Retrospective Study Of 36 Cases Of Caustic Upper Gastrointestinal Stricture

BackgroundAs acidic and alkaline compounds come closer to people as the ingredients of daily necessities,people are exposed to more and more caustic substances.Although the safety and precautions of these daily necessities have been repeatedly emphasized,incidents of unintentional or intentional caustic ingestion have been occurring.The incidence of caustic ingestion varies by country and cultural background,and its true incidence cannot be known from the existing literature and case reports,especially in developing countries.Alkaline and acidic caustics are the most common ingested chemicals that can cause digestive tract damage and cause tissue destruction through coagulation or liquefaction reactions.The clinical manifestations of caustic injury vary from no mucosal damage to severe damage.Perforation and necrosis may occur in the acute phase,and long-term complications include stricture of the digestive tract and the development of malignant tumors.Unlike children who generally ingest caustic substances by mistake,adults' ingestion primarily as a result of suicidal tendencies or mental illness.Upper gastrointestinal stricture is the most common long-term complication after ingestion of caustic substances,in which esophageal stricture accounts for the majority.The severity and extent of stricture depends on the physical form,type,quantity,concentration,mucosal contact time and viscera status at ingestion.The purpose of the treatment of caustic stricture is to improve the symptoms/signs,avoid the complications of gastrointestinal obstruction and prevent the recurrence of stricture.At present,stricture dilation is the most widely used treatment,including balloon dilation and bougie dilation,which can be performed either under endoscope,under X-ray fluoroscopy or under the combination of both.Compared with other benign gastrointestinal stricture,caustic stricture is often multiple,long and angled,low response to dilation and prone to complications such as perforation.For patients who need multiple and frequent dilation to keep the digestive tract unobstructed,stent placement can maintain the continuous dilation of the stricture segment,prolong the asymptomatic duration and reduce the pain caused by frequent dilation.However,considering the risk of postoperative reactive tissue hyperplasia and high incidence of stent displacement,the efficacy and clinical application of stent placement in the treatment of caustic gastrointestinal stricture has been controversial,and its clinical benefits need to be further evaluated.In addition,the current studies on caustic upper gastrointestinal stricture mainly target at children,and the treatment methods are mostly limited to stricture dilation.There are few reports on the clinical application of digestive tract stent placement and dilation combined with stent placement.With the development and clinical application of biodegradable stents,there is an urgent need for more randomized controlled studies to further evaluate the role and prospect of stenting in caustic upper gastrointestinal stricture.PurposeBased on a retrospective analysis of 36 cases of caustic upper gastrointestinal stricture,the application and efficacy of stricture dilation,stent placement and surgery in the treatment of caustic upper gastrointestinal stricture were preliminarily discussed.Patient Selection and methods1.Subjects A total of 36 patients with caustic upper gastrointestinal stricture who were treated in the First Affiliated Hospital of Zhengzhou University from January 2010 to June 2019 were included.All patients were clearly diagnosed with caustic upper gastrointestinal stricture(esophageal stricture,gastric outlet obstruction or either)and had obvious related symptoms.Patients treated conservatively with medication alone can be excluded.2.Data collection Collecting general and clinical data of patients,including age,gender,nature of the caustic substance,stricture site,disease course before treatment,dysphagia score or symptoms/signs of gastric outlet obstruction before treatment,treatment methods and complications,and the improvement of related symptoms after treatment was followed up.3.Treatment(1)stricture dilation:including endoscopic silicone bougie dilation and endoscopic/X-ray fluoroscopic balloon dilation;(2)stent placement;(3)surgery:esophageal replacement,subtotal gastrectomy,pyloroplasty.4.Evaluation criteria The degree of dysphagia before and after treatment was evaluated according to the Atkinson Dysphagia Scale.The therapeutically effective endpoint was defined as a 2-point or greater reduction in dysphagia or relief of symptoms/signs of gastric outlet obstruction after the last treatment and maintained for at least 12 months.5.Statistical analysis All statistical analyses were performed using SPSS 22.0 software.The quantitative data that conforming to the normal distribution were expressed as mean ± standard deviation,the quantitative data that do not conforming to the normal distribution were expressed as the median(interquartile range),and the qualitative data were expressed in terms of counts and percentages[n(%)].Results1.Retrospective analysis of 36 cases of caustic upper gastrointestinal stricture,including 14 cases of simple stricture dilation,15 cases of stenting,and 7 cases of surgery.After treatment,the patients were followed up for 5-95 months,and the median follow-up time was 34.50 months.Four patients did not complete the final efficacy evaluation because they did not reach 12 months after the last treatment.2.Among the 32 patients who completed the final efficacy evaluation,31(96.9%)patients had significantly improved symptoms of dysphagia/gastric outlet obstruction or basically returned to a normal diet after treatment,and the Atkinson score decreased by 3.00(3.00,4.00)points.Among them,13(100.0%)patients with simple stricture dilation were all effective;12(12/13,92.3%)patients with stent placement were effective;6(100%)surgical patients were all effective.3 Perforation is the most common complication of patients with stricture dilation,accounting for 12.1%;stent displacement is a common problem in stent placement,accounting for 68.4%;esophageal stump abdominal wall fistula occurred in 1(14.3%)case after tubular gastric esophagoplasty,and anastomotic stricture occurred more than 4 months after operation.ConclusionBoth stricture dilation and stent placement can achieve significant effects in the treatment of caustic upper gastrointestinal stricture.However,there are problems with high incidence of digestive tract perforation and stent displacement.Therefore,the treatment of caustic stricture requires a reasonable grasp of the indications of each treatment method,pay attention to the safety of treatment and reduce the occurrence of stent displacement.Furthermore,the efficacy of surgery as a second-line treatment should not be ignored.