Abstract ID: 100Self-Dilatation for the Management of Refractory Benign Oesophageal Strictures: Outcomes from the Largest European Tertiary Centre Experience to Date

Introduction: Benign esophageal strictures can result from long-standing GERD, ablative or radiation therapy, caustic ingestion and etc. Management of strictures could be very challenging. We describe a case of a refractory esophageal stricture with aim to focus on management challenges. Case Description/Methods: A 36-year-old Indian female with a history of esophageal strictures secondary to caustic ingestion present to our GI clinic with complaints of worsening dysphagia to solids. She underwent multiple serial endoscopies with dilatation at an outside facility and subsequently was performing self-dilatation with bougie dilators, until no further relief of her symptoms. An esophagram revealed a narrow caliber mid and distal esophagus with 3 prominent stricture points. The proximal stricture could not be traversed on initial endoscopy with 9.9 mm gastroscope, therefore a 4.9 mm bronchoscope was used to assess the size and location of the 3 esophageal strictures which were noted at 25 cm, 30 cm and 35 cm from incisors. Serial dilations were performed with a CRE balloon dilator and triamcinolone injection at the refractory stricture site post dilation. The esophageal strictures were able to be dilated with serial dilatations and the gastroscope was able to traverse all 3 strictures without difficulty and patient experienced symptomatic relief. Patient was counseled regarding high risk of perforation with subsequent dilatation and given surgical consultations for second opinion and alternative management options. Discussion: Late management of caustic strictures makes dilatation more complex owing to fibrosis in esophageal wall. Perforation rates for caustic strictures is higher than standard benign stricture dilatation with anything from 0.4 up to 32% recorded in the literature. Refractory strictures are more common in caustic ingestion and the management has been reported with intralesional steroid injection or topical mitomycin C at the time of dilatation, and temporary stent placement. Prior to dilatation one must consider the following prior to endoscopically dilating such as etiology of stricture, degree of patient’s dysphagia, length, tortuosity and luminal diameter of the stricture. Our patient’s strictures were refractory to dilatation and intralesional steroid use. Stent placement is technically not feasible given different size and diameter of strictures as it enhances risk of perforation. Surgery although a high-risk approach but remains as curative resort for such cases.

A few comments about benign esophageal strictures

Background: Esophageal stricture is an abnormal narrowing of the esophageal lumen, resulting in dysphagia. Despite its rarity, this condition could be caused by various etiologies, including Steven-Johnson Syndrome (SJS). In some cases, stricture could recur, which complicates the management. This case report presented a rare case of refractory esophageal stricture in children with Steven-Johnson Syndrome. Case: A 5-years-old boy with a prior history of SJS presented with dysphagia for one month. The patient experienced choking, blood vomiting, stomatitis, swelling on the lips, and difficulty in swallowing solid food. Barium meal and EGD test confirmed the diagnosis of esophageal strictures. The patient then underwent dilation using bougie dilator. However, he continued to experience dysphagia, resulting in a total of 15 serial dilation sessions. Discussion: Esophageal dysphagia is observed in patients who experience difficulty swallowing solid food. SJS can contribute to the development of esophageal dysphagia by causing inflammation of the esophageal mucosa, resulting in lesions and strictures. In patients with esophageal strictures, two types of dilation methods are available: bougie dilator with wire guidance (Savary-Gilliard) and balloon dilator, with the current consensus for dilation procedures supporting the rule of three. For patients with refractory strictures, other modalities such as mitomycin-C injection and stent placement are also available. Esophageal replacement surgery is considered as the last resort for refractory stricture patients who have not responded to previous treatments. Conclusion: Steven-Johnson Syndrome is a rare cause of esophageal strictures. The management of refractory esophageal stricture requires a comprehensive subspecialty care and long-term monitoring.

Introduction Management of refractory benign esophageal strictures remains a challenge for clinicians. Randomized trials are needed to determine the optimal treatment strategy for patients with refractory and recurrent benign postcorrosive esophageal strictures. Aim The aim of this study was to evaluate the management of refractory postcorrosive esophageal stricture by fully covered self-expandable metal stent (SEMS) and also the optimum time for stent placement. Patients and methods This study was conducted in GIT Endoscopy Unit in Qena University Hospital from June 2014 to June 2016 in collaboration with General Surgery, Cardiothoracic Surgery, and Tropical Medicine Departments, Qena Faculty of Medicine, South Valley University. Eleven patients with refractory postcorrosive esophageal strictures were managed by dilations and fully covered SEMS placement. Results Successful stent placement was done in all patients. The mean follow-up time was 22 (12–26) months. Stent migrations occurred in two patients, and minor bleeding in one patient, with no mortality and no recurrences in dysphagia during the follow-up period. Conclusion Fully covered SEMSs are safe and effective in treatment of postcorrosive esophageal stricture, with optimum duration for stent placement range from 6 to 8 weeks.

The endoscopic management of oesophageal strictures

Endoscopic submucosal dissection (ESD) is accepted as a standard therapeutic technique for superficial esophageal neoplasms (SENs). However, esophageal refractory stricture is a serious adverse event secondary to extensive ESD (≥ 3/4 of the luminal circumference). This retrospective study aimed to investigate the risk factors for refractory postoperative stricture after extensive ESD. The data of patients who underwent esophageal ESD at the Endoscopy Center of Changhai Hospital were reviewed between January 2011 and September 2019. Risk factors for postoperative refractory stricture [≥ 6 sessions of endoscopic balloon dilation (EBD)] after extensive ESD were then identified using univariate analysis and multivariate logistic regression analysis. A total of 69 SENs in 67 patients treated by extensive ESD were enrolled in this study. The refractory stricture incidence was 62% (43/69). Significant differences between non-refractory stricture group and refractory stricture group were observed in depth of infiltration (m1or m2/m3 or sm1:20/6 vs. 17/26, P = 0.003), longitudinal resection length (< 50mm/ ≥ 50mm:19/7 vs. 10/33, P < 0.001), circumferential range (3/4~ < 1/1:20/6 vs. 19/24, P = 0.008), muscular injury (NO/YES:18/8 vs. 19/24, P = 0.043), and clip number (≤ 5/ > 5:15/11 vs. 12/31, P = 0.014). Multivariate analysis revealed that longitudinal resection length ≥ 50mm (odds ratio [OR] 11.099, 95% confidence interval [CI] 2.620-47.019), depth of infiltration above m2 (OR 5.716, 95%CI 1.324-24.672) and muscular injury happened (OR 4.431, 95%CI 1.052-18.659) were independent risk factors for refractory stricture. In addition, the EBD sessions for treatment of refractory stricture was related to longitudinal resection length (relation coefficient γ = 0.528; P <0.05). The longitudinal resection length, depth of tumor infiltration and muscular injury are the reliable risk factors for esophageal refractory stricture after extensive ESD.

Background and study aims Endoscopic dilation is first-line management for benign esophageal strictures (ES). Depth of involvement of the esophageal wall on endosonography using high frequency mini-probe (EUS-M) may predict response to dilation. This study evaluated EUS-M characteristics to predict response of ES to endoscopic dilation.Patients and methods EUS-M was used to measure the total esophageal wall thickness (EWT), involved EWT, percentage of involved wall and layers of wall involved in consecutive patients of benign ES. After a maximum of five sessions of endoscopic dilation, the cohort was divided into responders and refractory strictures. EUS-M characteristics were compared for underlying etiology as also between responders and refractory strictures.Results Of the 30 strictures (17 females, age: 47.16 ± 15.86 yrs.) 13 were anastomotic, eight corrosive, seven peptic and 2 others. Corrosive strictures had the highest involved EWT and percentage of involved wall (3.51 ± 1.36 mm; 76.38 %) followed by anastomotic (2.73 ± 1.7 mm; 65.54 %) and peptic (1.39 ± 0.62 mm; 40.71 %) (P = 0.026 and 0.021 respectively). After five dilations, 22 were classified as responders and eight as refractory. Wall involvement > 70 % had a greater proportion of refractory strictures (P = 0.019). Strictures with involved EWT of ≥ 2.85 mm required more dilations (P = 0.011). Fewer dilations were required for stricture resolution with only mucosal involvement compared to deeper involvement such as submucosa andmuscularis propria(2.14 vs. 5.80;P = 0.001).Conclusion EUS-M evaluation shows that corrosive and anastomotic strictures have greater depth of involvement compared to peptic strictures. Depth of esophageal wall involvement in a stricture predicts response to dilation.

We aim to evaluate the efficacy and safety of endoscopic radial incision (ERI) versus endoscopic balloon dilation (EBD) treatment of naïve, recurrent, and refractory benign esophageal anastomotic strictures. One hundred and one ERI, 145 EBD, and 42 ERI combined with EBD sessions were performed in 136 consecutive patients with benign esophageal anastomotic stricture after esophagectomy at Zhongshan Hospital from January 2016 to August 2021. Baseline characteristics, operational procedures, and clinical outcomes data were retrospectively evaluated. Parameters and recurrence-free survival (RFS) were compared between ERI and EBD in patients with naïve or recurrent or refractory strictures. Risk factors for re-stricture after ERI were identified using univariate and multivariate analyses. Twenty-nine ERI versus 68 EBD sessions were performed for naïve stricture, 26 ERI versus 60 EBD for recurrent strictures, and 46 ERI versus 17 EBD for refractory stricture. With comparable baseline characteristics, RFS was greater in the ERI than the EBD group for naïve strictures (P=0.0449). The ERI group had a lower 12-month re-stricture rate than the EBD group (37.9% vs 61.8%, P=0.0309) and a more prolonged patency time (181.5±263.1 vs 74.5±82.0, P=0.0233). Between the two interventions, recurrent and refractory strictures had similar RFS (P=0.0598; P=0.7668). Multivariate analysis revealed initial ERI treatment was an independent predictive factor for lower re-stricture risk after ERI intervention (odds ratio=0.047, P=0.001). Few adverse events were observed after ERI or EBD (3.0% vs 2.1%, P=0.6918). ERI is associated with lower re-stricture rates with better patency and RFS compared with EBD for naive strictures.

Enteral stents: from esophagus to colon

Esophageal strictures are a problem frequently encountered by gastroenterologists. Dilation has been the customary treatment for benign esophageal strictures, and dilation techniques have advanced over the years. Depending on their characteristics and the response to treatment, esophageal strictures can be classified into two types: 1, simple (Schatzki rings, webs, peptic injury, and following sclerotherapy) - these are easily amenable to dilation, with a low recurrence rate after initial treatment; and 2, complex (caused by caustic ingestion, radiation injury, anastomotic strictures, and photodynamic therapy) - these are difficult to dilate and are associated with higher recurrence rates. Refractory strictures are those in which it is not possible to relieve the anatomic restriction successfully up to a diameter of 14 mm over five sessions at 2-weekly intervals, due to cicatricial luminal compromise or fibrosis; and recurrent strictures are those in which it is not possible to maintain a satisfactory luminal diameter for 4 wk once the target diameter of 14 mm has been achieved. There are no standard recommendations for the management of refractory strictures. The various techniques used include intralesional steroid injection combined with dilation; endoscopic incisional therapy, with or without dilation; placement of self-expanding metal stents, Polyflex stents, or biodegradable stents; self-bougienage; and endoscopic surgery. This review discusses the indications, technique, results, and complications of the use of intralesional steroid injections combined with dilation and endoscopic incisional therapy with dilation in refractory strictures.

Purpose: Esophageal dilation is a safe and effective initial therapeutic option for the treatment of benign strictures of the esophagus. Intralesional steroid therapy, electrosurgical incision, or stent placement can be used for specific patients with refractory benign esophageal stricture. However, in some patients with refractory esophageal stricture, these therapeutic modalities may not be effective. The purpose of this study is to evaluate oral fluticasone inhaler as a therapeutic modality for management of refractory peptic esophageal stricture. Methods: Patients with refractory peptic esophageal stricture (after eosinophilic esophagitis were ruled out) were enrolled in this study. As EGD with intralesional steroid injection must be performed at intervals, we prescribed patients oral inhalation therapy with fluticasone for use between dilations and compared its effect with that of intralesional steroid injection on frequency of esophageal dilation. To avoid any possible bias, oral steroid inhaler was given alternatively at each session of esophageal dilation and intralesional steroid injection, as showed in this flow diagram: A__B__A__B__A__B__A___B__. (A: esophageal dilation + intralesional lesion steroid injection; B: esophageal dilation + intralesional lesion steroid injection + oral steroid inhaler). We analyzed the data from the first 6 sessions. Results: With dilation only, patients required subsequent dilation about once a month. When intralesional steroid injection was performed in addition to dilation, patients required dilations about every 2 months. Use of inhaled oral steroids significantly decreased the frequency of esophageal dilations (see Table). There were no side effects with the use of fluticasone during this period.Table: [54] Days elapsed between esophageal dilationsConclusion: Oral steroid inhaler therapy is more effective than intralesional steroid injection in augmenting the effect of esophageal dilation in patients with refractory peptic esophageal stricture. To our knowledge, this is the first report of using orally inhaled steroid in treatment of refractory peptic esophageal stricture. A multiple center study is needed to investigate this novel observation further.

Most cases of esophageal benign stricture can be successfully managed with dilation; however, refractory stricture is often unresponsive to repeated dilation. Endoscopic incision is a novel technique for treating refractory esophageal stricture, although recurrence is noted in patients with stricture measuring greater than 1.5 cm, thus requiring the use of repeated incisions and/or preventive dilation. We herein report a case of refractory esophageal stricture treated with an endoscopic incision and esophageal stenting, which successfully allowed the gastrostomy tube to be removed.

Refractory esophageal anastomotic strictures are a frequent challenge for endoscopists. The current therapeutic strategies have a significant restenosis rate, and patients usually require repeated sessions and suffer from dysphagia. Therefore, we propose a modified method named endoscopic stricturotomy (ES) to treat refractory esophageal anastomotic strictures. The patients diagnosed with refractory esophageal anastomotic strictures were enrolled in the cohort study. The method of ES is to incise longitudinally only a single strip of mucosa at the most prominent part of fibrotic scar and completely cut fibrotic tissues under the mucosa. The primary endpoint was the times of endoscopic therapies. The secondary endpoints include the effective rate, success rate, recurrence rate, endoscopic treatment intervals, complications, length of hospital stay, and surgical cost. The patients were followed up for at least 6months after ES. The median anastomotic diameter of 12 patients was 2mm (range 1 to 4mm). Dysphagia were dramatically relieved in all patients (dysphagia grade from 3 to 1), the effective rate was 100%. During the follow-up, the 12 patients received a total number of 38 sessions, and the median number of ES sessions was 2.5 (1-9), and the success rate were 83%. Nine of the patients (75%) developed restenosis during follow-up, with a median interval of 38days (15-315days). No complications occurred during treatment and following up. The median hospital stay was 2days (2-2.9days), and the hospitalization costs was 3887.4 RMB (3632.8 RMB-4116.9 RMB). ES seems to be an effective treatment modality for refractory esophageal anastomotic strictures. Large prospective clinical trials are needed to confirm its utility and its place in the management of refractory esophageal anastomotic strictures (ChiCTR2000032997).

Temporary placement of an expandable polyester silicone-covered stent for treatment of refractory benign esophageal strictures

There is no clear consensus concerning the best endoscopic treatment of benign refractory esophageal strictures due to caustic ingestion. Different procedures are currently used: frequent multiple dilations, retrievable self-expanding stent, nasogastric intubation and surgery. We describe a new technique to fix a suspended esophageal silicone prosthesis to the neck in benign esophageal strictures; this permits us to avoid the frequent risk of migration of the expandable metallic or plastic stents. Under general anesthesia a rigid esophagoscope was placed in the patient's hypopharynx. Using transillumination from the optical device, the patient's neck was pierced with a needle. A n.0 monofilament surgical wire was pushed into the needle, grasped by a standard foreign body forceps through the esophagoscope and pulled out of the mouth (as in percutaneous endoscopic gastrostomy procedure). After tying the proximal end of the silicone prosthesis with the wire, it was placed through the strictures under endoscopic view. This procedure was successfully utilized in four patients suffering from benign refractory esophageal strictures due to caustic ingestion. The prosthesis and its suspension from the neck were well-tolerated until removal (mean duration 4 months). A postoperative transitory myositis was diagnosed in only one patient. One of the most frequent complications of esophageal prostheses in refractory esophageal strictures due to caustic ingestion is distal migration. Different solutions were proposed. For example the suspension of a wire coming from the nose and then fixed behind the ear. This solution is not considered optimal because of patient complaints and moreover the aesthetic aspect is compromised. The procedure we utilized in four patients utilized the setting of a silicone tube hanging from the neck in a way similar to that of endoscopic pharyngostomy. This solution is a valid alternative both for quality of life and for functional results.