Primary incisional therapy with a modified method for patients with benign anastomotic esophageal stricture

doi:10.1016/j.gie.2008.07.018

Gastrointestinal Endoscopy

Volume 69, Issue 6, May 2009, Pages 1029-1033

https://doi.org/10.1016/j.gie.2008.07.018 Get rights and content

Background

Benign anastomotic esophageal stricture after surgical resection is not uncommon and requires repeated dilation sessions to maintain patency because of the significant recurrence rate with bougie or balloon dilation.

Objective

Our study was designed to evaluate whether a modified method of incisional therapy is effective and maintains a good patency in a benign anastomotic esophageal stricture.

Design

A prospective outcome study.

Setting

Tertiary-care academic medical centers.

Patients

A total of 24 patients with benign anastomotic esophageal strictures after esophagojejunostomy.

Interventions

Under direct vision through a transparent hood, radial incisions parallel to the longitude of the esophagus were performed by pulling up the Iso-Tome or insulated-tip–knife.

Main Outcome Measurements

Efficacy, safety, and long-term patency after procedures were evaluated.

Results

During 24 months of follow-up observations, 21 of 24 patients (87.5%) who received only 1 dilation session resumed eating solid meals and had no dysphagia. Only 3 patients (12.5%) developed restricture at a mean of 1.6 months. Of the patients with a recurrence, 2 experienced no recurrence after one additional dilation session, and another patient was refractory and underwent 5 dilation sessions. The occurrence of restricture after incisional therapy was statistically more prevalent in long-segment stricture (>1 cm) (2/3 [66.7%]) than short-segment stricture (<1 cm) (1/21 [4.8%]) (P = .032). There were no significant procedure-related complications.

Limitation

Our study included a small number of patients. Therefore, further prospective randomized controlled trials are needed.

Conclusions

A modified method of incisional therapy as a primary treatment is safe and feasible, and appears to maintain a longer duration of patency in benign anastomotic esophageal stricture.

Section snippets

Patients

This study was designed as a prospective outcome study in endoscopy follow-up. From May 2005 until December 2007, a total of 24 patients who had developed anastomotic stricture after esophagojejunostomy were observed. The eligibility criteria for benign anastomotic stricture excluded etiologically peptic, corrosive-induced, radiation-induced, drug-induced, or malignant strictures. All patients had undergone surgical treatment for gastric and esophageal cancer (18 and 6 patients, respectively).

Results

The length of stricture was less than 1 cm for 21 of 24 patients (87.5%) and more than 1 cm for 3 of 24 patients (12.5%). Postoperative complications and whether or not staplers were used were not statistically significantly related to the length of stricture. Both the Iso-Tome (16 patients) and IT-knife (8 patients) were used according to the same methodology. In all patients, dilation of the strictures was successfully performed in a single treatment session, without any immediate

Discussion

The occurrence of benign anastomotic esophageal stricture after surgical resection is not uncommon. However, a significant rate of recurrence is problematic, and no one dilation method has proven to be superior. In various studies, the median number of dilation sessions varied between 2 and 9 per patient.1, 2, 3, 5, 11, 12 With these considerations in mind, electrocautery therapy has been proposed. In a study by Hordijk et al,¹⁴ 20 patients with fibrotic anastomotic esophageal stenosis were

References (21)

R. Kochhar et al.
Usefulness of intralesional triamcinolone in treatment of benign esophageal strictures
Gastrointest Endosc
(2002)
M.A. McBride et al.
The endoscopic management of esophageal strictures
Gastrointest Endosc Clin N Am
(1994)
R.P. Wadhwa et al.
Use of self-expandable metallic stents in benign GI diseases
Gastrointest Endosc
(2003)
S.J. Spechler
AGA technical review on treatment of patients with dysphagia caused by benign disorders of the distal esophagus
Gastroenterology
(1999)
M.L. Hordijk et al.
Electrocautery therapy for refractory anastomotic strictures of the esophagus
Gastrointest Endosc
(2006)
M.J. Bourke et al.
Sphincterotomy-associated biliary strictures: features and endoscopic management
Gastrointest Endosc
(2000)
G. Thorsen et al.
Endoscopic incision of postoperative stenoses in the upper gastrointestinal tract
Gastrointest Endosc
(1983)
R.P. Venu et al.
Endoscopic electrosurgical treatment for strictures of the gastrointestinal tract
Gastrointest Endosc
(1984)
L.V. Hernandez et al.
Comparison among the perforation rates of Maloney, balloon, and Savary dilation of esophageal strictures
Gastrointest Endosc
(2000)
J.S. Scolapio et al.
A randomized prospective study comparing rigid to balloon dilators for benign esophageal strictures and rings
Gastrointest Endosc
(1999)

There are more references available in the full text version of this article.

Cited by (57)

The endoscopic management of oesophageal strictures
2024, Best Practice and Research: Clinical Gastroenterology
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.
Benign Esophageal Strictures
2019, Clinical Gastrointestinal Endoscopy
In this chapter, we describe the evaluation, treatment, and subsequent long-term management for patients with benign esophageal strictures. Patients with clinically significant esophageal strictures present with symptoms of dysphagia, typically first to solid foods. Symptoms may then progress in frequency and severity and some patients may develop dysphagia to liquids. Patients often modify their diets to avoid foods that lead to symptoms and a thorough history is required to parse out the true severity of their symptoms. In the past, the most common etiology for esophageal strictures were peptic causes; however, the widespread use of proton pump inhibitor (PPI) therapy has markedly reduced the incidence of this etiology. Anastomotic and radiation induced strictures are now the most common types encountered overall, but the incidence of eosinophilic esophagitis associated strictures is increasing and being recognized more frequently in all age groups.
Comparison of the Efficacy of Endoscopic Radial Incision and Cutting Procedure and Endoscopic Balloon Dilation for Benign Anastomotic Stricture after Low Anterior Resection Combined with Preventive Loop Ileostomy in Rectal Cancer
2023, Diseases of the Colon and Rectum
Endoscopic Stricturotomy in the Treatment of Refractory Esophageal Anastomotic Strictures
2023, Dysphagia
Efficacy and safety of repeated endoscopic radial incision and cutting procedure for benign esophageal stricture
2023, Endoscopy International Open
Stricture Management: Interventional Options
2023, The SAGES Manual Operating through the Endoscope, Second Edition

View all citing articles on Scopus

: DISCLOSURE: All authors disclosed no financial relationships relevant to this publication.

: If you want to chat with an author of this article, you may contact him at [email protected].

View full text

Original articleClinical endoscopyPrimary incisional therapy with a modified method for patients with benign anastomotic esophageal stricture

Background

Objective

Design

Setting

Patients

Interventions

Main Outcome Measurements

Results

Limitation

Conclusions

Section snippets

Patients

Results

Discussion

Gastrointest Endosc

Gastrointest Endosc Clin N Am

Gastrointest Endosc

Gastroenterology

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Original article
Clinical endoscopy
Primary incisional therapy with a modified method for patients with benign anastomotic esophageal stricture