A randomized prospective study comparing rigid to balloon dilators for benign esophageal strictures and rings

Refractory esophageal strictures: what to do when dilation fails

Benign esophageal strictures arise from a diversity of causes, for example esophagogastric reflux, esophageal resection, radiation therapy, ablative therapy, or the ingestion of a corrosive substance. Most strictures can be treated successfully with endoscopic dilation using bougies or balloons, with only a few complications. Nonetheless, approximately one third of patients develop recurrent symptoms after dilation within the first year. The majority of these patients are managed with repeat dilations, depending on their complexity. Dilation combined with intra lesional steroid injections can be considered for peptic strictures, while incisional therapy has been demonstrated to be effective for Schatzki rings and anastomotic strictures. When these therapeutic options do not resolve the stenosis, stent placement should be considered. Self bougienage can be proposed to a selected group of patients with a proximal stenosis. As a final step surgery is an option, but even then the risk of stricture formation at the anastomotic site remains. This chapter reviews refractory benign esophageal strictures and the treatment options that are currently available.

Esophageal anastomotic strictures: outcomes of endoscopic dilation, risk of recurrence and refractory stenosis, and effect of foreign body removal

BACKGROUND & AIMS

Esophageal anastomotic strictures often require repeat dilation to relieve dysphagia. Little is known about factors that affect their remediation. We investigated long-term success and rates of recurrence or refractoriness after dilation and factors associated with refractory stenosis.

METHODS

We performed a retrospective study of 74 patients with an anastomotic stricture that had been dilated during a 5-year period (564 dilations; median follow-up period, 8 months). A stricture was refractory if luminal patency could not be maintained after ≥5 dilation sessions during 10 weeks.

RESULTS

Of the 74 patients, 93% had initial relief of dysphagia. The stricture recurred in 43% of patients, and 69% were considered refractory. Removal of sutures/staples protruding into the lumen did not accelerate time to initial patency (median, 37 days; interquartile range [IQR], 20-82 days) or lengthen the dysphagia-free interval (37.4 days; IQR, 8-41 weeks), compared with patients who did not undergo removal (initial patency, median 55 days; IQR, 14-109 days; P = .66 and median dysphagia-free interval, 21.7 days; IQR, 9-64 weeks; P = .8). Use of fluoroscopy during dilation (odds ratio, 8.92; 95% confidence interval, 1.98-40.14) was positively associated with development of refractory strictures, whereas neoadjuvant chemotherapy (odds ratio, 0.28; 95% confidence interval, 0.07-0.97) was inversely associated. Female sex and distal location of strictures increased risk of refractoriness as effect modifiers in multivariate analysis.

CONCLUSIONS

Endoscopic dilation is highly successful in achieving luminal remediation, yet anastomotic strictures are often refractory and frequently recur. Removal of sutures/staples within the lumen does not help achieve patency. Need for fluoroscopic guidance indicates a high likelihood of refractoriness to dilation, whereas prior neoadjuvant chemotherapy indicates a lower risk.

Prevention and treatment of esophageal stenosis after endoscopic submucosal dissection for early esophageal cancer

Endoscopic submucosal dissection (ESD) for the treatment of esophageal mucosal lesions is associated with a risk of esophageal stenosis, especially for near-circumferential or circumferential esophageal mucosal defects. Here, we review historic and modern studies on the prevention and treatment of esophageal stenosis after ESD. These methods include prevention via pharmacological treatment, endoscopic autologous cell transplantation, endoscopic esophageal dilatation, and stent placement. This short review will focus on direct prevention and treatment, which may help guide the way forward.

Risk of recurrent or refractory strictures and outcome of endoscopic dilation for radiation-induced esophageal strictures

BACKGROUND

Radiation therapy for head, neck, and esophageal cancer can result in esophageal strictures that may be difficult to manage. Radiation-induced esophageal strictures often require repeat dilation to obtain relief of dysphagia. This study aimed to determine the long-term clinical success and rates of recurrent and refractory stenosis in patients with radiation-induced strictures undergoing dilation.

METHODS

Retrospective cohort study of patients with radiation-induced strictures who underwent endoscopic dilation by a single provider from October 2007-October 2012. Outcomes measured included long-term clinical efficacy, interval between sessions, number of dilations, and proportion of radiation strictures that were recurrent or refractory. Risk factors for refractory strictures were assessed.

RESULTS

63 patients underwent 303 dilations. All presented with a stricture >30 days after last radiation session. Clinical success to target diameter was achieved in 52 patients (83%). A mean of 3.3 (±2.6) dilations over a median period of 4 weeks was needed to achieve initial patency. Recurrence occurred in 17 (33%) at a median of 22 weeks. Twenty-seven strictures (43%) were refractory to dilation therapy. Fluoroscopy during dilation (OR 22.88; 95% CI 3.19-164.07), severe esophageal stenosis (lumen <9 mm) (OR 10.51; 95% CI 1.94-56.88), and proximal location with prior malignancy extrinsic to the lumen (OR 6.96; 95% CI 1.33-36.29) were independent predictors of refractory strictures in multivariate analysis.

CONCLUSIONS

(1) Radiation-induced strictures have a delayed onset (>30 days) from time of radiation injury. (2) Endoscopic dilation can achieve medium-term luminal remediation but the strictures have a high long-term recurrence rate of up to 33%. (3) Remediation of radiation strictures following laryngectomy can be achieved but require frequent dilations. (4) Clinical and procedural predictors may identify patients at high risk of refractory strictures. (5) The optimal strategy in highly selected refractory patients is not clear.

Richard Schatzki: a familiar ring

OBJECTIVE

The Schatzki ring was named for Richard Schatzki, a renowned radiologist who described the entity with his colleague, John E. Gary. The purpose of this article is to shed more light on a man who made such a significant contribution and to chronicle developments concerning this important radiologic finding.

CONCLUSION

The Schatzki ring was described long ago, but its cause is poorly understood even today.

Stents for benign and malignant esophageal strictures

This paper presents commentaries on endotherapy for esophageal perforation/leaks; treatment of esophageal perforation; whether esophageal stents should be used for treating benign esophageal strictures; what determines the optimal stenting period in benign esophageal strictures/leaks; how to choose an esophageal stent; how a new fistula secondary to an esophageal stent should be treated; which strategy should be adopted when a fistula of a cervical anastomosis occurs; intralesional steroids for refractory esophageal strictures; balloon and bougie dilators for esophageal strictures and predictors of response to dilation; whether refractory strictures from different etiologies respond differently to endotherapy; surgical therapy of benign esophageal strictures; and whether stenoses following severe esophageal burns should be treated by esophageal resection or esophageal bypass.

Endoscopic repair of post-surgical gastrointestinal complications

Complications following gastrointestinal surgery may require re-intervention, can lead to prolonged hospitalization, and significantly increase health costs. Some complications, such as anastomotic leakage, fistula, and stricture require a multidisciplinary approach. Therapeutic endoscopy may play a pivotal role in these conditions, allowing minimally invasive treatment. Different endoscopic approaches, including fibrin glue injection, endoclips, self-expanding stents, and endoscopic vacuum-assisted devices have been introduced for both anastomotic leakage and fistula treatment. Similarly endoscopic treatments, such as endoscopic dilation, incisional therapy, and self-expanding stents have been used for anastomotic strictures. All these techniques can be safely performed by skilled endoscopists, and may achieve a high technical success rate in both the upper and lower gastrointestinal tract. Here we will review the endoscopic management of post-surgical complications; these techniques should be considered as first-line approach in selected patients, allowing to avoid re-operation, reduce hospital stay, and decrease costs.

Acute GI obstruction

Acute gastrointestinal obstruction occurs when the normal flow of intestinal contents is interrupted. The blockage can occur at any level throughout the gastrointestinal tract. The clinical symptoms depend on the level and extent of obstruction. Various benign and malignant processes can produce acute gastrointestinal obstruction, which often represents a medical emergency because of the potential for bowel ischemia leading to perforation and peritonitis. Early recognition and appropriate treatment are thus essential. The typical clinical symptoms associated with obstruction include nausea, vomiting, dysphagia, abdominal pain and failure to pass bowel movements. Abdominal distention, tympany due to an air-filled stomach and high-pitched bowel sounds suggest the diagnosis. The diagnostic process involves imaging including radiography, ultrasonography, contrast fluoroscopy and computer tomography in less certain cases. In patients with uncomplicated obstruction, management is conservative, including fluid resuscitation, electrolyte replacement, intestinal decompression and bowel rest. In many cases, endoscopy may aid in both the diagnostic process and in therapy. Endoscopy can be used for bowel decompression, dilation of strictures or placement of self-expandable metal stents to restore the luminal flow either as a final treatment or to allow for a delay until elective surgical therapy. When gastrointestinal obstruction results in ischemia, perforation or peritonitis, emergency surgery is required.

Endoscopic corticosteroid injections do not reduce dysphagia after endoscopic dilation therapy in patients with benign esophagogastric anastomotic strictures

BACKGROUND & AIMS

Benign anastomotic strictures are often difficult to treat. We assessed the efficacy of adding corticosteroid injections to endoscopic dilation therapy with Savary bougienage.

METHODS

In a multicenter, double-blind trial, 60 patients (mean age, 63 ± 9 years; 78% male) with an untreated cervical anastomotic stricture after esophagectomy with gastric tube reconstruction and dysphagia for at least solid food were randomly assigned to groups given 4 quadrant injections of 0.5 mL triamcinolone (40 mg/mL, n = 29) or saline (controls, n = 31) into the stricture, followed by Savary dilation to 16 mm. Dysphagia, complications, and quality of life were assessed after 1 and 2 weeks and 1, 3, and 6 months. The primary end point was a dysphagia-free period of 6 months.

RESULTS

In the corticosteroid group, 45% of the patients remained dysphagia-free for 6 months, compared with 36% of controls (relative risk, 1.26; 95% confidence interval, 0.68-2.36; P = .46). Median time to repeat dilation was 108 days (range, 15-180 days) in the corticosteroid group vs 42 days (range, 17-180 days) for controls (P = .11). A median number of 2 dilations (range, 1-7) was performed in the corticosteroid group vs 3 dilations (range, 1-9) in controls (relative risk, 0.76; 95% confidence interval, 0.42-1.38; P = .36). Two major intervention-related complications occurred, 1 submucosal laceration in the corticosteroid group and 1 hemorrhage in the control group. Four patients in the corticosteroid group, but none of the controls, developed Candida esophagitis (P = .03).

CONCLUSIONS

Corticosteroid injections do not provide a statistically significant decrease in frequency of repeat dilations or prolongation of the dysphagia-free period in patients with benign anastomotic esophagogastric strictures. Dutch Trial Registration Number 2236.

Balloon dilation of benign esophageal rings or strictures: a randomized clinical trial comparing two different inflation times

Although balloon dilatation is the primary treatment for benign dysphagia, information about the optimal inflation time is lacking. The aim of the current pilot study was to compare 10 seconds inflation time with 2 minutes inflation time, regarding the efficacy. Twenty patients with symptomatic strictures were prospectively studied in a randomized fashion. The 10-second group required an average of 1.4 dilations per patient; the 2-minute group required an average of 1.5 dilations per patient. This pilot study indicates that 10 seconds inflation time is as effective as 2 minutes. Because the treatment is both painful and unpleasant, this is an important finding.

Safety of dilation in adults with eosinophilic esophagitis

Esophageal dilation is an effective therapy for dysphagia in patients with stenosing eosinophilic esophagitis (EoE). Historically, there have been significant concerns of increased perforation rates when dilating EoE patients. More recent studies suggest that improved techniques and increased awareness have decreased complication rates. The aim of this study was to explore the safety of dilation in our population of EoE patients. A retrospective review of all adult EoE patients enrolled in a registry from 2006 to 2010 was performed. All patients who underwent esophageal dilation during this time period were identified and included in the analysis. Our hospital inpatient/outpatient medical records, radiology reports, and endoscopy reports were searched for evidence of any complication following dilation. Perforation, hemorrhage, and hospitalization were identified as a major complication, and chest pain was considered a minor complication. One hundred and ninety-six patients (41 years [12]; mean age [standard deviation], 80% white, 85% male) were identified. In this cohort, 54 patients (28%) underwent 66 total dilations (seven patients underwent two dilations, one patient underwent three dilations, and one patient underwent four dilations). Three dilation techniques were used (Maloney [24], Savary [29] and through-the-scope [13]). There were no major complications encountered. Chest pain was noted in two patients (4%). There were no endoscopic features (rings, furrows, plaques) associated with any complication. Type of dilator, size of dilator, number of prior dilations, and age of patient were also not associated with complications. Endoscopic dilation using a variety of dilators can be safely performed with minimal complications in patients with EoE.

Endoscopic balloon dilatation for benign fibrotic strictures after curative nonsurgical treatment for esophageal cancer

BACKGROUND

Endoscopic balloon dilatation (EBD) is performed to treat strictures after esophagectomy. However, little is known about using EBD for benign strictures that occur after nonsurgical treatments for esophageal cancer such as chemoradiotherapy (CRT) or endoscopic mucosal resection (EMR). The aim of this study was to evaluate the safety and efficacy of EBD for benign strictures after nonsurgical treatment compared with those after surgery.

METHODS

We identified 823 patients with esophageal cancer who completed definitive treatments between 2004 and 2007. Of these patients, 122 were enrolled in our study, including 60 who had surgery and 62 who did not have surgery (32 CRT, 30 EMR). The indication criteria for EBD were complaint of dysphagia and the inability to pass a conventional endoscope due to benign stricture. We retrospectively analyzed the safety and efficacy of EBD, and the measured outcomes were treatment success rate, time to treatment success, and refractory stricture rate.

RESULTS

Perforation occurred in 3 (0.3 %) of 1,077 EBD sessions, with no bleeding. Efficacy was evaluated in 110 of the 122 patients. While the treatment success rate was over 90 % in both the surgery and the nonsurgery group, there was a significant difference in the median time to treatment success between both groups (2.3 vs. 5.6 months, p = 0.02: log-rank test). There was a significant difference in the median time to treatment success between CRT and surgery groups (7.0 months, p = 0.01), with no significant difference in the EMR group (4.4 months, p = 0.85). A significant difference in the refractory stricture rate was evident between the nonsurgery group (75 %) and the surgery group (45 %, p < 0.01).

CONCLUSION

EBD for stricture after nonsurgical treatment of esophageal cancer was safe and effective. However, patients with benign strictures after nonsurgical treatment required significantly longer time to recover from dysphasia compared to those after surgery.

Endoscopic management of difficult or recurrent esophageal strictures

Esophageal strictures are a common problem in gastroenterological practice. In general, the management of malignant or benign esophageal strictures is different and requires a different treatment approach. In daily clinical practice, stent placement is a commonly used modality for the palliation of incurable malignant strictures causing dysphagia, whereas, if available, intraluminal brachytherapy can be considered in patients with a good performance status. Recurrent dysphagia frequently occurs in malignant cases. In case of tissue in- or overgrowth, a second stent is placed. If stent migration occurs, the stent can be repositioned or a second (preferably partially covered) stent can be placed. Food obstruction of the stent lumen can be resolved by endoscopic cleansing. The cornerstone of the management of benign strictures is still dilation therapy (Savary-Gilliard bougie or balloon). There are a subgroup of strictures that are refractory or recur and an alternative approach is required. In order to prevent stricture recurrence, steroid injections into the stricture followed by dilation can be considered. In case of anastomotic strictures or Schatzki rings, incisional therapy is a safe method in experienced hands. Temporary stent placement is a third option before considering self-bougienage or surgery as a salvage treatment. In this review, the most frequently used endoscopic treatment modalities for malignant and benign stricture management will be discussed based on the available literature, and some practical information for the management in daily clinical practice will be provided.

Treatment of GERD complications (Barrett's, peptic stricture) and extra-oesophageal syndromes

Apart from typical reflux symptoms and oesophagitis, the clinical presentation of GERD can be dominated by mucosal complications of reflux (Barrett's oesophagus, oesophageal adenocarcinoma, Peptic structure) or by extra-oesophageal syndromes, most notably asthma, laryngitis, or chronic cough. Managing these entities is much less straightforward than with oesophagitis. With respect to adenocarcinoma, metaplasia and dysplasia are recognised precursors, but the potential of these lesions to evolve to cancer has not been shown to lessen as a result of treatment, medical or surgical. Consequently, management focuses on strategies to identify and eliminate high-grade dysplasia and intramucosal cancer, lesions that are potentially curable by endoscopic ablation or surgical resection. With respect to the extra-oesophageal GERD syndromes, these are increasingly recognised as multifactorial conditions with reflux as an exacerbating factor. Treatment trials have been generally disappointing and the clinical challenge remains in accurately identifying afflicted patients who might benefit from more intensive medical or surgical reflux treatment.

Diagnosis and initial management of gastroesophageal complications

Chronic esophageal exposure to reflux of gastroduodenal contents can result in complications of GERD including esophageal stricture, Barrett's oesophagus or extraesophageal symptoms such as laryngitis, chronic cough or asthma. Endoscopy is the main diagnostic tool for patients with chronic reflux presenting with dysphagia to visualise esophageal mucosa and identify the underlying pathology. Barrett's oesophagus should be suspected in those with chronic reflux disease. Patients with Barrett's oesophagus should undergo surveillance endoscopy in order to risk stratify to dysplasia or adenocarcinoma. New endoscopic ablative therapies in patients with Barrett's oesophagus and high grade dysplasia are promising new treatment modality for those who may not be candidates for definitive intervention. Given poor sensitivity of diagnostic tests in extraesophageal reflux, empiric therapy with proton pump patients is the initial recommended approach. Diagnostic testing with esophagogastroduodenoscopy and ambulatory pH and impedance monitoring is usually reserved for those unresponsive to acid suppressive therapy. Many uncertainties remain in this group of patients including which patient subgroups might benefit from acid suppressive therapy. Future outcome studies are needed to assess the role of impedance/pH monitoring in this group of patients and to determine who might symptomatically benefit from medical or surgical intervention.

Long-term management of corrosive esophageal stricture with balloon dilation in children

BACKGROUND AND PURPOSE

There are only a few studies focused on efficacy and safety of balloon dilation in corrosive esophageal stricture in children. The aim of this study is to assess the long-term clinical results of balloon dilation in the treatment of corrosive esophageal stricture in children.

MATERIALS AND METHODS

We retrospectively analyzed the management of 18 children (median age 3 years) who were treated with balloon dilation because of caustic esophageal stricture between January 2001 and December 2008.

RESULTS

A total of 295 sessions of balloon dilation were performed in all patients over an 8-year period. Technical success was achieved in all patients, whereas clinical success was achieved only in eight (44.4%) patients after first dilation. Eight (44.4%) of all patients showed recovery within the first year and another six (33.3%) patients recovered within 2 years. Esophageal perforation occurred in one (5%) patient, during one dilation session (0.33%). The average number of dilation sessions was 12.7, 2.8, and 1, respectively, in the first, second, and third year. There was significant difference between the mean number of dilation sessions in the first and second year, and second and third year (p < 0.01 and p = 0.043).

CONCLUSION

Short-segment esophageal strictures, improvement of food intake capacity, and increase in intervals of dilation sessions are good patient indicators. We suggest that esophageal balloon dilatation is a safe and effective method of treatment in caustic esophageal strictures and recommend that balloon dilation program be performed for at least 2 years before deciding that dilation has failed and preferring other treatment modalities which have higher risk of complications.

Management of anticoagulation before and after gastrointestinal endoscopy

The management of anticoagulants and antiplatelet agents in patients undergoing gastrointestinal endoscopic procedures is a common clinical problem. Although guidelines have been published, they are supported by little prospective or randomized trial data, but are primarily based on observational studies, expert opinion, and best clinical practices. As a general principle, the risks of thromboembolism need to be balanced against the risks of bleeding during the endoscopic procedure. By understanding these risks, management plans for individual cases may be made. This article reviews the current data and guidelines on the management of anticoagulants, antiplatelet agents, use of reversal agents, and the role and risks of concomitant proton pump inhibitors.

A randomized comparison of electrocautery incision with Savary bougienage for relief of anastomotic gastroesophageal strictures

BACKGROUND

Benign gastroesophageal anastomotic strictures are common and often refractory to treatment. Various endoscopic dilation techniques have been reported, but none of these methods has been proven to be superior.

OBJECTIVE

Comparison of the efficacy and safety of dilation of previously untreated anastomotic strictures by using electrocautery incision (EI) and Savary bougienage (SB).

DESIGN

Randomized, prospective study.

SETTING

Multicenter study.

PATIENTS

Sixty-two patients with an anastomotic stricture after esophagogastrostomy and dysphagia Atkinson grades II to IV were included.

INTERVENTIONS

Patients were treated with EI or SB.

MAIN OUTCOME MEASUREMENTS

Objective and subjective results were compared with baseline and 1, 3, and 6 months after the first treatment. Complications of both treatments were noted. Primary endpoints after 6 months were the mean number of dilation sessions and success rate (percentage of patients with < or =5 dilations in 6 months). Study participation ended after 6 months or if dysphagia grades II to IV recurred despite 5 treatment sessions.

RESULTS

No complications occurred with both treatments. There was no significant difference between the EI and SB groups in the mean number of dilations (2.9; 95% CI, 2.7-4.1 vs 3.3; 95% CI, 2.3-3.6l; P = .46) or the success rate (80.6% vs 67.7%, P = .26 and 96.2% vs 80.8%, P = .19).

LIMITATIONS

In a small study with negative primary endpoints, secondary endpoints and subgroup analyses are hypothesis generating only.

CONCLUSIONS

This prospective trial demonstrated that EI of gastroesophageal anastomotic strictures is a safe therapy and equivalent to SB as a primary therapy. EI can be used as an alternative or additional therapy to SB. (Registered with Current Controlled Trials, Ltd, registration number ISRCTN81239664.).

Radiological balloon dilatation of post-treatment benign pharyngeal strictures

Aims:

To assess the technical success, clinical outcomes and complications of radiologically guided balloon dilatation of benign strictures developing after treatment for head and neck cancer.

Materials and methods:

Forty-six balloon dilatations were performed in 20 patients. All dilatations were performed over a guidewire.

Results:

Technical success was 100 per cent. Fifteen of the 20 patients demonstrated clinical improvement in dysphagia scores. Improvement in dysphagia was temporary in all patients (median 102 days), with multiple dilatations usually required (total dilatations ranged from one to seven). Immediate complications were encountered in six of the 46 (13 per cent) dilatations and were all minor. Late complications occurred after two procedures (4 per cent): localised perforation (later complicated by secondary infection) and recurrence of a previous, small, pharyngo-cutaneous fistula.

Conclusion:

Radiologically guided balloon dilatation is straightforward to perform and is well tolerated, but there is a small risk of perforation. Relief of symptoms is likely to be temporary, requiring multiple subsequent dilatations. A minority of patients will obtain no symptomatic relief.

Primary incisional therapy with a modified method for patients with benign anastomotic esophageal stricture

BACKGROUND

Benign anastomotic esophageal stricture after surgical resection is not uncommon and requires repeated dilation sessions to maintain patency because of the significant recurrence rate with bougie or balloon dilation.

OBJECTIVE

Our study was designed to evaluate whether a modified method of incisional therapy is effective and maintains a good patency in a benign anastomotic esophageal stricture.

DESIGN

A prospective outcome study.

SETTING

Tertiary-care academic medical centers.

PATIENTS

A total of 24 patients with benign anastomotic esophageal strictures after esophagojejunostomy.

INTERVENTIONS

Under direct vision through a transparent hood, radial incisions parallel to the longitude of the esophagus were performed by pulling up the Iso-Tome or insulated-tip-knife.

MAIN OUTCOME MEASUREMENTS

Efficacy, safety, and long-term patency after procedures were evaluated.

RESULTS

During 24 months of follow-up observations, 21 of 24 patients (87.5%) who received only 1 dilation session resumed eating solid meals and had no dysphagia. Only 3 patients (12.5%) developed restricture at a mean of 1.6 months. Of the patients with a recurrence, 2 experienced no recurrence after one additional dilation session, and another patient was refractory and underwent 5 dilation sessions. The occurrence of restricture after incisional therapy was statistically more prevalent in long-segment stricture (>1 cm) (2/3 [66.7%]) than short-segment stricture (<1 cm) (1/21 [4.8%]) (P = .032). There were no significant procedure-related complications.

LIMITATION

Our study included a small number of patients. Therefore, further prospective randomized controlled trials are needed.

CONCLUSIONS

A modified method of incisional therapy as a primary treatment is safe and feasible, and appears to maintain a longer duration of patency in benign anastomotic esophageal stricture.

Esophageal dysphagia

Esophageal dysphagia can arise from a variety of causes such as motility disorders, mechanical and inflammatory diseases. Adequate management includes a detailed history, evaluation with upper endoscopy, barium radiography and manometry. Treatment is usually tailored to the underlying disease process and in some cases, as in inoperable cancer, palliative management may be necessary.

Effective diameter of balloon dilation for benign esophagojejunal anastomotic stricture after total gastrectomy

BACKGROUND

Benign strictures at esophagojejunostomy sites may develop after total gastrectomy, and through-the-scope balloon dilation (TTS-BD) can relieve them. The aim of this study was to evaluate effective and safe balloon diameter for benign stricture after total gastrectomy.

METHODS

From June 2001 to December 2006, 930 gastric cancer patients underwent total gastrectomy with Roux-en-Y esophagojejunostomy in a cancer center hospital. We performed TTS-BD when benign strictures developed. Initial success rate, complication rate, and restenosis rate were evaluated. We classified the patients into three groups according to final dilation diameter and number of sessions.

RESULTS

A total of 58 patients (6.2%) developed a benign stricture at the esophagojejunostomy site. We classified them into three groups based on the final luminal diameter of the balloon used and the number of sessions, as follows: group A (n = 20), 13.5-15 mm in one or two sessions; group B (n = 13), 16.5-20 mm in one session; group C (n = 25), 16.5-20 mm in two sessions. The initial success rates were 100% for groups A and B and 96% for group C. A perforation occurred in one patient (7.7%) in group B. Restenosis occurred in two patients (10%) in group A, one patient (7.7%) in group B, and in no patients in group C (p = 0.29). Restenosis was resolved by one or two further TTS-BDs.

CONCLUSION

TTS-BD to 15 mm was a safe and effective treatment for benign esophagojejunostomy strictures following total gastrectomy. Restenosis was not common and could be resolved by one or two further TTS-BD sessions.

Treatment options for esophageal strictures

Esophageal strictures are a problem commonly encountered in gastroenterological practice and can be caused by malignant or benign lesions. Dysphagia is the symptom experienced by all patients, regardless of whether their strictures are caused by malignant or benign lesions. The methods most frequently used for palliation of malignant esophageal strictures are stent placement (particularly in patients with an expected survival of 3 months or less) and brachytherapy (in patients with a life expectancy of more than 3 months). Brachytherapy has been shown to be beneficial in patients with an expected survival of longer than 3 months with regard to (prolonged) dysphagia improvement, complications and quality of life. The mainstay of benign esophageal stricture treatment is dilation. Although dilation usually results in symptomatic relief, recurrent strictures do occur. In order to predict which types of strictures are most likely to recur, it is important to differentiate between esophageal strictures that are simple (i.e. focal, straight strictures with a diameter that allows endoscope passage) and those that are more complex (i.e. long (>2 cm), tortuous strictures with a narrow diameter). These complex strictures are considered refractory when they cannot be dilated to an adequate diameter. Novel treatment modalities for refractory strictures include temporary stent placement and incisional therapy.

Dilation of benign strictures in the esophagus and colon with the polyflex stent: a case series study

Polyflex, a new self-expanding plastic stent (SEPS), is increasingly used to treat obstructions in the gastrointestinal tract. The majority of reports on Polyflex come from tertiary referral centers. This retrospective study describes the efficacy and safety of this new SEPS for the treatment of benign strictures in esophagus and colon and its use in a community hospital. Seven patients were treated from August 2003 through December 2006. All of them presented with severe strictures, and were treated with Polyflex insertion. Four patients had esophageal obstructions (three peptic, one postoperative) and the remaining three patients had postoperative strictures in the rectosigmoid. One patient had a coexisting fistula. Two strictures (one esophageal and another colonic, both postoperative) received the Polyflex as the first line of treatment, without previous sessions of dilation. Esophageal strictures were solved after several consecutive SEPS insertions. Migrated stents were easily extracted from the stomach. On the other hand, colonic strictures achieved permanent dilation with a single stent. The patient with coexisting stricture and fistula became asymptomatic and still had the SEPS in place after four months. The one complication was mild pain after insertion. Polyflex seems to be a useful tool in the dilation of severe benign strictures in esophagus and rectosigmoid and, as in large centers, good results are achieved in a community hospital.

Practice patterns in the management of patients with esophageal strictures and rings

BACKGROUND

Only few data exist on the epidemiology and management of esophageal strictures and rings.

OBJECTIVE

To study the epidemiology and management of esophageal strictures and rings.

DESIGN

Case-control study.

SETTING

Endoscopic data repository of U.S. gastroenterology practices from 1998 to 2003 (Clinical Outcomes Research Initiative).

PATIENTS

Case subjects included 7287 patients with strictures and 4993 patients with rings. The control group consisted of 124,120 patients without endoscopic evidence of esophageal stenosis.

INTERVENTIONS

Esophageal dilation.

MAIN OUTCOME MEASUREMENTS

Patient demographics, types and diameters of esophageal dilators, frequency of repeat dilations.

RESULTS

Strictures displayed a male predominance, and rings displayed a small female predominance. Compared with the control population, strictures and rings both occurred most frequently in elderly white patients. Dysphagia and reflux were the most common indications for dilation in both conditions. Compared with strictures, rings were treated more often with larger dilators and rubber bougies. One-year rates of repeat dilation for strictures and rings were 13% and 4%, respectively. The mean interval length between repeat dilations was 82 days for strictures and 184 days for rings.

LIMITATIONS

Only a limited amount of information about individual patients was retrievable from the electronic database.

CONCLUSIONS

The variations in the demographic characteristics and the treatment practice allude to differences in the underlying pathophysiology of these 2 benign obstructing lesions of the esophagus.

Single-session, graded esophageal dilation without fluoroscopy in outpatients with lower esophageal (Schatzki's) rings: a prospective, long-term follow-up study

BACKGROUND

Distal esophageal (Schatzki's) ring is a frequent cause of dysphagia. Bougienage is generally effective but relapses are common. The aim of this study was to evaluate the safety and long-term efficacy of single-session graded esophageal dilation with Savary dilators, without fluoroscopic guidance, in outpatients who presented with Schatzki's ring.

METHODS

The study was performed on 44 consecutive patients with symptomatic Schatzki's ring, detected endoscopically and/or radiologically. Graded esophageal dilation was performed as an outpatient procedure in a single session with Savary dilators, without fluoroscopic guidance. After appropriate assessment with esophageal manometry and 24 h ambulatory pHmetry, patients with documented gastroesophageal reflux disease (GERD) were treated with omeprazole continuously. All results, including clinical follow up and technical aspects of bougienage, were recorded prospectively. The necessity for re-dilation after documentation of the ring with endoscopy and/or radiology was considered as a relapse of the ring.

RESULTS

In four (9%) patients a second session was necessary to ensure complete symptom relief. Two (4.5%) patients developed post-dilation bacteremia and were managed with antibiotics as outpatients. Patients with (n = 14) or without (n = 30) GERD were comparable with respect to sex, age, body mass index, smoke and ethanol consumption, diameter of the esophageal lumen at the level of the ring, resting lower esophageal sphincter pressure, duration of dysphagia, need for taking antacids during the follow-up period, and duration of follow-up. There was no recurrence of the ring in patients with GERD during a mean follow-up period of 43.8 +/- 9.3 months (range 27-62 months); however, in patients without GERD, during a mean follow-up period of 40.6 +/- 12.2 months (range 10-58 months), 32% of patients relapsed after a mean 19.9 +/- 10.6 months (P = 0.04).

CONCLUSIONS

Single-session graded esophageal dilation with large caliber Savary dilators without fluoroscopic guidance can be safely used for the symptomatic relief in patients with lower esophageal (Schatzki's) rings. GERD should be treated if present in order to prevent a symptomatic recurrence of the ring.

Through-the-scope balloon dilation for endoscopic ultrasound staging of stenosing esophageal cancer

Dilation of malignant esophageal strictures often is required to complete staging by endoscopic ultrasound (EUS). This study was designed to determine the successful dilation rate (ability to complete staging) and complication rate of through-the-scope (TTS) balloon dilation for malignant esophageal strictures during EUS. We retrospectively reviewed EUS reports for all cases of primary esophageal cancer staged at five centers between January 2002 and October 2004. All dilations were performed with TTS balloons. Among 272 endoscopic ultrasounds, dilation was required in 77 (28%) and was successful in 73 cases (95%). There was one esophageal perforation after dilation (1.3%; 95% confidence interval (CI), 0.2-7) and one esophageal perforation after EUS without dilation (0.5%; 95% CI, 0.1-2.8; P = 0.48 by two-sided Fisher exact test). There were no other major complications. TTS balloon dilation is highly successful in permitting complete staging of obstructing tumors. The rate of complications after dilation with a TTS balloon dilator is low and similar to the baseline rate of EUS in this setting.

Minimization of risks of esophageal dilation

Esophageal dilation, along with many other therapeutic endoscopic procedures, carries with it an increased risk of complications, most of which are transient events but some of which may be catastrophic. The author reviews the literature concerning the major and minor complications that one will encounter in a busy and aggressive gastrointestinal endoscopic practice. There are scant prospective data concerning risk minimization and most studies are retrospective case series. Careful identification of groups of patients who have risk factors that may increase the potential for an adverse event is worthwhile and is reviewed. The current literature is discussed and suggestions to provide guidance and pearls in helping to avoiding and diagnosing major complications are given.

The Optical Dilator: a clear, over-the-scope bougie with sequential dilating segments

PURPOSE

The safety and efficacy of esophageal dilation is enhanced when direct visualization is possible, tactile sensation and feedback from resistance is maintained, and multiple dilations with a single passage of the dilating device is an option. The InScope Optical Dilator (InScope, a Division of Ethicon Endo-Surgery, Inc, Cincinnati, Ohio) is a flexible, transparent bougie fitted over a standard endoscope, with 3 dilating segments allowing sequential dilation under direct visualization. We report our experience with this device in treating benign esophageal strictures.

METHODS

Patients with solid food dysphagia due to peptic strictures or Schatzki's ring were studied by using a 27F or 29F endoscope. Based on stricture appearance and estimated luminal diameter, 1 of 3 dilator sizes was chosen: IN0216 (14-, 15-, and 16-mm dilating segments), IN0218 (16-, 17-, and 18-mm dilating segments), or IN0220 (18-, 19-, and 20-mm dilating segments).

RESULTS

Twenty-six patients were dilated and included 17 peptic strictures and 9 Schatzki's rings. Before dilation, most patients reported difficulties with solids at every meal. Median improvement 3 weeks after dilation was rated by patients as "substantial relief." Patients rated the dilation experience as largely "not at all unpleasant" immediately after endoscopy and had no recollection at 3 weeks' follow-up. There were no complications. Endoscopists rated dilator use as typical of experience with other bougies, and visualization was rated as high.

CONCLUSION

The Optical Dilator maintains the value of tactile sensation and the convenience of 3 dilating sizes for each passage of the instrument with the added benefit of direct visualization.

Electrocautery therapy for refractory anastomotic strictures of the esophagus

BACKGROUND

Anastomotic esophageal stenoses after esophageal resection are common and sometimes are refractory to Savary bougie dilation. The efficacy of electrocautery needle-knife treatment in these patients is described.

METHODS

Twenty patients with a refractory anastomotic stricture of the esophagus were treated with electrocautery and were followed for 12 months. All patients had recurrence of dysphagia despite repeated bougienage.

OBSERVATIONS

All 12 patients with a stricture shorter than 1 cm remained without dysphagia after a single treatment. In all 8 patients with a long-segment stenosis of 1.5 to 5 cm, dysphagia recurred, and a mean of 3 treatments were necessary. The interval between electrocautery treatments was significantly longer compared with bougienage. There were no complications. The body weight of all patients increased.

CONCLUSIONS

Electrocautery seems to be a good single-treatment modality for refractory short-segment anastomotic strictures, whereas longer-segment stenoses appear to require repeated treatment sessions before similar results are obtained.

Evaluation and management of benign esophageal strictures

Patients with progressive or solid food dysphagia should be evaluated for the presence of an esophageal stricture. Barium esophagram and endoscopy can define strictures as benign or malignant. The majority of benign strictures are acid-related. Benign strictures are best managed by esophageal dilation with acid-suppressing medications if a peptic stricture is suspected. If dysphagia recurs, repeat dilation should be performed. There are a variety of interventions for refractory strictures which include injection of intralesional corticosteroids, temporary placement of self-expanding plastic stents and surgery.

Clinical presentation, diagnosis, and management of gastroesophageal reflux disease

GERD is ubiquitous throughout the adult population in the United States. It commonly adversely affects quality of life and occasionally causes life-threatening complications. The new and emerging medical and endoscopic therapies for GERD and the new management strategies for BE should dramatically reduce the clinical toll of this disease on society.

Esophageal dilation / dilators

Esophageal dilation is the treatment of choice for most patients with esophageal dysphagia (functional and mechanical). Multiple forms of esophageal dilators are available. Mechanical dilators (guidewire/nonguidewire assisted) are the major forms of dilators used. Balloon dilator use has increased but they offer only a marginal advantage over traditional mechanical dilators at a greatly increased cost (2 degrees to single use). Comparative trials are biased in favor of balloon dilators, but balloon dilators are not indicated for empiric dilation for dysphagia. Empiric dilation for solid food dysphagia is still controversial. Dilation is rarely associated with complications and is rarely contraindicated unless previous dilation attempts have been unsuccessful. Special circumstances such as caustic strictures, radiation stricture, and dysphagia associated with eosinophilic esophagitis should engender cautious dilation. Attention to detail about placement of guidewires and stricture type are still critical for safety. Predilation barium studies are not needed in all patients but should be employed if the endoscope is not able to pass the stricture and stricture length and angulation are unknown. Intralesional steroids and proton pump inhibitor therapy are important adjuvant treatments for resistant strictures and reflux associated strictures. Balloon dilation for achalasia is still a viable alternative, but it is likely to decrease in usage with the advent of more widespread laparoscopic myotomy.

Peptic esophageal stricture: a report from Argentina

Peptic esophageal stricture (PES) is a major complication of gastroesophageal reflux disease. The aims of this paper were to determine the characteristics of these patients with regard to demography, morphology, functional status and results of therapy. The charts of the patients treated at our service who underwent esophageal dilatation for PES between 1971 and 1998 were reviewed. Statistical analyses were performed by means of chi2, Mann-Whitney and Student's t-tests. One hundred and thirty-five patients with PES were dilated by various means. The mean age was 61.1 +/- 16.3 years, the ratio of men to women was 2.75/1 and mean duration of symptoms was 44.4 +/- 74.6 months. Their symptoms were dysphagia in 100%, pyrosis in 70%, and regurgitation in 40% of the cases. There was an average weight loss of 3.3 +/- 6 kg. The upper gastro-intestinal series showed pre- and post-dilatation diameters at the stricture of 8 +/- 2.5 mm and 15.9 +/- 1.2 mm, respectively. The stricture was located at the lower third of the esophagus in 97% and at the middle third in 3% of the cases. We found PES endoscopically in all instances, with different degrees of erosions in 64%, ulcers in 20% and Barrett's esophagus in 16% of the cases. The biopsy samples showed intestinal metaplasia in 16% and esophagitis in 75.5%, being normal in the remaining 8.5%. Brush cytology was negative for malignancy in 100% of the cases. Esophageal manometry showed peristaltic wave amplitude of 40 +/- 3 mmHg and presence of peristaltic waves of 62 +/- 38.6%. LES pressure was 8.6 +/- 6.3 mmHg (NV 24.2 +/- 6.3 mmHg). Measurement of pH showed 15% of patients had pH < 4. Patients needed a mean of 4.7 +/- 1.6 dilations per case, with successful results in 87.2% of cases. The perforation rate was 0.1% of the total number of procedures and 0.7%, of patients. The mortality rate was 0.7% (one case). We observed PES relapse in 32% of the cases. There was no correlation between relapse, age, duration of the stenosis or pharmacological treatment with H2 blockers or proton pump inhibitors. We conclude that in Argentina, demography, morphology, functional status and results of dilatation of PES patients are similar to those reported in the Western world, with the exception of the different behavior seen after treatment with H2 blockers or proton pump inhibitors.

Esophagitis and esophageal strictures

Esophagitis and esophageal strictures are important causes of esophageal disease in dogs and cats. Clinical suspicion is created when the clinician recognizes the clinical signs suggestive of esophageal disease and accounts for historical information and physical examination findings. Once suspected, the diagnosis of esophagitis and esophageal strictures is a fairly simple one in most cases. Although the benefit of diminishing secretion of gastric acid in patients with esophagitis is unquestioned, other questions regarding adjunctive medical treatments, such as sucralfate and glucocorticoids for dogs and cats with esophagitis, have not been answered through appropriate clinical studies. Esophageal strictures are readily treated with balloon dilation or esophageal bougienage, and clients can expect most patients to become functional, although dietary change may be necessary.