Esophageal Anastomotic Strictures: Outcomes of Endoscopic Dilation, Risk of Recurrence and Refractory Stenosis, and Effect of Foreign Body Removal

Abstract

Background & Aims Esophageal anastomotic strictures often require repeat dilation to relieve dysphagia. Little is known about factors that affect their remediation. We investigated long-term success and rates of recurrence or refractoriness following dilation, and factors associated with refractory stenosis. Methods We performed a retrospective study of 74 patients with an anastomotic stricture that had been dilated over a 5-year period (564 dilations; median follow-up period, 8 months). A stricture was refractory if luminal patency could not be maintained after ≥5 dilation sessions over 10 weeks. Results Of the 74 patients, 93% had initial relief of dysphagia. The stricture recurred in 43% of patients, and 69% were considered refractory. Removal of sutures/staples protruding into the lumen did not accelerate time to initial patency (median 37 days; interquartile range [IQR], 20–82 days) or lengthen the dysphagia-free interval (37.4 days; IQR 8–41 weeks), compared to patients who did not undergo removal (initial patency, median 55 days; IQR, 14–109 days; P=.66 and median dysphagia-free interval, 21.7 days; IQR, 9–64 weeks; P=.8). Use of fluoroscopy during dilation (odds ratio=8.92; 95% confidence interval, 1.98–40.14) was positively associated with development of refractory strictures, whereas neoadjuvant chemotherapy (odds ratio=0.28; 95% confidence interval, 0.07–0.97) was inversely associated. Female sex and distal location of strictures increased risk of refractoriness as effect modifiers in multivariate analysis. Conclusions Endoscopic dilation is highly successful in achieving luminal remediation, yet anastomotic strictures are often refractory and frequently recur. Removal of sutures/staples within the lumen does not help achieve patency. Need for fluoroscopic guidance indicates a high likelihood of refractoriness to dilation, whereas prior neoadjuvant chemotherapy indicates a lower risk.

Risk factors associated with refractoriness to esophageal dilatation for benign dysphagia

“…Caustic strictures, peptic strictures, and complex strictures were associated with a greater need for subsequent dilatations. Complex strictures, as longer, angulated, and irregular ones, were also expected to be [10,11,24]. Less satisfactory results in caustic strictures can be explained by a longlasting local inflammatory process that leads to a transmural process, tissue fibrosis, and irreversible deposition of collagen [22].…”

Outcomes of oesophageal self‐dilation for patients with refractory benign oesophageal strictures

“…However, 30%‐40% of these strictures recur despite rigorous dilations . Although a consensus definition does not exist, a stricture is typically termed as a refractory benign oesophageal stricture when there is a failure to maintain luminal patency after at least five endoscopic dilations . These strictures are fibrotic and cicatricial, and are most commonly the sequelae of radiation, surgery, caustic ingestion or endoscopic mucosal resection .…”

Endoscopic Management of Gastrointestinal Complications

“…16 Studies specifically looking at the effect of FB removal at esophageal anastomotic strictures did not demonstrate an accelerated time to luminal patency, but also grouped staple and suture removal together. 17 Because of clear differences in the amount of inflammation generated by surgical staples when compared with suture, our preference is to remove all suture material (especially permanent sutures like prolene and silk) when identified in a strictured anastomosis (►Fig. 4B).…”