Oesophageal strictures in the austere environment: innovative, cross-disciplinary endoscopic management

Introduction: Caustic oesophageal strictures are common in many low-income countries. Purpose-made endoscopes for dilatation may be unavailable, making management of long, eccentric strictures challenging. Methods: Within a formal health system strengthening partnership, international and local resources/expertise were pooled to manage caustic strictures in two children. Dilatation equipment: flexible bronchoscopes (Vathin H-steriScope2.8mm, 2.2mm™), mobile screen (Vathin DVM-A1), flexible guidewire (Terumo™ 0.035″ flexible tip), urethral dilators (Cook Medical, S ~ Curve®, G32789). Results: Two boys (4 years, 5 years) with caustic oesophageal strictures, unable to feed orally, had gastrostomies formed. Each underwent per-oral and via-gastrostomy combined endoscopy to pass guidewires. Urethral-S-dilators were used for dilatation in patient 1. Patient 2, with a long, eccentric stricture, required a second anaesthetic and combined fluoroscopy/endoscopy for guidewire passage. This facilitated dilatation with urethral-S-dilators. A string left from mouth to gastrostomy facilitated further non-endoscopic Savary-Gilliard dilatations for both. Subsequent dilatations were effective: both progressed rapidly to oral solids and remain well at 6-month follow-up. Discussion: Challenges with bronchoscopes: lack of rigidity; no continuous air insufflation; less manoeuvrability than purpose-made endoscopes. Collaborative, cross-disciplinary anaesthetic, and surgical working ensured optimal ‘frugal innovation’ equipment use and successful outcomes. Global surgery partnership and cross-disciplinary team working resulted in an innovative solution to a challenging clinical problem.