1. Therapeutic Results of Early and Late Endoscopic Dilatation Therapeutic Results of Early and Late Endoscopic Dilatation IN ESOPHAGEAL STRICTURE CAUSED BY CORROSIVE INGESTION IN ESOPHAGEAL STRICTURE CAUSED BY CORROSIVE INGESTION Sirikan Yamada, M.D, FRCST Department of Surgery Faculty of Medicine Chiang Mai University Thailand Sirikan Yamada, M.D, FRCST Department of Surgery Faculty of Medicine Chiang Mai University Thailand Yamada S, Chakrabandhu T, Sundo T, Ariyakhachorn V

2. BACKGROUND In Thailand, Esophageal stricture by corrosive ingestion is one of difficult problems to correct the result of injury. The strong concentrated alkaline or acid often caused the severe damage to the esophagus. The strong concentrated alkaline or acid often caused the severe damage to the esophagus. Mainly, the esophageal stricture will develop in the cicatrization phase following the ingestion after 2 to 3 weeks. Esophagogram is preferred to access the degree of stricture Ferguson MK MM.Am J Surg 1989;157: 116- 20 Ferguson MK MM.Am J Surg 1989;157: 116- 20

3. Corrosive Agent in Thailand (Conc. Acid and Conc. Base) Common in the Depatment store

4. LIQUID DRANO

5. The strong concentrated alkaline or acid often caused the severe damage to both esophagus and stomach. Esophageal stricture always occur in concentrate base ingestion and in the case that had repeated episode of injury or NG tube intubation

6. BACKGROUND  Esophageal and pyloric stricture were found in grade 2b and grade 3 injuries.  Currently, the controversial issues for the proper period to perform EARLY endoscopic dilatation was discussed. perform EARLY endoscopic dilatation was discussed.  Grade 0 Normal Examination Grade 1 Edema and hyperemia Grade 1 Edema and hyperemia Grade 2a Friability, hemorrhage, erosion,blisters,whitish Grade 2a Friability, hemorrhage, erosion,blisters,whitish membrane,exudates and superficial ulceration membrane,exudates and superficial ulceration Grade 2b 2a plus deep discrete or circumferential ulceration Grade 2b 2a plus deep discrete or circumferential ulceration Grade 3 Multiple ulceration and areas of necrosis Grade 3 Multiple ulceration and areas of necrosis Zargar SA Am J Gastroenterol 1992 Zargar SA Am J Gastroenterol 1992

7. Aim and Method  To study the therapeutic results of early and late endoscopic dilatation in esophageal stricture caused by corrosive ingestion  In 5 years, since November 1996 – November 2001,  In 5 years, since November 1996 – November 2001, The 44 patients who survived from the attempted suicide by corrosive ingestion or accidental caustic injuries were included in the study at Chiang Mai University hospital.   We critically reviewed endoscopic examination results for the degree of injuries in first 24- 48hrs. after admission and when the esophageal stricture occurred   No steroid therapy in all cases, and antibiotic ( penicillin group) were used in all grade 2-3 injuries

8. Aim and Method There were 15 patients who developed esophageal stricture divided into 2 groups as the following; 1) early ( 3-6 th week)- 10 patients and 2) late (After 6th week)- 5 patients endoscopic dilatation were performed by experience endoscopists and surgeons The failure rate, the improvement of dysphagia in grading, complication, and hospital stay were described.

9. Result The nasogastric intubation firmly related to the extent and degree of injury in 75% of cases (10/15 ). No difference in both group. 4/5 in early dilatation group 4/5 in early dilatation group 6/10 in late dilatation group 6/10 in late dilatation group All esophageal stricture patients occurred significantly in second and third degree lesion. About 40% (4 /10) failure rate occurred in endoscopic dilatation group after the sixth week comparing to 0% (0/ 5) failure rate occurred in early endoscopic dilatation after detection of stricture between the third to sixth week.

10. Result  The complication that needed intervention occurred in only the late endoscopic dilatation group.(3/4)  There was no significant difference for recovering of dysphagia grade after treatment in both groups ( Dysphagia are improved in all patients to grade 1-2) beside of 1 patient who still develop recurrence stricture in late treatment group that needed 2- year- follow up until now. ( Dysphagia are improved in all patients to grade 1-2) beside of 1 patient who still develop recurrence stricture in late treatment group that needed 2- year- follow up until now.  However, the late treatment group had longer hospital stay (mean 68 days, 2.7 times of mean hospital stay comparing to early dilate group) and needed more frequent repeated endoscopic dilatation in this study ( at least 5 times in late dilate group VS 2 times in early dilate group more frequent repeated endoscopic dilatation in this study ( at least 5 times in late dilate group VS 2 times in early dilate group

11. Early endoscopic dilatation First day

12. Dysphagia grade 4 develop since 10 th day without obvious complication from contrast study. Close observation was done and appointed her to perform repeated endoscopic examination at the 2 nd week with early dilatation at 6 th week since she recover from grade 4 to grade 1 dysphagia She needed repeated MH dilatation( until Fr 40) in another one time follow up

13. patient was underwented LATE Endoscopic Dilatation ( 8 th- 9 th week after ingestoion) who was consulted to Department of Surgery after diagnosis of Esophageal perforation. 2 nd degree injury was diagnosed

14. Gastro jejunostomy was performed previously Thoracotomy was decided to perform and small adhere perforation site was obscured. Mediastinal and pleural cavity were adequate drained. Large bore tube was used to stent the true lumen of esophagus.

15. Postoperation of corrected complication TPN therapy was given to improve nutrition for one month after operation.

19. Stricture developed at cervical esophagus. It was demostrated by barium study at 4 th week post operation Dysphagia grade 3 was improved by 3 times MH dilate (until 4o Fr was passed 2 times) to grade 1 in another 6 week by out patient follow up.

20. Recurrent stricture occured at the 7 th months after operation / Dysphagia grade 3 BW 39 45 kg.

21. Salvary Guilliard

22. Guide wire insertion

23. No. selection 3 Equal to Fr. No of MH dilator

25. Follow up at the 10 th month After 2 times SG dilatation and 3 times MH dilatation BW 49 kg Grade 1

26. Maloney Dilator

29. Conclusion and Discussion We recommend to perform the endoscopic examination and evaluate the extent of injury at first 24-48 hour. At the 3 rd week to the first month, the closed follow - up before dysphagia developed should be done by barium study and endoscopic examination. The early endoscopic dilatation between the third to the sixth week of injury can be done without major complications.