Home self‐dilatation for esophageal strictures

Esophageal strictures secondary to caustic ingestion, head and neck radiation and at the anastomosis post‐esophagectomy tend to be refractory to one or several dilatations. One option for these strictures is home self‐dilatation. The aim of this study was to assess the efficacy and safety of home self‐dilatation for a refractory esophageal stricture. A retrospective chart review was performed of all patients from 1997 to 2009 that performed home self‐dilatation for an esophageal stricture. Patients with proximal strictures without tortuosity or a shelf proximal to the stricture were selected for self‐dilatation. The patients were taught self‐dilatation by the surgeon and an experienced nurse, and an appropriate sized Maloney dilator was provided to the patient and returned when no longer needed. There were 16 patients (11 male and 5 female) with a median age of 60 years (range 38–78). The stricture was related to the anastomosis after esophagectomy in 12 patients, caustic injury in 3 patients and cervical chemoradiotherapy in 1 patient. Prior to initiation of self‐dilatation patients had a median of four endoscopic dilatations. Self‐dilatation was done with a Maloney dilator ranging in size from 45 to 60 French. The median duration of self‐dilatation was 16 weeks. No patient had a perforation or complication related to self‐dilatation. No patient required stenting or repetitive endoscopic dilatations because of failure of self‐dilatation. Strictures recurred in two patients after cessation of self‐dilatation and both responded to endoscopic dilatation followed by additional self‐dilatation. Self‐dilatation effectively resolves refractory esophageal strictures. It was well tolerated, and there were no complications in this series. Home self‐dilatation should be considered the treatment of choice in appropriate patients with refractory esophageal strictures in the cervical esophagus.     

Topical mitomycin C can effectively alleviate dysphagia in children with long‐segment caustic esophageal strictures

Caustic ingestion in children and the resulting long esophageal strictures are usually difficult to be managed, and eventually, esophageal replacement was required for cases refractory to frequent dilatation sessions. Topical mitomycin C (MMC) application has been used recently to improve the results of endoscopic dilatation for short esophageal strictures. The study aims to assess the role of MMC application in management of long‐segment caustic esophageal strictures. From January 2009 to June December 2013, patients presented with long caustic esophageal stricture (>3 cm in length) were included in this study and subjected to topical MMC application after endoscopic esophageal dilatation on multiple sessions. Regular follow‐up and re‐evaluation were done. A dysphagia score was used for close follow‐up clinically; verification was done radiologically and endoscopically. During the specified follow‐up period, 21 patients with long caustic esophageal stricture were subjected to topical MMC application sessions. Clinical, radiological, and endoscopic resolution of strictures occurred in 18 patients (85.7% cure rate). Number of dilatation sessions to achieve resolution of dysphagia was (n = 14.3 ± 5.7) with application of mitomycin two to six times. There was no recurrence in short‐ and mid‐term follow‐up. No complications were encountered related to topical MMC application. MMC is a promising agent in management of long‐segment caustic esophageal strictures. Long‐term follow‐up is needed to prove its efficacy and to evaluate potential long‐term side‐effects of MMC application.     

Endoprosthetics in the treatment of benign esophageal strictures

Benign esophageal strictures are a common problem in endoscopic practice. The predominant symptom of patients is dysphagia. The initial treatment option for a benign esophageal stricture is dilation. A small subgroup of strictures, that is, those that are long (>2 cm), are tortuous, and have a narrow diameter, or are associated with caustic or postradiotherapy etiology, tend to recur and are therefore called refractory. Temporary stent placement, with either a self-expandable metal stent or a self-expandable plastic stent, can be considered as a treatment option in these patients. From a technical point of view, placement of an expandable stent in benign strictures does not differ from placement in cases of palliation of malignant dysphagia. Deep sedation and careful stent placement, especially in proximal locations, is extremely important. Results of temporary stenting are still inconclusive; long-term clinical resolution of the stricture is achieved in less than 50% of patients. Moreover long-term data on safety and efficacy are scant. These disappointing results are mainly because of hyperplastic tissue ingrowth or overgrowth and stent migration. New stent designs are needed for this indication. Promising initial results show that biodegradable stents may be useful for refractory benign esophageal strictures; however, these preliminary data need to be further elucidated in future studies.     

Endoscopic treatment of benign esophageal strictures: a literature review

Introduction: Benign esophageal strictures arise from various etiologies and are frequently encountered. Although endoscopic dilation is still the first-line therapy, recurrent strictures do occur in approximately 10% of the cases and remains a challenge to gastroenterologists.

Areas covered: A literature search was performed using PubMed and Google Scholar databases for original and review articles on endoscopic treatment of benign esophageal strictures. This review outlines the main available treatment options and its controversies in the management of refractory benign esophageal strictures.

Expert commentary: Adding local steroid injections to dilation can be effective for peptic stenosis and strictures after endoscopic submucosal dissection, but remains uncertain for anastomotic strictures. Intralesional injections of mitomycin-C could be useful in corrosive strictures. Incisional therapy can be a reliable alternative in Schatzki rings and in anastomotic strictures, in experienced hands. By contrast, long-term outcome with endoprosthetic treatment is disappointing, and stent placement should be carefully considered and individualized.     

Evaluation and management of benign esophageal strictures

Patients with progressive or solid food dysphagia should be evaluated for the presence of an esophageal stricture. Barium esophagram and endoscopy can define strictures as benign or malignant. The majority of benign strictures are acid-related. Benign strictures are best managed by esophageal dilation with acid-suppressing medications if a peptic stricture is suspected. If dysphagia recurs, repeat dilation should be performed. There are a variety of interventions for refractory strictures which include injection of intralesional corticosteroids, temporary placement of self-expanding plastic stents and surgery.     

Removable esophageal stents have poor efficacy for the treatment of refractory benign esophageal strictures (RBES)

With the recent availability of removable esophageal stents, endoscopic stenting has been utilized to treat refractory benign esophageal strictures (RBES). The objective of this study was to review the feasibility and effectiveness of removable esophageal stents to treat RBES. Patients who received removable esophageal stents for the treatment of RBES at the institution between 2004–2010 using its stent implantation logs and endoscopic database were retrospectively identified. Patient demographics, stricture etiology and location, stent and procedure characteristics, and clinical outcomes were obtained. Twenty‐five patients with a mean age of 70 (72% male) underwent initial stent placement; 24 were successful. Overall clinical success was achieved in five of the 19 patients (26%) ultimately undergoing stent removal. RBES etiologies included anastomotic (13), radiation (5), peptic (3), chemotherapy (1), scleroderma (1), and unknown (2). Alimaxx‐E (Merit‐Endotek, South Jordan, UT, USA) stents were placed in 20 patients and Polyflex (Boston Scientific, Natick, MA, USA) stents were used in five patients. Immediate complications included failed deployment (1) and chest pain (7). Five patients died prior to stent removal. Stent migration was found in 53% (10/19) of patients who underwent stent removal: nine required additional therapy and one had symptom resolution. Out of the nine patients without stent migration, five required additional therapy and four had symptom resolution. Although placement of removable esophageal stents for RBES is technically feasible, it is frequently complicated by stent migration and chest pain. In addition, few patients achieved long‐term stricture resolution after initial stenting. In this study, most patients ultimately required repeated stenting and/or dilations to maintain relief of dysphagia.     

Defiant dysphagia: Small-caliber esophagus and refractory benign esophageal strictures

Among causes of defiant dysphagia, two pose a special challenge for the clinician: the small-caliber esophagus and refractory benign esophageal strictures. The small-caliber esophagus is a major cause of dysphagia for solids in young patients with eosinophilic esophagitis. A smooth, diffusely narrow esophageal lumen can be appreciated by barium esophagography or esophagoscopy. The term "small-caliber esophagus" is preferred over "stricture" because of the absence of cicatrization. A "subtle" small-caliber esophagus may defy detection by barium esophagogram and esophagogastroduodenoscopy. The only evidence to its diagnosis is the endoscopic finding of unusually long rents in the body of the esophagus immediately after esophageal dilation. The ringed esophagus seems to be a variant of the small-caliber esophagus, with the additional endoscopic finding of a variable number of rings (few to numerous) throughout the narrowed esophagus. Classification, diagnosis, and management of small-caliber esophagus are discussed in this review. Refractory esophageal strictures have various causes, including gastroesophageal reflux disease, nasogastric tube placement, mediastinal irradiation, and corrosive ingestion. Treatments used to eliminate or reduce the need for frequent esophageal bougienage include acid-suppressive medical therapy, surgery, intralesional corticosteroid injection, and esophageal self-expandable metal stents.     

Endoscopic dilation of esophageal stricture without fluoroscopy is safe and effective

AIM：Endoscopic dilation of esophageal strictures is a commonly performed procedure in the management of dysphagia,The procedure is usually done with fluoroscopic guidance,The aim of this study was to assess the use of Tracer guide wire in conjunciton with Savary-Gilliard dilators in the dilation of tight esophageal strictures without fluoroscopy,METHODS:Fifty-five patients with significant dysphagia from stricturen due to a variety of causes were dilated endoscopically,The procedure consisted of two parts,First,a guidewire was passed using endoscopic guidance,and then,dilation was performed without fluoroscopy.A modifled Tracer wire was employed and was particularly effective in negotiating very tight esophageal strictures,in which the lumen is less than 6mm,In general,the“Rule of Three”and“2-3sessions in 10days,maxinum dilation up to42French”andrules were followed.401dilations in a total of 55patients(malignant strictures30,benign25)in 177sessions were carried out.RESULTS:The guide wire placement and Savary-Gilliard dilation were successfully performed without fluoroscopy,and improvement of dysphagia was achieved in all patients,Esophageal plastic stent(out diameter 40 French)was placed in five patients with malignant stircture-three of them with tracheo-esophageal fistula.CONCLUSION:Dilation using Tracer gude wire without fluoroscopy is safe and effective in treatment of even very tight esophageal strictures.     

可拆出机织型捆绑式食管支架预防碱烧伤食管疤痕狭窄

目的 :研究置入可拆出机织型捆绑式食管支架能否预防和治疗碱烧伤所致的腐蚀性食管炎疤痕狭窄。方法 :2 4例消化道碱烧伤患者 ,经食管扩张后置入可拆出机织型捆绑式食管支架 ,4周后拆除食管支架 ,每 3个月定期随访患者的症状及胃镜检查。结果 :支架置入成功率 10 0 % ,2 0例患者能进食普食 ,4例进食半流 ,4周后拆除食管支架 ,当时显效 2 0例 ,有效 4例 ,总有效率 10 0 % ,随访观察 18～ 2 4个月 ,随访结果用Kaplan Meier法统计分析 ,发现只有大约 30 %的患者在日后需要行食管扩张治疗 ,其中大部分是发生在拆除食管支架后的 12～ 18个月。结论 :置入可拆出机织型捆绑式食管支架可预防和治疗碱烧伤后食管疤痕狭窄 ,与单纯食管扩张疗法比较 ,可明显减少患者术后再次进行食管扩张治疗的发生率。     

THERAPEUTIC OPTION FOR CHILDREN WITH ESOPHAGEAL CAUSTIC STENOSIS

Caustic ingestion is a leading cause of esophageal stenosis in children. Herein we report four cases using mitomycin C (MMC), a drug that inhibits cell division, protein synthesis and fibroblast proliferation and has been used as an adjuvant therapy for caustic esophageal stenosis that is recalcitrant to conventional dilation techniques. A retrospective chart review was performed on four pediatric patients with severe, recurrent esophageal stricture after caustic ingestion. The patients had required six to 20 esophageal dilations over a 4–16‐month period before MMC application. MMC was applied after an endoscopic dilation on saturated pledgets at a dose of 0.1 mg/mL for 2 min in the area where the strictures had been lyzed. From the four children treated with MMC, two have been asymptomatic for 16 and 20 months and two still require esophageal dilation, however, at longer intervals. All patients have shown satisfactory weight gain with food intake exclusively per oral. Although further studies are required, there is strong evidence that MMC is a safe and effective adjuvant therapy in the treatment of esophageal caustic stenosis.     

Acute therapy with intravenous omeprazole on caustic esophageal injury: a prospective case series

The ingestion of caustic substances may result in significant esophageal injury. There is no standard treatment protochol for esophageal injury and most patients are treated with a proton pump inhibitor or H2 antagonist. However, there is no clinical study evaluating the efficacy of omeprazole for caustic esophageal injury. A prospective study of 13 adult patients (>18 years of age) who were admitted to our hospital for caustic ingestion between May 2010 and June 2010 was conducted. Mucosal damage was graded using a modified endoscopic classification described by Zargar et al. Patients were treated with a proton pump inhibitor and maintained without oral intake until their condition was considered stable. Patients received omeprazole 80 mg in bolus IV, followed by continuous infusion of 8 mg/hour for 72 hours. A control endoscopy was performed 72 hours after admission. There was significant difference regarding endoscopic healing between the before and after omeprazole infusion (P = 0.004). There was no hospital mortality at the follow‐up. Omeprazole may effectively be used in the acute phase treatment of caustic esophagus injuries.     

Use of self-expandable plastic stents (SEPS) in management of refractory benign esophageal strictures: a single center experience

Back ground

Benign esophageal stricture is a common cause for dysphagia in adults. It can negatively affect the quality of patient’s life and may cause many complications. Benign esophageal strictures are caused by different procedures and disorders, such as gastroesophageal reflux disease, post-surgery anastomotic stricture, radiation, ablative therapy or caustic ingestion. The aim of the study was to assess the efficacy of Polyflex stent insertion in refractory benign esophageal strictures in patients admitted to the endoscopy unit of the Medical Research Institute hospital, Alexandria University, Alexandria, Egypt.

Patients and methods

Polyflex, self-expandable plastic stent, were inserted in nine patients with refractory benign esophageal strictures with follow-up for 1 year.

Results

Dysphagia was significantly improved in 88% of patients, after insertion of Polyflex stents. Complications reported were one patient with stent migration and 2 patients with esophageal ulceration.

Conclusion

The use of Polyflex stents in the management of benign refractory esophageal strictures appears to be promising with high clinical success rate and few manageable complications.

     

Intralesional steroid injection therapy in the management of resistant gastrointestinal strictures

Esophageal strictures are a problem frequently encountered by gastroenterologists. Dilation has been the customary treatment for benign esophageal strictures, and dilation techniques have advanced over the years. Depending on their characteristics and the response to treatment, esophageal strictures can be classified into two types: 1, simple (Schatzki rings, webs, peptic injury, and following sclerotherapy) - these are easily amenable to dilation, with a low recurrence rate after initial treatment; and 2, complex (caused by caustic ingestion, radiation injury, anastomotic strictures, and photodynamic therapy) - these are difficult to dilate and are associated with higher recurrence rates. Refractory strictures are those in which it is not possible to relieve the anatomic restriction successfully up to a diameter of 14 mm over five sessions at 2-weekly intervals, due to cicatricial luminal compromise or fibrosis; and recurrent strictures are those in which it is not possible to maintain a satisfactory luminal diameter for 4 wk once the target diameter of 14 mm has been achieved. There are no standard recommendations for the management of refractory strictures. The various techniques used include intralesional steroid injection combined with dilation; endoscopic incisional therapy, with or without dilation; placement of self-expanding metal stents, Polyflex stents, or biodegradable stents; self-bougienage; and endoscopic surgery. This review discusses the indications, technique, results, and complications of the use of intralesional steroid injections combined with dilation and endoscopic incisional therapy with dilation in refractory strictures.     

Stenting in esophageal strictures

The interventional management of esophageal strictures remains, to date, an important clinical challenge. Stenting is probably the best palliation modality in patients with incurable esophagogastric carcinoma. Conversely, the use of esophageal stents is still relatively uncommon for the treatment of refractory benign strictures. In the last few years, several new stents have become available as a result of significant advances that have been made in terms of design and materials. This review focuses on the endoscopic use of esophageal stents in malignant and benign esophageal strictures, revisiting the different types of expandable stents presently available, the techniques, the results, and the complications of stent insertion and giving some practical advices. Future developments in the field of esophageal stenting are also discussed.     

Intralesional steroid is beneficial in benign refractory esophageal strictures: A meta-analysis

AIM To analyze the effect of intralesional steroid injections in addition to endoscopic dilation of benign refractory esophageal strictures.METHODS A comprehensive search was performed in three databases from inception to 10 April 2017 to identify trials, comparing the efficacy of endoscopic dilation to dilation combined with intralesional steroid injections. Following the data extraction, meta-analytical calculations were performed on measures of outcome by the randomeffects method of Der Simonian and Laird. Heterogeneity of the studies was tested by Cochrane's Q and I~2 statistics. Risk of quality and bias was assessed by the Newcastle Ottawa Scale and JADAD assessment tools.RESULTS Eleven articles were identified suitable for analyses, involving 343 patients, 235 cases and 229 controls in total. Four studies used crossover design with 121 subjects enrolled. The periodic dilation index(PDI) was comparable in 4 studies, where the pooled result showed a significant improvement of PDI in the steroid group(MD:-1.12 dilation/month, 95% CI:-1.99 to -0.25 P = 0.012; I~2 = 74.4%). The total number of repeat dilations(TNRD) was comparable in 5 studies and showed a non-significant decrease(MD:-1.17, 95%CI:-0.24-0.05, P = 0.057; I~2 = 0), while the dysphagia score(DS) was comparable in 5 studies and did not improve(SMD: 0.35, 95%CI:-0.38, 1.08, P = 0.351; I~2 = 83.98%) after intralesional steroid injection.CONCLUSION Intralesional steroid injection increases the time between endoscopic dilations of benign refractory esophageal strictures. However, its potential role needs further research.     

Self-expandable metal coil stents in the treatment of benign esophageal strictures refractory to conventional therapy: a case series

BACKGROUND: Benign, refractory esophageal strictures are an important therapeutic challenge. Metallic self-expandable stents developed to treat malignant strictures have occasionally been used in the treatment of benign stenoses. This is a report of the use of 14 esophageal metallic stents in 10 patients with severe benign strictures. METHODS: Ten patients with peptic, post-surgical, or post-radiation esophageal strictures were treated with metallic stents. All patients had previously been treated, unsuccessfully, by endoscopic dilatation. Their strictures, although benign, gave rise to the same problems as malignant ones. RESULTS: In all patients, marked improvement of dysphagia was achieved with the use of metallic stents. They were inserted without early complications except for chest pain in one patient. Late complications were proximal and distal migration (in three patients) and a proximal stricture in one other patient. The best results were achieved in post-radiation strictures. CONCLUSIONS: Metallic stents can be considered as a therapeutic alternative in selected patients with severe benign esophageal strictures refractory to conventional treatment.     

Conservative management of caustic substance ingestion in a pediatric department setting,short‐term and long‐term outcome

Patients with caustic substance ingestion are usually referred to surgery departments where endoscopic evaluation is the first step towards appropriate treatment. The aim of this study was to evaluate the safety and efficacy of conservative management of caustic substance ingestion in a pediatric department setting following a standard protocol including endoscopy in selected cases and conservative treatment based on clinical and endoscopy criteria. In this single center observational study, all children admitted for caustic substance ingestion to a pediatric department over an 8‐year‐period were managed according to a standard protocol that included endoscopy within 24 hours, if the endoscopy criteria were met, and conservative treatment as judged appropriate according to endoscopic classification. Patients were followed up for 8–10 years. Of the 24 patients (age 4/12 to 6 years) admitted, 14 met the endoscopy criteria. Grade II and III esophageal burns were found in 10/14 patients, and they were treated with H2‐blockers, antibiotics, corticosteroids, and nutritional support (parenteral in 8/10). Patients with grade II or III esophageal burns necessitated prolonged hospitalization (x ± standard deviation, 23 ± 3 days; range, 21–30 days). Complications included esophageal strictures (n = 1), treated successfully with dilatations, and bleeding (n = 1) treated conservatively. During the 8‐ to 10‐year follow‐up all patients were recorded being well. Based on the study findings it is concluded that conservative management of children with caustic substance ingestion using a standard protocol, including endoscopy as indicated, is feasible within the pediatric department, and conservative treatment on demand is safe and effective in preventing short‐term and long‐term complications.     

Safety and outcome using endoscopic dilatation for benign esophageal stricture without fluoroscopy

AIM:To investigate the use of Savary-Gilliard marked dilators in tight esophageal strictures without fluoros-copy. METHODS:Seventy-two patients with signif icant dysphagia from benign strictures due to a variety of causes were dilated endoscopically. Patients with achalasia, malignant lesions or external compression were excluded. The procedure consisted of two parts. First, a guide wire was placed through video endoscopy and then dilatation was performed without fluoroscopy. In general, "the rule of three" was followed. Effective treatment was defi ned as the ability of patients, with or without repeated dilatations, to maintain a solid or semisolid diet for more than12mo. RESULTS: Six hundred and sixty two dilatations in a total of72patients were carried out. The success rate for placement of a guide wire was100%and for dilatation97%,without use of fluoroscopy, after6mo to4years of follow-up.The number of sessions per patient was between1and7,with an average of2sessions.The ability of patients, after 1 or more sessions of dilatation, to maintain a solid or semisolid diet for more than 12mo was obtained in70patients(95.8%).For very tight esophageal strictures, all patients improved clinically without complications after the endoscopic procedure without fluoroscopy, but we noted3failures. CONCLUSION:Dilatation using Savary-Gilliard dilators without fluoroscopy is safe and effective in the treatment of very tight esophageal strictures if performed with care.     

Mitomycin‐C: ‘a ray of hope’ in refractory corrosive esophageal strictures

Increasingly frequent dilation may become a self‐defeating cycle in refractory stricture as recurrent trauma enhance, scar formation, and ultimately recurrence and potential worsening of the stricture. In 12 patients of caustic induced esophageal stricture, who failed to respond despite rigorous dilatation regimen for more than one year, a trial of topical mitomycin‐C application to improve dilatation results was undertaken, considering the recently reported efficacy and safety of this agent. Mitomycin‐C was applied for 2–3 minutes at the strictured esophageal segment after dilation with wire‐guided Savary‐Gilliard dilator. Patient was kept nil by mouth for 2–3 hours. After 4–6 sessions of mitomycin‐C treatment, resolution of symptoms and significant improvement in dysphagia score and periodic dilatation index was seen in all 12 patients. Mitomycin‐C topical application may be a useful strategy in refractory corrosive esophageal strictures and salvage patients from surgery.     

Endoscopic radial incision and cutting method for refractory esophageal stricture after endoscopic submucosal dissection of superficial esophageal carcinoma

A 59‐year‐old woman and a 69‐year‐old man had esophageal strictures that were refractory to over 10 therapeutic attempts with endoscopic balloon dilation (EBD) after endoscopic submucosal dissections (ESD) for superficial esophageal carcinoma (SEC). The strictured lesions in both patients improved remarkably with a new endoscopic modality (endoscopic radial incision and cutting [ERIC]), which was carried out one to three times, and stricture recurrence was not noted throughout the follow‐up period. ERIC is a safe and efficient method for treating refractory strictures after EBD caused by ESD for SEC.