Refractory Esophageal Strictures: What To Do When Dilation Fails

Abstract

Opinion statementBenign esophageal strictures arise from a diversity of causes, for example esophagogastric reflux, esophageal resection, radiation therapy, ablative therapy, or the ingestion of a corrosive substance. Most strictures can be treated successfully with endoscopic dilation using bougies or balloons, with only a few complications. Nonetheless, approximately one third of patients develop recurrent symptoms after dilation within the first year. The majority of these patients are managed with repeat dilations, depending on their complexity. Dilation combined with intra lesional steroid injections can be considered for peptic strictures, while incisional therapy has been demonstrated to be effective for Schatzki rings and anastomotic strictures. When these therapeutic options do not resolve the stenosis, stent placement should be considered. Self bougienage can be proposed to a selected group of patients with a proximal stenosis. As a final step surgery is an option, but even then the risk of stricture formation at the anastomotic site remains. This chapter reviews refractory benign esophageal strictures and the treatment options that are currently available.

Benign Pharyngoesophageal Strictures: Increasingly Encountered and Still a Challenge

“…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]. Although other characteristics with recognized association to difficult treatment in this setting of aetiology, as stricture length, complexity, and location [8,9], would add value to this analysis if available in a larger population sample. Interestingly, refractory strictures did not present as a worse condition in this population and the authors suggested that these patients may still benefit from endoscopic therapy.…”

“…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.…”

“…It can be foreseen that in the future, novel therapies and a combination of currently available therapeutic methods should be considered, with promising results in reducing refractory and recurrent strictures [9,11,12]. While waiting for further prospective investigation, narrow diameters, recurrent stenosis, and the need for increased numbers of dilations may define a subgroup of patients with unfavorable outcome and alert physicians to the use of alternative approaches.…”

Endoscopic Management of Anastomotic Esophageal Strictures Secondary to Esophageal Atresia

“…41 The efficacy of intralesional triamcinolone injection in peptic strictures has been shown by Ramage and colleagues 42 in a randomized double-blind placebo-controlled trial. 42 In this study, 2 (13%, 95% confidence interval [CI] 4%-38%) of 15 patients in the steroid group and 9 (60%, 95% CI 36%-80%) of 15 in the sham group required repeat dilation (P 5 .021).…”

Treatment of Esophageal Strictures with Savary-Guilliard Bougies

“…In recurrent cases may need additional endoscopic treatment options such as incisional methods, stent placement or a combination of these. Rarely, in failure of these methods surgical intervention is used 1,6 . Serious complications such as perforation even death may occur during endoscopic dilatation of benign esophageal strictures 7,8 .…”