Management of the patient with benign esophageal stricture

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.

Endoscopic diagnosis and treatment of mucosal lesions of the esophagus

The rapid evolution of fiberoptic endoscopes over the past three decades has greatly enhanced our understanding of esophageal diseases and has stimulated significant improvements in their management. With the early endoscopic diagnosis of infectious and inflammatory lesions, specific medical or surgical treatment can be initiated promptly and the results monitored easily. Although the diagnosis of malignant lesions is still commonly delayed because of the absence of early symptoms, surveillance of Barrett's esophagus offers the hope of more definitive management in these patients. Endoscopy has assumed an increasingly important therapeutic role in patients with inoperable cancer because it provides access for new ablative techniques or the placement of palliative prosthetic devices. Continuing advances in the use of endoscopic ultrasound, the delivery of photodynamic therapy, and the adjunctive application of intraluminal irradiation promise to further broaden the scope of fiberoptic intervention.

Dilation of esophageal strictures: comparative morbidity of antegrade and retrograde methods

A total of 687 dilations of esophageal strictures were performed on 59 patients in the operating room over a 17-year period. Seventy-nine percent of the strictures were secondary to caustic ingestion and 89% of the dilations were in these patients. Antegrade dilations were performed 389 times and retrograde dilations were performed 298 times. Esophageal perforation occurred seven times with antegrade dilations. There were no perforations with retrograde dilations. The retrograde method using Tucker bougies is the safest and most successful method of dilating severe strictures.

Colonic interposition for benign esophageal disease. Long-term clinical and endoscopic results

Replacement of the esophagus for benign disease requires familiarity with the long-term results of various esophageal substitutes. In the present study, 60 esophageal reconstructions for benign disease using colonic interposition have been presented. The operations were performed mainly without thoracotomy, using both antiperistaltic and isoperistaltic colonic segments. There were no differences in swallowing ability between patients with antiperistaltic and patients with isoperistaltic interpositions. Regurgitation symptoms, however, seemed to be somewhat more common and more difficult in patients with antiperistaltic colonic transpositions. Endoscopic signs of colitis were common, but they did not correlate with regurgitation symptoms. Bacterial cultures from the transplanted colon mainly revealed the usual mouth organisms. Candida albicans was frequently found in the fungal samples. There were no differences in the results between patients with follow-up periods of more and less than 2 years. The clinical results were good or fair in a great majority of the patients.

Drug-induced esophageal strictures

A retrospective study of 55 patients with a benign esophageal stricture showed that in 11 patients (20%) the cause was a drug-induced lesion due to potassium chloride (3), tetracyclines (3), aspirin (2), vitamin C (1), phenytoin (1), and quinidine (1). Five of the 11 patients would have been diagnosed as having a reflux etiology of their stricture if 24-hour esophageal pH monitoring was not performed. Six patients responded to dilatation and five patients required resection or bypass. A prospective study of 18 asymptomatic volunteers showed a high incidence of esophageal lodgment of a radiolabeled medicinal capsule, with subsequent dissolution and release of the isotope. This occurred most frequently in elderly subjects and was reduced by increasing the volume of water chaser. The sites of lodgment correspond to the location of the observed strictures in the patient population. An in vitro study showed that, when the causative drugs were mixed with saliva, dissolution occurred within 60 minutes and was associated with significant changes in pH. These investigations show that drug-induced esophageal strictures are more common than previously appreciated, and can be confused with a reflux etiology. Diagnosis is suggested by a history of drug ingestion, location of the stricture, and a normal esophageal acid exposure on 24-hour pH monitoring. The severity of the esophageal injury is variable and requires dilatation to resection for therapy.

Reflux stricture of the oesophagus

Benign oesophageal stricture remains a common problem. Following accurate diagnosis, early treatment allows dilatation in the great majority of patients. Resection can frequently be avoided and in fit patients dilatation should be combined with an anti-reflux operation plus gastroplasty where necessary. Frail elderly patients may be managed by continued dilatation and medical means to reduce and combat the effects of reflux. Resection should now be necessary in only about 5 per cent of patients and colonic interposition offers good long-term results. It must be remembered that adenocarcinoma is a small but real risk in patients with reflux stricture.

Surgical diseases of the esophagus

The diagnosis and management of surgical diseases of the esophagus are discussed. Esophageal foreign bodies, strictures, esophagobronchial fistulas, diverticula, gastroesophageal intussusception, hiatal hernias, and megaesophagus are included in the discussion.