A few comments about benign esophageal strictures

Abstract

We read with great interest the article by Vermeulen et al1Vermeulen B.D. de Zwart M. Sijben J. et al.Risk factors and clinical outcomes of endoscopic dilation in benign esophageal strictures: a long-term follow-up study.Gastrointest Endosc. 2020; 91: 1058-1066Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar in which the authors discussed endoscopic dilation for benign esophageal strictures. However, we do have some concerns. Our first concern is the definition of refractory benign esophageal stricture (BES). In previous studies, we found that the Kochman definition may not be suitable for observational studies unless data were collected prospectively. Dilation sessions are easier to obtain, so many studies choose the number of sessions as standard, such as ≥6 sessions of endoscopic dilation (ED).2Tang J. Kong F. Li J. et al.Independent risk factors for esophageal refractory stricture after extensive endoscopic submucosal dissection.Surg Endosc. 2021; 35: 3618-3627Crossref Scopus (5) Google Scholar,3Sami S.S. Haboubi H.N. Ang Y. et al.UK guidelines on oesophageal dilatation in clinical practice.Gut. 2018; 67: 1000-1023Crossref PubMed Scopus (55) Google Scholar Because no clear definition is mentioned, we are curious about the standard of refractory BES in this retrospective study. The authors reported the number and times of endoscopic dilation sessions during 2 years to illustrate the relationship between endoscopic dilation and different causes of BES. Our further concerns are about this approach. First, the time interval for stent placement should be considered. In our previous study, the stents were placed 6 times in 2 patients with refractory BES patients in only 4 ED sessions.4Lu Q. Yan H. Wang Y. et al.The role of endoscopic dilation and stents in refractory benign esophageal strictures: a retrospective analysis.BMC Gastroenterol. 2019; 19: 95Crossref Scopus (6) Google Scholar The use of stents can affect the analysis of efficacy of endoscopic dilation. Second, the dysphagia-free period is considered a better proxy for survival quality, rather than the time from first to last endoscopic dilation.5Repici A. Small A.J. Mendelson A. et al.Natural history and management of refractory benign esophageal strictures.Gastrointest Endosc. 2016; 84: 222-228Abstract Full Text Full Text PDF PubMed Scopus (45) Google Scholar Although the time from first to last ED sessions was long, the dilation could be considered effective only when the dysphagia-free period increases per endoscopic therapy. Finally, the authors included 390 patients with postesophagectomy anastomotic strictures in the analysis of risk factors for refractory strictures. However, the total number of patients with refractory BES was not provided. The conclusion that dilation at least to ≤16 mm to reduce the number of ED sessions may therefore be hardly applied in strictures of other causes, such as strictures after endoscopic submucosal dissection of superficial esophageal neoplasms. All authors disclosed no financial relationships. Risk factors and clinical outcomes of endoscopic dilation in benign esophageal strictures: a long-term follow-up studyGastrointestinal EndoscopyVol. 91Issue 5PreviewEndoscopic dilation (ED) is still the mainstay of therapeutic management of benign esophageal strictures (BESs). This study aimed to establish risk factors for refractory BESs and assess long-term clinical outcomes of ED. Full-Text PDF