Radial incision and cutting for refractory benign esophageal stricture

A novel self-inflatable balloon for treating refractory benign esophageal strictures: a prospective, single-arm, multicenter study

BACKGROUND AND AIM

Current treatments for refractory benign esophageal strictures (BESs) often take several years and have poor effects. The authors propose a novel method of self-help inflatable balloon (SHIB) and evaluate its efficacy and safety.

METHODS

A prospective, multicenter study was conducted from January 2019 to March 2022. All enrolled patients were diagnosed with refractory BESs and received SHIB. The primary endpoint was the clinical success rate at 12 months after removing SHIB. The secondary endpoints were the number of days of placing SHIB, and changes from baseline in BMI and health-related quality of life at 1, 3, 6, and 12 months.

RESULTS

The clinical success rate was 51.2% (21/41) with the median days of placing SHIB being 104.0 days (range: 62.0-134.5 days), which was higher in the endoscopic group compared to the caustic and surgery groups (63.3 vs. 28.6% vs. 0, P=0.025). All patients (100%) showed significant improvement in dysphagia scores during placing SHIB. Although 20 patients (48.8%) experienced recurrent stricture, the median stricture length was decreased (P<0.001) and the median intervention-free interval was prolonged (P<0.001). In all patients, the mean BMI at and health-related quality of life at 1, 3, 6, and 12 months were significantly increased compared with baseline (P<0.05). On multivariate analysis, stricture etiology and wearing time were independent predictors of recurrent stricture.

CONCLUSIONS

The SHIB has high efficacy and safety in treating refractory BESs of different origins, especially for endoscopic resection. Stricture etiology and wearing time were independent predictors of recurrent stricture.

Combined treatment of refractory benign stricture after esophageal endoscopic mucosal dissection: A case report

BACKGROUND

Endoscopic submucosal dissection (ESD) post-procedure stricture is a relatively common long-term complication following ESD treatment. A range of approaches has been implemented for the treatment of post-procedural stricture using endoscopic techniques such as endoscopic dilation, self-expandable metallic stent insertion, local steroid injection in the esophagus, oral steroid administration, radial incision and cutting (RIC). The actual efficacy of these different therapeutic options is highly variable, and uniform international standards for the prevention or treatment of stricture.

CASE SUMMARY

In this report, we describe the case of a 51-year-old male diagnosed with early esophageal cancer. To protect against esophageal stricture, the patient was administered oral steroids and underwent self-expandable metallic stent insertion for 45 d. Despite these interventions, stricture was detected at the lower edge of the stent following its removal. The patient remained refractory to multiple rounds of endoscopic bougie dilation treatment, and thus suffered from complex refractory benign esophageal stricture. As such, RIC combined with bougie dilation and steroid injection was employed to treat this patient more effectively, ultimately achieving satisfactory therapeutic efficacy.

CONCLUSION

Combination of RIC, dilation, and steroid injection can be safely and effectively implemented to treat cases of post-ESD refractory esophageal stricture.

Endoscopic radial incision to treat a congenital esophageal stenosis in a 10-year-old child

A 10-year-old boy was admitted to our hospital because of frequent vomiting and impaired growth. Esophagogastroduodenoscopy showed there was a benign annular stenosis (diameter 0.6 cm) of the middle esophagus. Then, using an ultrafine painless gastroscope, we observed that the narrowed segment was approximately 2.0 cm in length. The stenosis of the esophagus was diagnosed as congenital esophageal stenosis (CES). Then，the patient was referred for endoscopic radial incision (ERI) under general anesthesia. We used an insulated-tip knife to perform ERI. A radial incision was made to cut the muscle layer along the line that connects the esophageal lumen on the oral side and the lumen on the anal side in the 3 and 6 o'clock directions . The diameter of the esophagus was approximately 1.0 cm post-operation. The gastroscopy was able to pass through smoothly. The operation time was approximately 30 minutes. The child's oral liquid diet started on postoperative day 1 and was discontinued on postoperative day 4. Vomiting was significantly relieved for the patient. No intraoperative and postoperative complications were detected. An endoscopy performed 3 months post-operation showed smooth esophageal mucosa, and the diameter of the esophageal lumen increased to approximately 1.0 cm without recurrent stenosis .

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.

Mitomycin C Inhibits Esophageal Fibrosis by Regulating Cell Apoptosis and Autophagy via lncRNA-ATB and miR-200b

Benign esophageal strictures (BESs) frequently results from esophageal fibrosis. The transformation of fibroblasts into fibrocyte is an important cause of fibrosis. The treatment of fibrosis is challenging. Some previous studies have indicated the antifibrotic effect of mitomycin C (MMC). However, the mechanism of action of MMC and its optimal dose for treatment remains unclear. In the present study, the role of MMC in fighting fibrosis and its mechanism was investigated. Human esophageal fibroblast cells (HEFs)were treated without or with MMC, at 2, 5, 10 μg/ml, combining with mimic lncRNA-ATB, miR-200b inhibitor, rapamycin (RAPA), and 3-Methyladenine (3-MA). The cell viability, and cell apoptosis were evaluated. In addition, expression of apoptosis related proteins (caspase8 and caspase3), autophagy related proteins (LC3II and ATG5) and fibrosis related proteins (α-SMA collagen-1 and TGF-β) were also evaluated. Furthermore, autophagosome was observed by transmission electron microscope. Results showed that the expression of lncRNA-ATB was down-regulated and miR-200b was up-regulated after treated with MMC. And MMC induced cell apoptosis and inhibited cell autophagy. On the other hand, RAPA, mimic lncRNA-ATB and miR-200b inhibitor reduced fibrogenic effect of MMC on HEFs. Collectively, this study suggests that MMC inhibited esophageal fibrosis by regulating cell apoptosis and autophagy via downregulating lncRNA-ATB and upregulating miR-200b.

Utility of radial incision and cutting with steroid injection for refractory stricture after endoscopic submucosal dissection for large superficial esophageal squamous cell carcinoma

BACKGROUND AND AIMS

Endoscopic submucosal dissection (ESD) for superficial esophagus squamous cell carcinoma (SESCC) may cause esophageal stricture and related dysphagia symptoms, especially when the lesion is widespread. Endoscopic balloon dilation (EBD) is the prior choice to treat post-ESD stricture. However, certain patients show poor response to EBD treatment and frequent dilations are required. We perform radial incision and cutting combined with intralesional steroid injection to manage refractory stricture. The study aims to evaluate the safety and efficacy of this new combined treatment.

METHODS

From October 2017 to February 2019, 25 patients who accepted repeated EBD because of refractory stricture after extensive ESD for large SESCC were enrolled. Radial incision and cutting followed by local steroid injection was performed on all the patients, and therapeutic EBD was conducted to treat recurring stricture after combined treatment. The incidence of recurrent stricture, clinical outcome of combined treatment, and following therapeutic EBD, procedure-related adverse events were assessed and analyzed.

RESULTS

During the follow-ups, the incidence of recurrent esophageal strictures was 92%. Combined treatment reduced the severity of stenosis and lowered the corresponding dysphagia scores significantly, compared with previous EBD. Mean symptom-relief duration of EBD was prolonged significantly from 29.9 to 76.0 days. Perforation was observed in one patient during operation and successfully sealed with metal clips.

CONCLUSIONS

Combination of radial incision and cutting with steroid injection is a safe and feasible treatment for esophageal refractory stricture after extensive ESD, appearing to improve the therapeutic EBD outcome and maintain a longer symptom-relief duration.

Endoscopic incision for treatment of benign gastrointestinal strictures

INTRODUCTION

Benign gastrointestinal strictures are common, and can be congenital or acquired (anastomotic, corrosive, induced by Crohn's disease or endoscopic treatments, etc.). Patients usually present with stricture-related symptoms such as vomiting, dysphagia, dyschezia, abdominal pain, which impair their quality of life. Endoscopic balloon dilation (EBD) is the first-line treatment for most of the benign strictures; however, long-term efficacy is suboptimal, and the recurrence rate can be up to 38%. Endoscopic incision (EI) was firstly reported for treatment of congenital membranous stricture, and then applied to other benign gastrointestinal strictures.

AREA COVERED

In the present review, we provided a comprehensive review of EI for the treatment of benign gastrointestinal strictures, mainly focus on the technical details, indication, safety, and efficacy of EI. The present review is expected to provide tips for operators who are going to perform EI.

EXPERT OPINION

EI can serve as an alternative method for treatment of gastrointestinal strictures, the best indications are congenital membranous stricture and short-segmental (<1 cm) anastomotic strictures refractory to EBD. EI may also be attempted for strictures induced by other reasons. Combination with other endoscopic methods such as EBD, local steroid injection, stent placement, may improve the efficacy of EI.

Endoscopic radial incision method for two strictures of the esophagus after endoscopic submucosal dissection: a case report

Background

The development of severe esophageal stricture after endoscopic submucosal dissection (ESD) for early esophageal carcinoma is not uncommon. Dilation by Savary-Gilliard dilators or balloon dilators is the first-line treatment for such complex refractory benign stricture, but it has a high risk of treatment failure. So far, endoscopic radial incision (ERI) as a new technology for the treatment of post-ESD esophageal stricture has been rarely reported. We report a case, which we designed to assess the efficacy and safety of ERI technology for two severe strictures of the esophagus after ESD.

Case presentation

A 67-year-old man had suffered from two complex refractory benign strictures of the esophagus after ESD for early esophageal carcinoma. The patient was refractory to multiple endoscopic balloon dilation (EBD) therapy previously. Thus, the patient underwent ERI successfully and without postoperative complications such as fever, poststernal pain, bleeding, and perforation. During 3 months of follow-up after ERI, the patient had no recurrence of dysphagia.

Conclusions

Refractory strictures of the esophagus after ESD are common. ERI is a safe and efficient strategy for treating such multiple refractory esophageal strictures.