Endoscopic Dilation of Pharyngoesophageal Strictures: There Are More Dimensions than a Diameter

Abstract

Background/Aims: Dysphagia due to benign pharyngoesophageal strictures (PES) often requires repeated dilations; however, a uniform definition for the therapeutic efficacy of this technique has not been yet established. We aimed to assess the overall efficacy of endoscopic dilation of pharyngoesophageal anastomotic or post-radiotherapy (post-RT) strictures. Methods: The data of 48 patients with post-RT (n = 29) or anastomotic PES (n = 19) submitted to endoscopic dilation during a 3-year period were retrospectively assessed. The Kochman criteria were used to determine refractoriness and recurrence. Patients were asked to answer a questionnaire determining prospectively the dilation program efficacy as (a) dysphagia improvement, (b) dysphagia resolution, (c) need for further dilations, or (d) percutaneous endoscopic gastrostomy (PEG) during the previous 6 months. Need for additional therapy was considered an inefficacy criterion. Results: The median number of dilations per patient was 4 (total of 296 dilations) with a median follow-up of 29 months. The mean predilation dysphagia Mellow-Pinkas score was 3 and the initial stenosis diameter was 7 mm. Fifteen and 29% of patients presented with the Kochman criteria for refractory and recurrent strictures, respectively. Moreover, 96 and 60% showed dysphagia improvement and resolution, respectively. Seventy-five-percent did not require dilations during 6 months, and 89% did not require PEG. From the patients' perspective, overall efficacy was achieved in 58% of cases. Nine additional therapies were required. Number of dilations (OR 0.7), stricture diameter (OR 2.2), and nonrecurrence criteria (OR 14.2) appeared as significant predictors of overall efficacy, whereas refractory stenosis criteria did not. Conclusions: Endoscopic dilation seems to be effective for patients with dysphagia after RT or surgery, especially when assessed as patient perception of improvement. Narrow strictures, recurrent ones, and strictures requiring a higher number of dilations may predict worse outcomes. Key Message: Health professionals should establish well-defined efficacy criteria for dilations and base their decision beyond exclusively objective measurements. Dilatação Endoscópica de Estenoses FaringoEsofágicas: Mais Dimensões do que Diâmetros Palavras Chave Estenoses esofágicas benignas · Endoscopia · Dilatação · Satisfação pessoal · Resultado do tratamentoResumo Introdução e objetivo: A disfagia devido a estenoses faringo-esofágicas benignas requer frequentemente dilatações repetidas, não existindo, contudo, uma definição estabelecida para a eficácia desta terapêutica. Pretendemos avaliar a eficácia-global de dilatações endoscópicas de estenoses rádicas e anastomóticas faringo-esofágicas. Métodos: 48 doentes com estenoses pós-radioterapia (n = 29) e estenoses anastomóticas (n = 19) submetidos a dilatação endoscópica durante um período de 3 anos foram avaliados retrospetivamente. Os critérios de Kochman foram utilizados para determinar refratariedade e recorrência. Os doentes fora...

Benign Pharyngoesophageal Strictures: Increasingly Encountered and Still a Challenge

“…Martins et al [5] also reported a low complication rate (0.7%), specifically one deep laceration and one fistula. The infrequent use of more technically challenging dilation techniques (1%) may have contributed to these results.…”

“…In this issue of GE -Portuguese Journal of Gastroenterology, Martins et al [5] report a 3-year experience of treating pharyngoesophageal strictures at a tertiary oncologic center. The overall long-term efficacy of endoscopic dilation program on radiotherapy and anastomotic PES was evaluated.…”

“…Martins et al [5] defined overall efficacy as dysphagia improvement based on patient perception and a 6-month period of being dilation free and feeding per os. Based on their long-term follow-up results, overall efficacy was reached in 21 patients (58.8%).…”

“…Despite the relatively small cohort, Martins et al [5] revealed on univariate analysis that narrow lumens, recurrent strictures, and a higher number of dilations (some concept redundancy with recurrence) may predict worse outcomes. It supports previous data that also exposed an increasing number of dilations during the first year as a predictive factor for non-responsive PES [7] and severely narrowed strictures as a challenging situation [2,8].…”

“…The subjective "improvement" of dysphagia included in their definition of efficacy may contribute to this. However, it is known that the long-term outcome of endoscopic treatment for refractory benign esophageal strictures is time-consuming and disappointing with less than one-third of the patients achieving a resolution of the dysphagia, even when other techniques such as steroid injections, incisional therapy, stent placement, or self-bouginage are added to dilation therapy [5,9]. Patients and physicians should realize that repeated sessions (with inherent risks) and visits to the hospital will be needed for a possible effective treatment.…”