Feasibility of Endless String with self-bougienage as an alternative to coloplasty in corrosive esophageal stricture
This study demonstrates that Endless String-guided Savary-Gilliard dilation followed by supervised and independent self-bougienage is a feasible and effective alternative to esophagocoloplasty for compliant patients with refractory corrosive esophageal strictures, successfully restoring normal swallowing, improving quality of life, and averting the need for major surgery in the majority of cases.
Original paper licensed under CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). This is an AI-generated explanation of the paper below. It is not written or endorsed by the authors. For technical accuracy, refer to the original paper. Read full disclaimer
Imagine a tube that carries food from the mouth to the stomach, a vital highway that can become blocked by a severe chemical burn. When someone accidentally or intentionally swallows a corrosive substance, the lining of this tube can scar over, narrowing into a tight, rigid tunnel that makes swallowing impossible. For decades, the standard solution for the most stubborn cases has been major surgery: removing the damaged section and replacing it with a piece of the colon. While effective, this operation is a heavy burden, carrying risks of infection, leakage, and a long recovery that leaves the patient without their original esophagus. Doctors have long sought a way to keep the native tube open without resorting to such a drastic replacement, particularly for patients whose blockages are too long or complex for simple balloon stretching.
A team of surgeons at Seth GS Medical College and KEM Hospital in Mumbai has explored a less invasive path for a specific group of patients. They focused on individuals with long, tight scars who had already failed standard endoscopic treatments but whose blockages were still passable enough to thread a thin wire through. Instead of cutting out the esophagus, the researchers used a technique involving an "endless string." This is a continuous loop of thread that is passed through the nose, down the esophagus, out through a small opening in the abdomen, and then brought back up, creating a guide rail inside the body. Once this string is in place, it acts as a track for progressively larger dilators—smooth, tapered rods that gently stretch the scar tissue over time. The ultimate goal was to train the patient to perform this stretching themselves at home, maintaining the opening without needing further hospital visits or major surgery.
The study followed 58 patients who had been referred for the major colon-replacement surgery. The medical team identified 26 of these individuals whose strictures met the specific criteria for the string-guided approach. After excluding two patients who could not be followed up, the researchers analyzed the outcomes of the remaining 24. The process began by inserting the endless string, which required a combination of endoscopy and, in many cases, minor surgical exploration to guide the wire through the damaged tissue. Once the string was secured, the team performed a series of dilations in the hospital, gradually increasing the width of the esophagus until it could comfortably accommodate a rod 12 millimeters in diameter. This phase took an average of nine sessions over a period of roughly six and a half months.
Once the esophagus was wide enough, the patients were taught to perform the dilation themselves using a 12-millimeter dilator, initially under supervision and then independently at home. The results were promising for those who stayed committed to the regimen. Normal swallowing was restored in 38% (22 out of the 58 total referred) of patients, moving them from a state where they could barely swallow saliva to a state where they could eat a regular diet. Their body weight increased significantly, rising from an average of roughly 36 kilograms to over 41 kilograms, reflecting their ability to nourish themselves properly. The vast majority of these patients reported a marked improvement in their quality of life, noting less interference with daily activities and a sense of control over their treatment.
However, the method was not a universal cure. Two patients required the major colon-replacement surgery after all. One patient did not follow the daily self-dilation routine, causing the stricture to tighten again, while the other accidentally created a false passage—a tear in the wall of the esophagus—during self-dilation. Other complications included localized pain in nearly a third of the patients and a small number of cases involving salivary fistulas, which are leaks of saliva that required surgical repair. Despite these setbacks, the study demonstrates that for a select group of patients with passable, long-segment corrosive strictures, the endless string technique followed by disciplined self-dilation can keep the esophagus open and functional. This approach offers a viable alternative to the more invasive coloplasty, allowing patients to retain their native anatomy and avoid the significant morbidity associated with replacing the esophagus with a section of the colon.
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