Late malignant transformation of chronic corrosive oesophageal strictures

Surgical management of esophageal stenosis due to ingestion of corrosive substances

BACKGROUND

Corrosive ingestion is a significant challenge for healthcare systems. Limited data are available regarding the best treatments, and there remains a lack of consensus about the optimal surgical approach and its outcomes. This study aims to review the current literature and show a single institution's experience regarding the surgical treatment of esophageal stenosis due to corrosive substance ingestion.

METHODS

A retrospective review that accounted for demographics, psychiatric profiles, surgical procedures, and outcomes was performed. A systematic review of the literature was performed using PubMed.

RESULTS

In total, 27 surgical procedures for esophageal stenosis due to corrosive substance ingestion were performed from 2010 to 2019. Depression and drug abuse were diagnosed in 30% and 22% of the included patients, respectively. Esophagectomies and esophageal bypasses were performed in 13 and 14 patients, respectively. No 30-day mortality was recorded.

CONCLUSION

Surgical intervention either by esophagectomy or esophageal bypass results in durable relief from dysphagia. However, successful clinical outcomes depend on a high-quality multidisciplinary network of esophageal and thoracic surgeons, intensivists, psychologists, psychiatrists, and nutritional teams.

The prevalence of esophageal cancer after caustic and pesticide ingestion: A nationwide cohort study

Habits such as smoking and alcohol drinking and existing esophageal malfunction are considered the main risk factors for esophageal carcinogenesis. Caustic ingestion of acidic or alkaline agents or strong irritants can induce severe esophageal corrosive injury and increase esophageal cancer risk. We studied the relationship between esophageal carcinoma and acute detergent or pesticide poisoning by using nationwide health insurance data. Methodology/Principle findings: We compared a pesticide/detergent intoxication cohort (N = 21,840) and an age- and gender-matched control cohort (N = 21,840) identified from the National Health Insurance Research Database between 2000 and 2011. We used the multivariable Cox proportional model to determine esophageal carcinoma risk. The overall incidence density of esophageal cancer was 1.66 per 10,000 person-years in the comparison cohort and 4.36 per 10,000 person-years in the pesticide/detergent intoxication cohort. The corresponding adjusted hazard ratio (HR) for esophageal cancer was 2.33 (95% confidence interval [CI] = 1.41–3.86) in the pesticide/detergent intoxication cohort compared with the control cohort. Patients with corrosive and detergent intoxication did not have a higher risk of esophageal cancer (adjusted HR = 0.98, 95% CI = 0.29–3.33) than those without pesticide/detergent intoxication. However, patients with pesticide intoxication had a significantly higher risk of esophageal cancer (adjusted HR = 2.52, 95% CI = 1.52–4.18) than those without pesticide/detergent intoxication. Conclusion: In the present study, after adjusting for conventional risk factors, we observed that pesticide intoxication could exert substantial effects through increased esophageal cancer risk. However, patients with detergent intoxication may not have an increased risk of esophageal cancer.

Presentation and management outcome of childhood corrosive oesophageal injury in Benin City

BACKGROUND

Corrosive ingestion in children occurs usually at home and frequently results in debilitating strictures. Prevention and early intervention programs are very important for good outcomes.

AIMS AND OBJECTIVES

This study aims at examining the immediate causative factors and problems of this subset of patients with a special focus on treatment and outcome. This study was to audit the management of patients in the paediatric age group who presented for treatment with history and sequelae of corrosive ingestion seen by the cardiothoracic unit of the University of Benin Teaching Hospital from January 2005 till December 2018.

MATERIALS AND METHODS

This is a 14year retrospective study of patients that presented with oesophageal burn injuries from ingestion of corrosive agents to the Cardiothoracic Unit at the University of Benin Teaching Hospital between January 2005 and December 2018. Essentially the first 5years were retrospectively included but the subsequent years were prospective. All available medical data on these patients were retrieved and studied for epidemiological, clinical and operative procedures and outcome.

RESULTS

A total of 49 patients were seen and admitted during the period under review. Male (29) : Female (20) ratio was 1:1.4 Mean age was 4.7±4.8 years with a range of 1-16years, The males presented earlier and had worse strictures as well as more surgical procedures. Caustic soda preparations ingested more (93.9%), all ingestions were within the household setting, and all had first aid given by way of oral palm oil. Only two (4.1%) ingested acids with only one flat battery ingestion. 45.5% of the patients had dilatation only and of these 50% recovered after 3 sessions and required no more sessions. A further 50% were lost to follow up. 38.8% had oesophageal replacement with colon following oesophagectomy.

CONCLUSION

In conclusion, corrosive oesophageal stricture is a debilitating disease in children and affects males more, but it is treatable by multiple dilatations and oesophageal replacement with colon. Prevention should be actively pursued as well as early intervention.

[Esophageal cancer after chemical burn]

AIM

To analyze patients with chemical burn of esophagus followed by cancer.

MATERIAL AND METHODS

Since 2010 till 2017 esophageal cancer has been diagnosed in 4 patients with esophageal cicatrical stenosis after previous chemical burn. Cervical segment of the esophagus was involved in 1 case.

RESULTS

Resectable tumor was observed only in 1 patient. In 3 cases stenting was performed (palliative intervention in 2 patients and as preoperative stage in 1 case). Stomach probe for feeding was deployed in 1 observation.

CONCLUSION

Patients after previous chemical burn of the esophagus and esophagoplasty should be under follow-up for timely diagnosis and treatment of esophageal malignancies.

Non-acid gastro-oesophageal reflux is associated with squamous cell carcinoma of the oesophagus

INTRODUCTION

Squamous cell carcinoma of the oesophagus is a common cancer among South Africans. Due to the absence of effective screening and surveillance programme for early detection and late presentation, squamous cell carcinoma of the oesophagus is usually diagnosed at an advanced stage or when metastasis has already occurred. The 5-year survival is often quoted at 5%-10%, which is poor.

OBJECTIVES

To determine the association between oesophageal squamous cell carcinoma (OSCC) and non-acid gastro-oesophageal reflux disease.

METHODS

Study design: A cross-sectional case-control analytical study of patients referred to the Gastroenterology Division of Steve Biko Academic Hospital in Pretoria, South Africa. All patients had combined multichannel impedance and pH studies done and interpreted after upper gastroscopy using the American College of Gastroenterology guidelines by two clinicians.

RESULTS

Thirty-two patients with OSCC were recruited: non-acid reflux was found in 23 patients (73%), acid reflux in 2 patients (6%) and 7 patients (22%) had normal multichannel impedance and pH studies.Forty-nine patients matched by age, gender and race were recruited as a control group. Non-acid reflux was found in 11 patients (22%), acid reflux in 31 patients (63%) and 7 patients (14%) had normal multichannel impedance and pH monitoring study.

CONCLUSION

The significance of the association between non-acid reflux and OSCC was tested using χ2, and simple logistic regression was used to adjust for the effects of potential confounders.The OR of developing OSCC in patients with non-acid gastro-oesophageal reflux was 8.8 (95% CI 3.2 to 24.5, P<0.0001) in this South African group.Alcohol and smoking had no effect on these results.

LUGOL’S IODINE CHROMOENDOSCOPY VERSUS NARROW BAND IMAGE ENHANCED ENDOSCOPY FOR THE DETECTION OF ESOPHAGEAL CANCER IN PATIENTS WITH STENOSIS SECONDARY TO CAUSTIC/CORROSIVE AGENT INGESTION

ABSTRACT BACKGROUND The diagnosis of corrosion cancer should be suspected in patients with corrosive ingestion if after a latent period of negligible symptoms there is development of dysphagia, or poor response to dilatation, or if respiratory symptoms develop in an otherwise stable patient of esophageal stenosis. Narrow Band Imaging detects superficial squamous cell carcinoma more frequently than white-light imaging, and has significantly higher sensitivity and accuracy compared with white-light. OBJECTIVE To determinate the clinical applicability of Narrow Band Imaging versus Lugol´s solution chromendoscopy for detection of early esophageal cancer in patients with caustic/corrosive agent stenosis. METHODS Thirty-eight patients, aged between 28-84 were enrolled and examined by both Narrow Band Imaging and Lugol´s solution chromendoscopy. A 4.9mm diameter endoscope was used facilitating examination of a stenotic area without dilation. Narrow Band Imaging was performed and any lesion detected was marked for later biopsy. Then, Lugol´s solution chromoendoscopy was performed and biopsies were taken at suspicious areas. Patients who had abnormal findings at the routine, Narrow Band Imaging or Lugol´s solution chromoscopy exam had their stenotic ring biopsied. RESULTS We detected nine suspicious lesions with Narrow Band Imaging and 14 with Lugol´s solution chromendoscopy. The sensitivity and specificity of the Narrow Band Imaging was 100% and 80.6%, and with Lugol´s chromoscopy 100% and 66.67%, respectively. Five (13%) suspicious lesions were detected both with Narrow Band Imaging and Lugol’s chromoscopy, two (40%) of these lesions were confirmed carcinoma on histopathological examination. CONCLUSION Narrow Band Imaging is an applicable option to detect and evaluate cancer in patients with caustic /corrosive stenosis compared to the Lugol´s solution chromoscopy.

Esophageal remnant cancer 35 years after acidic caustic injury: A case report

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The risk for esophageal cancer increases after ingestion of caustic substances.

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Management of patients with corrosive injuries remains controversial.

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Surgical approach does not seem to eliminate the risk for cancer, as confirmed in our case.

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The need for long-term follow up in these patients has to be underscored.

Introduction

Esophageal squamous cell carcinoma has been described as a long-term consequence following ingestion of corrosive substances.

Presentation of case

We report a rare case of a 62-year-old female patient with a history of acidic caustic injury 35 years ago, for which she had undergone near total esophagogastrectomy with right colon interposition. Recently, she presented with worsening dysphagia, weight loss, neck swelling and chest pain. After the diagnostic workup, an invasive squamous cell carcinoma of the esophagus was confirmed. To our knowledge, this is the first such report in the literature.

Discussion

The risk for esophageal carcinoma increases substantially after ingestion of caustic substances. It is notable that distinct patterns of carcinogenesis between acids and alkalis may be postulated, since the corresponding pathophysiological impact of each one differ significantly. Although such esophageal cancers tend to have good prognosis due to early detection, both the diagnostic and therapeutic strategy may be challenging due to the limited available data in this field. Surgical treatment does not seem to eliminate the risk of cancer, as evident upon the present case report.

Conclusion

Optimal management of esophageal corrosive injuries remains a debatable issue in terms of choosing between conservative therapy and surgical intervention. For this reason, the need for long-term follow up regardless the ingested substance and the preferred therapeutic approach is highlighted.

Esophageal stenting in caustic injuries: a modified technique to avoid laparotomy

OBJECTIVE

To compare the outcomes of a modified laparoscopic intraluminal stenting with the conventional laparatomic technique in patients with esophageal caustic injuries.

METHODS

A total of 103 patients with esophageal burns were included in this retrospective analysis. Patients were candidates for esophageal stenting to prevent future stenosis. According to patient preference, stenting was done with either the innovatory stent with the modified technique (52 patients) or the conventional method that required laparotomy (51 patients). The modified technique consists of placing an inflation balloon stent via laparoscopy. Overall mortality and complications after follow-up period (3 months) were compared between the two groups.

RESULTS

Two perioperative mortalities were seen, one in each group. Except one patient in the modified technique, all patients returned to normal intake after 3 months of follow-up. However, five patients of the modified group and three in the conventional group developed esophageal strictures (p > 0.05). Gastric outlet obstruction was observed in three patients of the modified group and one in the conventional group (p > 0.05). DeMeester scores showed that there was no gastro-esophageal reflux in both groups (p > 0.05).

CONCLUSION

Our results show that the modified technique can reach the efficacy of the conventional method without requiring laparotomy. Thus, far several studies have demonstrated the advantages of laparoscopy over laparotomy. Thus, and in line with the clinical guidelines of the Society of American Gastrointestinal and Endoscopic Surgeons, we recommend using the presented modified technique in patients with caustic esophageal injuries.

Isoperistaltic left colic graft interposition via a retrosternal approach for esophageal reconstruction in patients with a caustic stricture: mortality, morbidity, and functional results

PURPOSE

To report our results of treating esophageal caustic stricture with an isoperistaltic left colic graft interposed via a retrosternal route.

METHODS

We reviewed 70 patients who underwent substernal left colon interposition, performed retrosternally, for an esophageal caustic stricture, between January, 1999 and December, 2011.

RESULTS

The median operative time in this series was 3 h. A pharyngoplasty was performed in 10 patients (14.28 %), the thoracic inlet was found to be enlarged in 33 patients (47.1 %), and posterior cologastric anastomosis was performed in 58 patients (82.8 %). Two patients (2.8 %) died. Minor and major postoperative complications developed in 28 patients (40 %), including graft ischemia in 2 (2.8 %) and cervical anastomotic leakage in 14 (20 %). Five patients (7.14 %) developed a cervical anastomotic stricture. The functional results were satisfactory.

CONCLUSION

Retrosternal isoperistaltic left colic transplant interposition is an excellent long-term replacement for an esophageal caustic stricture. If performed by experienced surgeons, this procedure is effective for esophageal reconstruction.

In patients with corrosive oesophageal stricture for surgery, is oesophagectomy rather than bypass necessary to reduce the risk of oesophageal malignancy?

A best evidence topic in cardiothoracic surgery was written according to a structured protocol. The question addressed was, 'is there an increased risk of cancer in a non-resected corrosive oesophageal stricture?' Altogether, 133 papers were found using the reported search; six papers were identified that provided the best evidence to answer the question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these studies were tabulated. From the studies, 198 consecutive patients had corrosive oesophageal stricture resulting from corrosive oesophageal injury, 50 of whom (25.3%) developed oesophageal cancer. The interval between the burn and the diagnosis of scar carcinoma was 46.1 years and ranged between 25 and 58 years. The incidence of carcinoma of the oesophagus among patients from the study was significantly higher than that of the general population. In one review, seven (13%) of 54 consecutive patients treated by conservative means for caustic oesophageal stricture (COS) developed oesophageal cancer, leading to the conclusion that simultaneous resection of the oesophagus with reconstruction for such patients would provide a better probability of being completely cured of the disease. Furthermore, in patients with COS in need of operation who had a bypass procedure, it was pointed out that malignancy may develop even years after the bypass operation in the remaining part of the oesophagus and so total oesophagectomy was suggested instead of bypass. In another study, as many as 10 (31.3%) of 32 patients with corrosive oesophageal stricture developed cancer. That gave further credence to the arguments against conservative treatment or bypassing of corrosive oesophageal strictures. The risk of morbidity for intrathoracic oesophageal replacement in uncomplicated cases was 2.4%. There were basically two things that were agreed from the studies: that corrosive-induced carcinoma can occur with a reasonably high incidence if part or all of the oesophagus was left during reconstructive surgery; and that simultaneous resection of the oesophagus at the time of reconstruction in a patient with corrosive stricture offered a better outcome. The limitations of the present review were the lack of randomized controlled trials and no close follow-up.

The mystery of male dominance in oesophageal cancer and the potential protective role of oestrogen

Oesophageal cancer is the sixth most common form of cancer death globally with almost 400,000 deaths annually. More than 90% of all cases are either adenocarcinomas (OAC) or squamous-cell carcinomas (OSCC). There is a strong male predominance with up to 8 and 3 men for every woman affected with OAC and OSCC, respectively. It has been hypothesised that sex hormonal factors may play a role in the development of oesophageal cancer or more specifically that oestrogen prevents such development. This article reviews the available literature on this topic. Basic science studies suggest an inhibitory effect of oestrogen in the growth of oesophageal cancer cells, and a possible mechanism of any oestrogen protection might be mediated through oestrogen receptors. But from the few epidemiological studies in which the hypothesis of oestrogen protection has been tested, no firm conclusions can yet be drawn of the role of oestrogen in human oesophageal cancer aetiology. More evidence from valid and large human studies is needed before any conclusions can be drawn.

[Surgical treatment for early Barrett cancer]

Adenocarcinomas in Barrett's oesophagus are more commonly diagnosed at an early stage due to effective surveillance programmes. Subtotal oesophagectomy with extended lymphadenectomy is considered the best curative treatment for patients with early adenocarcinoma of the oesophagus. However, such treatment carries substantial morbidity and compromises quality of life. Limited resection, minimal invasive surgical procedures or endoscopic mucosal ablation have been proposed as less invasive alternatives. A comparison of treatment associated morbidity, recurrence rate, long-term survival and functional outcome suggests that none of these alternative methods can be universally recommended. An individualized strategy should be employed based on staging (tumour penetration into the mucosa/submucosa, presence of lymph node metastasis), multicentricity, length of the underlying Barrett mucosa and risk factors of the patient. Surgical resection (radical or limited) remains the treatment of choice for tumours invading the submucosa, or multicentric and recurrent tumours after endoscopic mucosectomy.

[Development of scar cancer after subtotal oesophagectomy for corrosive injury]

INTRODUCTION

The incidence of cicatricial carcinoma of the scarred esophagus in patients with corrosive injuries is relatively high. Therefore, the necessity to resect the diseased oesophagus was raised as opposed to carry out a simple by-pass reconstruction only.

CASE REPORT

A 56-year-old female patient with a past medical history of lye consumption presented with a stricture of the esophagus. She underwent resection of the diseased esophagus with mediastinal colon interposition. 28 years after surgery the patient had symptoms of progressive dysphagia and loss of weight caused by scar cancer of the esophagus. After neoadjuvant chemo-radiotherapy, resection of the remainder oesophagus was performed with free jejunal transplantation. On postoperative day 14 the patient had been discharged with no complications and good swallowing function.

CONCLUSION

In our case, scar cancer developed 28 years after oesophageal resection and more than 50 years after the corrosive injury. This case is another argument for simple bypass.

Dedicated multi-detector CT of the esophagus: spectrum of diseases

Multi-detector computed tomography (CT) offers new opportunities in the imaging of the gastrointestinal tract. Its ability to cover a large volume in a very short scan time, and in a single breath hold with thin collimation and isotropic voxels, allows the imaging of the entire esophagus with high-quality multiplanar reformation and 3D reconstruction. Proper distention of the esophagus and stomach (by oral administration of effervescent granules and water) and optimally timed administration of intravenous contrast material are required to detect and characterize disease. In contrast to endoscopy and double-contrast studies of the upper GI tract, CT provides information about both the esophageal wall and the extramural extent of disease. Preoperative staging of esophageal carcinoma appears to be the main indication for MDCT. In addition, MDCT allows detection of other esophageal malignancies, such as lymphoma and benign esophageal tumors, such as leiomyma. A diagnosis of rupture or fistula of the esophagus can be firmly established using MDCT. Furthermore, miscellaneous esophageal conditions, such as achalasia, esophagitis, diverticula, and varices, are incidental findings and can also be visualized with hydro-multi-detector CT. Multi-detector CT is a valuable tool for the evaluation of esophageal wall disease and serves as an adjunct to endoscopy.

Pharyngocolonic anastomosis for esophageal reconstruction in corrosive esophageal stricture

BACKGROUND

The aim of our study is to observe the outcome of pharyngocolonic anastomosis in esophageal reconstruction for diffuse corrosive esophageal stricture involving hypopharynx.

METHODS

This is a retrospective report of the experience and results of 14 patients undergoing esophageal reconstruction with pharyngocolonic anastomosis without resection of the strictured intrathoracic esophagus. The left colonic segment was pulled up to the neck through the substernal space in all patients.

RESULTS

There was no operative or hospital death. Postoperative complications included cervical anastomotic leakage in 4 patients, rupture of abdominal incision in 1 patient, and aspiration pneumonia in 2 patients. The length of follow-up ranged from half a year to 10 years, with an average of 4 years. Anastomotic stenosis occurred in 2 patients. One patient was improved after dilatation and the other was relieved by plastic operation. One patient began to have vomiting after meals 7 months after surgery and was found to have redundant abdominal colon graft, which was corrected with a side-to-side anastomosis between the colon and the stomach.

CONCLUSIONS

A successful reconstruction for hypopharyngoesophageal stricture requires a sufficiently large hypopharyngocolonic anastomosis and a technique of good anastomosis. From our experience, this procedure is shown to be safe and effective.

Corrosive induced carcinoma of esophagus: report of three patients and review of literature

Patients with corrosive induced esophageal strictures have more than a 1000-fold risk of developing carcinoma of the esophagus. We report three cases of corrosion carcinoma seen by us (a team of gastroenterologists, radiologists and a surgeon) in the last 15 years. Two cases were among 156 patients with corrosive induced strictures on our follow-up, and constituted the only corrosion carcinoma out of 650 esophageal carcinomas operated on by us. Nearly all reported patients with corrosion carcinoma in the published literature had consumed an alkali, but two of our three patients had consumed an acid.

Management of corrosive esophageal burns in 149 cases

OBJECTIVES

We sought to present our experience in the management of esophageal burns.

METHODS

From April 1976 through October 2003, 149 patients with corrosive esophageal burns were included in this study. Treatment modalities consisted of modified intraluminal stenting in 28, colon interposition in 71, gastric transposition in 25, repair of cervical stricture with platysma myocutaneous flap in 17, and miscellaneous operations in 12 patients. Eleven of these patients underwent the above procedures twice at our institute. The remaining 7 patients were treated with conservative therapy.

RESULTS

Twenty-three patients recovered from intraluminal stenting, and 5 experienced stricture after stent removal. One of the 5 patients with failed stents responded to bougienage, and the remaining 4 patients required esophageal reconstruction later. Of the 71 colon interpositions, 5 patients died postoperatively, and complications consisted of proximal anastomotic fistula in 17, anastomotic stenosis in 6, and abdominal incision dehiscence in 2 patients. Postoperative complications in the 25 patients with gastric transpositions comprised anastomotic stricture in 2 patients and empyema in 1 patient. There was a cervical leak in 1 of the 17 patients undergoing the repair of cervical esophageal or anastomotic stricture with a platysma myocutaneous flap. One of the patients in the group undergoing 12 miscellaneous procedures died 8 months after surgical intervention. All the survivors currently eat regular diets.

CONCLUSIONS

Intraluminal stenting can prevent the formation of caustic esophageal stricture. The location of the cicatricial esophagus dictates whether to perform concomitant esophagectomy during esophageal reconstruction. Platysma myocutaneous flap repair is an excellent method for the treatment of severe cervical esophageal or anastomotic stricture.

Minimally invasive esophagectomy for caustic esophageal stricture in children

Esophageal stricture after lye ingestion in children is the most frequent indication for esophagectomy in children, but this operation entails significant risks for complications. With continuing advances in minimally invasive technology, complex procedures such as esophagectomy can be performed using small incisions, with the aim of reducing morbidity and mortality. Experience with minimally invasive esophagectomy is limited and has involved thoracoscopic dissection with the addition of laparotomy for gastric mobilization. The authors report a case of intractable caustic esophageal stricture in a child treated by a totally minimally invasive esophagectomy through a combined thoracoscopic and laparoscopic approach. In adult patients, this procedure has been associated with decreased hospital stay and more rapid return to normal activities, and we believe similar benefits will be obtained in children. Until further studies are done to show the advantage over the standard open technique, this procedure should be performed only in centers with experience in open esophageal surgery in children as well as by surgeons with advanced thoracoscopic and laparoscopic skills.

Pharyngo-enteral anastomosis for esophageal reconstruction in diffuse corrosive esophageal stricture

BACKGROUND

Diseases involving the entire esophagus usually require extensive surgical procedures to accomplish functional reconstruction. These procedures are extremely stressful for undernourished patients. We have utilized a simpler procedure for total esophageal reconstruction.

METHODS

This retrospective report reviews the experience in 8 patients who underwent esophageal reconstruction by pharyngo-colo-gastrostomy or jejunostomy without any resection of bony structures.

RESULTS

There was no operative or hospital death. Complications included anastomotic stenosis, transient leak from the ileal stump, and late enterocutaneous fistula, each in 1 patient. Laryngeal function was maintained without special treatments. After swallowing training for approximately 1 week, oral feeding was resumed. All patients have gained 7 to 21 kg at 35 to 67 months after surgery.

CONCLUSIONS

Our surgical procedure is shown to be safe and effective in undernourished patients with diffuse esophageal stricture.

Caustic Injury to the Esophagus

The potentially catastrophic presentation and lifelong complications that result from caustic ingestion make it one of the most challenging clinical situations in gastroenterology. Patients who present with a history of caustic ingestion, particularly with a strong alkali or acid, should undergo emergent endoscopy once stabilized to assess the degree of oropharyngeal, esophageal, and gastric damage regardless of presence or lack of symptoms. Once staged, patients with moderate to severe injury should be restricted from any oral intake, placed on intravenous fluids, and observed, provided there are no signs of perforation or transmural necrosis that require immediate esophagectomy. For those who will require lengthy periods without oral intake, feeding should be initiated through a jejunostomy tube (preferably) or through total parenteral nutrition. Patients that have survived the first several weeks of injury should be reassessed for esophageal stricture formation. Chronic strictures may require serial dilations initially to establish patency and in some patients, dilation will be needed chronically to maintain the adequate lumen diameter. More severe strictures may require esophagectomy or bypass with colon or small bowel interposition. Finally, although there is an increased incidence of esophageal carcinoma in these patients, regular endoscopic screening is not advocated.

Emergency esophagogastrectomy for treatment of hydrochloric acid injury

Eight patients with severe hydrochloric acid injury of the esophagus and stomach had early esophagogastrectomy. Four patients survived and 6 to 8 weeks later underwent successful substernal colon replacement. The value of early diagnosis and subsequent aggressive surgical management of patients who have ingested hydrochloric acid is stressed.