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

Postlaryngectomy pharyngoplasty with melolabial flap

To the best of our knowledge, this is the largest case series describing the use of a melolabial flap for postlaryngectomy pharyngoplasty. It is an excellent alternative for pharyngoplasty, especially in cases post chemoradiotherapy. It accomplishes the goal while removing the restrictions of local and distant flaps. Although donor site morbidity is acceptable, specific consent is required due to the possibility of functional and cosmetic impairment. Additional cases with a larger sample size and a longer follow-up period can assist corroborate our first findings. In addition, because we tend to protect facial vessels for this flap, a follow-up about the compromise of oncological safety at level IB is required. In our case series, however, there was no recurrence until the final follow-up. As a result, it is a better option to pharyngoplasty post laryngectomy.

The endoscopic management of oesophageal strictures

An oesophageal stricture refers to a narrowing of the oesophageal lumen, which may be benign or malignant. The cardinal feature is dysphagia, and this may result from intrinsic oesophageal disease or extrinsic compression. Oesophageal strictures can be further classified as simple or complex depending on stricture length, location, diameter, and underlying aetiology. Many endoscopic options are now available for treating oesophageal strictures including dilatation, injectional therapy, stenting, stricturotomy, and ablation. Self-expanding metal stents have revolutionised the palliation of malignant dysphagia, but oesophageal dilatation with balloon or bougienage remains first-line therapy for most benign strictures. The increase in endoscopic and surgical interventions on the oesophagus has seen more benign refractory oesophageal strictures that are difficult to treat, and often require advanced endoscopic techniques. In this review, we provide a practical overview on the evidence-based management of both benign and malignant oesophageal strictures, including a practical algorithm for managing benign refractory strictures.

Design and Material Characterization of an Inflatable Vaginal Dilator

There are more than 13,000 new cases of cervical cancer each year in the United States and approximately 245,000 survivors. External beam radiation and brachytherapy are the front-line treatment modalities, and 60% of patients develop vaginal damage and constriction, i.e., stenosis of the vaginal vault, greatly impeding sexual function. The incidence of vaginal stenosis (VS) following radiotherapy (RT) for anorectal cancer is 80%. VS causes serious quality of life (QoL) and psychological issues, and while standard treatment using self-administered plastic dilators is effective, acceptance and compliance are often insufficient. Based on published patient preferences, we have pursued the design of a soft inflatable dilator for treating radiotherapy-induced vaginal stenosis (VS). The critical component of the novel device is the dilator balloon wall material, which must be compliant yet able to exert therapeutic lateral force levels. We selected a commercially available silicone elastomer and characterized its stress-strain characteristics and hyperelastic properties. These parameters were quantified using uniaxial tensile testing and digital image correlation (DIC). Dilator inflation versus internal pressure was modeled and experimentally validated in order to characterize design parameters, particularly the dilator wall thickness. Our data suggest that an inflatable silicone elastomer-based vaginal dilator warrants further development in the context of a commercially available, well-tolerated, and effective device for the graded, controlled clinical management of radiotherapy-induced VS.

A combined predicting model for benign esophageal stenosis after simultaneous integrated boost in esophageal squamous cell carcinoma patients (GASTO1072)

Purpose

We aimed to develop a combined predicting model for benign esophageal stenosis (BES) after simultaneous integrated boost (SIB) with concurrent chemotherapy in patients with esophageal squamous cell carcinoma (ESCC).

Methods

This study included 65 patients with EC who underwent SIB with chemotherapy. Esophageal stenosis was evaluated using esophagograms and the severity of eating disorders. Risk factors were investigated using univariate and multivariate analyses. Radiomics features were extracted based on contrast-enhanced CT (CE-CT) before treatment. The least absolute shrinkage and selection operator (LASSO) regression analysis was used for feature selection and radiomics signature construction. The model’s performance was evaluated using Harrell’s concordance index and receiver operating characteristic curves.

Results

The patients were stratified into low- and high-risk groups according to BES after SIB. The area under the curves of the clinical model, Rad-score, and the combined model were 0.751, 0.820 and 0.864, respectively. In the validation cohort, the AUCs of these three models were 0.854, 0.883 and 0.917, respectively. The Hosmer-Lemeshow test showed that there was no deviation from model fitting for the training cohort (p=0.451) and validation cohort (p=0.481). The C-indexes of the nomogram were 0.864 and 0.958 for the training and validation cohort, respectively. The model combined with Rad-score and clinical factors achieved favorable prediction ability.

Conclusion

Definitive chemoradiotherapy could alleviate tumor-inducing esophageal stenosis but result in benign stenosis. We constructed and tested a combined predicting model for benign esophageal stenosis after SIB. The nomogram incorporating both radiomics signature and clinical prognostic factors showed favorable predictive accuracy for BES in ESCC patients who received SIB with chemotherapy.

Trial registration number and date of registration

Registered in www.Clinicaltrial.gov, ID: NCT01670409, August 12, 2012

Perforations from Endoscopic Dilation of Corrosive Strictures in Adults: A Systematic Review and Meta-Analysis

BACKGROUND AND AIMS

Endoscopic dilation is an important therapeutic option for treatment of corrosive strictures. Its safety is unclear with variable perforation rates in previous studies. We aimed to evaluate its safety with regard to perforations and the effect of dilator type to perforation risk.

METHODS

A systematic review of published literature from inception to April 24, 2021, using PubMed and EMBASE databases was conducted. Studies in adult subjects (mean age ≥ 18 years) reporting perforation rates of endoscopic dilation of corrosive esophageal and/or gastric strictures were included. Pooled cumulative perforation rates were computed as primary outcome. Secondary outcomes included, perforation with each dilator subtypes, surgical or conservative modes of management and mortality. Random effect meta-analysis was used to estimate the frequency of each of these outcomes. Variables were reported as percentages with 95% CI.

RESULTS

A total of 712 subjects (N) who underwent 4840 dilations (n) were noted in the 15 studies that were included. Of which, eight were retrospective, while the remaining seven were prospective. On meta-analysis, the cumulative pooled perforation rate was 1% (1-2%) of the number of dilations (n%). The perforation rates with SG (1%, 0-3%) and balloon (1%, 0-5%) dilators were similar (p value < 0.01). 45/64 (59%, 11-94%) perforations were subjected to surgery while the remaining 14/64 (41%, 6-89%) was managed conservatively. Choice of management strategy was biased to the norms of the treating team. About 3/712 patients (0%, 0-2%) succumbed following perforation.

CONCLUSION

Perforation from endoscopic dilation of corrosive strictures occurs rarely, and there is no significant difference in perforation risk related to the type of dilator.

Dysphagia, hypothyroidism, and osteoradionecrosis after radiation therapy for head and neck cancer

OBJECTIVES

To analyze the long-term side effects of radiation therapy (RT) for head and neck cancer (HNC).

METHODS

Retrospective chart analysis of all 688 HNC patients treated during 2010-2015 at Turku University Hospital, Finland. All patients who survived for more than a year after RT/chemoRT were included (n = 233). Intensity modulated RT (IMRT) with standard fractionation was applied in each case.

RESULTS

One hundred and six patients (45%) reported persisting dysphagia, for which neck RT increased risk. Definitive neck RT to high-risk volume did not increase late toxicity risks compared to elective neck RT. Radiation-induced hypothyroidism (29%, n = 67) was more common among younger patients and females. Osteoradionecrosis (12%, n = 29) was more common in the oral cavity cancer group (20.7%, n = 92) compared to all other subsites.

CONCLUSIONS

Late toxicities of RT for HNC are common. Age, gender, tumor subsite, and neck RT affect susceptibility to long-term side effects.

LEVEL OF EVIDENCE

4.

Risk factors of refractory post-endoscopic submucosal dissection esophageal strictures

INTRODUCTION

To comparatively assess the treatment outcomes of endoscopic dilatation in Barrett's neoplasia and squamous cell carcinoma (SCC) post- endoscopic submucosal dissection (ESD) strictures and to determine the risk or factors associated to refractory strictures Methods: Observational study. All consecutive patients presenting with a post-ESD stricture in 2007-2016 who underwent dilation therapy were included. Clinical, morphological and technical features were assessed to determine the risk factors of refractory strictures.

RESULTS

Of 414 consecutive patients treated by ESD, 83 (mean age: 65±10 years, 76% men) with 254 dilations (median: 3, range: 1-27) were considered. Barrett's neoplasia and SCC were the indications in 58 (69.9%) in 25 (30.1%) cases. Clinical success was achieved in 84.3% with a median of 3 sessions (range: 1-22). Circumferential resection in one-single procedure (13.2%) was associated to the need for a higher number of dilation sessions. By multivariable analysis, upper-esophageal location (OR: 11.479 [95%CI: 2.058-64.043], p=0.005), recurrent strictures (OR: 17.252 [95%CI: 2.833-105.069], p=0.002), and dilation-related complications (OR: 26.420 [95%CI: 1.736-401.966], p=0.018) were risk factors of refractory stenosis.

CONCLUSION

Preventive strategies, concomitant treatment, and careful dilatation protocols should be considered and undertaken in patients presenting with SCC located in the upper superior esophagus, intra-procedural perforation, and recurrent strictures.

Endoscopic Management of Refractory Benign Esophageal Strictures

Benign esophageal strictures are commonly encountered in clinical practice. The principal etiologies of benign esophageal strictures include long term acid reflux, caustic injuries, eosinophilic esophagitis, anastomotic strictures or endoscopic therapy. Dysphagia is most prominently present in esophageal strictures along with a variety of other symptoms which depend on the stricture etiology. Benign esophageal strictures can be categorized into two groups: simple or complex depending on their structure. Most strictures can be treated successfully with endoscopic dilation by bougies or balloons dilators. In some cases, treatment is more challenging, involving a higher risk of the patient developing recurrent or refractory strictures. To improve symptoms in these patients, other endoscopic treatments such as steroid injection, incisional therapy and stent placement should be considered. In this manuscript, we provide a comprehensive review of the main treatment options currently available to manage recurrent benign esophageal strictures.

Feasibility and Safety of Office-Based Transnasal Balloon Dilation for Neopharyngeal and Proximal Esophageal Strictures in Patients with a History of Head and Neck Carcinoma

The aim of this study was to assess feasibility and safety of office-based transnasal balloon dilation of neopharyngeal and proximal esophageal strictures in patients with a history of head and neck carcinoma. The secondary objective was to explore its effectiveness. This prospective case series included patients previously treated for head and neck carcinoma with neopharyngeal or proximal esophageal strictures who underwent transnasal balloon dilation under topical anesthesia. The target dilation diameter was 15 mm; if necessary dilation procedures were repeated every 2–4 weeks until this target was reached. Completion rates, adverse events, and patient experiences measured by VAS scores (0 = no complaints – 10 = unbearable complaints), dysphagia scores based on food consistency (0 = no dysphagia – 5 = unable to swallow liquids/saliva), and self-reported changes in swallowing symptoms were recorded. Follow-up was 2 months. Twenty-six procedures were performed in 12 patients, with a completion rate of 92%. One minor complication occurred, i.e. an infection of the dilation site. Tolerance of the procedure was good (median VAS = 2). The dysphagia score improved after a mean of 2.2 procedures per patient, however not significantly. Eight patients reported improvement in dysphagia, of whom 3 had recurrence of dysphagia within 1 month post-treatment. Office-based transnasal balloon dilation is a feasible and safe in-office procedure which is well-tolerated by patients. The dilations can improve dysphagia, although effects might be transient.

Endoscopic management of benign recalcitrant esophageal strictures

Benign esophageal strictures are one of the common clinical conditions managed by endoscopists. Nearly 90% of the benign esophageal strictures respond to endoscopic dilation. However, a small percentage of patients progress to recalcitrant strictures. The benign recalcitrant esophageal strictures are difficult to manage both medically and endoscopically as they do not respond to conventional treatment with proton pump inhibitors and esophageal dilations. Patients with benign recalcitrant esophageal strictures are at a high risk of developing debilitating malnutrition and morbidity due to severe dysphagia. This condition is associated with psychological trauma to patients as treatments are usually prolonged with poor outcomes. Also, this can be a financial burden on the healthcare industry due to several sessions of treatment. In this article, we discuss the classification of benign esophageal strictures, evidence-based treatment strategies, endoscopic procedural techniques, and complications of endoscopic interventions. We aim to guide providers in managing benign esophageal strictures with a focus on endoscopic management of benign recalcitrant esophageal strictures.

Outcomes of Combined Antegrade-Retrograde Dilations for Radiation-Induced Esophageal Strictures in Head and Neck Cancer Patients

The purpose of this study is to analyze outcomes of combined antegrade-retrograde dilations (CARD). This retrospective study was conducted on 14 patients with a history of head and neck cancer, treated with radiation therapy that was complicated by either complete or near-complete esophageal stenosis. All patients had minimal oral intake and depended on a gastrostomy tube for nutrition. Swallow function before and after CARD was assessed using the Functional Oral Intake Scale, originally developed for stroke patients and applied to head and neck cancer patients. Patients undergoing CARD demonstrated a quantifiable improvement in swallow function (p = 0.007) that persisted at last known follow-up (p = 0.015) but only a minority (23.1%) achieved oral intake sufficient to obviate the need for tube feeds. Complication rates were 24% per procedure or 36% per patient, almost all complications required procedural intervention, and all complications occurred in patients with complete stenosis. Our study suggests further caution when considering CARD, careful patient selection, and close post-operative monitoring.

Risk factors and clinical outcomes of endoscopic dilation in benign esophageal strictures: a long-term follow-up study

BACKGROUND AND AIMS

Endoscopic dilation (ED) is still the mainstay of therapeutic management of benign esophageal strictures (BESs). This study aimed to establish risk factors for refractory BESs and assess long-term clinical outcomes of ED.

METHODS

We performed a retrospective study in 891 patients who underwent ED from 2003 to 2018 for BESs. We searched electronic medical records in 6 tertiary care centers in the Netherlands for data on clinical outcome of ED. Median follow-up was 39 months. The primary endpoint was risk factors for refractory BESs, defined as factors associated with an increased number of ED sessions during follow-up. Secondary endpoints were time from first to last ED session and adverse events.

RESULTS

Dilation up to 13 to 15 mm was associated with a higher number of ED sessions than dilation up to 16 to 18 mm (5.0 vs 4.1; hazard ratio [HR], 1.4; P = .001). Compared with peptic strictures, anastomotic (4.9 vs 3.6; HR, 2.1; P < .001), radiation (5.0 vs 3.6; HR, 3.0; P < .001), caustic (7.2 vs 3.6; HR, 2.7; P < .001), and postendotherapy (3.9 vs 3.6; HR, 1.8; P = .005) strictures were associated with a higher number of ED sessions. After 1 year of follow-up, the proportions of patients who remained free of ED was 75% in anastomotic, 71% in radiation, 70% in peptic, 83% in postendotherapy, and 62% in caustic strictures. Esophageal perforation occurred in 23 ED sessions (.4%) in 22 patients (2.4%).

CONCLUSIONS

More than 60% of patients with BESs remain free of ED after 1 year of follow-up. Because dilation up to 16 to 18 mm diameter was associated with fewer ED sessions during follow-up, we suggest that clinicians should consider dilation up to at least 16 mm to reduce the number of ED sessions in these patients.

Outcomes of Self-Esophageal Dilation for Head and Neck Cancer Patients

Introduction Dysphagia is common following treatment for head and neck cancers, and self-esophageal dilation is a safe and effective treatment method. Prior studies on self-dilation have reported only qualitative results and included heterogeneous populations with dysphagia. The objective of this study is to quantitatively assess the safety and efficacy of a self-esophageal dilation program for patients with oropharyngeal squamous cell cancer with treatment-induced dysphagia. Materials and Methods This is a retrospective review of patients with oropharyngeal squamous cell cancer treated at the University of Southern California from 2009 to 2013 with dysphagia following radiation treatment that persisted after swallow therapy. The treatment program consisted of swallow therapy in conjunction with weekly self-esophageal dilation at home with increasing size bougie dilators. Oral intake was monitored using the Functional Oral Intake Scale (Crary, Mann, & Groher, 2005), Modified Barium Swallow Impairment Profile Pharyngoesophageal opening score, and Penetration-Aspiration Scale (Rosenbek, Robbins, Roecker, Coyle, & Wood, 1996) pre- and posttreatment. Results Thirty-three patients met study criteria and completed the program. Twenty-five patients required nutrition via a gastrostomy tube prior to starting therapy, and 84% (21/25) of these patients were able to have the feeding tube removed. Median Functional Oral Intake Scale (Crary et al., 2005) predilation was 1 (range: 1-5), and postdilation was 6 (range: 3-6, p < .05). In addition, there was improvement of the Modified Barium Swallow Impairment Profile Pharyngoesophageal opening score from 2 to 1 after treatment (p < .05). No complications were encountered. Discussion Home self-dilation with concurrent swallowing therapy is a safe and feasible procedure to be used in motivated patients with dysphagia following head and neck cancer treatment.

The role of endoscopic dilation and stents in refractory benign esophageal strictures: a retrospective analysis

Background

The outcomes of patients with refractory benign esophageal strictures (RBES) are unclear, and the clinical efficacy of dilation versus stent placement is lacking. Our objective was to explore the role of endoscopic dilation and stents placement in the management of RBES.

Methods

RBES patients treated with dilation and stents in our hospital between January 2009 and December 2017 were included in this study. The primary outcomes were to assess clinical effectiveness and adverse events. The secondary outcome was to identify factors that predicted the dysphagia-free period.

Results

Among 75 RBES patients (54 male; median age 59 years), 39 (52%), 20 (26.7%), 3 (4%), 10 (13.3%), and 3 (4%), were postsurgical, post-ESD, achalasia of cardia, caustic and mixed etiology, respectively. The median number of endoscopic therapy was 5 times (range 3, 21). Endoscopic therapy was successful in 46 patients (61.3%). Patients treated with dilation showed a higher success rate (70.9%, 39/55) than that treated with stents (35%, 7/20). Fifteen patients died during follow-up. Nineteen patients had adverse events after endoscopic therapy. In total, the mean dysphagia-free period was 3.4 months (95% CI, 2.5–4.3). The patients treated with dilation demonstrated a dysphagia-free period of 3.7 months (95% CI, 2.7–5), while patients treated with stents displayed a dysphagia-free period of 2.3 months (95% CI, 1.5–3). The dysphagia-free period had a linear growth trend over time, with an increase of 12 days per endoscopic therapy.

Conclusion

The dysphagia-free period increased by 12 days per endoscopic therapy, so the endoscopic therapy tended to be effective in patients with RBES by increasing the dysphagia-free period. However, compared to dilation therapy, stent therapy was not effective in increasing the dysphasia-free period and reducing the times and frequency of dilation. In addition, univariate and multivariate analyses also indicated that etiology may predict the endoscopic therapy outcome.

Trial registration

This study was retrospectively registered and approved by the Ethics Committee of West China Hospital of Sichuan University (IRB number: ChiCTR1800016321).

Esophageal Stricture Following Radiation, Concurrent Immunochemotherapy, Treated With Hyperbaric Oxygen and Dilation

Low-dose palliative radiation may offer symptomatic relief in patients with spinal metastases from primary renal cell cancer and is unlikely to result in radiation injury. Patients with advanced malignancy requiring palliative radiation are often also receiving chemotherapy. Synergistic adverse effects resulting from combined palliative radiation and novel antiprogrammed cell death-1 (anti-PD 1) and/or multityrosine kinase inhibitors are rare.

We report about a 60-year-old woman with metastatic clear-cell renal cancer, status post-left nephrectomy, with debilitating mid-back pain from metastatic tumor burden and foraminal nerve compression. Her chemotherapeutic regimen was repeatedly altered because of progression of disease until she was maintained on the anti-PD 1 checkpoint inhibitor, nivolumab. She received palliative radiation to her thoracic spine over a 2-week period, and nivolumab was then switched to cabozantinib midway through a course of palliative radiation. The patient rapidly developed severe esophagitis, progressing to esophageal stricture, and required placement of a percutaneous endoscopic gastrostomy tube. She was successfully treated with serial esophageal dilation and hyperbaric oxygen treatments to diminish inflammation and improve tissue vascularity. Concurrent use of anti-PD 1 and/or multityrosine kinase drugs may accelerate development of radiation injury regardless of radiation dosage. Radiation-induced esophageal stricture was managed successfully in this patient with serial esophageal dilation and adjuvant hyperbaric oxygen.

Use of tunnel endoscopy for diagnosis of obscure submucosal esophageal adenocarcinoma: A case report and review of the literature with emphasis on causes of esophageal stenosis

BACKGROUND

The tunnel endoscopic technique is the treatment of choice for submucosal tumors. However, the use of tunnel endoscopy to diagnose adenocarcinoma of the esophagus originating from the submucosa has not been well studied.

CASE SUMMARY

A 74-year-old man who presented with dysphagia for half a year underwent a series of checks, such as gastroendoscopy, X-ray contrast examination of the upper digestive tract, endoscopic ultrasonography, high-resolution esophageal manometry, and positron emission computed tomography. It should be noted that the stenosis of the esophagus was too narrow for endoscopic ultrasound-guided fine needle aspiration. The cause remained undiagnosed. Eventually, the tunnel endoscopic technique was perform for the pathological examination in the submucosa and the final diagnosis was adenocarcinoma of the esophagus. The patient and family members chose expectant treatment due to the patient’s age and the high costs of surgical treatment.

CONCLUSION

Tunnel endoscopy could be used to diagnose tumors. Moreover, we review the literature to provide guidance regarding the causes of esophagostenosis.

Endoscopic management of refractory benign oesophageal strictures

Refractory benign oesophageal strictures are an infrequent presentation but a cause of significant morbidity and mortality. The treatment of these strictures has changed little in recent years, yet new evidence is emerging for the optimal timing and application of different therapies. In this article, we have carefully reviewed the current literature on the evaluation and management of refractory strictures and provided practical advice as to their management. A number of areas require attention in future research, including carefully designed randomised trials of endoscopic and medical therapies, and a focus on risk factors at a patient and molecular level to facilitate development of medical therapies that can reduce recurrent fibrosis in these patients.

Endoscopic Dilation of Pharyngoesophageal Strictures: There Are More Dimensions than a Diameter

Background/Aims

Dysphagia due to benign pharyngoesophageal strictures (PES) often requires repeated dilations; however, a uniform definition for the therapeutic efficacy of this technique has not been yet established. We aimed to assess the overall efficacy of endoscopic dilation of pharyngoesophageal anastomotic or post-radiotherapy (post-RT) strictures.

Methods

The data of 48 patients with post-RT (n = 29) or anastomotic PES (n = 19) submitted to endoscopic dilation during a 3-year period were retrospectively assessed. The Kochman criteria were used to determine refractoriness and recurrence. Patients were asked to answer a questionnaire determining prospectively the dilation program efficacy as (a) dysphagia improvement, (b) dysphagia resolution, (c) need for further dilations, or (d) percutaneous endoscopic gastrostomy (PEG) during the previous 6 months. Need for additional therapy was considered an inefficacy criterion.

Results

The median number of dilations per patient was 4 (total of 296 dilations) with a median follow-up of 29 months. The mean predilation dysphagia Mellow-Pinkas score was 3 and the initial stenosis diameter was 7 mm. Fifteen and 29% of patients presented with the Kochman criteria for refractory and recurrent strictures, respectively. Moreover, 96 and 60% showed dysphagia improvement and resolution, respectively. Seventy-five-percent did not require dilations during 6 months, and 89% did not require PEG. From the patients' perspective, overall efficacy was achieved in 58% of cases. Nine additional therapies were required. Number of dilations (OR 0.7), stricture diameter (OR 2.2), and nonrecurrence criteria (OR 14.2) appeared as significant predictors of overall efficacy, whereas refractory stenosis criteria did not.

Conclusions

Endoscopic dilation seems to be effective for patients with dysphagia after RT or surgery, especially when assessed as patient perception of improvement. Narrow strictures, recurrent ones, and strictures requiring a higher number of dilations may predict worse outcomes.

Key Message

Health professionals should establish well-defined efficacy criteria for dilations and base their decision beyond exclusively objective measurements.

Endoscopic treatment of benign esophageal strictures: a literature review

Benign esophageal strictures arise from various etiologies and are frequently encountered. Although endoscopic dilation is still the first-line therapy, recurrent strictures do occur in approximately 10% of the cases and remains a challenge to gastroenterologists. Areas covered: A literature search was performed using PubMed and Google Scholar databases for original and review articles on endoscopic treatment of benign esophageal strictures. This review outlines the main available treatment options and its controversies in the management of refractory benign esophageal strictures. Expert commentary: Adding local steroid injections to dilation can be effective for peptic stenosis and strictures after endoscopic submucosal dissection, but remains uncertain for anastomotic strictures. Intralesional injections of mitomycin-C could be useful in corrosive strictures. Incisional therapy can be a reliable alternative in Schatzki rings and in anastomotic strictures, in experienced hands. By contrast, long-term outcome with endoprosthetic treatment is disappointing, and stent placement should be carefully considered and individualized.

Therapeutic intervention in oropharyngeal dysphagia

Oropharyngeal dysphagia is a frequent consequence of several medical aetiologies, and even considered part of the normal ageing process. Early and accurate identification provides the opportunity for early implementation of dysphagia treatments. This Review describes the current state of the evidence related to dysphagia therapies - focusing on treatments most clinically utilized and of current interest to researchers. Despite successes in select studies, the level of evidence to support the efficacy of these treatments remains limited. Heterogeneity exists across studies in both how interventions are administered and how their therapeutic value is assessed, thereby making it difficult to establish external validation. Future work needs to address these caveats. Also, to be most efficacious, dysphagia therapies need to account for influences from pre-morbid patient characteristics as these factors have potential to increase the risk of dysphagia and the resulting complications of aspiration, malnutrition and psychological burden. Dysphagia therapies therefore need to incorporate the medical aetiology that is at its root, the resulting swallow physiology captured from comprehensive clinical and/or instrumental assessments, and the existing needs and supports of patients.

Swallowing assessment and management pre and post head and neck cancer treatment

PURPOSE OF REVIEW

Head and neck cancer (HNC) imposes significant structural, functional, and cosmetic burdens upon those affected. Although advances in multimodality organ preservation therapy have assisted in ameliorating a number of previous treatment-related sequelae, dysphagia remains a foremost concern for members of the multidisciplinary team. Given its acute and long-term impact on physical and psychological wellbeing, and subsequent bearing on delivery of treatment, treatment-related morbidity and overall mortality, prompt recognition, and accurate assessment and optimization of management are pivotal.

RECENT FINDINGS

Qualitative research has provided greater insight into the psychosocial burdens dysphagia imposes on HNC patients and carers, highlighting the need for holistic strategies of management. There is a growing body of evidence to support dietary alterations and preventive swallowing exercise regimens for maintenance of oral intake throughout and following HNC therapy. The role of prophylactic enteral feeding, however, remains uncertain, with conflicting institutional data and lack of high-quality prospective studies for meaningful systematic literature assessment. Endoscopic surgical techniques hold promise in relieving stricture-related dysphagia; however, multiple treatments are required and recurrence is common.

SUMMARY

Swallowing rehabilitation encompassing education, dietary modification, and swallowing exercises comprise the mainstay of current evidence-based dysphagia management in HNC patients.

Endoscopic and non-endoscopic approaches for the management of radiation-induced rectal bleeding

Pelvic radiation is a commonly utilized treatment for malignancy of the genitourinary and lower gastrointestinal tract. Radiation proctitis and the resultant clinical picture varies from asymptomatic to potentially life threatening. Similarly, treatment options also vary greatly, from medical therapy to surgical intervention. Commonly utilized medical therapy includes sucralfate enemas, antibiotics, 5-aminosalicylic acid derivatives, probiotics, antioxidants, short-chain fatty acids, formalin instillation and fractionated hyperbaric oxygen. More invasive treatments include endoscopic-based, focally ablative interventions such as dilation, heater and bipolar cautery, neodymium/yttrium aluminum garnet argon laser, radiofrequency ablation or argon plasma coagulation. Despite its relatively common frequency, there is a dearth of existing literature reporting head-to-head comparisons of the various treatment options via a randomized controlled approach. The purpose of our review was to present the reader a consolidation of the existing evidence-based literature with the goal of highlighting the comparative effectiveness and risks of the various treatment approaches. Finally, we outline a pragmatic approach to the treatment of radiation proctitis. In light of the lack of randomized data, our goal is to pursue as least invasive an approach as possible, with escalation of care tailored to the severity of the patient’s symptoms. For those cases that are clinically asymptomatic or only mildly symptomatic, observation or medical management can be considered. Once a patient fails such management or symptoms become more severe, invasive procedures such as endoscopically based focal ablation or surgical intervention can be considered. Although not all recommendations are supported by level I evidence, reported case series and single-institutional studies in the literature suggest that successful treatment with cessation of symptoms can be obtained in the majority of cases.

Natural history and management of refractory benign esophageal strictures

BACKGROUND AND AIMS

The natural history of refractory benign esophageal strictures (RBES) is unclear, and surgery or percutaneous endoscopic gastrostomy (PEG) may be the only viable long-term options. The aim of the present study was to assess the long-term outcomes of patients with RBES.

METHODS

Clinical data of consecutive patients with RBES treated in the previous 15 years in 2 tertiary-care referral academic centers with specialized interest in esophageal stricture management were retrospectively analyzed. RBES was defined as the persistence and/or recurrence of dysphagia despite at least 5 dilation sessions and/or cycles with dilation to at least 14 mm. Information regarding the use of dilation or stents and the dysphagia-free period between subsequent interventions and adverse events was collected. Clinical success was defined as no need for endoscopic interventions for at least 6 months; unfavorable outcomes were defined as the need for endoscopic treatment at the end of follow-up, surgery, or percutaneous endoscopic gastrostomy (PEG). Predictors of unfavorable outcomes were assessed by multivariate analysis. A linear mixed-effect model was used to measure dysphagia-free period changes over time.

RESULTS

Overall, 70 patients with RBES (46 male; mean age 60 years) were followed for a mean of 43.9 months (range 3.7-157 months). Caustic, postradiotherapy, surgical, mixed, and postinflammatory etiology accounted for 10%, 14.3%, 31.4%, 40%, and 4.3% of causes, respectively. All patients underwent sequential sessions of pneumatic or bougie dilation, with a median of 15.5 dilation sessions per patient. Self-expandable metal stents (SEMSs) and biodegradable stents were placed in 18 (25.7%) and 14 (20%) patients, respectively. RBES resolution was achieved in only 22 of 70 (31.4%) patients. Two deaths (3%) were related to RBES. The success rate was lower in those who also were treated with endoprosthetics (odds ratio [OR] 3.7; 95% confidence interval [CI], 1.01-18.0). The mean dysphagia-free period was 3.3 months (95% CI, 2.4-4.1) for patients treated with dilation and 2.4 months (95% CI, 1.2-3.6) for those treated with stents (P = .062). Over time, the total dysphagia-free period increased at a rate of 4.1 days (95% CI, 1.7-6.4) per dilation. There was no difference in the rate of change across groups defined by sex (P = .976), age (P = .633), or endoscopic treatment (P = .267).

CONCLUSIONS

Our multicenter series showed a disappointing long-term outcome for RBES, with only 1 of 3 achieving clinical resolution. The dysphagia-free period was relatively short, affecting the quality of life. Endoprosthetics did not appear to affect the natural history of RBES.

Risk factors associated with refractoriness to esophageal dilatation for benign dysphagia

BACKGROUND

Benign esophageal strictures need repeated dilatations to relieve dysphagia. Literature is scarce on the risk factors for refractoriness of these strictures.

AIM

This study aimed to assess the risk factors associated with refractory strictures.

MATERIALS AND METHODS

This is a retrospective study of patients with benign esophageal strictures who were referred for esophageal dilatation over a period of 3 years.

RESULTS

A total of 327 esophageal dilatations were performed in 103 patients; 53% of the patients reported dysphagia for liquids. Clinical success was achieved in 77% of the patients. There was a need for further dilatations in 54% of patients, being more frequent in patients with dysphagia for liquids [78 vs. 64%, P=0.008, odds ratio (OR) 1.930], in those with caustic strictures (89 vs. 70%, P=0.007, OR 3.487), and in those with complex strictures (83 vs. 70%, P=0.047, OR 2.132). Caustic strictures, peptic strictures, and complex strictures showed statistical significance in the multivariate analysis. Time until subsequent dilatations was less in patients with dysphagia for liquids (49 vs. 182 days, P<0.001), in those with peptic strictures (49 vs. 98 days, P=0.004), in those with caustic strictures (49 vs. 78 days, P=0.005), and in patients with complex strictures (47 vs. 80 days P=0.009). In multivariate analysis, further dilatations occurred earlier in patients with dysphagia for liquids [hazard ratio (HR) 1.506, P=0.004], in those with peptic strictures (HR 1.644, P=0.002), in those with caustic strictures (HR 1.581, P=0.016), and in patients with complex strictures (HR 1.408, P=0.046).

CONCLUSION

Caustic, peptic, and complex strictures were associated with a greater need for subsequent dilatations. Time until subsequent dilatations was less in patients with dysphagia for liquids and in those with caustic, peptic, and complex strictures.

Refractory strictures despite steroid injection after esophageal endoscopic resection

BACKGROUND

Although steroid injection prevents stricture after esophageal endoscopic submucosal dissection (ESD), some patients require repeated sessions of endoscopic balloon dilation (EBD). We investigated the risk for refractory stricture despite the administration of steroid injections to prevent stricture in patients undergoing esophageal ESD. Refractory stricture was defined as the requirement for more than three sessions of EBD to resolve the stricture. In addition, the safety of steroid injections was assessed based on the rate of complications.

PATIENTS AND METHODS

We analyzed data from 127 consecutive patients who underwent esophageal ESD and had mucosal defects with a circumferential extent greater than three-quarters of the esophagus. To prevent stricture, steroid injection was performed. EBD was performed whenever a patient had symptoms of dysphagia.

RESULTS

The percentage of patients with a tumor circumferential extent greater than 75 % was significantly higher in those with refractory stricture than in those without stricture (P = 0.001). Multivariate analysis adjusted for age, sex, history of radiation therapy, tumor location, and tumor diameter showed that a tumor circumferential extent greater than 75 % was an independent risk factor for refractory stricture (adjusted odds ratio [OR] 5.49 [95 %CI 1.91 - 15.84], P = 0.002). Major adverse events occurred in 3 patients (2.4 %): perforation during EBD in 2 patients and delayed perforation after EBD in 1 patient. The patient with delayed perforation underwent esophagectomy because of mediastinitis.

CONCLUSIONS

A tumor circumferential extent greater than 75 % is an independent risk factor for refractory stricture despite steroid injections. The development of more extensive interventions is warranted to prevent refractory stricture.