|Treatment of Esophagus caustic Stenosis - English Version|
Translator: By Beatriz Lopes Campos
Authors: Marcos de Melo Araújo1, Paulo Fernando Souto Bittencourt1, Daniel Vargas Ribeiro1, Emerson Rodrigo Santos2, Ana Paula Aquino F. Monteiro2, Aurélia Silva e Albuquerque2, Selme S. Matos3.
Caustic stenosis is produced by formation and contraction of scar tissue formation secondary to the intense inflammatory process after caustic injury of the esophageal mucosa, exposing deep tissues to the muscle layer of the organ. The stenosis can reach different regions of the esophagus and can even be observed in more distal area, affecting the stomach and pylorus.
Esophageal stricture, Barrett's esophagus, caustic stenosis; Humanization
To report the experience of humanized care and treatment of patients with caustic esophageal stricture carried on in a large public hospital and a large charity hospital in Belo Horizonte.
MATERIAL AND METHODOLOGY:
It is about a reported experience to provide care to patients suffering from caustic lesions of the esophagus performed at the Department of Otolaryngology of João XXII (Emergency Police) and Felicio Roxo hospitals.
The series of consultations used in this study refers to those calls made over several years in such hospitals, being the most recent experience the use of mitomycin in two cases in the latter service.
The authors' experience has contributed effectively to detail the specific procedures and the importance of humanized care. This report was authorized by the board of institutions of technical production field of study. Were assured the anonymity of patients as recommended by the 196/96 resolution of the National of Health Board.
CONSIDERATIONS ON ESOPHAGEAL PHISIOLOGY:
Functionally, the esophagus presents at its upper end a sphincter constitute by the muscle cricopharyngeal located at the level of the cricoid cartilage and the 6th cervical vertebra. At its lower end, at its junction with the stomach it presents another sphincter called the cardia.
Along its 30 cm path in adults, two strictures are noticed one at the arch of the aorta and the other at its intersection with the left main bronchus.
The esophagus is composed of two types of muscles. The cervical esophagus and the beginning of the thoracic esophagus are composed of striated muscle and as it deepens its muscles in the thorax undergoes a transition to smooth muscle so that at the lower esophagus is predominantly smooth muscle.
Such muscles disposition feature will determine the speed of passage of food more slowly in its lower third. Once inside the esophagus, the food will be propelled by peristalsis of the esophagus itself, and this is produced by waves that are classified into primary, secondary and sometimes tertiary.
The function of the esophagus is get food from the pharynx to the stomach, an involuntary phase of swallowing. At an earlier stage, food is crushed at the oropharynx and mixed with the salivary glands secretions , thus forming the so-called bolus. This is driven voluntarily to the posterior oropharynx, where its presence triggers a complex series of involuntary muscle stimulation that culminates with the propulsion of the bolus to the esophagus and from it to the stomach.
THE EXPERIENCE IN THE SCIENTIFIC TECHNICAL PROCEDURE
The caustic stenosis is produced by formation and contraction of scar tissue formation secondary to inflammatory injury after severe caustic esophageal mucosa exposing deep tissues to the muscle layer of the organ. The stenosis can reach different regions of the esophagus and can even be observed in a distal area affecting stomach and pylorus.
The immediate symptoms after a caustic substance ingestion is burning sensation on lips, tongue, palate, pharynges and esophagus along with dysphasia and odinophasia. After 3 to 4 weeks it can be observed a reduction of symptoms reported by the patient. At this phase it would be a mistake to assume that the patient is getting better as after such phase there is a peeling off the affected area and from this point on a gradual process of eesophageal stricture fibrosis is formed with consequent restriction of its light. We believe that this is the best moment to start the treatment indicated here. It is discouraged the insertion of entrial probe in the acute phase of the process because due to the tissue necrosis that follows the area burnt, a larger friability of the tissues occurs and there could be the risk of inadvertent esophageal perforation. Esophagealcospy is also avoided it is preferred in this phase the performance of contrast study (REED) for injury location.
The treatment using dilations should be initiated within 4 to 6 weeks after the accident, the moment which initial dysphasia disappears or has an improvement.
Initially it was proposed to retrograde esophageal dilatation of distal esophagus to proximal by introducing a Tuker probe entering through a gastrostomy after placement of a guide wire into the oral cavity to the its own orifice. This technique was replaced by Dr.Joao Sena Horta’s proposal who initiated the introduction of urethral probe in the proximal to distal esophagus by transnasal via of progressively larger diameters, followed by the introduction of naso-tracheal tubes this same pattern until the esophagus diameter reached a possible expansion with the aid of inflatable balloon. When there is associated significant fibrosis,it is used initially Savary probe for dilation, followed by topical Mitomycin C, an antibiotic isolated from the bacterium Streptomyces caespitosus and used as an antineoplastic alkylating agent , it is an inhibitor of DNA synthesis dependent on RNA, of protein synthesis in fast-growing cells and fibroblast proliferation.
The drug is used in such cases in order to modulate the associate inflammatory processes, by preventing the exacerbated action of fibroblasts in the resulting wound, thus acting on the healing process making it less intense.
After a week of this procedure it is initiated dilations with a probe, not forgetting to leave the tracheal suction probe (delay) to new expansions, at intervals of 2 to 3 times per week in order to avoid re-stenosis of the fibrous part of the esophagus, keeping its diameter until further dilations with larger diameter probes, and finally using the inflatable balloon.
The expansions are carried out at regular intervals of 3 days and this interval is increased to 7, 15 and 30 days respectively until the patient can be discharged from such monitoring, if necessary returning for further expansion. Topical anesthesia with 10% xylestesyn spray application of Xylocaine gel on nasoenteric feeding tube is recommended for use in our service for greater patient comfort. Then pass a nasogastric tube.
During this process and after completion of the same it should be administered omeprazole 20 mg BID and ranitidine hydrochloride 150 mg BID in order to prevent injury caused by gastroesophageal reflux disrupting the process. Especially in the beginning of the expansion it should be observed not to cause esophageal perforation and for that we use our experience with touch as a guide in this direction.
The hypothesis of secondary neoplasia to severe injury and permanent changes to the esophageal mucosa caused by caustic substance should always be taken into consideration when dealing with such patients.
The importance of Humanized Care:
In health care, to humanize is the process that seeks to offer the patient treatment and care that takes into account the totality of the individual, based on a concept inserted into the biopsychosocial context. This concept takes on a larger scale, beyond the limits of the bed, the patient and it expands up to the professionals who make up the multidisciplinary team.
It goes beyond the terms offered by the institution as ambience, physical and technological infrastructure, the ergonomic working conditions of professionals and other minor components, but essential for quality care to patients and their families.
The patient looks for more than cure or relief, seeks to preserve life, restore health and emotional comfort, seeks to be treated more holistically, with solidarity, ethics and values that go beyond the limits of the technique, all together can help motivate the patient and lead him to be willing to fight for life.
To report our experience in humanized care and treatment of patients with caustic esophageal stricture carried out in a large public hospital and a large charity hospital in Belo Horizonte. The report proposes guidance to health professionals for the following precautions:
- Do not expect for the outcome in a case to check the esophagus;
- The treatment should be initiated right after the beginning of esophagus
- The balloons should be of different diameters;
- To understand that perforation is from top to bottom;
- One should not force the instruments;
- A multidisciplinar approach is of great importance in treating such these
- One should always bear in mind the possibility of disruptive psychiatric
disorders associated with most cases treated in our daily practice.
1- Physian in otorhinolaringology at Felicio Rocho Hospital
2- Resident of the Otorhinolaryngology department of Felicio Roxo
3- Nurse teacher of EEUFMG. CEP Coordinator CEP – Felicio Roxo
•The present research was based on the study "The Use of Mitomycin-C in Endoscopic Treatment of Strictures Subglottic" by otorhinolaringology Luiz Ubirajara Sennes, Robison Koji Tsuji, Rui Inamura e Domingos Hiroshi Tsuji
Special thanks to:
The experience report study was motivated by the encouragement of renowned orthopedist Dr. Marcio Ibrain de Carvalho, memberof thehigher councilof the Felice Rosso foundation, forthis workoriginated from the joint of Dr. Silva Guimarães, Dr. João de Sena Horta and Dr. Pedro Sena Horta, former physicians of Felício Rocho hospital staff.
Stenosis in the upper
Same patient: beginning of treatment three months after caustic soda ingestion
Same patient: Six months after treatment
Same patient: Nine months after treatment
Same patient: Twelve months after beginning treatment
patient was being fed on solid with the exception of meat and bread
Second case: beginning of treatment three months after caustic soda ingestion
Second case: same patient
Pneumatic balloons (inflatable) of various diameters
Pneumatic balloons (inflatable) of various diameters
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