www.elsevier.es/rgmx
REVISTA
DE
GASTROENTEROLOGIA
DE
MEXICO
´
´
ORIGINAL
ARTICLE
Topical
mitomycin
C
versus
intralesional
triamcinolone
in
the
management
of
esophageal
stricture
due
to
caustic
ingestion
夽
C.M.
Méndez-Nieto
a,∗,
F.
Zarate-Mondragón
b,
J.
Ramírez-Mayans
b,
M.
Flores-Flores
caDepartamentodeGastroenterologíayEndoscopia,HospitalÁngeles,CiudadJuárez,Chihuahua,Mexico bDepartamentodeGastroenterologíayNutrición,InstitutoNacionaldePediatría,MexicoCity,Mexico cDepartamentodeEnse˜nanza,HospitalGeneraldeZonaNo.35,CiudadJuárez,Chihuahua,Mexico
Received4March2015;accepted2July2015 Availableonline10November2015
KEYWORDS MitomycinC; Triamcinolone; Esophagealstricture; Esophagealdilation; Causticingestion Abstract
Background: Esophagealstrictureduetocausticingestionisoneofthemostdifficultproblems to manage.Esophageal dilationsarethe usual treatment andthey require agreat number ofsessionsinthemajorityofcases.Thisimpliestime,risksfor thepatient,anguishforthe relatives,andveryoften,frustrationforthephysician.
Objectives:ToevaluatetheefficacyoftheapplicationoftopicalmitomycinCandintralesional triamcinoloneinthepreventionofpost-dilationesophagealstricturerecurrence.
Materialandmethods: A prospective, comparative, nonrandomized, and longitudinal study wasconductedthatcomparedacohortof16patientstreatedwithmitomycinC(2009-2012) witharetrospectivecohortof34patientstreatedwithtriamcinolone(2002-2009).
Results:The patientstreatedwith intralesionaltriamcinolonehada medianof11dilations (minimum 4 and maximum 24), whereas the median in the patients treated with topical mitomycin Cwas 4.5 (minimum 3 and maximum 8). The groups were compared using the Mann-WhitneyUtest,findingastatisticallysignificantdifferenceofatwo-tailedP<.001.
Inthemultiplelinearregressionmodel,thedependentvariablewasthenumberofdilations andtheindependent variableswerethetypeoflesionandtreatment.Theresultwas anR2
.676withasignificancelevelofP<.001,inwhichtheregressioncoefficientfortreatmentwas B−.682(95%CI−8.286to−5.025)andthelesiongradewasB.435(95%CI2.043-4.573).
TheANOVAresultwasanF49.08andaP<.001andshowedthattheindependentvariables oftypeoflesionandtreatmenthadalinearrelationwiththenumberofdilations,reinforcing thefactthatourresultswerenotduetochance.
夽 Please citethisarticle as:Méndez-Nieto CM, Zarate-Mondragón F,Ramírez-MayansJ, Flores-Flores M.Mitomicina C tópica contra
triamcinolonaintralesionalenelmanejodelaestenosisesofágicaporcáusticos.RevistadeGastroenterologíadeMéxico.2015;80:248---254.
∗Correspondingauthor.HospitalÁngeles,CiudadJuárez,Chihuahua,México.Av.CamposElíseosNo.9371-145,Col.CamposElíseosCP
32452.Tel.:+6562271908;fax:+6562271909.
E-mailaddress:deniskar@yahoo.com(C.M.Méndez-Nieto).
2255-534X/©2015AsociaciónMexicanadeGastroenterología.PublishedbyMassonDoymaMéxicoS.A.Thisisanopenaccessarticleunder theCCBY-NC-NDlicense(http://creativecommons.org/licenses/by-nc-nd/4.0/).
Conclusions: Topicalmitomycin Cconsiderablyreduced the number ofesophageal dilations comparedwiththeuseofintralesionaltriamcinolonetoalleviatedysphagia,andthereforewe suggestitasatreatmentoptioninstricturesduetocausticingestion.
© 2015Asociación Mexicana deGastroenterología. Publishedby MassonDoyma MéxicoS.A. ThisisanopenaccessarticleundertheCCBY-NC-NDlicense(http://creativecommons.org/ licenses/by-nc-nd/4.0/). PALABRASCLAVE MitomicinaC; Triamcinolona; Estenosisesofágica; Dilataciónesofágica; Ingestióndecáusticos
MitomicinaCtópicacontratriamcinolonaintralesionalenelmanejodelaestenosis esofágicaporcáusticos
Resumen
Antecedentes: Laestenosisesofágicasecundariaaingestióndecáusticosesunodelos proble-masdemásdifícilmanejo.Eltratamientohabitualsonlasdilatacionesesofágicasquerequiere enlamayoríadeloscasosungrannúmerodesesiones,locualimplicatiempo,riesgosparael paciente,angustiaenlosfamiliaresyenmuchasocasionesfrustraciónparaelmédico. Objetivos: ValorarlaeficaciadelaaplicacióndemitomicinaCytriamcinolonaenlaprevención derecurrenciadeestenosisesofágicaposdilatación.
Materialymétodos: Estudioprospectivo,comparativo,noaleatorizadoylongitudinalendonde seincluyóunacohortede16pacientestratadosconmitomicinaC(2009-2012)ysecompararon conunacohorteretrospectivade34pacientestratadoscontriamcinolona(2002-2009). Resultados: Lamediana dedilatacionesdelospacientesenlosqueseutilizótriamcinolona intralesionalfuede11(mínimo4máximo24),mientrasquelosmanejadosconmitomicinaC tópicafuede4,5(mínimode3ymáximode8).AlcompararestosgruposconUdeMann-Whitney, seencontróqueladiferenciaesestadísticamentesignificativaa2colasp<0.001.
Alrealizarseelmodeloderegresiónlinealmúltipleconvariabledependienteelnúmerode dilatacionesyvariablesindependientestipodelesiónytratamientoseencontróunaR20.676
conunniveldesignificaciónp<0.001,endondeelcoeficientederegresiónparatratamiento fue≡---0.682(ICdel95%,---8.286a---5.025)yeldegradolesiónfue≡0.435(ICdel95%, 2.043-4.573).
AnovaconunaF49.08conunap<0.001,loquedemuestraquelasvariablesindependientes tipodelesiónytratamientoobservanunarelaciónlinealconelnúmerodedilataciones,loque refuerzaquenuestrosresultadosnosondebidosalazar.
Conclusiones:La mitomicina Ctópica redujo considerablementeel número de dilataciones esofágicas encomparaciónalusodetriamcinolonaintralesionalpara aliviarla disfagia,por loquelasugerimoscomounaopcióneneltratamientodelasestenosisporcáusticos. ©2015AsociaciónMexicanadeGastroenterología.Publicado porMassonDoymaMéxicoS.A. EsteesunartículoOpen AccessbajolalicenciaCCBY-NC-ND(http://creativecommons.org/ licenses/by-nc-nd/4.0/).
Introduction
One of the main complications of the ingestion of
caus-ticsubstancesisesophagealstricture.Themanagementof
theseproblemsisadifficultanddistressingchallengeforthe
patient, the parents, and for the physician in charge of
thetreatment. Esophagealrehabilitationhasbeen carried
outformanyyearswithdifferenttechniques,dependingon
the experienceof each physician.1 Esophageal prostheses
or splints,dilationswithballoonsor Savary-Gilliard plugs,
Hurstdilators,etc.,havebeenused,butinreality,thereis
noworldwidestandardizationforthemanagementofthese
patientsandevenlesssofortheuseofcertainsubstances
suchastriamcinoloneacetonideappliedintralesionally,or
morerecently, topicalmitomycin C.1,2 Triamcinolone
ace-tonideisasyntheticcorticosteroidwithapreventiveeffect
oncollagensynthesis,fibrosis,andchroniccicatrizationthat
hasbeenusedformanyyears,appliedinintralesional
injec-tionafteresophagealdilationsforthepurposeofdelaying
cicatrization and thus reducing the number of dilations.2
MitomycinCisanantineoplasticandantiproliferativeagent
thatreducestheformationof collagenthroughfibroblasts
andimpedescellduplication.Itcandelaythecicatrization
processincertaintissues,whichiswhyithasbeenused
top-icallyfortreatingesophagealstricture.3,4Themainaimof
thisstudy wastoevaluatethenumberofesophageal
dila-tionsrequired toachieve clinicalimprovement in agroup
of patients treated with mitomycin C and another
grouptreatedwithtriamcinoloneacetonide.
Methods
A prospective, comparative, nonrandomized, longitudinal
Table1 Classificationofcausticesophagitis(Maratka). GradeI Hyperemiaandedema
GradeII Yelloworwhiteplaqueswith pseudomembraneformation IIa Lesionslocatedonone-thirdofthe
esophagusandasinglewall
IIb Concentriclesionslocatedonone-thirdof theesophagus
IIc Linearorconcentriclesionsin2or3thirds oftheesophagus
GradeIII Bleedingandulceratedmucosawithathick exudate
treatedwithmitomycinC(2009-2012)andtheywere com-paredwitharetrospectivecohortof34patientstreatedwith triamcinolone(2002-2009).The50patientswereattended toatthezone6,66,and35hospitalsoftheInstituto Mexi-canodelSeguroSocialinCiudadJuárez,Chihuahua,Mexico. Theywerediagnosedwithesophagealstricturesecondaryto causticingestionandmanagedwithesophagealdilations.
Writtenstatements ofinformedconsentwereobtained fromtheparentsofthepatients.
Inthefirst24haftercausticingestion,upperendoscopy wasdonetoclassifytheesophageallesiongradeaccording tothemodifiedMaratkaclassification5,6(Table1).
Fourweeksafterthefirstendoscopy,abarium
esopha-gogram andendoscopy were carried out,establishing the
diagnosisofesophagealstricture.
All the patients included in the dilation protocol
pre-sented with some grade of dysphagia that was classified
accordingtotheMellowandPinkasscale7(Table2).Because
thecohortwasapediatriconeandthemajorityofthe
chil-drenwerepreschoolers,thedysphagiawasevaluatedbythe
parents,andclassifiedasgrade0:nodifficultyin
swallow-ing foods, grade 1: difficulty in swallowing solids (pieces
offood),grade2:difficultyinswallowingsoftsolids (baby
food),grade3:difficultyinswallowinganytypeofsolidor
liquid,andgrade4:difficultyinswallowingsaliva(important
sialorrhea).
Procedure
All the esophageal dilations were carried out with the
patientundergeneral anesthesia, always administeredby
a certified pediatric anesthesiologist. The dilations were
performedwithSavary-Gilliardplugs(flexibleanddirected
plasticdilators),firstpassing aflexiblemetallicguidewire
throughthe strictureuntilreachingthestomach andthen
passingadifferentcaliberSavarydilator,dependingonthe
Table2 Dysphagiascale(MellowandPinkas). Gradesofdysphagia Typeofdysphagia
Grade0 Nodysphagia
Grade1 Dysphagiatosolids
Grade2 Dysphagiatosoftsolids Grade3 Dysphagiatosolidsandliquids Grade4 Cannotevenswallowsaliva
Figure 1 Punctiform esophageal stricture and passage of theflexibleguidewirethroughthestrictureuntilreachingthe stomach.
diameterofthestricture,throughthatsamespace(Fig.1).
Afterthedilations,weappliedintralesionaltriamcinolonein
4quadrants.Thesteroidwasappliedinthefirst5dilations
withanintervalofoneweekbetweenthefirstandsecond
dilationandthenevery2weeksormore,dependingonthe
clinicalandendoscopicresponse.
Inthemitomycin Cgroup,thesamedilation technique
wasfollowed,afterwhichthemedicationwasapplied
top-ically inthe first5dilationswithan intervalof oneweek
betweenthefirstandseconddilationandthenevery2weeks
ormore,dependingontheclinicalandendoscopicresult.
Allthepatientsweremanagedwithprophylacticoral
ran-itidine,begunafterthefirstdilationandnotsuspendeduntil
thetreatmentwasfinished.
The absence of dysphagia for 6 months after the last
dilationwasconsideredgoodtreatmentresponse.
Allthepatientshadfollow-upofatleastoneyearafter
beingreleasedfromthehospital.
Instrumentsutilized
Savary-Gilliard dilators of different diameters or French
sizeswereused(Fig.2).
A Pentax endoscope of 7.8mm in diameter was used
for the first diagnostic endoscopy, the esophageal
dila-tions, and the application of intralesional triamcinolone
acetonide.
APentaxendoscopeof9.0mmindiameterandan
operat-ingchannelof2.8mmwasusedformitomycinCapplication.
ADormiabasketandcottonswabwereusedforirrigation
(Fig.3).
Descriptionofthetechnique
Intralesionaltriamcinoloneacetonideapplication:
1. Esophageal dilation under general anesthesia with a
Pentax 7.8mm flexible endoscope and Savary-Gilliard
Figure2 Savary-Gilliarddilators.
2. After esophageal dilation the Pentax 7.8mm flexible
endoscopewas introduced and a sclerotherapy needle
waspassedthroughtheoperatingchanneltoapplythe
triamcinoloneacetonideintralesionallyata
concentra-tionof40mg/ml(1mlofthesteroidwasdilutedin3ml
ofsterile water). Alwaysunderdirect vision,0.5ml to
1mlwasappliedperquadrantinthedilatedarea.
Topicalapplicationofmitomycin
1. EsophagealdilationundergeneralanesthesiawithPentax
7.8mmflexibleendoscopeandSavary-Gilliarddilators.
2. After esophageal dilation the Pentax 9.0mm
flexi-ble endoscope with a 2.8mm operating channel was
introduced,throughwhichaDormiabasketwithasmall
cottonswabatitstipwaspassed(Fig.4).
3. Once thedilatedarea waslocated,the Dormiabasket
irrigatorsaturatedthe cotton swabwith 2cc of
mito-mycinC ataconcentrationof0.4mg/ml.Pressurewas
placedontheerodedmucosawiththeswab,thus
topi-callyapplyingthemitomycinCfor3min, alwaysunder
directvision(Fig.5).
Figure3 Dormiabasket with irrigationchannel andcotton swabatthetip.
Figure 4 Pentax 9mm endoscope with 2.8mm operating channelthroughwhichtheDormiabasketwithcottonswabon thetippasses.
Diagnosisandmanagementofallthepatientswere
car-riedoutbythesamepediatricgastroenterologist.
Statistical
analysis
The SPSS 16 statistical package was utilized. Descriptive
statisticswereappliedusingmeasuresofcentraltendency
anddispersionandnormalitytestsforthequantitative
varia-blesandfrequencies, andpercentages for thecategorical
variables.Thegroupcomparisonswereperformedwiththe
Mann-WhitneyUtestbecausethedistributionwasnot
nor-mal. Multiple linear regression was carried out with the
number of dilations as the dependent variable, and the
typeof lesion and typeof treatment as the independent
variables.
Figure5 CottonswabsaturatedwithmitomycinCand topi-callyappliedtothedilatedarea.
Table3 Patientswithcausticstrictureandapplicationof intralesionaltriamcinolone. Age (months) Sex Lesion classification Dysphagia grade Numberof dilations 27 M IIb 3 14 11 F IIb 2 9 23 F III 4 24(3)a 18 F IIb 3 10 36 M IIb 1 7 26 M IIb 1 12 22 F IIb 1 6 28 M IIb 2 8 27 F IIb 2 9 19 F IIb 1 14 17 F IIc 1 11 20 M IIb 1 4 22 F III 3 20(2)b 28 M IIb 2 12 18 F IIc 3 17 148 M IIb 2 9 14 M IIc 3 14 32 M IIc 4 16(2)b 31 F IIb 2 10 48 F IIb 3 12 56 M IIb 3 15 22 F IIb 3 12 12 M IIb 2 10 14 F IIc 2 9 19 F IIb 1 11 28 M IIb 1 12 32 M IIb 2 8 17 F IIb 2 14 12 M IIc 1 11 27 M IIb 1 9 30 M IIc 3 15 24 F IIb 3 11 26 M IIb 1 12 22 F IIb 1 10
aPatientwith3esophagealstricturesatthetimeofdiagnosis. b Patientwith2esophagealstricturesatthetimeofdiagnosis.
Results
Distributionbysexwas24females(48%)and26males(52%).
Themedianagewas24months(minimum11,maximum148
months).Theclinical findingsandnumberof dilationsare
showninTables3and4.
Alkaliswerethecauseofthelesionin46(92%)casesand
acidswerethecausein4(8%).
At the time of initial diagnosis, 4 patients had 2
esophagealstricturesitesandonecasehad3sites.
TheresultsoftheKolmogorov-SmirnovandShapiro-Wilk
normalitytestsforthevariablesofage,dysphagia,and
num-berof dilations, groupedaccording totreatment, showed
thatageinthemitomycingroupwastheonlyvariablewith
normaldistribution.
Therewerenostatisticallysignificantdifferencesinthe
groupcomparisonusingtheMann-WhitneyUtestinrelation
toage,sex,ordysphagia.
Table4 Patientswithcausticstrictureandapplicationof topicalmitomycinC. Age (months) Sex Lesion classification Dysphagia grade Numberof dilations 36 M IIb 1 4 22 M IIb 3 7 18 F IIb 1 5 28 M IIb 3 8(2)a 27 F IIc 1 4 31 F IIb 2 3 38 F IIb 1 4 27 M IIb 2 5 20 F IIb 1 5 19 M III 3 7(2)a 32 M IIb 2 4 24 F IIb 2 5 22 M IIb 1 3 23 M IIb 1 4 19 F IIb 1 4 31 M IIc 3 6
a Patientswith2esophagealstricturesatthetimeofdiagnosis.
The median of dilations in the patients treated with
intralesional triamcinolonewas11 (minimum4,maximum
24),whereasitwas4.5(minimum3,maximum 8)inthose
managedwithtopicalmitomycinC.IntheMann-WhitneyU
testgroupcomparison,therewasastatisticallysignificant
differenceofatwo-tailedp<0.001.
Inregardtolesionclassification,thepatientswithagrade
IIcandIIIweretheonesthatingeneralrequiredagreater
numberofdilations(Tables3and4).
In the multiple linear regression model, in which the
dependent variable was the number of dilations, and
theindependentvariableswerethetypeoflesionand
treat-ment, the resultwasR2 0.676,with asignificant level of
p<0.001. The regression coefficient for treatment was B
−0.682(95%CI−8.286to−5.025)andthelesiongradewas
B0.435(95%CI2.043-4.573).
The ANOVAresult wasan F49.08 and ap < 0.001 and
showed that the independent variables of type of lesion
andtreatmenthadalinearrelationwiththenumberof
dila-tions,reinforcingthefactthatourresultswerenotdueto
chance.
All the patients had a favorable treatment response,
defined as the absence of dysphagia and endoscopic
improvementforatleast6monthsafterthelastdilation.
No secondary effects were reported with the use of
intralesionaltriamcinoloneortopicalmitomycinC.
Discussion
Causticingestioncontinuestobeapediatrichealthproblem
andthegroupatgreatestriskarechildrenunder5yearsof
age,withnosex-relatedpredominance,concurringwithour
results.8,9
Diagnosticendoscopyatthefirst24haftertheaccident
is a subject of debate, given that some authors
recom-mend it only if the patient presents with some kind of
thisdiagnosticprocedurewasperformedinallthepatients
becausetherewasnodirectcorrelationinalargenumberof
patientsbetweentheclinicalfindingsrelatedtothebuccal
mucosa and the grade of the esophageal lesion.
There-fore,wefeltitwasimportanttoclassifythelesionandin
thismanner beginpatientmanagement,whetherwiththe
patienthospitalized,watchingforpossiblecomplications,or
releasinghimor herwithouttreatmentor withoutpatient
treatment.12,13
Different therapeutic modalities have been used in an
attempt to prevent post-caustic ingestion complications,
suchastheuseofantibiotics,systemiccorticosteroids,total
parenteral nutrition, nasogastric tubes, anti-acids, splint
placement,etc.However,none ofthem havebeen shown
tobetrulyeffective.14 Inourwork,wealwaysused
antibi-otics and systemic steroids, depending on the grade of
the esophageal lesion. Nevertheless, as in the majority
ofthestudiespublished,complicationswerealmostalways
present.
Inthepresentstudy,weobservedthatthepatientsthat
developedesophagealstricture,allhadatleastaIIblesion.
ThisproblemwasnotfoundinthepatientsthathadIorIIa
lesions.Thepatients thatwerethemost difficultto
man-ageinrelationtothenumberofdilationswerethosewitha
gradeIIIlesionwiththeMaratkaclassification.Inour
liter-aturereviewwefound nostudyrelatingesophageallesion
gradeaccordingtotheMaratkaclassificationwiththe
pres-enceofstricture.
Whenthepatientpresentswithdysphagia,firstan
esoph-agogram is done to evaluate the type of stricture, its
location,number,length,etc.Inthismanner we canplan
thecommencementofdilations,performingthemunder
flu-oroscopywhenthestricturesarecomplex.15
We administer a prophylactic acid secretion inhibitor,
suchasranitidine,toallpatientsthatundergoanesophageal
dilation program, given that these patients can present
with gastroesophageal reflux due to esophageal motility
alterations secondary to the burn, or present with short
esophagus.1,14
Ofthe50patientswithesophagealstricture,weobserved
that5ofthemhadmorethanonestrictureatthetimeof
diagnosis and theywere the patients that required more
dilationsessions.
Themajorityofpatientshadshortstrictures,butitwas
notpossibletoobtainthatdatuminallthepatients,andso
itwasnotincludedintheanalysis.
Initialmanagementofesophagealstricturecontinuesto
bebasedprimarily onesophagealdilations. Insome cases
the post-dilationuse of substances such astriamcinolone
acetonideandmitomycinChasbeenemployedinanattempt
toreducethelengthoftimeoftreatment.15
Triamcinoloneacetonideisasyntheticcorticosteroidthat
hasbeenusedintopical,oral,orinhaledforms,oras
intra-articularorintramuscularinjectionastreatmentindiverse
pathologieswithimportantinflammatory processes.It has
been appliedfor many years in patients with esophageal
stricture,asanintralesionalinjectionaftertheesophageal
dilations, for the purpose of delaying cicatrization.
How-ever, contradictory study results have been published.14
In our experience,we had moderate results withits use,
giventhatthemeanofdilationsperpatientwaspractically
12sessions,signifyingatreatmenttimeofupto2years.
MitomycinCisanantibioticderivedfromStreptomyces
caespitosus. It is an antineoplastic and antiproliferative
agentthathasbeenusedindifferentspecialities,including
oncology,ophthalmology,otorhinolaryngology,andrecently
inpatientswithesophagealstricture.15Itsuseinthelatter
pathologyvariesfromarticletoarticle,butthelarge
major-itystate thatitis appliedtopically withgauzesor cotton
swabsimpregnatedwiththesubstance.Othersreportitsuse
withsprayersorappliedthroughrigidorflexible
esophago-scopes at the tip of the hood, to avoid contact of the
substancewithhealthymucosa.1,12,15 Inanefforttofinda
morepracticaltechniqueandpreventingasmuchaspossible
thecontactofmitomycinCwithhealthymucosa,we
devel-opedanewapplicationtechnique.Weapplythesubstance
bymeansofaDormiabasketandhavehadgoodresults,
con-curringwiththemajorityofarticlesinwhichitstopicaluse
hasimportantlyreducedthenumberofdilationsinpatients
withdifficult-to-manageesophagealstrictures.Thereisno
uniformconsensusonthe numberofapplicationsofthese
medications,giventhatthepublishedarticlesdescribe1to
12applicationsperpatient.1,15Inour7-yearexperience,we
haveusedtriamcinoloneacetonideinthefirst5dilationsof
eachpatient withdifferentclinical responses. Duetothe
poorresponse of somepatients tothe use of the
intrale-sionalsteroid,in2009wedecidedtousetopicalmitomycin
Cduringthefirst5dilationsofeach patientandcompare
itsuse withthat of thesteroid. We found thatthe
num-ber of sessions decreased significantly with mitomycin C.
ConcentrationsofmitomycinChavebeenusedfrom0.1mg
up to 1mg/ml.1,15 In our patients we used a
concentra-tionof 0.4mg/ml,asin the majority ofthe studies, with
goodresults, and we found no secondary effects with its
use.
Eventhoughtheresultsshowedaclearstatistical
differ-enceinfavorofmitomycinC,ourstudyhasthelimitation
thatthecohortwascomparedwitharetrospectiveoneand
therewasnorandomizing.Thispavesthewayforconducting
afuture randomized, comparative, andprospective study
blindedtotheevaluator tobeabletoarrive atdefinitive
conclusions.
Conclusions
Itis difficult todevelop the protocol of a study on
caus-ticingestion andevenmoresoonitscomplications,given
thatallpatientsdonotingestthesamesubstance,thesame
concentration,norisitincontactwiththemucosaforthe
samelengthoftime.Nevertheless,inaccordancewithour
studyresults,wesuggesttheuseofmitomycinCasan
alter-nativeinthemanagementofpatientswithdifficult-to-treat
esophagealstrictureduetocausticingestion.
Ethical
responsibilities
Protection of persons and animals.The authors declare
thatnoexperimentswereperformedonhumansoranimals
forthisstudy.
Data confidentiality.The authors declare that they have
followedthe protocolsof theirwork center in relation to
Righttoprivacyandinformedconsent.Theauthorshave
obtainedtheinformedconsentofthepatientsand/or
sub-jects referred to in the article. This document is in the
possessionofthecorrespondingauthor.
Financial
disclosure
No financial support was received in relation to this
study/article.
Conflict
of
interest
Theauthorsdeclarethatthereisnoconflictofinterest.
References
1.BergerM,UreB,LacherM.MitomycinCinthetherapyof recur-rentesophagealstrictures:Hypeorhope?EurJPediatrSurg. 2012;22:109---16.
2.KochharR,Ray JD,SriramPV.Intralesionalsteroidsaugment theeffectsofendoscopicdilationincorrosiveesophageal stri-ctures.GastrointestEndosc.1999;49:509---13.
3.OlutoyeOO,ShulmanRJ,CottonRT.MitomycinCinthe manage-mentofpediatriccausticesophagealstrictures:Acasereport. JPediatrSurg.2006;41:E1-E3.
4.KhaledM,MohamedA,HeshamM.TopicalmitomycinC applica-tioniseffectiveinmanagementoflocalizedcausticesophageal. strictures. Adoubleblinded, randomized,placebo-controlled trial.JPediatrSurg.2013;48:1621---7.
5.MaratkaZ.Terminología,definicionesycriteriosdiagnósticosen endoscopiadigestiva.3ed.Madrid:NormedVerlag;1994. 6.RodriguezL.Ingestiónde sustanciascáusticas:reportedeun
casoyrevisiondelaliterature.RevGastrohnup.2010;12Supl 1:S4---9.
7.NagaichN,NijhawanS,KatiyarP,etal.MitomycinC:Arayof hopeinrefractorycorrosiveesophagealstrictures.DisEsoph. 2014;27:203---5.
8.AustriaMR.EsofagitisporcáusticosenPediatría. Procedimien-tos endoscópicos en gastroenterología. 1 ed. México, D.F.: Mipliformas;1998.p.337-341.
9.EdmonsonMB.Causticalkaliingestionsbyfarmchildren. Pedi-atrics.1987;79:413---6.
10.Gupta SK, Croffie JM, Fitzgerald JF. Is esophagogastroduo-denoscopy necessary in all caustic ingestions? J Pediatr GastroenterolNutr.2001;32:50---3.
11.LamireauT,RebouissouxL,DenisD,etal.Accidentalcaustic ingestióninchildren:Isendoscopyalwaysmandatory?JPediatr GastroenterolNutr.2001;33:81---4.
12.BaskinD,UrganciN,AbbasogluL,etal.Astandardisedprotocol fortheacutemanagement ofcorrosiveingestioninchildren. PediatrSurgInt.2004;20:824---8.
13.Glodman LP, Weigert JM. Corrosive substance ingestion: Areview.AmJGastroenterol.1984;79:85---90.
14.BicakiU,BurakT,GulayD.Minimallyinvasivemanagementof childrenwithcausticingestion:Lesspainforpatients.Pediatr SurgInt.2010;26:251---5.
15.El-AsmarKM,HassanMA,AbdelkaderHM,etal.Topical mit-omycinCapplicationiseffectiveinmanagementoflocalized causticesophagealstricture: Adouble blinded, randomized, placebocontrolledtrial.JPediatrSurg.2013;48:1621---7.
