Skip to main content

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

  • Review Article
  • Published:

Treatment options for esophageal strictures

Nature Clinical Practice Gastroenterology & Hepatology volume 5, pages 142–152 (2008)Cite this article

Abstract

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.

Key Points

  • Esophageal strictures are a problem frequently encountered by the gastroenterologist and can be subdivided into those with a malignant origin and those with a benign origin

  • The method most frequently used to treat dysphagia caused by esophageal cancer is stent placement, with brachytherapy increasingly being performed, particularly in patients with an expected survival of longer than 3 months

  • Ultraflex™ stents, Flamingo Wallstents and Niti-S stents can all be used for the palliation of dysphagia caused by esophageal cancer, whereas Z-stents and Polyflex® stents seem less preferable because of a higher risk of complications

  • No clear difference in effectiveness has been reported for the Savary-Gilliard® and through-the-scope balloon dilators for the treatment of benign esophageal strictures

  • Stents can be used in patients with complex strictures if these are refractory to dilation therapy

  • Incisional therapy can be a safe alternative treatment modality in patients with firm fibrotic benign strictures, such as can be found at an anastomotic site

This is a preview of subscription content, access via your institution

Access options

Buy this article

  • Purchase on Springer Link
  • Instant access to full article PDF
Buy now

Prices may be subject to local taxes which are calculated during checkout

Figure 1: An algorithm used at the University Medical Center Utrecht, The Netherlands for the management of malignant esophageal strictures.
Figure 2: Examples of recurrent dysphagia after stent placement for a malignant stricture in the esophagus.
Figure 3: Endoscopic management of a malignant stricture close to the upper esophageal sphincter.
Figure 4: Examples of radiation esophagitis after brachytherapy for a malignant stricture of the esophagus.
Figure 5: An algorithm used at the University Medical Center Utrecht, The Netherlands for the management of benign esophageal refractory strictures.
Figure 6: Endoscopic management of an anastomotic stricture in a gastric tube interposition.48

Similar content being viewed by others

References

  1. Siersema PD (2006) New developments in palliative therapy. Best Pract Res Clin Gastroenterol 20: 959–978

    Article  Google Scholar 

  2. Lew RJ et al. (2002) A review of endoscopic methods of esophageal dilation. J Clin Gastroenterol 35: 117–126

    Article  Google Scholar 

  3. Steyerberg EW et al. (2005) Stent placement or brachytherapy for palliation of dysphagia from esophageal cancer: a prognostic model to guide treatment selection. Gastrointest Endosc 62: 333–340

    Article  Google Scholar 

  4. May A et al. (1996) Self-expanding metal stents for palliation of malignant obstruction in the upper gastrointestinal tract. Comparative assessment of three stent types inplemented in 96 inplantations. J Clin Gastroenterol 22: 261–266

    Article  CAS  Google Scholar 

  5. Dorta G et al. (1997) Comparison between esophageal Wallstent and Ultraflex stents in the treatment of malignant stenoses of the esophagus and cardia. Endoscopy 29: 149–154

    Article  CAS  Google Scholar 

  6. Schmassmann A et al. (1997) Self-expanding metal stents in malignant esophageal obstruction: a comparison between two stent types. Am J Gastroenterol 92: 400–406

    CAS  PubMed  Google Scholar 

  7. Vakil N et al. (2001) A prospective, randomized, controlled trial of covered expandable metal stents in the palliation of malignant esophageal obstruction at the gastroesophageal junction. Am J Gastroenterol 96: 1791–1796

    Article  CAS  Google Scholar 

  8. Siersema PD et al. (2001) A comparison of 3 types of covered metal stents for the palliation of patients with dysphagia caused by esophagogastric carcinoma: a prospective, randomized study. Gastrointest Endosc 54: 145–153

    Article  CAS  Google Scholar 

  9. Sabharwal T et al. (2003) A randomized prospective comparison of the Flamingo Wallstent and Ultraflex stent for palliation of dysphagia associated with lower third oesophageal carcinoma. Gut 52: 922–926

    Article  CAS  Google Scholar 

  10. Homs MY et al. (2004) Causes and treatment for recurrent dysphagia after self-expanding metal stent placement for palliation of esophageal carcinoma. Endoscopy 36: 880–886

    Article  CAS  Google Scholar 

  11. Verschuur EM et al. (2007) New design esophageal stents for the palliation of dysphagia from esophageal or gastric cardia cancer: a randomized trial. Am J Gastroenterol [10.1111/j.1572-0241.2007.01542.x]

  12. Dumonceau JM et al. (1999) Esophageal fistula sealing: choice of stent, practical management, and cost. Gastrointest Endosc 49: 70–78

    Article  CAS  Google Scholar 

  13. Verschuur EM et al. (2007) Esophageal stents for malignant strictures close to the upper esophageal sphincter. Gastrointest Endosc 66: 1082–1090

    Article  Google Scholar 

  14. Bethge N et al. (1998) Palliation of malignant esophageal obstruction due to intrinsic and extrinsic lesions with expandable metal stents. Am J Gastroenterol 93: 1829–1832

    Article  CAS  Google Scholar 

  15. Gupta NK et al. (1999) Self-expanding oesophageal metal stents for the palliation of dysphagia due to extrinsic compression. Eur Radiol 9: 1893–1897

    Article  CAS  Google Scholar 

  16. Homs MY et al. (2005) Single-dose brachytherapy for the palliative treatment of esophageal cancer. Endoscopy 37: 1143–1148

    Article  CAS  Google Scholar 

  17. Sharma V et al. (2002) Palliation of advanced/recurrent esophageal carcinoma with high-dose-rate brachytherapy. Int J Radiat Oncol Biol Phys 52: 310–315

    Article  Google Scholar 

  18. Homs MY et al. (2006) Predictors of outcome of single-dose brachytherapy for the palliation of dysphagia from esophageal cancer. Brachytherapy 5: 41–48

    Article  Google Scholar 

  19. Homs MY et al. (2004) Single-dose brachytherapy versus metal stent placement for the palliation of dysphagia from oesophageal cancer; multicenter, randomised trial. Lancet 364: 1497–1504

    Article  Google Scholar 

  20. Bergquist H et al. (2005) Stent insertion or endoluminal brachytherapy as palliation of patients with advanced cancer of the esophagus and gastroesophageal junction. Results of a randomized, controlled clinical trial. Dis Esophagus 18: 131–139

    Article  CAS  Google Scholar 

  21. Pereira-Lima JC et al. (1999) Endoscopic dilation of benign esophageal strictures: report on 1043 procedures. Am J Gastroenterol 94: 1497–1501

    Article  CAS  Google Scholar 

  22. Poley JW et al. (2004) Ingestion of acid and alkaline agents: outcome and prognostic value of early endoscopy. Gastrointest Endosc 60: 372–377

    Article  Google Scholar 

  23. Honkoop P et al. (1996) Benign anastomotic strictures after transhiatal esophagectomy and cervical esophagogastrostomy: risk factors and management. J Thorac Cardiovasc Surg 111: 1141–1148

    Article  CAS  Google Scholar 

  24. McClean GK et al. (1989) Shear stress in the performance of esophageal dilation: comparison of balloon dilation and bougienage. Radiology 172: 983–986

    Article  Google Scholar 

  25. Cox JG et al. (1988) Balloon or bougie for dilatation of benign oesophageal strictures? An interim report of a randomized controlled trial. Gut 29: 1741–1747

    Article  CAS  Google Scholar 

  26. Yamamoto H et al. (1992) Treatment of benign esophageal strictures by Eden-Puestow or balloon dilators: a comparison between randomized and prospective nonrandomized trials. Mayo Clin Proc 67: 228–236

    Article  CAS  Google Scholar 

  27. Saeed ZA et al. (1996) Prospective randomized comparison of polyvinyl bougies and through-the-scope balloons for dilation of peptic strictures of the esophagus. Gastrointest Endosc 41: 189–195

    Article  Google Scholar 

  28. Scolapio JS et al. (1999) A randomized prospective study comparing rigid to balloon dilators for benign esophageal strictures and rings. Gastrointest Endosc 50: 13–17

    Article  CAS  Google Scholar 

  29. Anderson SH et al. (2004) Efficacy and safety of endoscopic dilation of esophageal dilation of esophageal strictures in epidermolysis bullosa. Gastrointest Endosc 59: 28–32

    Article  Google Scholar 

  30. Hernandez LV et al. (2000) Comparison among the perforation rates of Maloney, balloon, and Savary dilation of esophageal strictures. Gastrointest Endosc 51: 460–462

    Article  CAS  Google Scholar 

  31. Chiu YC et al. (2004) Factors infuencing clinical applications of endoscopic balloon dilation for benign esophageal strictures. Endoscopy 36: 595–600

    Article  Google Scholar 

  32. Zein NN et al. (1995) Endoscopic intralesional steroid injections in the management of refractory esophageal strictures. Gastrointest Endosc 41: 596–598

    Article  CAS  Google Scholar 

  33. Lee M et al. (1995) Preliminary experience with endoscopic intralesional steroid injection therapy for refractory upper gastrointestinal strictures. Gastrointest Endosc 41: 598–601

    Article  CAS  Google Scholar 

  34. Kochhar R et al. (1999) Intralesional steroids augment the effects of endoscopic dilation in corrosive esophageal strictures. Gastrointest Endosc 49: 509–513

    Article  CAS  Google Scholar 

  35. Ramage Jr JI et al. (2005) A prospective, randomized, double-blind, placebo-controlled trial of endoscopic steroid injection therapy for recalcitrant esophageal peptic strictures. Am J Gastroenterol 100: 2419–2425

    Article  Google Scholar 

  36. Bueno R et al. (2001) Combined antegrade and retrograde dilation: a new endoscopic technique in the management of complex esophageal obstruction. Gastrointest Endosc 54: 368–372

    Article  CAS  Google Scholar 

  37. Lew RJ et al. (2004) Technique of endoscopic retrograde puncture and dilatation of total esophageal stenosis in patients with radiation-induced strictures. Head Neck 26: 179–183

    Article  Google Scholar 

  38. Fiori A et al. (2000) Self-expandable metal coil stents in the treatment of benign esophageal strictures refractory to conventional therapy: a case series. Gastrointest Endosc 52: 259–262

    Article  Google Scholar 

  39. Cwikiel W et al. (1993) Self-expanding metal stent in the treatment of benign esophageal strictures: experimental study and presentation of clinical cases. Radiology 187: 667–671

    Article  CAS  Google Scholar 

  40. Evrard S et al. (2004) Self-expanding plastic stents for benign esophageal lesions. Gastrointest Endosc 60: 894–900

    Article  Google Scholar 

  41. Repici A et al. (2004) Temporary placement of an expandable polyester silicone-covered stent for treatment of refractory benign esophageal strictures. Gastrointest Endosc 60: 513–519

    Article  Google Scholar 

  42. Holm AN et al. (2007) Self-expanding plastic stents in treatment of benign esophageal conditions. Gastrointest Endosc [10.1016/j.gie.2007.04.031]

  43. Conio M et al. (2007) A modified self-expanding Niti-S stent for the management of benign hypopharyngeal strictures. Gastrointest Endosc 65: 714–720

    Article  Google Scholar 

  44. Yoon CJ et al. (2004) Removal of retrievable esophageal and gastrointestinal stents: experience in 113 patients. AJR Am J Roentgenol 183: 1437–1444

    Article  Google Scholar 

  45. Johansson J et al. (2000) Anastomotic diameters and strictures following esophagectomy and total gastrectomy in 256 patients. World J Surg 24: 78–84

    Article  CAS  Google Scholar 

  46. Schlegel RD et al. (2001) Results of reoperations in colorectal anastomotic strictures. Dis Colon Rectum 44: 1464–1468

    Article  CAS  Google Scholar 

  47. Hordijk ML et al. (2006) Electrocautery therapy for refractory anastomotic strictures of the esophagus. Gastrointest Endosc 63: 157–163

    Article  Google Scholar 

  48. Schubert D et al. (2003) Endoscopic treatment of benign gastrointestinal anastomotic strictures using argon plasma coagulation in combination with diathermy. Surg Endosc 17: 1579–1582

    Article  CAS  Google Scholar 

  49. Beilstein MC et al. (2005) Endoscopic incision of a refractory esophageal stricture: novel management with an endoscopic scissors. Gastrointest Endosc 61: 623–625

    Article  Google Scholar 

  50. DiSario JA et al. (2002) Incision of recurrent distal esophageal (Schatzki) ring after dilation. Gastrointest Endosc 56: 244–248

    Article  Google Scholar 

  51. Fry SW and Fleischer DE (1997) Management of a refractory benign esophageal stricture with a new biodegradable stent. Gastrointest Endosc 45: 179–182

    Article  CAS  Google Scholar 

  52. Sandha GS et al. (1999) Expandable metal stents for benign esophageal obstruction. Gastrointest Endosc Clin N Am 9: 437–446

    Article  CAS  Google Scholar 

  53. Won JH et al. (2002) Self-expandable covered metallic esophageal stent impregnated with beta-emitting radionuclide: an experimental study in canine esophagus. Int J Radiat Oncol Biol Phys 53: 1005–1013

    Article  Google Scholar 

  54. Lucktong TA et al. (2002) Resection of benign esophageal stricture through a minimally invasive endoscopic and transgastric approach. Am Surg 68: 720–723

    CAS  PubMed  Google Scholar 

  55. Willingham FF et al. (2007) Taking NOTES: translumenal flexible endoscopy and endoscopic surgery. Curr Opin Gastroenterol 23: 550–555

    Article  Google Scholar 

Download references

Acknowledgements

Charles P Vega, University of California, Irvine, CA, is the author of and is solely responsible for the content of the learning objectives, questions and answers of the Medscape-accredited continuing medical education activity associated with this article.

Author information

Author notes

  1. Department of Gastroenterology & Hepatology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands p.d.siersema@umcutrecht.nl

Authors and Affiliations

  1. PD Siersema is Professor of Gastroenterology and Director of the Department of Gastroenterology and Hepatology, University Medical Center Utrecht, The Netherlands.,

    Peter D Siersema

Authors
  1. Peter D Siersema
    View author publications

    You can also search for this author in PubMed Google Scholar

Ethics declarations

Competing interests

The author declares no competing financial interests.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Siersema, P. Treatment options for esophageal strictures. Nat Rev Gastroenterol Hepatol 5, 142–152 (2008). https://doi.org/10.1038/ncpgasthep1053

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1038/ncpgasthep1053

This article is cited by

Search

Advanced search

Quick links

Nature Briefing

Sign up for the Nature Briefing newsletter — what matters in science, free to your inbox daily.

Get the most important science stories of the day, free in your inbox. Sign up for Nature Briefing