\documentclass[10pt]{article}

\usepackage{fullpage}
\usepackage{setspace}
\usepackage{parskip}
\usepackage{titlesec}
\usepackage[section]{placeins}
\usepackage{xcolor}
\usepackage{breakcites}
\usepackage{lineno}
\usepackage{hyphenat}





\PassOptionsToPackage{hyphens}{url}
\usepackage[colorlinks = true,
            linkcolor = blue,
            urlcolor  = blue,
            citecolor = blue,
            anchorcolor = blue]{hyperref}
\usepackage{etoolbox}
\makeatletter
\patchcmd\@combinedblfloats{\box\@outputbox}{\unvbox\@outputbox}{}{%
  \errmessage{\noexpand\@combinedblfloats could not be patched}%
}%
\makeatother


\usepackage{natbib}




\renewenvironment{abstract}
  {{\bfseries\noindent{\abstractname}\par\nobreak}\footnotesize}
  {\bigskip}

\titlespacing{\section}{0pt}{*3}{*1}
\titlespacing{\subsection}{0pt}{*2}{*0.5}
\titlespacing{\subsubsection}{0pt}{*1.5}{0pt}


\usepackage{authblk}


\usepackage{graphicx}
\usepackage[space]{grffile}
\usepackage{latexsym}
\usepackage{textcomp}
\usepackage{longtable}
\usepackage{tabulary}
\usepackage{booktabs,array,multirow}
\usepackage{amsfonts,amsmath,amssymb}
\providecommand\citet{\cite}
\providecommand\citep{\cite}
\providecommand\citealt{\cite}
% You can conditionalize code for latexml or normal latex using this.
\newif\iflatexml\latexmlfalse
\providecommand{\tightlist}{\setlength{\itemsep}{0pt}\setlength{\parskip}{0pt}}%

\AtBeginDocument{\DeclareGraphicsExtensions{.pdf,.PDF,.eps,.EPS,.png,.PNG,.tif,.TIF,.jpg,.JPG,.jpeg,.JPEG}}

\usepackage[utf8]{inputenc}
\usepackage[ngerman,english]{babel}



\usepackage{float}








\begin{document}

\title{Follow-up outcomes of corrosive esophageal strictures with different
endoscopic therapy: A case report}



\author[1]{Haixia Wang}%
\author[2]{Wei Tao}%
\affil[1]{Zigong First People's Hospital}%
\affil[2]{General Hospital of Ningxia Medical University}%


\vspace{-1em}



  
  \date{May 20, 2024}


\begingroup
\let\center\flushleft
\let\endcenter\endflushleft
\maketitle
\endgroup








\sloppy


Follow-up outcomes of corrosive esophageal strictures with different
endoscopic therapy: A case report

\emph{\textbf{Authors}: Haixia Wang MD\textsuperscript{1}. Wei Tao
PD\textsuperscript{2}}

\emph{\textbf{Affiliation:} \textsuperscript{1}Department of
Gastroenterology, Zigong First Peopls Hospital;
\textsuperscript{2}Department of Gastroenterology, General Hospital of
Ningxia Medicale'}

\emph{\textbf{corresponding author}: Wei Tao; tw475006@163.com}

Ethics approval

\emph{The principles outlined in the Declaration of Helsinki was
followed. The subject of the case report provided informed consent to
publish the included information.}

\emph{\textbf{Patient Anonymity and Informed Consent}: Obtained informed
consent from the patient.}

\emph{\textbf{Author Conflict of Interest}: The authors declare that
they have no conflict of interest.}

\emph{\textbf{Guarantor of the article}:~wang haixia}

\emph{\textbf{Specific author contributions}:~Conception and design: Wei
Tao. Acquisition, analysis and interpretation of data and statistical
analysis: Haixia Wang. Drafting the article: Haixia Wang. Critically
revising the article: Wei Tao. Reviewed submitted version of manuscript:
Wei Tao. Approved the final version of the manuscript on behalf of all
authors: Haixia Wang, Wei Tao. All authors had approved the final draft
submitted.}

\emph{\textbf{Financial support}:~No funding.}

\emph{\textbf{Potential competing interests}:~No.}

\emph{\textbf{Declaration of Funding Source}: NO funding.}

\emph{\textbf{Objective} Oral corrosive substances can cause esophageal
or gastrointestinal strictures, leading to malnutrition and
gastrointestinal dysfunction, directly affecting the patients' quality
of life. The aim of the case was to compare the efficacy of different
endoscopic therapy methods.}

\emph{\textbf{Keywords} corrosive esophageal strictures; endoscopic
therapy; dilatation; stent placement; endoscopic radial incision}

Abbreviations

\emph{CES: corrosive esophageal strictures}

\emph{ERI: Endoscopic radial incision}

\emph{Corrosive esophagitis is characterized by caustic injury due to
the ingestion of chemical agents, mainly alkaline substances such as
detergents, cleaning compounds, and bleaches{[}1{]}. The severity of the
injuries caused by caustic ingestion depends on gastric contents and
caustic agent properties, including pH, concentration, ingested volume,
and tissue contact duration{[}2{]}. In general, tissues are more
severely damaged by alkaline solutions than by acidic solutions. This is
because alkalis cause liquefactive necrosis, while acids cause
coagulative necrosis resulting in eschar formation, thereby protecting
the mucosal epithelium from deep ulcer formation. High-degree corrosive
esophagitis may result in esophageal bleeding, perforation, and even
death in the worst cases. In particular, esophageal strictures are one
of the more serious complications of corrosive esophagitis. corrosive
strictures are frequently very tight, long, eccentric, and multiple, and
may require recurrent endoscopic therapy procedures, which are highly
expensive. There is a belief that these patients have a very high
stricture recurrence rate because of extensive esophageal damage and
fibrosis. For these reasons, patients with corrosive strictures often
undergo surgery In the past, which carries significant morbidity and
mortality. But now, early endoscopic therapy is very useful in cases of
corrosive esophageal strictures(CES), not only for determining the
degree of mucosal injury and severity but also for predicting
prognosis{[}3{]}.}

\emph{Current endoscopic management for CES includes esophageal
dilatation, stent placement, endoscopic~incision, injection of steroids
into the strictures segment, and so on{[}4{]}. The foremost goal of
therapy for CES is to preserve the esophagus and restore its function.
Dilatation has been considered as the therapy of choice for CES and can
be performed endoscopically, using a balloon dilator or rigid dilator.
Esophageal stent placement or endoscopic~incision is indicated when
dilatation is not successful. Several case series reports have shown
that endoscopic therapy is a safe and effective therapy with
CES{[}5-7{]}. However, there is still a lack of a well-established
consensus on when and how to optimize endoscopic therapy with CES. Here,
we report the case of a male Chinese patient with CES with scar
constitution due to the ingestion of caustic soda achieved a favorable
outcome after repeated different endoscopic therapy to compare the safe
and effectiveness of different endoscopic therapy.}

Case

\emph{A 36-year-old male ingested approximately 100 mL of caustic soda
liquid(sodium hydroxide) in a suicide attempt. he presented to our
emergency department after 2 hours on November 13, 2016 with nausea,
vomiting, retrosternal pain, hematemesis (approximately 100mL), and
dyspnea. He was belonged to the scar constitution previously. Upon
admission, Physical exam was positive for tachycardia, tachypnea, and
coarse respiratory sounds.and body temperature was 37.9, blood pressure
was 108/62mmHg. The oropharyngeal injury and hemorrhagic, however, her
abdomen was flat and soft. Bowel sounds were normal. Although marked
epigastric tenderness was present, there was no rebound tenderness or
guarding. His complete blood count and biochemistry tests were in normal
ranges, except for a white blood cell count of 20.93*10\^{}9/L,
neutrophils 16.94*10\^{}9/L, and neutrophil percentage 80.9\%.
contrast-enhanced computed tomography (CT) Chest and CT of the whole
abdomen revealed no esophageal or gastrointestinal perforations. During
hospitalization, The major short-term complications of pneumonias,
hemorrhage, and airway obstruction with the patient. His therapy
included tracheotomy, intravenous fluid, total parenteral nutrition, H2
receptor blocker, antibiotherapy, , and other symptomatic therapies. And
he can drinking water slowly without choking and coughing until day 10,
and was allowed to eat fluids until week 2 . Initial endoscopy was
withheld because there was a high risk of esophageal or gastric
perforation. Besides, The patient underwent upper gastrointestinal
endoscopy on week 4 after admission revealed multiple serious strictures
in the whole of esophagus(Fig. 1). It was concordant with the grade IIb
of caustic esophageal injury classification defined by Zargar et
al.{[}8{]}. Finally, the patient was diagnosed with CES caused by sodium
hydroxide. He is a scar constitution, surgery was traumatic and risky,
and the patient refused to undergo surgical therapy, so he was fed by
nasogastric tube.}

\emph{11 weeks later, the patient underwent a gastroscopy (Fig. 2),
which found that ''a stenotic segment was visible at a distance of
16-20cm from the hilar tooth and the gastroscope (Olympus GIFXP260: 9
mm) could not be passed''. After absolute contraindications were ruled
out, the patient was treated with careful serial graded dilatations by
selecting an initial dilator size based on the estimated stricture
diameter(diameters of 7mm, 9mm, 11mm, 13mm, 15mm), the number of bougies
[?]3 at a time. From January 22, 2017, to February 19, 2017, the patient
used to be handled with weekly dilatation per week, with unfavorable
outcomes after 5 therapies. Esophageal stent placement or ERI was
indicated when dilatation is not successful. After that, the patient was
treated endoscopically if the Stooler{[}9{]} grade of his dysphagia was
[?]2. From February 26, 2017 to April 19, 2018, The patient underwent 4
times stent placement (The average remission time of his dysphagia was
47.25 days) combined with intermittently dilatation 13 times (the
average remission time was 18.85 days) to improve esophageal dysphagia.
Due to scar constitution, stent migration, stent dislocation, and so on,
the patient still had recurrent dysphagia. So from May 17 to September
27, 2018, the patient underwent endoscopic radial incision (ERI) for 4
times (the average time of remission was 59.75 days) while taking oral
steroids (the initial amount was 30 mg qd, and the amount was reduced by
5 mg every 2 weeks until the drug was stopped. During the period of oral
steroids, the patient was treated with ERI 3 times and once stenting,
the mean remission time was 33.25 days) and once ERI, after therapies
his dysphagia improved significantly. However, the patient reoccurred
dysphagia grade 3 again after 5 months, he chose dilatation 6 times
again from February 24, 2019, to September 15, 2019 (the average
remission time was 37.83 days), and then he was stented 1 time (the
remission time was 98 days). Implanted stents was difficult to take out
several times due to the severe scar hyperplasia (Fig. 3), so that the
patient was continued to be maintained on dilatation 6 times (the
average remission time was 127.33 days). The patient had no similarly
esophageal strictures and able to eat solid food at 2 years of
follow-up. The therapy has achieved a favorable outcome (Figure 4).}

\emph{The patient underwent endoscopic dilatation therapy 30 times,
stent placement 6 times, ERI 4 times, and oral hormones for 3 months
during the 6-year course of the disease. The number of therapies per
year decreased with the duration of the disease, and the remission time
to dilatation gradually increased. ERI had the longest average remission
time among the 4 therapy modalities and the shortest remission time for
oral hormone(Table 1).}

\emph{A favorable outcome was defined as patients being able to swallow
solid or semisolid food and maintain a nutritional status for [?]6 months
without any endoscopic therapy or surgical intervention{[}2{]}.}

\emph{\textbf{Table1} Remission time to after different endoscopic
therapies}\selectlanguage{english}
\begin{longtable}[]{@{}lll@{}}
\toprule
& \emph{The number of therapies{[}n{]}} & \selectlanguage{ngerman}\emph{x±s(day)}\tabularnewline
\emph{Dilatation} & \emph{30} & \selectlanguage{ngerman}\emph{45.84±61.27}\tabularnewline
\emph{Stent placement} & \emph{6} & \selectlanguage{ngerman}\emph{52.33±30.32}\tabularnewline
\emph{ERI} & \emph{4} & \selectlanguage{ngerman}\emph{59.75±59.61}\tabularnewline
\emph{Endoscopic therapies during oral hormone} & \emph{4} &
\selectlanguage{ngerman}\emph{33.25±7.41}\tabularnewline
\bottomrule
\end{longtable}\selectlanguage{ngerman}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image1/image1}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image2/image2}

\end{center}
\end{figure}

Fig.1 Fig.2\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image3/image3}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image4/image4}

\end{center}
\end{figure}

Fig.3 Fig.4

Discussion

\emph{Corrosive esophagitis is characterized by caustic injury following
the ingestion of chemical agents. Esophageal bleeding, perforation, or
stricture can be worsened by high-degree corrosive esophagitis. Alkalis
substances may cause severe post-corrosive injuries of the upper
gastrointestinal tract, including perforation that often results in
death. The most common complications are esophageal and gastric
strictures, which are found in greater percentages than in poisonings
with acid substances. Strictures of the esophagus may appear three weeks
after ingestion of the corrosive substance, in the first three months
,or according to some authors, even after one year following caustic
ingestion{[}10{]}. Liquid corrosive substance ingestion more often
initiates stenosis than corrosive substances in crystal form. Currently,
the majority of endoscopists recommend early endoscopy to determine the
severity and extent of the injury and thereby predict prognosis.
However, comprehensive guidelines informing the timing and patient
selection for endoscopy following ingestion of caustic agents have yet
to be established. The timing recommended in the literature remains
particularly controversial. Numerous studies recommend that the most
optimal timing for esophagogastroduodenoscopy is the first 12--24 hours
post-ingestion{[}11{]}. Conversely, other studies recommend endoscopy
should be performed between 24 hours and 48 hours as damage will have
yet to mature before 12 hours and will therefore be underestimated by
examination. Since the initiation of fibroplasia, inflammatory changes,
and the healing process of the post-corrosive injuries begin on the 5th
and are most intensive until the 15th day, it is suggested to avoid
endoscopy during this period.}

\emph{Scarring stricture is very difficult to treat in clinical
practice. Esophageal or gastric strictures can cause many symptoms such
as dysphagia, and malnutrition, which seriously affects the quality of
patients' life{[}12-13{]}. It is especially important to choose the
appropriate therapy plan in time to reduce complications and mortality.
In recent years, endoscopic therapy has become the optimal therapy
method for benign esophageal strictures. Corrosive esophageal stricture
is common with complex stenosis. For esophageal strictures, endoscopic
therapies include dilatation, stent placement, endoscopic dissection,
medication, and cell transplantation, all of which can relieve
dysphagia.}

\emph{Benign esophageal strictures using different endoscopic therapy is
considered safe and effective for both short and long-term relief of
dysphagia. endoscopic therapy, rather than surgery, has therefore been
suggested as the primary therapy for most of these patients. The
reported experience is mostly in patients with peptic strictures and
there is little information on the efficacy and safety of different
endoscopic therapy in patients with CES. Due to this lack of formal
criteria, we are still unable to clarify how to choose the optimal
endoscopic therapy method based on the situation of patients with benign
esophageal strictures. many scholars suggested that the decision to
select the type of endoscopic therapy is based on the assessment of
stricture (simple vs complex), length and distal extent of the
stricture, and the experience of the endoscopist{[}14{]}. Here, We
describe first the case of a patient who ingested sodium hydroxide and
consequently presented with CES, moreover, he was treated with multiple
endoscopic methods. Since the esophageal strictures were located in the
upper and the high risk of surgery, the patient chose endoscopic
therapies. During the 6-year period, By comparing the remission time of
these 4 endoscopic therapies, we found that ERI had the longest
remission time, and the shortest was oral hormone, and the remission
time continued to lengthen as the number of therapies increased, besides
the therapeutic efficacy became more and more favorable.}

\emph{In this case, the patient was initially treated with bougie
dilatation. During the dilatation process, we started with a 7-mm bougie
according to the degree of stenosis, and then increased the diameter of
dilatation step by step to expand the stenosis to the maximum extent
possible, and then decided to terminate the diameter of the bougie
according to the patient's condition. We found that the strict
implementation of these procedures helped prevent complications and
avoid restenosis after therapy. The shortest remission time with oral
hormone therapy may be related to the Koebner{[}15{]} phenomenon, which
can induce ulcers, affect wound healing, and let to proliferate faster
since scar constitution. For complex benign esophageal strictures, ERI
has been observed to have a longer remission time and better efficacy
than other endoscopic therapies in clinical practice and can be the
therapy of choice.}

\emph{Complex esophageal strictures usually requires numerous endoscopic
therapies. There is no consensus endpoint for endoscopic therapy, and
which is optimal therapy{[}4 {]}. some person suggested that endoscopic
dilatation is the first choice for certain peptic strictures. But for
complex strictures, dilatation can not offer durable remission, so the
requirement for multiple dilatation treatment sessions. Stenting or
endoscopic incision may be performed in patients with complex stenosis
who achieve a unfavorable outcome with repeated dilatation21. xx
reported that stents could achieved a satisfactory
improvement/resolution of the refractory strictures with a success rate
of 35\%--45\%; however, migration rates(25\%--35\%) and adverse events
(20\%--25\%) are fairly common{[}16{]}. A study by Manabu Muto{[}17{]}
et al. showed that radial incision and cutting is an effective and safe
method for gastroesophageal anastomotic strictures that are refractory
to repeated endoscopic dilation, at the same time radial incision and
cutting also avoided perforation and bleeding, which is consistent with
our conclusion. For CES, the use of steroids remains controversial.
Using steroids is believed to inhibit the inflammatory response and
consequently reduce the stricture formation. Studies have shown that the
use of steroid injections, in conjunction with antisecretory therapy and
dilations, reduces the number of repeat dilations and increases the
dilation-free period{[}18-19{]}. But the effectiveness of using steroids
was not satisfactory in the case. Therefore, we believe that the
preferred choice of steroids for CES is not recommended.}

\emph{In summary, complex esophageal strictures due to corrosive
esophagitis combined with scar constitution is difficult to treat, and a
favorable outcome can be achieved after numerous endoscopic therapies.
What's more, the ERI and occasionally stents can provide durable
remission for such patients, which is safe and effective in clinical
practice. But more better modalities can provide durable efficacy need
to be investigated further.}

Reference

\begin{enumerate}
\tightlist
\item
  Seo JY, Kang KJ, Kang HS, et al. Corrosive esophagitis caused by
  ingestion of picosulfate. Clin Endosc 2015;48:66-9.
\item
  Tharavej C, Pungpapong SU, Chanswangphuvana P. Outcome of dilatation
  and predictors of failed dilatation in patients with acid-induced CES.
  Surg Endosc 2018;32:900-907.
\item
  Acehan S, Satar S, Gulen M, et al. Evaluation of corrosive poisoning
  in adult patients. Am J Emerg Med, 2021;39:65-70.
\item
  Desai M, Hamade N, Sharma P. Management of Peptic Strictures. Am J
  Gastroenterol, 2020;115:967-970.
\item
  Joshi P, Yadav R, Dangi A, et al. CES: From Dilatation to Replacement:
  A Retrospective Cohort Study. Dysphagia, 2020;35(4):558-567.
\item
  Dhaliwal HS, Kumar N, Siddappa PK, Singh R, Sekhon JS, Masih J,
  Abraham J, Garg S. Tight near-total corrosive strictures of the
  proximal esophagus with concomitant involvement of the hypopharynx:
  Flexible endoscopic management using a novel technique. World J
  Gastrointest Endosc, 2018;10(11):367-377.
\item
  Nijhawan S, Udawat HP, Nagar P. Aggressive bougie dilatation and
  intralesional steroids is effective in refractory benign esophageal
  strictures secondary to corrosive ingestion. Dis Esophagus,
  2016;29(8):1027-1031.
\item
  Zargar SA, Kochhar R, Mehta S, et al. The role of fiberoptic endoscopy
  in the management of corrosive ingestion and modified endoscopic
  classification of burns. Gastrointest Endosc, 1991;37(2):165-9.
\item
  Qi L, He W, Yang J, et al. Endoscopic balloon dilation and submucosal
  injection of triamcinolone acetonide in the treatment of esophageal
  stricture: A single-center retrospective study. Exp Ther Med,
  2018;16(6):5248-5252.
\item
  Hoffman RS, Burns MM, Gosselin S. Ingestion of Caustic Substances. N
  Engl J Med, 2020;382(18):1739-1748.
\item
  Ramasamy K, Gumaste VV. Corrosive ingestion in adults. J Clin
  Gastroenterol, 2003;37(2):119-24.
\item
  Chirica M, Kelly MD, Siboni S, et al. Esophageal emergencies: WSES
  guidelines. World J Emerg Surg, 2019;14:26.
\item
  Faron M, Corte H, Poghosyan T, et al. Quality of Life After Caustic
  Ingestion. Ann Surg, 2021;274(6):e529-e534.
\item
  Fugazza A, Repici A. Endoscopic Management of Refractory Benign
  Esophageal Strictures. Dysphagia, 2021;36(3):504-516.
\item
  Reissmann A, Hahn EG, Faller G, et al. Sole treatment of lichen
  planus-associated esophageal stenosis with injection of
  corticosteroids. Gastrointest Endosc, 2006;63(1):168-9.
\item
  Fuccio L, Hassan C, Frazzoni L, et al. Clinical outcomes following
  stent placement in refractory benign esophageal stricture: a
  systematic review and meta-analysis. Endoscopy, 2016;48(2):141-8.
\item
  Muto M, Ezoe Y, Yano T, et al. Usefulness of ERI and cutting method
  for refractory esophagogastric anastomotic stricture (with video).
  Gastrointest Endosc, 2012;75(5):965-72.
\item
  Ramage JI Jr, Rumalla A, Baron TH, et al. A prospective, randomized,
  double-blind, placebo-controlled trial of endoscopic steroid injection
  therapy for recalcitrant esophageal peptic strictures. Am J
  Gastroenterol, 2005;100(11):2419-25.
\item
  Altintas E, Kacar S, Tunc B, et al. Intralesional steroid injection in
  benign esophageal strictures resistant to bougie dilation. J
  Gastroenterol Hepatol, 2004;19(12):1388-91.
\end{enumerate}

\selectlanguage{english}
\FloatBarrier
\end{document}

