Novel endoscopic treatment to prevent refractory caustic esophageal strictures: a propensity score-matched analysis

Refractory caustic esophageal stricture (RCES) is a highly morbid condition. Prevention, rather than treatment, remains the ultimate goal. During the acute phase of injury, we have observed abundant fibrinous adhesions on the luminal surface of the injured esophagus, leading to luminal obliteration. We hypothesize that maintaining luminal patency during this period using our novel technique—Repeated Endoscopy with Intraluminal Fibrinous adhesioLysis of the Esophagus (RIFLE)—is crucial for successful subsequent esophageal dilation and for reducing the prevalence of RCES. Patients with Zargar grade IIb to IIIa caustic acid esophageal injuries were included in the study. Those who underwent the RIFLE program were assigned to the study group. Upper endoscopy with gentle lysis of intraluminal fibrinous adhesions was performed by advancing the endoscopic tip along with normal saline irrigation through the lesions, initially on the second or third day post-ingestion, and then repeated twice weekly during the first two weeks after the injury. Patients who received conventional treatment comprised the control group. Individuals in both groups who developed esophageal strictures underwent a dilation program. One-to-one propensity score matching was conducted. Fifty patients (25 in the RIFLE group and 25 in the conventional group) met the inclusion criteria. The median number of RIFLE sessions was four, and no endoscopic treatment-related complications occurred in patients undergoing RIFLE. At a median follow-up of 9 months, the rates of esophageal stricture, RCES, and esophageal reconstruction were significantly lower in the RIFLE group compared to the conventional group: 6/25 (24%) vs. 24/25 (96%), p < 0.001; 2/25 (8%) vs. 19/25 (76%), p < 0.001; and 2/25 (8%) vs. 17/25 (68%), p < 0.001, respectively. Patients with severe caustic acid esophageal injury without transmural necrosis who underwent the RIFLE procedure experienced a reduced prevalence of RCES and subsequent esophageal reconstruction.