although the caustic agents and motives are different among countries and age groups, endoscopy still plays an invaluable role in diagnosis and treatment. Endoscopy can determine the severity of caustic ingestion which is of great importance in choosing appropriate treatment. However, some aspects of endoscopy in diagnosis of caustic injury remain controversial. Whether or not all patients need endoscopy, when to perform endoscopy and how to assess the severity are just some examples of these controversies. Due to lack of randomized controlled trials, many findings and suggestions are inconclusive. Computerized tomography scan of the chest and abdomen gains popularity in assessing the severity of caustic injury and avoiding unnecessary surgery. If esophageal stricture eventually develops, endoscopic dilatation is a mainstay. Maneuvers such as steroid injection and esophageal stent may be used in a refractory stricture. Nevertheless, some patients have to undergo surgery in spite of vigorous attempts with esophageal dilatation. To date, caustic injury remains a difficult situation. This article reviews all aspects of caustic injury of the esophagus focusing on endoscopic role. Pre-endoscopic management, endoscopy and its technique in acute and late phase of caustic injury including the endoscopic management of refractory stricture, and the treatment outcomes following each endoscopic intervention are thoroughly discussed. Finally, the role of endoscopy in the long term follow-up of patients with esophageal caustic injury is addressed.