ENDOSCOPIC FINDINGS IN PATIENTS PRESENTING WITH DYSPHAGIA

INTRODUCTION: Dysphagia is a condition in which disruption of swallowing process interferes with patient ability to eat due various causes. Endoscopy is the mainstay of diagnostic workup of these patients and subsequent treatment. AIM: The objective of the study was to determine the frequency of various types of endoscopic ndings in patients with dysphagia. METHODS: Cross-section descriptive study carried out in DDHD, KMC, Chennai, a tertiary care hospital from November 2018 to May 2019. Duration of symptoms was noted and all patients underwent upper gastrointestinal endoscopy to nd out the cause of dysphagia. Tissue biopsies were obtained and further histopathological examination was performed to correlate the ndings with symptoms of dysphagia. RESULTS: A total of 197 patients presenting with dysphagia were studied, 93 (47%) were males and 104 (53%) were females. The mean age was 55 ± 8 years. Oesophageal malignancy was the most common nding noted in 54(27%) patients. It was followed by post cricoid web in 24 (12%), benign stricture oesophagus 21(10%), cricopharngeal malignancy in 14(7%), anastomatic stricture 14(7%), normal UGI in 12(6%), post RT stricture in 11(5%), peptic stricture in 8(4%), hypopharynx malignancy in 8(4%), OGJ growth in 8(4%), corrosive stricture in 7(4%), patients and reux esophagitis in 5 (2.9%) patients, oesophageal candidiasis in 5(2.9%), achalasia in 4(2%) ,pyriform fossa malignancy in 3(1.5%),oesophageal web in 3(1.5%), one patient each in Schatzki's ring, pill esophagitis, oesophageal varices, oesophageal diverticula(0.5 %). CONCLUSION: Malignancies and malignancy related conditions are more common cause of dysphagia in our set of population. Patient presenting with dysphagia, endoscopy is initial and better choice of investigation unless contraindicated

Study of definitive surgical management of patients with corrosive stricture of upper gastrointestinal tract

Background: Corrosive injury of the oesophagus and stomach is a cause of major morbidity and mortality and is usually seen in the younger age group. Although definitive surgical procedures are available, there is a considerable debate on the timing of a definitive surgery and its electiveness. This study aims to document the benefits of elective surgery and the outcomes of various surgical procedures.Methods: A retrospective observational study of 25 cases of corrosive stricture of upper gastrointestinal tract who underwent definitive surgical procedure was conducted in the department of general surgery at the new civil hospital and government medical college, Surat during a period of 60 months from July 2014 to July 2019. Patients were followed up till a period of 6 months post definitive surgical procedure and were evaluated.Results: Out of 25 patients in our study subjected to definitive surgical procedure in the form of either gastrojejunostomy (GJ) or colonic transposition, 18 patients (72%) could take fully oral and required no further intervention till 6 months post-operative follow up; 3 patients (12%) due to post-operative oesophageal stricture required serial 3 monthly oesophageal dilatation with controlled radial expansion (CRE) balloon; 4 patients (16%) had expired.Conclusions: The choice of definitive surgical procedure according to the level of oesophageal stricture and its optimal timing gives good outcomes with less morbidity and mortality in patients with corrosive substance ingestion.

Two-Point Fixation Technique in Retrosternal Midcolon Interposition for Corrosive Stricture of Esophagus-Our Experience With 25 Patients

Background. In 1911, Vuillet and Kelling independently described the anatomical and surgical bases of esophageal replacement with the colon. An important complication, in particular in later follow-up, is redundancy of the interposed colon, seen more after retrosternal interposition. The best treatment is prevention by a meticulous surgical technique and measurement of the length of the colon needed to replace the esophagus. Methods. This was a retrospective study of innovative surgical technique. A total of 25 patients with corrosive stricture of the esophagus undergoing two-point fixation in retrosternal colon interposition were included in the study. Preventive Operative Technique. After straightening of conduit by pulling very delicately over both sides, first fixation point we considered cervical anastomoses and second fixation point was made in subxiphoid space, taking two seromuscular stiches from the antimesenteric border of the colon to falciform ligament situated on the right side of the conduit. Results. There were 07 male and 18 female patients with M:F was 1:2.5; mean age was 29 years (range: 23-45 years) and mean hospital stay was 14 days (range: 10-23 days). In this study, we did not encounter any subjective or objective evidence of redundancy in any patients in follow-up barium swallow after 2.5 years of follow-up. Conclusion. Our Two-point fixation technique is refinement of already performed and tried fixation techniques to prevent redundancy of the colon conduit considering kinetics, anatomical alignment, and pathology.

423 OUTCOME OF LAPAROSCOPIC SURGERY FOR THE MANAGEMENT OF CORROSIVE STRICTURE OF THE OESOPHAGUS

The surgical treatment for a corrosive stricture of the oesophagus, after failed endoscopic dilatation, often involves oesophageal replacement using a gastric or a colonic conduit. This is traditionally done via the conventional open approach. The objective of this study was to ascertain short and long term outcomes of Laparoscopic gastric (LGP) and colon pull up (LCP) for the treatment of corrosive stricture of the oesophagus Methods Retrospective study of patients of corrosive oesophageal stricture, who, following a failed endoscopic dilatation, underwent a laparoscopic gastric or colon pullup between Jan 2011 and November 2019. All patients were evaluated with an upper endoscopy/contrast study to determine upper level and extent of stricture. Stomach was the preferred conduit, colon was used when either stomach was involved in the scarring process or in high pharyngeal strictures. Early and late postoperative outcomes were ascertained. Results During the study period, 254 patients with corrosive stricture oesophagus were managed surgically. Of these 50 underwent LGP and 10 underwent a LCP and these formed the study group. Mean age was 22.4 (2–42) years. The mean operative time (174.6 ± 43 and 322 ± 63 min) and blood loss (58.6 ± 23.9 and 108 ± 30.8 mL) for LGP and LCP respectively. Four patients developed mild respiratory infection. Eight patients developed cervical anastomotic leak. One patient had a colojejunal leak and another leak from the gastric tube staple line which was managed with drainage and antibiotics. At a mean followup of 51 months all patients were euphagic. Conclusion Laparoscopic surgery for corrosive strictures of oesophagus is safe and provides good short and long term outcomes.

Iso-peristaltic colonic loop interposition for the treatment of benign oesophageal stricture: a case report with review of literature

Corrosive oesophageal strictures are a common and debilitating condition in India. Patients generally have dysphagia, cachexia, drooling of saliva, aspiration pneumonitis, and lung abscess. Though endoscopic dilatations are done in cases of short segment strictures, surgical oesophageal by pass is the permanent solution for this condition. A 24 years female presented with complaints of dysphagia and cachexia, due to corrosive stricture. Patient had a history of poison ingestion 2 years back. Intra-operatively stricturous mucosa is excised and an iso peristaltic colonic loop by pass was carried out. Post operatively patient had a complication of anastomotic leak which was treated conservatively, excepting which patient is symptom free and gaining weight on a follow up period of 1 year. Ever since first described by Kelling and Vuillet in 1911 colonic interposition is mostly used around the globe for oesophageal bypass in both benign and malignant conditions. Stomach and jejunum are the other conduits that can be used. Iso peristaltic loop is mostly used to reduce the incidence of reflux. Right colon or transverse colon graft based on the mid colic artery or the left colic artery owing to the reliable blood supply and less diameter. This procedure has a high complication rate of around 27% most of which are due to the vascular comprise of the graft.

Spontaneous Perforation of a Malignified Corrosive Stricture of the Esophagus and Subsequent Perforation of a Giant Duodenal Stress ULCUS

Surgical interventions for corrosive stricture of the esophagus are extremely difficult and technically challenging. In this manuscript, we present a patient with esophagectomy due to perforation of a corrosive stricture of the esophagus that underwent malignant transformation and subsequent perforation of a giant duodenal stress ulcus, which occurred 12 days after the intervention. We performed a total esophagectomy, pharyngo- and gastrostomy, suture of the duodenal perforation but the postoperative period was challenging and despite our efforts, the patient died on the 50th postoperative day due to respiratory and renal failure.

Colon interposition in the treatment of corrosive esophageal strictures: 100 patients in seven years

Background: The purpose of this study is to represent the change in our concept of principles and techniques of esophagocoloplasty (midcolon esophagocoloplasty) with repetitive performance of the operation and approach of early surgical intervention (within 4-6 month of corrosive ingestion) in place of repetitive trials of dilatations and medical management, provides early better quality of life with lesser period of suffering and saving expenditure of treatment.Methods: This retrospective study comprises of consecutive 100 patients operated for colon interposition for corrosive stricture of esophagus done at two university linked government teaching hospitals during March 2011 to March 2018. Out of 100 patients, 77 female and 23 male (3:1), mean age 30.6 years (range from 21 to 47 years), mean hospital stay was 14.5 days (range 10 to 25 days) and mean operative duration was 4.5 hours (range 2.5 to 7 hours).Results: The 30 day in hospital mortality rate was 9%. There were 14 instances of leak at the esophagocolic anastomosis (14%), graft necrosis occurred in 01 patient, 08 patients (8%) developed stenosis at the esophagocolic anastomosis. More than 90% patients (n=77) had ‘Good’ result, 06 patients had ‘Fair’ and 02 had ‘Poor’ result.Conclusions: Midcolon graft is a solution for confusion in judgment of adequate length of graft and offer uniformity in procedure with effectively lesser operative time. Early (4-6 months after ingestion) operative intervention is advantageous to patients suffering from crippling dysphagia with repeated admission and expenditure from multiple endoscopic dilatations.

Minimally invasive oesophagectomy for corrosive stricture oesophagus

Corrosive oesophageal stricture is commonly encountered in developing countries. Historically resection of strictured oesophagus was feared due to adhesions but with minimally invasive surgery it is possible to resect esophagus.. A 19 year female patient with history of bed bug poisoning presented with complete dysphagia. On endoscopy there was upper thoracic esophageal stricture. Endoscopic dilatation of esophagus was tried at first but failed. Since her cervical oesophagus was not diseased and considering her young age for the risk of malignancy in long term, thoracoscopic oesophagectomy was done. There were no perioperative complications. Patient doing well on follow up.

PS01.117: TOTAL LAPAROSCOPIC MIDCOLON RETROSTERNAL ESOPHAGEAL BYPASS FOR CORROSIVE STRICTURE ESOPHAGUS

Description Colonic bypass for corrosive stricture of the esophagus is traditionally performed using the conventional open approach. A laparoscopic mid colon retrosternal bypass has not been reported in the literature. Total laparoscopic left colic artery based mid colon retrosternal esophageal bypass is described in this report. Method: A 25-year-old female presented with acid-induced long esophageal stricture starting at 18cm from incisors refractory to endoscopic dilatation. The laparoscopic mid colon esophageal bypass was performed using 5 abdominal ports. The essential steps are colonic mobilization and assessment of the adequacy of the mesocolic vascular arcade by clamping middle colic, right colic, and ileocolic vessels proximal to their branching, creation of the retrosternal tunnel, preparation of left colic artery based colon conduit by dividing terminal ileum proximal to ileocecal junction, neck dissection to expose cervical esophagus and delivering the colonic conduit retrosternally into the neck. Reconstruction was performed by side to side esophagocoloplasty, side to side cologastric and ileocolic anastomosis. Results: The duration of surgery was 410 minutes and blood loss was 150 mL. The patient had an uneventful postoperative course. She was started on oral semisolids on postoperative day 7 and discharged on the tenth postoperative day. At 9 months follow up the patient is euphagic to solid diet with an excellent cosmetic result. Conclusion: Total laparoscopic mid colon esophageal bypass is a feasible procedure for the management of corrosive stricture of the esophagus Disclosure All authors have declared no conflicts of interest.

PS01.113: RISK FACTORS FOR ESOPHAGEAL STRICTURE IN GRADE 2B AND 3A CORROSIVE ESOPHAGEAL INJURIES

Background Ingestion of corrosive agents remains an important public health problem. Early endoscopic examination of post-corrosive esophageal injuries has an important role in management of the patient. Publications document the risk of developing esophageal stricture as a sequential complication of esophageal injury grades 2b and 3a. Although there are studies describing the risk factors of post-corrosive stricture, there is limited literature on these factors. The aim of this study was to evaluate the different factors with post-corrosive esophageal stricture and non-stricture groups in endoscopic grades 2b and 3a of corrosive esophageal injuries. Methods Data were retrospectively analyzed in the patients with esophageal injury grades 2b and 3a between January 2011 and December 2017. Results 196 corrosive ingestion patients were admitted with 32 patients (15.8%) in grade 2b and 12 patients (6.1%) in grade 3a and stricture was developed in 19 patients (61.3%) with grade 2b and in 10 patients (83.3%) with grade 3a. Substances of alkaline reaction were predominant in stricture patients (68.4% in 2b Stricture group, 60% in 3a Stricture group). The patients’ height of non-stricture group was greater than that of stricture groups (2b Stricture group, 1.58 ± 0.08 m, 2b Non-stricture group, 1.66 ± 0.07 m, P < 0.004; 3a Stricture group, 1.52 ± 0.09 m, 3a Non-stricture group, 1.71 ± 0.02 m, P < 0.001). Omeprazole was more commonly used in non-stricture than stricture group (26.3% in 2b Stricture group, 69.2% in 2b Non-stricture group, P = 0.017; 50% in 3a Stricture group, 100% in 3a Non-stricture group, 1.71 ± 0.02 m, P = 0.015). Conclusion In this study, the corrosive esophageal injuries grades 2b and 3a are important groups of patients who are at risk of developing post-corrosive esophageal stricture. Alkaline substances play the major role in stricture sequelae. The height of patients and the prescription of omeprazole may help to minimize the risks of post-corrosive esophageal stricture. Disclosure All authors have declared no conflicts of interest.