Why Do Esophageal Dialations Have to Been Done Again?
Curr Treat Options Gastroenterol. 2015; thirteen(i): 47–58.
Refractory Esophageal Strictures: What To Do When Dilation Fails
Petra G. A. van Boeckel
Section of Gastroenterology and Hepatology, HP: F02.618, Academy Medical Centre, Heidelberglaan 100, 3584 CX Utrecht, Netherlands
Peter D. Siersema
Department of Gastroenterology and Hepatology, HP: F02.618, Academy Medical Center, Heidelberglaan 100, 3584 CX Utrecht, Netherlands
Opinion argument
Benign esophageal strictures ascend from a diversity of causes, for instance esophagogastric reflux, esophageal resection, radiation therapy, ablative therapy, or the ingestion of a corrosive substance. Virtually strictures tin can be treated successfully with endoscopic dilation using bougies or balloons, with only a few complications. All the same, approximately one third of patients develop recurrent symptoms after dilation within the commencement twelvemonth. The majority of these patients are managed with echo 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 exist considered. Self bougienage can be proposed to a selected group of patients with a proximal stenosis. As a final pace surgery is an pick, but even then the chance of stricture formation at the anastomotic site remains. This chapter reviews refractory benign esophageal strictures and the treatment options that are currently bachelor.
Keywords: Refractory beneficial esophageal stricture, Dysphagia, Dilation, Incisional therapy, Intralesional steroid injection, Stent placement, Self-expandable plastic stent, Self-expandable metal stent, Biodegradable stent placement, Esophagectomy, Self-bougienage
Introduction
Beneficial esophageal strictures are acquired past a multifariousness of esophageal disorders or injuries, for instance gastroesophageal reflux, radiation therapy, ablative therapy, or the ingestion of a corrosive substance. In addition, stricture germination may be a complication of esophageal resection with gastric tube formation [i, 2]. More than eighty–90 % of esophageal strictures can be treated successfully with endoscopic dilation using Savary bougies or balloons. Esophageal dilation is a procedure with a very low rate of serious complications, mainly bleeding and perforation [three–5]. Unfortunately, approximately ane third of patients develop recurrent dysphagia afterward dilation inside the first yr. The bulk of these patients are managed with repeat dilations, depending on their complexity [2, six].
Simple strictures are considered to exist short, focal, directly, and to allow passage of a normal diameter endoscope. Examples include Schatzki rings, esophageal webs, and peptic strictures [7]. Overall, ane to three dilations are sufficient to relieve dysphagia in simple strictures. Only 25–35 % of patients require additional sessions, with a maximum of v dilations in more 95 % of patients [4]. Complex strictures are usually longer (>ii cm), angulated, irregular, or have a severely narrowed diameter. These strictures are more difficult to treat and take a tendency to be refractory or to recur despite dilation therapy. A fair number of complex strictures include round, anastomotic strictures in the absenteeism of endoscopic evidence of inflammation [8••, 9]. Other etiologies include radiation induced strictures, caustic strictures, and photodynamic therapy induced strictures [7].
Dysphagia is the nearly mutual symptom in patients with a beneficial esophageal stricture. Remarkably, most patients exercise not experience severe weight loss, as can exist seen in malignant esophageal strictures [9]. Treatment aims to relieve symptoms, with the avoidance of complications and the prevention of recurrences. Still, dilation is the offset line pick to care for beneficial esophageal strictures. When strictures are refractory or recur, dilation therapy combined with steroid injections, incisional therapy, stent placement, self-bougienage, or surgery can exist considered [10]. According to the Kochman criteria, refractory or recurrent strictures are divers as an anatomic brake because of a cicatricial luminal compromise or fibrosis resulting in clinical symptoms of dysphagia in the absence of endoscopic evidence of inflammation. This may occur as the result of either an inability to successfully remediate the anatomic trouble to a bore of at to the lowest degree 14 mm over 5 sessions at two-week intervals (refractory); or as a result of an inability to maintain a satisfactory luminal diameter for four weeks once the target diameter of xiv mm has been achieved (recurrent). This definition is non meant to include patients with an inflammatory stricture (which will not resolve until the inflammation subsides), or those with a satisfactory diameter but having dysphagia on the basis of neuromuscular dysfunction (for case those with dysphagia due to postoperative and/or postradiation therapy) [8••].
Treatment of benign esophageal strictures
Dilation
The beginning step in managing benign esophageal strictures remains dilation with an inflatable balloon or a (Savary) bougie [4, 9, 11]. In the literature, no differences have been shown betwixt balloon and bougie dilation in relief of dysphagia and/or recurrence of dysphagia. Also no differences take been shown in the take a chance of major complications [12–fourteen]. Major complications include perforation, bleeding, and bacteremia. Perforation take chances varies betwixt 0.one % and 0.4 % [eleven]. Although the majority of patients are effectively treated with up to five dilations, approximately x % of patients need ongoing dilations to become dilation costless [eight••, 15]. In order to reduce the number and burden of endoscopic dilations to become dysphagia free, diverse endoscopic handling options have been suggested.
Dilation combined with steroid injection
Adding steroid injection to endoscopic dilation into the stricture followed by dilation to avoid recurrent dysphagia has been reported to foreclose stricture recurrence. This method, advocated since 1966, has shown encouraging results in patients with peptic strictures [sixteen]. However, almost of these studies were pocket-sized and uncontrolled [17–19]. Randomized trials are unfortunately express and small-sized [xx–22]. Camargo, et al., randomized 14 patients with corrosive strictures allocated to steroid injection or placebo [twenty]. These authors did not find a difference in dilation frequency or recurrent dysphagia between the two groups. In another randomized trial, 21 patients with strictures of different etiologies were included. An increase in the dysphagia gratis menstruation and periodic dilation index was reported in the steroid arm, just in that location was not a departure in the total number of dilations. Another study demonstrated a decrease in mean dilation frequency in patients with peptic strictures, from six dilations in the control group to ii dilations in the steroid group after one year follow upwards [21]. Ramage, et al., performed a randomized trial comparing dilation to intralesional 4-quadrant injection of triamcinolone injections [22]. 30 patients with peptic strictures with recurrent dysphagia after at least one dilation session were included. They concluded that dilation combined with steroid injection and gastric acid suppression therapy reduced the number of repeat dilations and the dysphagia gratuitous catamenia, with re-dilation rates of 13 % in the steroid group versus lx % in the command grouping (p = 0.01).
Hirdes, et al., recently evaluated the efficacy of intralesional triamcinolone injections combined with endoscopic dilation in a relatively large group of patients with anastomotic strictures [23•]. A full of threescore patients with untreated cervical anastomotic esophageal strictures after esophagectomy with gastric tube reconstruction and dysphagia for at least solid food were enrolled and randomized to dilation with or without steroid injections. They concluded that adding intralesional steroid injections to Savary dilation in patients with untreated beneficial anastomotic esophageal strictures did not result in a clinical benefit. Furthermore, an increased incidence of candida esophagitis was found in the remaining esophagus proximal to the anastomosis.
In conclusion, in that location is bear witness that steroid injection in combination with dilation is able to reduce the risk of recurrent dysphagia in refractory benign esophageal strictures of peptic origin. Notwithstanding, this result comes from various small-sized studies with poorly defined patient populations. Furthermore the optimal injection dose, technique and frequency remain to be determined. On the contrary, adding steroid to dilation was not found to be constructive in anastomotic strictures. The pathogenesis of anastomotic strictures differs from that of peptic strictures, in that the quondam is due to ischemia whereas the latter develops as a consequence of inflammation and ulceration from reflux of gastric acid [24]. Steroids are suggested to locally inhibit the inflammatory response, resulting in a reduction of collagen germination [22].
Needle knife incision
Incisional therapy with a needle knife was outset reported for the treatment of Schatzki rings [25, 26]. Subsequently, incisional therapy added to balloon dilation, or incisional therapy using a polypectomy snare with additional argon plasma coagulation, were shown to be effective in a small series of patients with anastomotic strictures, without the occurrence of complications [27–xxx]. Hordijk, et al., included xx patients with anastomotic strictures that were refractory to dilation, and demonstrated that incisional therapy was safe and effective in simple, short strictures (<ten mm) [31]. In another study, 24 patients with anastomotic strictures without previous dilation were included. They were treated with endoscopic incisional therapy applying a transparent hood on the tip of the endoscope to raise control and rubber. After 2 years of follow up 87.5 % of the patients were even so dysphagia costless after ane session [32]. In 2009, Hordijk, et al., randomized 62 patients with a main anastomotic stricture subsequently esophagectomy (who were not previously treated with dilation therapy), to Savary dilation or electrocautery incision. No pregnant difference in clinical success rates were detected between the incisional therapy and dilation therapy arms [33]. Furthermore no complications were observed afterwards incisional therapy. So, incisional therapy can exist considered as an culling handling in patients with a (relatively) short stenosis (Fig.1).
Endoscopic view of. a Anastomotic stricture. b Directly after incisional therapy. c Later on long term follow up.
Stent placement
Dilation of an esophageal stricture with a balloon or a bougie is usually done for a menstruum of a few seconds or some minutes. Information technology tin, notwithstanding, be imagined that if the dilator can be kept in place for a longer time, the benefits of dilation may be longer lasting. In the past few years, temporary stent placement has increasingly been used for refractory benign esophageal strictures. Self-expandable plastic stents (SEPS) are FDA approved for this indication, and have been used [34, 35]. Partially and fully covered self-expandable metal stents (SEMS), although non FDA approved, are besides frequently used to care for benign esophageal strictures. An alternative for SEPS and SEMS is the biodegradable stent [36], which has the advantage of not requiring removal.
Self-expandable metallic stents (SEMS)
Uncovered SEMS were initially used for the handling of refractory benign esophageal strictures [37–41]. In more recent years, partially or fully covered SEMS accept go available and are now normally used for this indication [35, 40, 42–44]. One of the major drawbacks of uncovered and partially covered SEMS, is that they are associated with a relatively loftier complication rate, generally due to hyperplastic tissue ingrowth through the stent mesh resulting in embedding of the stent in the mucosa [45]. The complication rate of uncovered or partially stents has been reported to be equally high every bit lxxx %. The well-nigh common complications of these stents is indeed new stricture formation due to tissue ingrowth, but also stent migration, pain, gastroesophageal reflux if the stent is positioned beyond the gastroesophageal junction, and fistula formation [46]. Tissue ingrowth consists histologically of granulation tissue, but reactive hyperplasia and fibrous tissue are also seen [47]. Tissue reaction ofttimes results in recurrent dysphagia and may hamper stent removal. On the other hand, particularly minor tissue ingrowth may also reduce the take a chance of stent migration (simply 12 % vs. 36 % for fully covered SEMS) [35, 48, 49•, 50, 51]. The risk of tissue ingrowth increases with stenting time, but tin can already be seen afterward one to 4 weeks. Tissue ingrowth can successfully be treated with the stent-in-stent method described by Hirdes, et al. Using this technique a fully covered stent is placed inside the previously placed embedded stent [49•]. The fully covered stent should have a length that at least overlaps and to have a size that is equal, or slightly larger than, the initially placed partially covered stent. Over a period of 10–14 days pressure necrosis of the hyperplastic tissue occurs as a result of friction. Hereafter, both stents tin can usually hands be removed.
To overcome the problem of stent ingrowth, fully covered stents (SEMS or SEPS) seem preferable for benign esophageal strictures. Currently, data on the employ of fully covered SEMS is express. In the beginning study performed by Eloubeidi, et al., a total of 36 stents were placed in 31 patients over a catamenia of 16 months. A clinical success charge per unit of 29 % was reported. A total of 47 % of these patients had no recurrence of dysphagia [48]. Bakken, et al., performed a retrospective study including vii patients with a refractory stricture. Stent migration occurred in more than half of the patients. None of the patients were treated successfully [52]. In 2011, Eloubeidi, et al., included 10 patients with a benign refractory esophageal stricture. A clinical success rate of 21 % was reported, with a migration charge per unit of 10 % [53]. A new generation of fully covered SEMS, the fully covered Wallflex (Boston Scientific, Natick, MA), was recently evaluated by Hirdes, et al. They included 15 patients with a refractory beneficial esophageal stricture. The migration rate was 35 %, while tissue overgrowth was seen in 20 % of patients. Recurrent dysphagia occurred in all patients subsequently a median of just 15 days afterward stent removal. These disappointing results were yet most probable due to the highly refractory patient population in this study [54].
Self-expandable plastic stents (SEPS)
SEPS have been proposed every bit an alternative to SEMS to minimize hyperplastic tissue reflection. In 2010, Repici, et al., performed a pooled data analysis of all bachelor studies on the employ of SEPS for benign esophageal strictures. A total of 130 treated patients were included from 10 studies. Stent placement was technically successful in 98 % of the patients. In 52 % of patients no further dilations were required afterwards a median follow upward of xiii months afterward stent removal. Median stenting time in these studies was not reported. In patients with a proximal stricture the success rate was somewhat lower (33 %). As can be expected, due to the fully covered stent design, a relatively high percentage (24 %) of stents migrated within four weeks, resulting in a high charge per unit of endoscopic re-interventions (21 %). Major complications were seen in ix % of patients. One patient died of massive bleeding [55]. More recently, Ham, et al., published an updated systematic review. A total of 172 patients with a benign esophageal stricture were included and treated with SEPS. They found a technical success rate of 98 % and a clinical success rate of 45 % with a rate of early stent migration of 31 % [56]. It tin can be concluded that SEPS are effective for the treatment of refractory esophageal strictures, but the blueprint needs further comeback to reduce the risk of migration. Moreover, the stent has a loftier radial and axial strength, which may be the cause of an increased hazard of stent-related complications to the esophageal wall, for example astringent bleeding.
In general, more than studies are needed to compare different stent designs head-to-head for the handling of benign esophageal strictures. An alternative treatment option that has recently been introduced is the placement of a biodegradable stent (Fig.2). Van Boeckel, et al., compared biodegradable stents with SEPS, i.eastward., Polyflex stent (Boston Scientific, Natick, MA), in a nonrandomized caput-to-head comparison. They found that both SEPSs and biodegradable stents provided long-term relief of dysphagia in 30 % and 33 %, respectively, of patients with a refractory esophageal stricture. Withal, biodegradable stents require fewer procedures than SEPSs [57•].
Endoscopic view of a peptic stricture with an expanding BD stent in the esophageal lumen.
Biodegradable stents
Only a small number of cohort studies on the utilise of biodegradable stent placement in the esophagus take been published, with only a few studies including 10 or more patients [36, 57•, 58–66]. Repici, et al., included over 30 patients with a refractory benign esophageal stricture and placed an Ella BD stent (Ella CS, s.r.o., Czech Commonwealth). Complete relief of dysphagia was reported in 43 % of patients afterward a median follow up of 53 weeks [36]. In this written report, eight (26 %) patients had recurrent dysphagia resulting from a recurrence of the stricture. No major complications were seen. In the above-mentioned study, van Boeckel, et al., reported complete relief of dysphagia in 33 % of patients treated with a biodegradable stent after a median of 166 days. In this report, major complications occurred in four (22 %) patients (ii hemorrhage and two severe retrosternal hurting) [57•]. Ibrahim, et al., included 20 patients treated with an Ella BD stent. Half of them needed ane or more additional procedures for recurrent dysphagia after six months of follow up [64]. Van Hooft, et al., besides ended that placement of an Ella BD stent was an constructive ane step handling in 60 % (6 of 10), of patients with an anastomotic stricture in the esophagus. No major complications were reported [66]. The other forty % of the patients required endoscopic dilation because of stricture related recurrent dysphagia. Recently, Hirdes, et al., reported the efficacy and safety of sequential Ella BD stent placement in 28 patients with a refractory beneficial strictures [58]. A total of 59 biodegradable stents were placed in these patients. Subsequently initial stent placement patients remained dysphagia costless for a period of 90 days, while afterwards six months withal 25 % of patients were dysphagia costless. Afterwards placement of a second biodegradable stent in patients with recurrent stricture formation, patients remained dysphagia free for a median period of 55 days. Later half dozen months only fifteen % of these patients were still dysphagia free. After a third biodegradable stent placement, the median dysphagia free menses was 106 days merely none of the patients remained dysphagia costless after a menstruum of six months. Major complications occurred in 29 %, eight %, and 28 % of patients after one, two, and iii Ella BD stents respectively. From these studies it tin be concluded that a unmarried biodegradable stent is simply temporarily effective in the majority of patients. The relatively depression radial force and degradable nature of these stents may contribute to early on stricture recurrence [67]. Stent placement was also found to exist associated with considerable complications, like retrosternal hurting and vomiting. All the same, in selected patients with a refractory benign esophageal stricture, sequential biodegradable stent placement can be an constructive alternative to avert the burden of frequent serial dilations. Further (prospective), studies including larger numbers of patients, and comparing biodegradable stents with fully covered SEMS (or SEPS), are needed. In those studies patient satisfaction and costs should be evaluated besides efficacy and safety.
Optimal duration of stent placement in refractory beneficial esophageal strictures
The optimal duration of stent placement for treating refractory beneficial esophageal strictures is unknown, but likely depends on a number of variables, such as stricture type, severity of the inflammation, stricture length, and stent type. These factors should be evaluated in all patients. The general principle is to exit the stent in identify until the inflammation is resolved. In strictures longer than 5 cm or those due to ischemic injury, dilation for a period of at to the lowest degree 8–xvi weeks is recommended. For shorter strictures and other etiologies shorter stenting times can exist recommended, simply still these strictures may too be refractory. Simply fully covered stent designs can safely be removed after a prolonged time of stenting. When partially covered stents are used, repeat endoscopy should be performed at 2–4 week intervals to evaluate embedding of the stent in the wall. After biodegradable stent placement, a completely different treatment strategy can be followed. Only when patients treated with a biodegradable stent present with recurrent dysphagia should a repeat endoscopy be performed. In nigh cases this means that the stent is dissolved and a new stent, either biodegradable or SEMS, can be placed.
Treatment selection (algorithm)
In absenteeism of bear witness based handling guidelines for patients with dysphagia due to refractory benign esophageal strictures [68, 69], an algorithm has been suggested for the therapeutic management of patients with beneficial dysphagia [10, 70], which is shown in Effigy3. Dilation remains the first choice equally the least invasive approach with a depression complication rate (0.001–0.040 %) [69]. If the selected approach is not sufficient a adjacent step in the algorithm should be discussed with the patient, i.e., dilation with steroids, incisional therapy for selected strictures, or stent placement. If still refractory, self-bougienage can exist proposed to patients with a stenosis in the proximal esophagus [71, 72]. An ultimate pace in the management of (refractory), benign esophageal strictures includes surgery, taking into account that even afterward a surgical solution the risk of stricture germination remains [24–26]. In our experience, the majority of benign strictures can exist managed by non-surgical means.
Recommended treatment scheme for patients with benign esophageal stricture.
Randomized trials are needed to determine the optimal handling strategy in patients with refractory and recurrent beneficial esophageal strictures. One such trial includes a comparison between Savary or balloon dilation therapy and stent placement, either a fully covered SEMS or biodegradable stent, to determine whether stent placement could be positioned at an earlier stage in the treatment algorithm. Furthermore, biodegradable stents should be compared with fully covered stent designs (every bit discussed before). Finally, the use of a (locally practical) treatment aiming to improve oxygenation (anastomotic strictures), and/or to reduce the inflammatory procedure in strictures, could be an important step.
Conclusion
The treatment of refractory beneficial esophageal strictures remains a challenge for clinicians. Dilation of the stricture with Savary or balloon remains the first pace. Dilation combined with intra lesional injections with steroids tin can be considered for peptic stenosis, while incisional therapy is plant to be effective for Schatzki rings and anastomotic strictures. After failure of these therapeutic options stent placement tin can be considered. A last footstep includes cocky bougienage or surgery. Following this treatment algorithm means that most patients with a difficult to treat esophageal stricture can be managed without an invasive surgical procedure.
Compliance with Ethics Guidelines
Disharmonize of Interest
Petra G.A. van Boeckel declares that she has no conflict of interest.
Peter D. Siersema declares that he has no conflict of interest.
Human being and Animal Rights and Informed Consent
This article does not comprise any studies with human or animal subjects performed by any of the authors.
Footnotes
This article is part of the Topical Collection on Esophagus
References and Recommended Reading
Papers of particular interest, published recently, accept been highlighted as: • Of importance •• Of major importance
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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4328110/
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