Caustic ingestions represent a well-known public health concern, with 80% of cases worldwide seen in children because of accidental ingestion.1–4 Treatment of caustic ingestion injuries is well studied, with endoscopic management as the first-line treatment.5 However, if endoscopic treatment is unsuccessful, surgical management is the next step with overall positive outcomes.6 Despite the success of surgical treatments in the management of esophageal injury, the potential for morbidity and complications after surgery is not insignificant.7 Consequently, gastrointestinal (GI) experts must remain up to date on the spectrum of GI sequelae and workup of complications that arise with surgical treatment.
A 53-year-old African American woman presented to her primary care physician after 6 months of new-onset dysphagia to solids with aspiration and regurgitation of undigested food. She reported that her symptoms occurred 3 times a week and also described having substernal chest pain resembling heartburn throughout the day, which worsened when lying down. Notably, she did not report pain with meals. She suffered an accidental lye ingestion from drinking drain cleaner at the age of 4 years. She does not recall if an endoscopy was performed at that time but reported no GI issues until the age of 25 years when she began having progressive dysphagia initially to solids and then to liquids. She underwent serial esophageal dilations for 3 years for refractory esophageal strictures (exact locations not known) without symptomatic improvement. Owing to resultant malnutrition and poor quality of life, she underwent esophagectomy with colon interposition at the age of 28 years.
Owing to her recurrent symptoms of dysphagia and aspiration 2 decades after her esophageal surgery, she underwent an esophagogastroduodenoscopy (EGD) after a 2-day clear liquid diet. The EGD revealed an anastomotic stricture at the level of the upper esophageal sphincter with an estimated diameter of 8 mm and severely dilated, aperistaltic colonic mucosa with a high amount of retained partially digested food throughout the entire length of the neoesophagus (Figure 1).
She subsequently underwent a timed barium esophagram with both liquid barium and a 12-mm barium tablet because of concern for dysmotility. The study results showed completely altered anatomy due to esophagectomy with colonic interposition, delayed clearance of the contrast throughout almost the entire length of the neoesophagus, reflux of liquid barium, and the barium tablet was retained at the junction of the neoesophagus and stomach (Figure 2). She also underwent a computed tomography scan without contrast of her thorax, which showed a dilated neoesophagus with colonic haustra and air-fluid levels throughout (Figure 3). Her clinical picture was consistent with anastomotic stricture and dysmotility of her neoesophagus.
The patient was offered empiric dilation of the upper esophageal stricture, which she underwent with serial through-the-scope balloon dilation up to 15 mm. She had sustained symptomatic relief at 3-month follow-up in combination with dietary changes to more soft and liquid diet and acid suppression therapy. She was offered esophageal manometry testing, speech pathology referral for swallow evaluation and exercises, and surgical consultation but was not interested in pursuing any of these options. She will be followed in GI specialty clinic with the help of a nutritionist for long-term care.
After lye ingestion injuries, endoscopic evaluation and management are the preferred first-line treatments for esophageal injury.5 In cases where endoscopic treatment is unsuccessful, partial or total esophagectomy with gastric transposition or colonic transposition is the 2 major options available to patients seeking surgical management.6 Gastric transposition/pull-up has become the preferred method of surgically replacing a damaged esophagus. It is less technically challenging that the colon interposition, although patients may develop subsequent functional issues including reflux, recurrent strictures, and metaplasia.8 Colonic transposition is another surgical option more commonly used in the past, as in the case of our patient who can offer effective long-term function with overall low likelihood of stricture recurrence and functional complications.9,10
Despite the success of colon interposition in restoring functionality in most patients, postoperative complications are not uncommon. The most common complaint among patients after colonic transposition is dysphagia. Traditional workup often begins with swallow studies and EGD if symptoms continue to persist. EGD findings often help direct the management of complications. Knezevic et al reported in a long-term follow-up of 285 patients with colon interpositions after caustic strictures that 13 patients reported unsatisfactory functional results. These patients reported dysphagia and aspiration as their primary complaints and were subsequently trained to swallow over a period of 6–12 months, after which all patients were able to satisfactorily swallow food.7 However, more serious complications such as anastomotic leakage and stricture formation are also associated with colon interposition.7 Recurrent stricture formation is often the underlying mechanism of dysmotility in patients with caustic injury after surgical management and is believed to be caused by corrosive damage to cricopharyngeal muscles, which may explain the upper esophageal anastomotic stricture present in our patient.8
Treatment of recurrent strictures continues to be a challenge; numerous surgical options, including colopharyngoplasty and reconstruction, have been attempted with varying degrees of success.8 Furthermore, patients with extensive laryngeal scarring may require a permanent tracheostomy to minimize the risk of aspiration.9 In cases where these surgical approaches fail or are anatomically contraindicated, a gastrostomy feeding tube may be used.11
Notably, the complications in our patient's case arose >20 years after the initial esophageal surgery. Her initial presenting symptoms were dysphagia and aspiration, with EGD and barium esophagram workup revealing an upper esophageal anastomotic stricture and an aperistaltic neoesophagus with contrast retention at the gastric junction and reflux. Although anastomotic strictures as a complication after colonic interposition are commonly reported, aperistalsis is rare. To our knowledge, limited literature exists on the etiology and treatment options available to patients with aperistalsis after colon interposition after esophagectomy. Furthermore, previous literature discusses the management and successful treatment of patients presenting with common complications shortly after surgery, but occurrence of multiple complications is rare and reports of the workup and management of such patients in the long-term remain limited. Our case adds to the community's understanding of potential postsurgical complications, workup, and treatment options and highlights the importance of provider reporting of patient cases from which we can all learn.
Author contributions: All authors contributed equally to this manuscript. N. Khalaf is the article guarantor.
Financial disclosure: None to report.
Informed consent was obtained for this case report.
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