Hoffman, Robert S.; Burns, Michele M.; Gosselin, Sophie
∗Division of Medical Toxicology, Ronald O. Perelman Department of Emergency Medicine, NYU School of Medicine, NY
†Division of Emergency Medicine/Harvard Medical Toxicology Fellowship, Boston Children's Hospital, Boston, MA
‡Department of Emergency Medicine, McGill University Health Center, Montreal
§Centre Antipoison du Québec, Quebec City, Canada Hôpital Charles-LeMoyne, Greenfield Park, Canada
To the Editor:
Although we read with interest the recent meta-analysis on the use of corticosteroids for the prevention of strictures following caustic esophageal injuries (1), we question the accuracy of results. After the ground-breaking efforts of Rosenberg et al (2,3), researchers attempted to define which patients with caustic ingestions would benefit from corticosteroids. The 3 included studies use 3 different regimens (dose and duration) of 2 different corticosteroid preparations. It is invalid to assume that all regimens from a given drug class are therapeutically equivalent without comparative data. In addition, 2 of the study's results are diluted by the inclusion of grade 1 injuries that almost never progress to strictures and grade 3 injuries that inevitably either perforate or progress to strictures (4,5). Finally, 1 study combines data for acid and alkali injuries (5).
This degree of heterogeneity invalidates any attempt to combine these 3 trials as a whole. To date, only 1 study uses a low-risk short-course corticosteroid administration protocol in patients with a high likelihood of stricture progression (grade 2b), and a low likelihood of perforation (6). The findings of this trial cannot and should not be negated by an inadequate meta-analysis. Rather, they should be confirmed or questioned based on replication or by a meta-analysis selecting injuries that are comparable and using similar treatments. Unfortunately, we are not aware of studies with such similarities. Pending new results, we suggest following Usta's protocol as the cost is negligible, the likelihood of harm is minimal, and the potential for benefit seems great.
REFERENCES
1. Katibe R, Abdelgadir I, McGrogan, et al. Corticosteroids for preventing caustic esophageal strictures: systematic review and meta-analysis.
J Pediatr Gastroenterol Nutr 2018; 66:898–902.
2. Rosenberg N, Kunderman PJ, Vroman L, et al. Prevention of experimental lye strictures of the esophagus by cortisone.
AMA Arch Surg 1951; 63:147–151.
3. Rosenberg N, Kunderman PJ, Vroman L, et al. Prevention of experimental esophageal stricture by cortisone. II. Control of suppurative complications by penicillin.
AMA Arch Surg 1953; 66:593–598.
4. Anderson KD, Rouse TM, Randolph JG. A controlled trial of corticosteroids in children with corrosive injury of the esophagus.
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5. Tuncer R, Soyupak S, Sen N, et al. Does steroid treatment prevent caustic esophageal stricture? A prospective study.
Ann Med Sci 2000; 9:56–58.
6. Usta M, Erkan T, Cokugras FC, et al. High doses of methylprednisolone in the management of caustic esophageal burns.
Pediatrics 2014; 133:E1518–E1524.
