Endoscopic intralesional steroid injections in the management of refractory esophageal strictures

Comprehensive review of materials, applications, and future innovations in biodegradable esophageal stents

Esophageal stricture (ES) results from benign and malignant conditions, such as uncontrolled gastroesophageal reflux disease (GERD) and esophageal neoplasms. Upper gastrointestinal endoscopy is the preferred diagnostic approach for ES and its underlying causes. Stent insertion using an endoscope is a prevalent method for alleviating or treating ES. Nevertheless, the widely used self-expandable metal stents (SEMS) and self-expandable plastic stents (SEPS) can result in complications such as migration and restenosis. Furthermore, they necessitate secondary extraction in cases of benign esophageal stricture (BES), rendering them unsatisfactory for clinical requirements. Over the past 3 decades, significant attention has been devoted to biodegradable materials, including synthetic polyester polymers and magnesium-based alloys, owing to their exceptional biocompatibility and biodegradability while addressing the challenges associated with recurring procedures after BES resolves. Novel esophageal stents have been developed and are undergoing experimental and clinical trials. Drug-eluting stents (DES) with drug-loading and drug-releasing capabilities are currently a research focal point, offering more efficient and precise ES treatments. Functional innovations have been investigated to optimize stent performance, including unidirectional drug-release and anti-migration features. Emerging manufacturing technologies such as three-dimensional (3D) printing and new biodegradable materials such as hydrogels have also contributed to the innovation of esophageal stents. The ultimate objective of the research and development of these materials is their clinical application in the treatment of ES and other benign conditions and the palliative treatment of malignant esophageal stricture (MES). This review aimed to offer a comprehensive overview of current biodegradable esophageal stent materials and their applications, highlight current research limitations and innovations, and offer insights into future development priorities and directions.

Management of Adults With Esophageal Atresia

Esophageal atresia (EA) with or without trachea-esophageal fistula is relatively common congenital malformation with most patients living into adulthood. As a result, care of the adult patient with EA is becoming more common. Although surgical repair has changed EA from a fatal to a livable condition, the residual effects of the anomaly may lead to a lifetime of complications. These include effects related to the underlying deformity such as atonicity of the esophageal segment, fistula recurrence, and esophageal cancer to complications of the surgery including anastomotic stricture, gastroesophageal reflux, and coping with an organ transposition. This review discusses the occurrence and management of these conditions in adulthood and the role of an effective transition from pediatric to adult care to optimize adult care treatment.

Endoscopic Treatment for Pediatric Esophageal Stenosis Induced by Chemical Burn, Congenitally, or After Surgical Repair of Esophageal Atresia

OBJECTIVES

To evaluate the safety and efficacy of endoscopic treatment for congenital pediatric esophageal stenosis or pediatric stenosis that develops after a chemical burn or surgical repair of esophageal atresia.

METHODS

We retrospectively reviewed the medical records of 15 pediatric patients who underwent endoscopic treatments (dilation and/or stenting and/or incision) for congenital esophageal stenosis or esophageal stenosis that developed after a chemical burn or surgical repair of esophageal atresia, between January 2010 and January 2019. The patients were periodically followed-up to assess the safety and efficacy of treatment by comparing the diameter of stricture and dysphagia score before and after procedures, and complications or recurrence.

RESULTS

All children successfully underwent the procedures. Fourteen of the 15 patients received endoscopic balloon dilation (EBD) as the first step of treatment, but EBD alone only resolved the symptoms in two patients. The remaining patients received other comprehensive treatments, such as EBD with endoscopic incision (EI), EBD with stent replacement, or a combination of EBD, stent replacement, and EI. Eleven (11/15, 73.3%) patients experienced symptomatic relief after endoscopic treatment, and recurrence was noted in four patients on 3-36 months after the final endoscopic treatment. All four patients underwent esophageal surgery to relieve their symptoms. Until October 2021, all patients experienced symptom relief, and their dysphagia scores decreased from 3-4 to 0-1 during the follow-up period of 8-121 months. The average diameter of stenosis was increased from 0.34 cm (range 0.2-0.7 cm) to 1.03 cm (range 0.8-1.2 cm). No severe complications occurred during endoscopic treatment and follow-up.

CONCLUSIONS

Endoscopic treatment is safe and effective for pediatric esophageal stenosis that is congenital or induced by chemical burns or surgical repair of esophageal atresia. Comparative large-scale studies are required to confirm our findings.

Devices for drug delivery in the gastrointestinal tract: A review of systems physically interacting with the mucosa for enhanced delivery

The delivery of macromolecules via the gastrointestinal (GI) tract remains a significant challenge. A variety of technologies using physical modes of drug delivery have been developed and investigated to overcome the epithelial cell layer of the GI tract for local and systemic delivery. These technologies include direct injection, jetting, ultrasound, and iontophoresis, which have been largely adapted from transdermal drug delivery. Direct injection of agents using needles through endoscopy has been used clinically for over a century. Jetting, a needle-less method of drug delivery where a high-speed stream of fluid medication penetrates tissue, has been evaluated pre-clinically for delivery of agents into the buccal mucosa. Ultrasound has been shown to be beneficial in enhancing delivery of macromolecules, including nucleic acids, in pre-clinical animal models. The application of an electric field gradient to drive drugs into tissues through the technique of iontophoresis has been shown to deliver highly toxic chemotherapies into GI tissues. Here in, we provide an in-depth overview of these physical modes of drug delivery in the GI tract and their clinical and preclinical uses.

The Safety of Intralesional Steroid Injections in Young Children and Their Effectiveness in Anastomotic Esophageal Strictures-A Meta-Analysis and Systematic Review

OBJECTIVE

Intralesional steroid injections (ISI) are a widely used technique for various pediatric indications and represent a possible adjuvant treatment for anastomotic esophageal strictures. Yet, no consensus has been reached neither on their safety in the pediatric population or their effectiveness in esophageal atresia patients. This systematic review aimed to assess the safety of ISI in young children through a meta-analysis and to summarize the current knowledge on the effectiveness of ISI in anastomotic esophageal strictures.

METHODS

A systematic literature search was performed in Embase, Medline, Web of Science Core Collection, Cochrane Central Register of Controlled Trials and Google Scholar up to August 16 2021. Studies focusing on ISI and involving children up to 2 years were included in the meta-analysis for the safety assessment. All studies evaluating the use of ISI as adjuvant treatment in anastomotic esophageal strictures in children were included in the systematic review to assess the effectiveness of the intervention.

RESULTS

The literature search yielded 8,253 articles. A total of 57 studies were included, of which 55 for the safety and five for the effectiveness assessment. The overall complication rate was 7%, with a greater incidence of local complications compared to systemic complications. Six studies (with a total of 367 patients) evaluated adrenocorticotropic hormone and cortisol levels, of which four reported hypothalamic-pituitary axis suppression. Two children (0.6%) received replacement therapy and all patients recovered uneventfully. A mean number of 1.67 ISI were performed per esophageal atresia (EA) patient. A reduction of needed dilatations was seen after ISI, compared to the number of dilatations performed before the intervention (5.2 vs. 1.3).

CONCLUSION

The insufficient data emphasized the need for further prospective and comparative studies. Results from this meta-analysis and systematic review address ISI as a safe and effective technique. Close clinical follow-up and growth curve evaluation are advisable in patients receiving ISI.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, identifier: CRD42021281584.

Intralesional Steroid Injection Therapy for Esophageal Anastomotic Stricture Following Esophageal Atresia Repair

OBJECTIVES

The role of intralesional steroid injection (ISI) in the treatment of anastomotic stricture in patients with esophageal atresia remains unclear. The aim of this study was to evaluate the efficacy and safety of ISI.

METHODS

A total of 158 patients with esophageal atresia with at least 1 ISI for the treatment of esophageal anastomotic stricture between 2010 and 2017 were identified. The change in stricture diameter (ΔD) was compared between procedures with dilation alone (ISI-) and dilation with steroid injection (ISI+).

RESULTS

A total of 1055 balloon dilations were performed (452 ISI+). The median ΔD was significantly greater in the ISI+ group: 1 mm (interquartile range [IQR] 0, 3) versus 0 mm (IQR -1, 1.5) (P < 0.0001). The ISI+ group had greater percentage of improved diameter (P < 0.0001) and lesser percentages of unchanged and decreased diameters at subsequent endoscopy (P = 0.0009, P = 0.003). Multivariable logistic regression confirmed the significance of ISI on increasing the likelihood of improved stricture diameter with an adjusted odds ratio of 3.24 (95% confidence interval: 2.15-4.88) (P < 0.001). The ΔD for the first 3 ISI+ procedures was greater than the ΔD for subsequent ISI+ procedures: 1 mm (IQR 0, 3) versus 0.5 mm (IQR-1.25, 2) (P = 0.001). There was no difference in perforation incidence between ISI+ and ISI- groups (P = 0.82).

CONCLUSIONS

ISI with dilation was well tolerated and improved anastomotic stricture diameter more than dilation alone. The benefit of ISI over dilation alone was limited to the first 3 ISI procedures.

The effect of intralesional steroid injections on esophageal strictures and the child as whole: A case series

BACKGROUND

The most frequent complication after esophageal atresia repair remains anastomotic stricture formation. The initial treatment is endoscopic dilatation. Intralesional steroid injection (ISI) might be an effective adjuvant treatment in case of recurrent strictures. In this series we present our initial experience with this intervention.

METHODS

Data on primary surgery, stricture treatment, postoperative complications, outcome and growth were retrospectively collected from electronic patient records. Findings were analyzed by descriptive statistics and mixed model analysis.

RESULTS

Between 2014 and 2017, ISI was performed for severe recurrent anastomotic strictures in six patients (median age at injection 12.4 (2.1-34.7) months) after a median of 6 (2-20) dilatations. In five patients ISI was successful and the stenosis was cleared. No postoperative complications were reported, especially none related to acute adrenal suppression. Comparing the year before with the year after ISI, a significant positive change for weight (r = 0.70, p = 0.003) was calculated versus a negative change for height (r = -0.87, p = 0.003).

CONCLUSIONS

We found ISI to be an effective adjuvant treatment to recurrent anastomotic stricture dilatation after esophageal atresia repair, without postoperative complications or symptoms of adrenal suppression. It remains important, however, to monitor growth effects. Further evaluation is required in a large prospective study.

TYPE OF STUDY

Treatment study, Level IV (case series).

Intralesional steroid injections to prevent refractory strictures in patients with oesophageal atresia: study protocol for an international, multicentre randomised controlled trial (STEPS-EA trial)

INTRODUCTION

Anastomotic stricture formation is the most common postoperative complication after oesophageal atresia (OA) repair. The standard of care is endoscopic dilatation. A possible adjuvant treatment is intralesional steroid injection, which is thought to inhibit scar tissue formation and thereby to prevent stricture recurrence. We hypothesise that this intervention could prevent refractory strictures and reduce the total number of dilatations needed in these children.

METHODS AND ANALYSIS

This is an international multicentre randomised controlled trial. Children with OA type C (n=110) will be randomised into intralesional steroid injection followed by balloon dilatation or dilatation only. Randomisation and intervention will take place when a third dilatation is performed. The indication for dilatation will be confirmed with an oesophagram. One radiologist-blinded for randomisation-will review all oesophagrams. The primary outcome parameter is the total number of dilatations needed with <28 days' interval, which will be analysed with a linear-by-linear χ² association test. Secondary outcome parameters include the level of dysphagia, the luminal oesophageal diameter and stricture length (measured on the oesophagrams), the influence of comedication on stricture formation, systemic effects of intralesional steroids (cortisol levels, length and weight) and the cost-effectiveness. Patients will undergo a second oesophagram; length and weight will be measured repeatedly; a scalp hair sample will be collected; and three questionnaires will be administered. The follow-up period will be 6 months, with evaluation at 2-3 weeks, 3 and 6 months after the intervention.

ETHICS AND DISSEMINATION

Patients will be included after written parental informed consent. The risks and burden associated with this trial are minimal. The institutional review board of the Erasmus Medical Centre approved this protocol (MEC-2018-1586/NL65364.078.18). The results of the trial will be published in a peer-reviewed scientific journal and will be presented at international conferences.

TRIAL REGISTRATION NUMBERS

2018-002863-24 and NTR7726/NL7484.

Recurrent Esophageal Stricture Secondary to Pemphigus Vulgaris: A Rare Diagnostic and Therapeutic Challenge

Pemphigus vulgaris (PV) is an autoimmune blistering disorder of skin and mucous membranes, characterized by acantholysis, can be life threatening, and carries significant morbidity. Esophageal involvement is uncommon, and the diagnosis can often be delayed. Esophageal stricture secondary to PV is extremely rare, and there are no guidelines on the management of this complication. We present a case of recalcitrant esophageal stricture, secondary to PV, successfully treated with topical and intralesional steroids. Moreover, we review the literature pertaining to esophageal PV and the management of esophageal strictures.

Caustic Agents Ingestion in Children: A 51-Year Retrospective Cohort Study

OBJECTIVES

Children experience serious gastrointestinal tract injuries due to consumption of caustic agents more often than adults. The aim of the study was to analyze diagnostic methods and treatment of children with esophageal burns according to the degree of the injury.

METHODS

Our one-center population-based retrospective cohort study included 150 children admitted between 1967 and 2018 to Clinic of Pediatric Otolaryngology, Phoniatrics and Audiology of University Children's Hospital in Lublin, Poland, due to the chemical burn of the mouth, throat, larynx, and esophagus. Each patient underwent a thorough laryngological examination and endoscopy to assess the place and degree of injury.

RESULTS

Of 150 patients, 65.3% were male and 34.7% female. The median age was 4 years and 3 months. Salivation, dysphagia, burning sensation, edema, and whitish coating on the oral mucosa, palate, and throat were the most common clinical symptoms. In addition, dyspnea and chest pain were observed in 30% of patients. Esophagus endoscopy results were: Zargar grade I burn (84.7%), grade IIA (8%), grade IIB (2.6%), grade III (0%), and grade 0 (4.7%). Treatment included antibiotics, proton pump inhibitors, analgesics, and intravenous fluid therapy. Late sequelae (scarred esophageal strictures) developed in 20 (13.3%) patients.

CONCLUSIONS

Accidental intake of caustic agents is observed in young children, especially younger than the age of 5. Early esophagus endoscopy should be performed in all patients to assess the grade of injury, plan initial treatment, and predict the risk of developing complications. Early diagnosis and immediate pharmacological treatment reduce the number of late sequelae.

How to Care for Patients with EA-TEF: The Known and the Unknown

PURPOSE OF REVIEW

Guidelines were recently published highlighting why esophageal atresia (EA) patients are prone to complication risks, and the need for long-term follow-up. In this review, we will focus on how to investigate and treat potential complications, as well as the pros and cons of different investigative and treatment modalities, and what areas continue to need further research.

RECENT FINDINGS

EA patients are at high risk for gastroesophageal reflux and esophageal strictures, and the sequela that result. Extraintestinal manifestations of gastroesophageal reflux disease (GERD) can appear similar to other pathologic diagnoses commonly found in EA patients, such as congenital stricture, eosinophilic esophagitis, esophageal dysmotility, tracheomalacia, recurrent fistula, aspiration, etc. Therefore, it is important to have a standardized way to monitor for these issues. pH impedance allows for detection of nonacid reflux and the height of reflux, which are important in correlating symptoms with reflux episodes. A multidisciplinary approach is beneficial in evaluating and monitoring EA patients in the long term.

The Efficacy of Intralesional Steroid Injection in the Treatment of Corrosive Esophageal Strictures in Children

PURPOSE OF THE STUDY

Esophageal dilatation can be insufficient in the treatment of severe corrosive esophageal strictures. In this study, we aimed to present the efficacy of intralesional steroid injection as an adjunct to dilatation therapy.

MATERIALS AND METHODS

Retrospective analysis of children who underwent intralesional steroid injection between 2004 and 2014 was performed. Patients' age, type of corrosive substance, length of stricture, number of injection and dilatation sessions and complications were reviewed. The success was evaluated by the comparison of number, frequency, and requirement of dilatation therapy before and after injection.

RESULTS

Intralesional steroid injection was performed to 32 children with a mean age of 3.6±2.5 years. The types of corrosive agents were alkali (24) or acid (8). Mean number of injection sessions was 2.5±1.1(1 to 6). Mean number of dilatation sessions was decreased from 10±8.8 to 5.4±4.6 after injection (P=0.003). Mean frequency of dilatations was extended from 3.6±0.9 weeks to 8.7±3.9 weeks (P=0.000). Dilatation treatment was successfully terminated in 25 of 27 children with short-segment strictures after injection (92%). Whereas all of the children with long-segment strictures could not resolved and finally required esophageal replacement (5 patients). One patient had transient cushingoid phenotype as a complication. There was not seen any major complication-like perforation. The mean follow-up period was 6±3 years.

CONCLUSIONS

Intralesional steroid injection is an effective adjunct to dilatation in most of the children with short-segment strictures. It should be performed as a safe and efficient treatment option in patients with short-segment corrosive esophageal strictures resistant to dilatation therapy.

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.

Anastomotic Strictures after Esophageal Atresia Repair: Incidence, Investigations, and Management, Including Treatment of Refractory and Recurrent Strictures

Improved surgical techniques, as well as preoperative and postoperative care, have dramatically changed survival of children with esophageal atresia (EA) over the last decades. Nowadays, we are increasingly seeing EA patients experiencing significant short- and long-term gastrointestinal morbidities. Anastomotic stricture (AS) is the most common complication following operative repair. An esophageal stricture is defined as an intrinsic luminal narrowing in a clinically symptomatic patient, but no symptoms are sensitive or specific enough to diagnose an AS. This review aims to provide a comprehensive view of AS in EA children. Given the lack of evidence-based data, we critically analyzed significant studies on children and adults, including comments on benign strictures with other etiologies. Despite there is no consensus about the goal of the luminal diameter based on the patient's age, esophageal contrast study, and/or endoscopy are recommended to assess the degree of the narrowing. A high variability in incidence of ASs is reported in literature, depending on different definitions of AS and on a great number of pre-, intra-, and postoperative risk factor influencing the anastomosis outcome. The presence of a long gap between the two esophageal ends, with consequent anastomotic tension, is determinant for stricture formation and its response to treatment. The cornerstone of treatment is endoscopic dilation, whose primary aims are to achieve symptom relief, allow age-appropriate capacity for oral feeding, and reduce the risk of pulmonary aspiration. No clear advantage of either balloon or bougie dilator has been demonstrated; therefore, the choice is based on operator experience and comfort with the equipment. Retrospective evidences suggest that selective dilatations (performed only in symptomatic patients) results in significantly less number of dilatation sessions than routine dilations (performed to prevent symptoms) with equal long-term outcomes. The response to dilation treatment is variable, and some patients may experience recurrent and refractory ASs. Adjunctive treatments have been used, including local injection of steroids, topical application of mitomycin C, and esophageal stenting, but long-term studies are needed to prove their efficacy and safety. Stricture resection or esophageal replacement with an interposition graft remains options for AS refractory to conservative treatments.

Aggressive bougie dilatation and intralesional steroids is effective in refractory benign esophageal strictures secondary to corrosive ingestion

Endoscopic dilatation of corrosive esophageal strictures is effective, but some patients are refractory to it and require long-term repeated dilatations. The present study was carried out to analyze whether rigorous schedule of endoscopic bougie dilatation along with intralesional injection of triamcinolone in patients refractory to endoscopic dilatation alone could decrease the number and frequency of endoscopic dilatations. The inclusion criterion for this prospective study was patients with refractory corrosive esophageal stricture of any age group. Refractory benign esophageal stricture is defined as an anatomic fibrotic esophageal restriction with inability to achieve dilatation of ≥14 mm or to maintain dilatation for 4 weeks once ≥14 mm diameter is achieved. The patients were followed up prospectively for 1 year. Patients with refractory strictures were subjected to weekly bougie dilatation (Savary-Gilliard) of the strictures along with injections of intralesional triamcinolone (40 mg/mL, 1 mL diluted in 1 mL of saline, 0.5 mL injected per quadrant of stricture) for consecutive 5 weeks, referred to as rigorous schedule. Further dilatation was done on an 'on-demand' basis. Eleven patients were enrolled for the study. Dysphagia score improved from pre-intervention score of 3.54 ± 0.52 to 0.45 ± 0.52 post-intervention (P < 0.001). The maximum dilatation achieved pre-intervention was 9.90+1.04 mm Savary-Gilliard and post-intervention significantly improved to 14.7 + 0.7 mm Savary-Gilliard (P < 0.001). The periodic dilatation index defined as number of dilatations per month also significantly improved from pre-intervention score of 2.54 ± 1.06 to post-intervention score of 0.19 + 0.13 (P < 0.001). No adverse effects were reported by the patients. Rigorous weekly schedule of bougie dilatation and intralesional triamcinolone in combination is safe and effective in achieving significant dilatation, reducing the frequency dilatations, maintaining dilatation and improving dysphagia till 1 year of follow-up.

Motility, digestive and nutritional problems in Esophageal Atresia

Esophageal atresia (EA) with or without tracheoesophageal fistula (TEF) is a rare congenital malformation. Digestive and nutritional problems remain frequent in children with EA both in early infancy and at long-term follow-up. These patients are at major risk of presenting with gastroesophageal reflux and its complications, such as anastomotic strictures. Esophageal dysmotility is constant, and can have important consequences on feeding and nutritional status. Patients with EA need a systematic follow-up with a multidisciplinary team.

Endoscopic Incision for the Treatment of Refractory Esophageal Anastomotic Strictures in Children

OBJECTIVES

The aim of the present study was to assess the safety and efficacy of endoscopic incision (EI) for the treatment of refractory anastomotic esophageal strictures in pediatric patients.

METHODS

We retrospectively reviewed the medical records of pediatric patients with refractory anastomotic strictures after surgical repair of esophageal atresia who underwent ≥3 sessions of endoscopic treatments (dilation and/or stenting). They were treated with EI alone or together with esophageal stenting. Efficacy and safety were evaluated during periodical follow-up.

RESULTS

All of the 7 children received the procedure successfully with the operation time of 15 to 60 minutes. Four of them received EI alone, whereas the other 3 received EI with esophageal stenting (EIES). The symptoms remitted in all of the patients, and the dysphagia score decreased from 3-4 to 0-1 during follow-up from 1 to 21 months. The average diameter of stricture was enlarged from 3 mm (range 2-5 mm) to 10.6 mm (range 8-12 mm). One patient suffered from chest pain, which resolved within 3 days. Patient 1 had recurrence 11 months after EIES, and patient 6 had recurrence 3 months after EI. They all underwent an additional EI to maintain patency. No severe complications were observed during operation and periodical follow-up.

CONCLUSIONS

EI is safe and appears effective for refractory esophageal anastomotic strictures in children in the short term. Large comparative studies are warranted to further confirm our findings. The long-term follow-up is necessary for assessing the long-term efficacy of the new technique.

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.

Efficacy of intralesional corticosteroid injection in endoscopic treatment of esophageal strictures

BACKGROUND

The present study was conducted to determine the effectiveness of intralesional triamcinolone to improve the results of endoscopic dilation in esophageal strictures.

METHODS

We treated 9 patients with complex strictures of different etiologies (2 postsurgery, 3 gastroesophageal reflux disease, and 4 caustic) with intralesional injections of triamcinolone followed by endoscopic dilations. Outcomes of triamcinolone-treated patients were compared with those of historical control. We injected triamcinolone before dilating the strictures. All the patients were followed up for 1 year. The interval between dilations, frequency of dilation, and refractory rates were calculated.

RESULTS

There was no difference between the control group and the patients with steroids regarding baseline characteristics (age and sex distribution of patients and stricture etiologies, length, and location). The patients in the triamcinolone group had a bigger improvement of their dysphagia and had a lower refractority rate than the patients in control group, these differences being statistically significant.

CONCLUSIONS

Intralesional triamcinolone presented a higher improvement of dysphagia and a lower refractority rate in patients with complex strictures with statistically significant differences.

Refractory strictures post-esophageal atresia repair: what are the alternatives?

Esophageal strictures remain the most frequent complication after esophageal atresia (EA) repair despite refinements in operative techniques. With an incidence of anastomotic stricture between 8% and 49%, EA is the most frequent cause of benign esophageal stricture in children. The mainstay of treatment for esophageal stricture is dilatation with a 58-96% success rate. In order to relieve dysphagia, between 1 and 15 dilatations will be required in each EA patient with an esophageal stricture. However dilatations may lead to complications including perforation (0.1-0.4% of all esophageal benign strictures) and sociopsychological morbidity. Fifty percent of EA strictures will improve in 6 months. However, 30% will persist and require repeat dilatations. The present article explores the variety of non-surgical alternative treatments for anastomotic strictures after EA repair, focusing on triamcinolone acetonide, mitomycin C and esophageal stents. We propose an algorithm for a more standardized therapeutic approach, with the hope that an international panel of experts could meet and establish a consensus.

Feasibility study of corticosteroid treatment for esophageal ulcer after EMR in a canine model

BACKGROUND

Intralesional or systemic steroid administration is a promising strategy for the prevention of esophageal stricture after endoscopic therapy. The aim of this study was to evaluate the influence of steroid therapy on the process of healing of defects in the esophageal mucosa after endoscopic mucosal resection (EMR).

METHODS

Nine beagle dogs were divided into three equal groups: group A, intralesional injection (n = 3), group B, peroral administration (n = 3), and group C, untreated control (n = 3). In group A, triamcinolone acetonide 1 ml (10 mg) was injected directly into the exposed submucosal layer immediately after EMR, and again on postoperative day (POD) 7. In group B, dogs were administered prednisolone 0.5 mg/kg/day orally for 14 days after EMR. In group C, 1 ml normal saline was injected by the same method as that used for group A. On POD 28, histological examination was performed to evaluate epithelialization, inflammation, angiogenesis, and atrophy of the muscularis propria.

RESULTS

In groups A, B, and C, the mean ulcer area was 50.1, 22.7, and 7.4 mm(2), respectively. The difference between groups A and C was significant (p < 0.01). Inflammatory cells were significantly more evident in the lesions of group A than in those of group C (p < 0.05). In all groups, atrophy of the muscularis propria was evident. However, transmural destruction and fibrosis were observed only in group A.

CONCLUSION

It was speculated that the esophageal ulcer causes the fibrosis of the submucosa and atrophy of the muscularis propria during process of healing. Intralesional steroid injection deepened the esophageal ulcers and delayed epithelialization, whereas systemic administration did not clearly improve the lesion healing process.

Balloon dilation and intralesional steroid for benign rectal stricture management in a cat

A 4-year-old castrated male domestic shorthair presented for 1 week of constipation and tenesmus. A rectal stricture had been diagnosed 8 months prior at the time of adoption and the cat had been successfully managed with stool softeners until presentation. A complete diagnostic work-up failed to reveal an underlying etiology for the stricture and colonoscopy was performed. Endoscopic biopsies of the stricture revealed benign non-specific inflammatory changes. Balloon dilation of the rectal stricture was performed during the initial colonoscopy and 3 and 9 days later. Triamcinolone acetonide was injected into the stricture site with endoscopic guidance during the third dilation procedure. The patient has been monitored for over 27 months; follow-up indicates no signs of tenesmus and repeated rectal examinations reveal no stricture recurrence. This case report demonstrates that endoscopic balloon dilation with intralesional steroid injection represented a minimally invasive and effective option for the treatment of a benign rectal stricture in this cat, and deserves further prospective investigation.

Clinical outcomes after self-expanding plastic stent placement for refractory benign esophageal strictures

BACKGROUND

Refractory benign esophageal strictures (RBES) are defined as those that persist structurally and symptomatically after repeated dilation sessions. Small series have reported favorable outcomes after placement and subsequent removal of Polyflex self-expanding plastic stents (SEPS).

AIMS

To characterize the outcomes after Polyflex stent placement in patients with RBES.

METHODS

Outcomes of consecutive patients who underwent Polyflex stent placement for RBES between April 15, 2005 and November 20, 2006 were analyzed retrospectively. The etiology of the stricture, number of dilations prior to initial SEPS placement, size of stent placed, stricture resolution after SEPS removal, cases of stent migration, duration of SEPS placement, time to repeat dilation and/or SEPS replacement after stent removal, and complications were assessed.

RESULTS

Twenty-three Polyflex stents were placed in 13 patients suitable for analysis. The majority of stenoses (11/13) were attributable to anastomotic strictures after curative esophagogastrectomy for esophageal neoplasms. All 11 patients in this group had satisfactory relief of dysphagia to solids determined clinically with indwelling SEPS placement. SEPS migration occurred in seven instances (30% of SEPS placed). Dysphagia remediation after subsequent SEPS removal was observed in only three patients (23%). Placement of a partially covered metal stent within a Polyflex stent was necessary in one case due to epithelial hyperplasia. The mean time for repeat dilation and/or SEPS reinsertion due to recurrent dysphagia after stent removal was 37 days (range 6-120 days).

CONCLUSIONS

Polyflex stents provided satisfactory palliation of dysphagia for RBES while in place. However, unplanned SEPS migration and dysphagia recurrence after stent removal were common.

Intralesional steroid injection therapy in the management of resistant gastrointestinal strictures

Esophageal strictures are a problem frequently encountered by gastroenterologists. Dilation has been the customary treatment for benign esophageal strictures, and dilation techniques have advanced over the years. Depending on their characteristics and the response to treatment, esophageal strictures can be classified into two types: 1, simple (Schatzki rings, webs, peptic injury, and following sclerotherapy) - these are easily amenable to dilation, with a low recurrence rate after initial treatment; and 2, complex (caused by caustic ingestion, radiation injury, anastomotic strictures, and photodynamic therapy) - these are difficult to dilate and are associated with higher recurrence rates. Refractory strictures are those in which it is not possible to relieve the anatomic restriction successfully up to a diameter of 14 mm over five sessions at 2-weekly intervals, due to cicatricial luminal compromise or fibrosis; and recurrent strictures are those in which it is not possible to maintain a satisfactory luminal diameter for 4 wk once the target diameter of 14 mm has been achieved. There are no standard recommendations for the management of refractory strictures. The various techniques used include intralesional steroid injection combined with dilation; endoscopic incisional therapy, with or without dilation; placement of self-expanding metal stents, Polyflex stents, or biodegradable stents; self-bougienage; and endoscopic surgery. This review discusses the indications, technique, results, and complications of the use of intralesional steroid injections combined with dilation and endoscopic incisional therapy with dilation in refractory strictures.

Successful treatment of severe refractory anastomotic stricture in an infant after esophageal atresia repair by endoscopic balloon dilation combined with systemic administration of dexamethasone

A boy with a history of esophageal atresia repair received an esophagoesophagostomy at 14 months for a severe refractory anastomotic stricture, which had already required repeated balloon dilation with intralesional dexamethasone injection. Anastomotic leakage and stricture was again evident after the second surgery, and the patient underwent five procedures of balloon dilations with intralesional dexamethasone injection. Dysphagia was persistent and the patient required dilation every 2-3 weeks. After the sixth dilation, the patient was given 1 mg/kg per day of dexamethasone i.v. for 3 days. Dexamethasone i.v. was tapered during the following 3 days and finished at day 6. A week later, endoscopic findings showed an apparent improvement in the stricture. Another dilation was followed by 1 mg/kg per day dexamethasone i.v. for 7 days, and 0.75 kg/mg per day oral dexamethasone for another 7 days. The stricture improved completely and the anastomosis was patent after the second dilation. The patient is doing well without dysphagia and has not required additional dilation for over 18 months after the last dilation. Balloon dilation in combination with systemic dexamethasone administration may be an effective treatment that could substitute invasive techniques including surgical manipulation for severe refractory strictures.

Removable self-expanding plastic esophageal stent as a continuous, non-permanent dilator in treating refractory benign esophageal strictures: a prospective two-center study

BACKGROUND

Refractory benign esophageal strictures (RBES) are difficult to treat requiring frequent dilatations or surgery. Conceptually, while maintaining luminal patency, if a dilator is kept in place continuously for several weeks, the benefits may be longer lasting. An expandable esophageal stent will be ideal in achieving the above. Preliminary results on using a removable self-expanding plastic esophageal stent, Polyflex stent (PS), for treating RBES have been mixed.

AIM

To evaluate the efficacy of PS in the treatment of RBES.

METHODS

Forty patients with RBES [mean age 60 +/- 15 SD yrs, female 14, male 26, Anastomotic 12 (fistula 4), Corrosive 8, Radiation 7, Pill induced 4, Post trauma 3 (fistula 3), Peptic 2, Others 4 (fistula 1)] were prospectively studied. Continuous non-permanent dilation was performed by placing a PS and removing it after 4 wk. The patients were then followed at regular intervals. Pre-insertion baseline data and post-removal information on dysphagia status, complications, and change in outcome were prospectively collected.

RESULTS

The technical success in stent placement and stent removal were 95% and 94%, respectively. Mean post-stent dysphagia score was 0.6 +/- 0.7 SD, which was significantly better than pre-stent scores (3.0 +/- 0.8 SD; P < 0.001). At median follow-up of 53 wk (range 11-156), only 40% (intention to treat 30%) patients were dysphagia-free. However, the overall change in outcome from baseline options (ongoing dilatations, or surgery) was 66% (dysphagia-free 12, did not want removal 2, did not remove 1, preferred long-term stenting 10). The stent was successful in closing the fistula in five of eight (63%) patients. Complications observed were migration eight (22%), severe chest pain four (11%), bleeding three (8%), perforation two (5.5%), GE reflux two (5.5%), impaction two (5.5%), and new fistula one (2.7%). There was one mortality from massive bleeding.

CONCLUSIONS

It was feasible to deploy and remove PS stents in the majority of patients with RBES. Some patients achieved long-term relief without further re-interventions while several others re-strictured and preferred long-term stenting over repeated dilations or surgery. The procedure carries significant risks and hence should only be considered in carefully selected patients.

Nonsurgical management of severe esophageal and gastric injury following alkali ingestion

The ingestion of caustic substances may result in significant gastrointestinal injury. Endoscopy can play a major role in the initial evaluation and subsequent therapy of such injuries. The case of a 50-year-old man who ingested an alkaline floor stripper is described, including the endoscopic management of esophageal and pyloric strictures, with good functional results. The role of endoscopy, steroids and acid suppression in the management of such patients is also explored.

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.

Usefulness of biodegradable stents constructed of poly-l-lactic acid monofilaments in patients with benign esophageal stenosis

AIM: To report 13 patients with benign esophageal stenosis treated with the biodegradable stent.

METHODS: We developed a Ultraflex-type stent by knitting poly-l-lactic acid monofilaments.

RESULTS: Two cases were esophageal stenosis caused by drinking of caustic liquid, 4 cases were due to surgical resection of esophageal cancers, and 7 cases were patients with esophageal cancer who received the preventive placement of biodegradable stents for post-endoscopic mucosal dissection (ESD) stenosis. The preventive placement was performed within 2 to 3 d after ESD. In 10 of the 13 cases, spontaneous migration of the stents occurred between 10 to 21 d after placement. In these cases, the migrated stents were excreted with the feces, and no obstructive complications were experienced. In 3 cases, the stents remained at the proper location on d 21 after placement. No symptoms of re-stenosis were observed within the follow-up period of 7 mo to 2 years. Further treatment with balloon dilatation or replacement of the biodegradable stent was not required.

CONCLUSION: Biodegradable stents were useful for the treatment of benign esophageal stenosis, particularly for the prevention of post-ESD stenosis.

Endoscopic balloon dilation of stomal stenosis following gastric bypass

BACKGROUND

Roux-en-Y gastric bypass (RYGBP) is a common operation for severely obese patients, particularly those with co-morbid disease. Postoperative complications include those amenable to endoscopic therapy, specifically those involving the gastric stoma.

METHODS

26 patients with prior history of RYGBP for morbid obesity presented with symptoms of gastric outlet obstruction. Symptoms included accelerated weight loss (n=22), nausea/vomiting (n=26), dehydration (n=5), and dysphagia (n=2). Endoscopic dilatation was performed using through-the-scope dilating balloons (8-15 mm). Following dilatation, a steroid solution was injected to prevent re-stenosis.

RESULTS

Patients underwent 1-7 dilating sessions (mean 2.7/patient) at 2-week intervals. Estimated stoma diameter prior to dilation ranged from 1 mm to 8 mm (mean 3.5). Following dilation, diameter of the stoma increased to 10 to 15 mm (mean 12.4) at final endoscopy. In patients requiring a single dilating session (n=7), predilation stoma size was a mean 5.8 mm (range 3-8 mm), which increased to a mean of 12.7 mm (range 10-15 mm). In patients requiring multiple dilating sessions (n=19), pre-dilation stoma size was a mean of 2.7 mm (range 0-4 mm), which increased to a mean of 12.2 mm (range 10-14 mm). 25 of 26 patients had good long-term response, with follow-up of 6-38 months (mean 26). No treatment-related complications occurred. All had appropriate weight loss as determined at the bariatric clinic following endoscopic therapy.

CONCLUSIONS

Of the complications following bariatric surgery that are amenable to endoscopic therapy, stomal stenosis appears to be relatively common. Endoscopic balloon dilation is an effective nonsurgical method for treatment of stomal stenosis, with no complications observed in this, the largest reported, series.

A prospective, randomized, double-blind, placebo-controlled trial of endoscopic steroid injection therapy for recalcitrant esophageal peptic strictures

BACKGROUND AND AIMS

The aim of the study was to examine whether endoscopic intralesional corticosteroid injection into recalcitrant peptic esophageal strictures reduces the need for repeat stricture dilation.

METHODS

Patients with a peptic esophageal stricture and recurrent dysphagia having had at least one dilation in the preceding 18 months were enrolled in a prospective randomized, double-blind study comparing steroid and sham injection. After endoscopic confirmation of recurrent stricture, patients were randomized to receive either 0.5 cc/quadrant triamcinolone (40 mg/cc) or sham injection into the stricture followed by balloon dilation of the stricture. Patients were stratified by the number of dilations required in the preceding 18 months, severity of dysphagia, the presence of esophagitis, stricture severity, and prior therapy with a proton-pump inhibitor. Patients and their physicians were blinded to the type of intervention received. Baseline dysphagia questionnaires were completed. Post-procedurally all patients were placed on a standardized proton-pump inhibitor regimen and standardized telephone follow-up questionnaires were completed at 1 wk and at 1, 3, 6, 9, and 12 months. The original sample-size calculation of 60 patients could not be met in a timely fashion because of a low incidence of recalcitrant peptic stricture patients.

RESULTS

A total of 30 patients were enrolled, 15 in the steroid group (10 men, mean age 66 yr) and 15 in the sham group (11 M, mean age 67 yr). Patients were followed for 1 yr, unless they underwent an antireflux operation or died. Two patients, one per group, died of non-esophageal causes at 1 and 12 months. Four patients had fundoplication, two in each group, unrelated to stricture or dysphagia. Two patients in the steroid group (13%) and nine in the sham group (60%) required repeat dilation (p= 0.011).

CONCLUSIONS

In patients with recalcitrant peptic esophageal stricture, steroid injection into the stricture combined with acid suppression significantly diminishes both the need for repeat dilation and the average time to repeat dilation compared to sham injection and acid suppression alone.

Short Esophagus and Esophageal Stricture

Short esophagus and peptic esophageal stricture are complications of chronic severe GERD. Short esophagus is properly diagnosed by an objective,intraoperative assessment after appropriate dissection of the GEJ. A laparoscopic Collis gastroplasty combined with an antireflux procedure comprises effective therapy. Peptic stricture should be addressed with an initial course of dilator therapy and optimization of antiacid medication. Consideration is given to an antireflux procedure if conservative therapy fails. Laparoscopic techniques have proven to be safe and effective in treating short esophagus and peptic stricture.

Dysphagia in aging

Dysphagia is a common problem in older patients and is becoming a larger health care problem as the populations of the United States and other developed countries rapidly age. Changes in physiology with aging are seen in the upper esophageal sphincter and pharyngeal region in both symptomatic and asymptomatic older individuals. Age related changes in the esophageal body and lower esophageal sphincter are more difficult to identify, while esophageal sensation certainly is blunted with age. Stroke, Parkinson's disease, amyotrophic lateral sclerosis, Zenker's diverticula, and several other motility and structural disorders may cause oropharyngeal dysphagia in an older patient. Esophageal dysphagia can also be caused by both disorders of motility (achalasia, diffuse esophageal spasm, scleroderma and others) and structure (malignancy, strictures, rings, external compression, and others). Many of these disorders have an increased prevalence in older patients and should be sought with an appropriate diagnostic evaluation in older patients. The treatment of dysphagia in older patients is similar to that in younger patients, but more invasive therapies such as surgery may not be possible in some older patients making less aggressive medical and endoscopic therapy more attractive.

Intralesional steroid injection in benign esophageal strictures resistant to bougie dilation

OBJECTIVE

Some benign esophageal strictures are highly resistant to bougie dilation. The aim of this study was to determine whether intralesional steroid injection had additional benefit to Savary-Gilliard's bougie dilation therapy (SGBD).

METHODS

Twenty-one patients were treated with a bougie dilator. The patients were randomized into control and study groups. There were 11 patients in the control group (7 males, 4 females; mean age 45.09 +/- 24.64 years) and 10 patients in the study group (4 males, 6 females; mean age 49.40 +/- 16.49 years). The patients in the control group underwent only SGBD, but patients in the study group received an additional intralesional steroid injection (8 mg triamcinolone acetate into each quadrant). The number of dilations was divided by the follow-up period (in months) to determine the periodic dilatation index.

RESULTS

There was no difference in age, sex, etiology, localization and recurrence of lesions, treatment outcome, complications and the number of dilations between the study and control groups. In the study group, the mean periodic dilatation index was 0.712 (range 0.097-2.75) and 0.289 (range 0-1) before and after injections, respectively (P = 0.03). Additionally, the mean number of dilations was 5.3 (range 2-11) and 1.6 (range 0-5) before and after injections, respectively (P = 0.03). The mean symptom-free interval was 24 +/- 12.75 months in the study group and 5.18 +/- 5.06 months in the control group (P < 0.001). The total periodic dilatation index was 0.193 +/- 0.123 in the study group, while it was 0.597 +/- 0.583 in the control group (P < 0.05).

CONCLUSIONS

It can be concluded that intralesional steroid injections increase efficacy of bougie dilation and decrease the requirement for repetition of bougie dilatation.

Defiant dysphagia: small-caliber esophagus and refractory benign esophageal strictures

Among causes of defiant dysphagia, two pose a special challenge for the clinician: the small-caliber esophagus and refractory benign esophageal strictures. The small-caliber esophagus is a major cause of dysphagia for solids in young patients with eosinophilic esophagitis. A smooth, diffusely narrow esophageal lumen can be appreciated by barium esophagography or esophagoscopy. The term "small-caliber esophagus" is preferred over "stricture" because of the absence of cicatrization. A "subtle" small-caliber esophagus may defy detection by barium esophagogram and esophagogastroduodenoscopy. The only evidence to its diagnosis is the endoscopic finding of unusually long rents in the body of the esophagus immediately after esophageal dilation. The ringed esophagus seems to be a variant of the small-caliber esophagus, with the additional endoscopic finding of a variable number of rings (few to numerous) throughout the narrowed esophagus. Classification, diagnosis, and management of small-caliber esophagus are discussed in this review. Refractory esophageal strictures have various causes, including gastroesophageal reflux disease, nasogastric tube placement, mediastinal irradiation, and corrosive ingestion. Treatments used to eliminate or reduce the need for frequent esophageal bougienage include acid-suppressive medical therapy, surgery, intralesional corticosteroid injection, and esophageal self-expandable metal stents.

Lichen planus esophagitis: report of three patients treated with oral tacrolimus or intraesophageal corticosteroid injections or both

Clinically significant involvement of the esophagus is uncommon in patients who have lichen planus, a common disorder of squamous epithelium. In three patients who had oral, cutaneous, and esophageal lichen planus, endoscopic intralesional esophageal injection of corticosteroids (in all three patients) and oral tacrolimus (FH506) (in two patients) resulted in improvement in dysphagia, a less frequent need for dilation, and improvement in esophageal inflammation.

Predictors of early recurrence of benign esophageal strictures

OBJECTIVE

In the era of liberal proton pump inhibitor (PPI) use, benign esophageal strictures remain a significant management problem, with 30-40% of patients experiencing symptomatic recurrence within 1 yr of successful dilation. We therefore sought to examine predictors of early recurrence of benign esophageal strictures after endoscopic dilation.

METHODS

Predictors for stricture recurrence were examined in 87 consecutive outpatients undergoing initial dilation over a 1-yr period. Patients with symptomatic recurrence of dysphagia requiring repeat dilation within 1 yr of initial successful dilation (cases) were compared to patients who did not require redilation (controls). Predictors were assessed by univariate and multivariate analysis. Kaplan-Meier analysis of significant predictors using time to first redilation was also performed.

RESULTS

Of the patients, 36 required repeat dilation within 1 yr, whereas 51 did not (median follow-up, 33 months). Of all strictures, 67 (77%) were peptic, with the remainder caused by radiation, drug-related injury, or congenital stenosis, among other causes. In multivariate analysis, nonpeptic strictures were significant predictors for early recurrence, as was a narrower stricture diameter. For peptic strictures, the persistence of heartburn after dilation and the presence of a hiatal hernia were significant predictors. Of all peptic strictures, 84% of patients were on PPIs after dilation, with no difference between cases and controls. Of all patients with persistent heartburn after dilation, 90% were on PPIs.

CONCLUSIONS

The persistence of heartburn after dilation is a strong predictor for early symptomatic recurrence of benign esophageal peptic strictures, despite a high rate of PPI use. This may suggest persistent acid reflux requiring optimization of acid reduction therapy. Alternatively, combined acid and alkaline reflux may account for progressive injury despite PPI therapy. Esophageal pH studies may be invaluable in making the distinction between acid and non-acidic (alkaline) reflux. Nonpeptic strictures are also more likely to have early recurrences and are therefore more difficult to manage.

Usefulness of intralesional triamcinolone in treatment of benign esophageal strictures

INTRODUCTION

The cornerstone treatment for benign esophageal strictures is endoscopic dilation. There are reports suggesting that intralesional corticosteroid injection decreases the frequency of endoscopic dilation.

METHODS

Seventy-one patients (mean age 42.39 [17.52] years; range, 13-78 years) with benign esophageal strictures (corrosive 29, peptic 14, anastomotic 19, radiation-induced 9) were recruited for this study. All were being managed with a program of intermittent endoscopic dilation by using over-the-wire polyvinyl dilators. All patients were treated by intralesional injections of triamcinolone acetonide (40 mg/mL diluted 1:1 with saline solution) by using a 23-gauge, 5-mm long sclerotherapy needle in aliquots of 0.5 mL. At each session, 4 injections (4 quadrants) were made at the proximal margin of the stricture with another 4 injections into the strictured segment itself whenever possible. The intervals between dilations and frequency of dilations were calculated before and after triamcinolone injections. A periodic dilation index (defined as number of dilations required per month) before and after the triamcinolone injections was calculated.

RESULTS

The overall mean (SD) duration of treatment before intralesional injection was 10.9 (19.8) months (range, 1-120 months) and the mean number (SD) of esophageal dilations required was 9.67 (13.06) (range, 1-70). The mean number of sessions of intralesional injection was 1.4 (0.62). After initiation of intralesional injections mean follow-up was 8.1 (5.6) months (range 3-30 months) and the mean number of esophageal dilations was 3.8 (3.0) (range 0-16). The periodic dilation index decreased significantly from 1.24 (0.05) (range 0.13-3.16) before injection to 0.5 (0.33) (range, 0-2) after injection (p < 0.001). For each category of stricture, the periodic dilation index decreased significantly: corrosive, 1.24 (0.5) to 0.53 (0.34) (p < 0.001); peptic, 0.92 (0.44) to 0.42 (0.2) (p < 0.001); anastomotic, 1.24 (0.49) to 0.51 (0.4) (p < 0.001); and radiation-induced, 1.32 (0.6) to 0.6 (0.3) (p < 0.02).

CONCLUSION

Intralesional injections of triamcinolone augment the effects of dilation in patients with benign esophageal strictures.

Resection of Benign Esophageal Stricture through a Minimally Invasive Endoscopic and Transgastric Approach

Recurrent benign esophageal strictures that are refractory to dilation can be difficult to manage. We report a novel technique for treatment of a recurrent esophageal stricture using a minimally invasive endoscopic and transgastric approach. The patient is a 40-year-old women who developed a recurrent distal esophageal stricture after repair of an esophageal perforation. Multiple prior dilations had been unsuccessful in achieving sustained esophageal patency, and the patient presented with a complete distal obstruction demonstrated on barium esophagram. Two flexible endoscopes were used: one placed through the mouth and another through a gastrostomy. While the transilluminated lesion was visualized from below the obstruction was traversed with an endoscopic aspiration needle from above. A guidewire was placed through the needle and pulled out the gastrostomy. Both the esophageal lesion and the gastrostomy tract were then serially dilated over the wire. After dilation the residual stricture was resected using a circular stapler placed through the dilated gastrostomy tract. After this procedure the patient maintained esophageal patency with a diminished need for dilation. Details of our technique are described and the literature is reviewed.

A review of endoscopic methods of esophageal dilation

Esophageal strictures from a variety of benign and malignant causes require dilation therapy when patients develop symptoms of dysphagia. Dilation can be accomplished using a variety of dilating devices and adjunctive techniques. The approach to management of esophageal strictures is reviewed with a focus on dilation technique and special considerations for various stricture types.

Upper gastrointestinal tract endoscopy in inflammatory bowel disease

Upper gastrointestinal endoscopy is used to evaluate upper gastrointestinal symptoms in patients with inflammatory bowel disease. This article discusses the procedure, which may allow for the diagnosis of Crohn's disease of the esophagus, stomach, and/or duodenum. Biopsies of normal gastric mucosa in patients with indeterminate colitis may be helpful in making a diagnosis of Crohn's colitis. Upper gastrointestinal endoscopy may allow for therapeutic intervention in terms of bleeding and stricturing disease.