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Step Down Approach in Managment of Pharyngoesophageal Stricture
Sundeep Saluja1, Vaibhav K. Varshney*1, Siddharth Srivastava3, Pritul D. Saxena3, Ravi Meher2, Pramod Mishra1
1Gastrointestinal Surgery, GB Pant Institute of Postgraduate Medical Education and Research, New Delhi, Delhi, India; 2ENT, Lok Nayak Hospital, New Delhi, India; 3Gastroenterology, Govind Ballabh Pant Institute of Postgraduate Medical Education and Research, New Delhi, India
Introduction: Pharyngo-esophageal corrosive strictures are among the most difficult strictures to manage. We used advances in endoscopic techniques to manage these strictures in a step-wise manner to improve its outcome. We classified the stricture according to the level of narrowing and dilatability of stricture and then planned their treatment.
Material and Method: Patients with stricture at cricopharynx or within 1 cm were classified as pharyngoesophageal stricture while those where cervical esophagus was available was classified as low strictures.PES was sub-categorised: Group-1 Stricture with available cervical esophagus; Group-2 Stricture extending into esophagus dilated to place a nasogastric tube pre-operatively and anastomosis in cervico pharyngeal area; Group-3 Stricture not amenable for dilatation, anastomosis done at the pharynx. Endoscopic dilatation was performed using through the scope (TTS) pyloric balloon 12-16 mm diameter inflated at a pressure of 4.5-6 Atm for 90 seconds. Number and duration of dilatation sessions before surgery,Type of conduit [colon pull up (CPU)/ gastric pull up (GPU)],incidence of tracheostomy, time and incidence for re-stricture, and present status of swallowing were evaluated.
Results: Of 226 patients managed, 100 underwent esophageal replacement surgery and 46 had PES. Group 1, 2 and 3 had 12, 14 and 20 patients respectively. CPU was performed in 10, 9, 19 patients while GPU in 2, 5, 1 patients in group 1,2,3 respectively.Average pre-operative balloon dilatation sessions vary from 2-3 over 6-8 weeks. CPU was performed in 10, 9, 19 patients while GPU in 2, 5, 1 patients in group 1,2,3 respectively.Tracheostomy was required in 1, 0, 9 patients and mean hospital stay was 9, 10 and 13 days in group 1, 2, 3 respectively. Colonic conduit necrosis & neck leak occurred in 2 patients each in group 2. Re-stricture developed in 4/12, 4/14, 9/20 patients with average sessions of dilatation required in post-operative period was 3, 2 and 4 in group 1, 2, 3 respectively. Re-surgery was performed for re-stricture in 3 patients in group 3. >90% of patients are taking normal diet in each group.
Conclusion: We attempted to avoid the high anastomosis by dilating the stricture and including the stricture wall in the anastomosis. Making neo-esophagus with myocutaneous flap or neck exploration with retrograde dilatation could be avoided with pre-operative rigorous attempts to dilate the stricture. This helped to step down the level of anastomosis, thereby avoiding tracheostomy, aspiration and swallowing problems related to high strictures.
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