Endoscopic dilation of benign post-esophagectomy anastomotic strictures: long-term outcomes and risk of recurrence

Risk Factors Associated With Anastomotic Stricture in Patients Undergoing Minimally Invasive Esophagectomy: Experience From a High-Volume Center

BACKGROUND

Esophageal cancer is a prevalent cancer, with a high incidence in low socioeconomic category countries. Minimally invasive esophagectomy is increasingly being used to treat this malignant condition. However, anastomotic stricture is a serious complication post esophagectomy. The study aims to enhance diagnostic consistency, improve treatment methods, guide patient management, stratify outcomes, and offer evidence-based preventive interventions.

METHODS

A retrospective analysis of 550 patients who had minimally invasive esophagus surgery was carried out at Shaukat Khanum Memorial Cancer Hospital and Research Centre in Lahore between 2015 and 2020. All patients were treated with radical resection. For tumors of the lower esophagus and gastroesophageal junction, transhiatal esophagectomy was used; for tumors of the middle and upper thoracic esophagus, right video-assisted thoracoscopic surgery (VATS) was used in a three-stage procedure. Patients were routinely followed up two weeks after discharge, then every three, six, and 12 months.

RESULTS

The mean age and BMI were 46.7 years and 19.4 kg/m2, respectively. Anastomotic leaks were rare, with only 13 patients experiencing them. The grade of tumor differentiation was poor, moderate, and well-differentiated. The study found that older age, high Eastern Cooperative Oncology Group (ECOG) performance status, and malignancies located in the upper and middle one-third of the esophagus had significant associations with anastomotic stricture. However, some variables, like sex, did not show significant associations in either analysis.

CONCLUSION

The study reveals that factors such as older patient age, high ECOG performance status, single comorbidity, and malignancies located in the upper and middle one-third of the esophagus significantly influence anastomotic stricture. The study suggests that measures against anastomotic stricture such as endoscopic procedures and minimally invasive esophagectomy should be implemented to minimize the complications.

Endoscopic incisional therapy for benign anastomotic strictures after esophagectomy or gastrectomy: a systematic review and meta-analysis

BACKGROUND

Studies have evaluated the efficacy of endoscopic incisional therapy (EIT) for benign anastomotic strictures. We performed a systematic review and meta-analysis to evaluate stricture recurrence after EIT following esophagectomy or gastrectomy.

METHODS

A systematic search of databases was performed up to April 2nd, 2023, after selection of key search terms with the research team. Inclusion criteria included human participants undergoing EIT for a benign anastomotic stricture after esophagectomy or gastrectomy, age ≥ 18, and n ≥ 5. Our primary outcome was the incidence of stricture recurrence among patients treated with EIT compared to dilation. Our secondary outcome was the stricture-free duration after EIT and rate of adverse events. Meta-analysis was performed with RevMan 5.4.1 using a Mantel-Haenszel random-effects model. Publication bias was evaluated with funnel plots and the Egger test.

RESULTS

A total of 2550 unique preliminary studies underwent screening of abstracts and titles. This led to 33 studies which underwent full-text review and five studies met the inclusion criteria. Meta-analysis revealed reduced odds of overall stricture recurrence (OR 0.35, 95% CI 0.13-0.92, p = 0.03; I2 = 71%) and reduced odds of stricture recurrence among naïve strictures (OR 0.32, 95% CI 0.17-0.59, p = 0.0003; I2 = 0%) for patients undergoing EIT compared to dilation. There was no significant difference in the odds of stricture recurrence among recurrent strictures (OR 0.63, 95% CI 0.12-3.28, p = 0.58; I2 = 81%). Meta-analysis revealed a significant increase in the recurrence-free duration (MD 42.76, 95% CI 12.41-73.11, p = 0.006) among patients undergoing EIT compared to dilation.

CONCLUSION

Current data suggest EIT is associated with reduced odds of stricture recurrence among naïve anastomotic strictures. Large, prospective studies are needed to characterize the safety profile of EIT, address publication bias, and to explore multimodal therapies for refractory strictures.

Clinical outcomes on weekly endoscopic dilations as the initial approach to manage patients with complex benign esophageal strictures: report on 488 dilations

BACKGROUND

Success rate of endoscopic dilation (ED) of complex benign esophageal strictures (CBES) can be as low as 65%. Since EDs are usually performed at 2-4-week intervals, the aim of this study was to evaluate the clinical outcomes of EDs done initially at weekly intervals.

METHODS

A cohort of patients with CBES (luminal diameter < 10 mm) underwent ED at weekly intervals and subsequent dilation intervals adjusted based on response. Weekly EDs were also re-initiated in those requiring additional interventions (electro-cautery/stents). Group A patients: Failed prior EDs done at ≥ 2-week intervals. Group B: CBES with no prior dilations. Success was defined as achieving and maintaining a luminal diameter of ≥ 14 mm and patient remaining dysphagia-free with minimal re-interventions.

RESULTS

488 EDs were performed on a cohort of 57 consecutive patients with CBES. Median follow-up was 4 years. Group A: 21 patients (mean age 65 ± 13 years; mean interval between prior failed dilations 17 ± 9 days). 57% of these patients achieved long-term success with weekly dilations (mean 8 ± 4.7 dilations/patient). Group B: 36 patients (mean age 61 ± 13 years, mean 6.5 ± 5.5 dilations/patient). Long-term success was 83.3% (P = 0.033). Despite weekly dilations, unable to achieve a diameter of 14 mm in 5 patients. AE: perforation 1 (0.2%), bleeding 1 (0.2%).

CONCLUSION

Significant proportion of patients with CBES who failed prior dilations done at ≥ 2-week intervals achieved dysphagia-free status by initiating weekly dilations. Hence, before considering other options (electro-cautery/stents), one can consider using this approach. This approach can also be used upfront in patients with newly diagnosed CBES.