Esophageal self-dilations as a treatment for refractory benign esophageal strictures

Abstract

It was with great interest that we read the study by Repici et al1Repici 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 (48) Google Scholar on refractory benign esophageal strictures (RBES) and the accompanying editorial by Dr Siersema.2Siersema P.D. Treatment of refractory benign esophageal strictures: it is all about being “patient”.Gastrointest Endosc. 2016; 84: 229-231Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar This study should be commended for reporting a long-term follow-up in RBES treated with endoscopic dilation, self-expandable metallic stents, biodegradable stents, and steroid injections. The study was also comprehensive in analyzing the treatment effect on strictures that differ in location, length, and cause. Ultimately, the study found only a 31.4% rate of clinical resolution for patients with RBES; patients treated with endoprostheses had even a lower rate of successful outcome. It was concluded that RBES presents a unique therapeutic challenge for which currently available endoscopic therapies have not been optimally effective. We were surprised, however, that esophageal self-dilation was neither offered as therapy in the study nor mentioned as a potential therapy for RBES by the authors. This highly effective therapy has been described as a treatment for RBES since 1984.3Grobe J.L. Kozarek R.A. Sanowski R.A. Self-bougienage in the treatment of benign esophageal stricture.J Clin Gastroenterol. 1984; 6: 109-112Crossref PubMed Scopus (25) Google Scholar After endoscopic dilation, patients are taught to pass a bougie dilator through their strictures, repeating this routine at home with the goal of maintaining patency. The largest study to date was a retrospective review of 32 patients from our center by Dzeletovic et al.4Dzeletovic I. Fleischer D.E. Crowell M.D. et al.Self-dilation as a treatment for resistant, benign esophageal strictures.Dig Dis Sci. 2013; 58: 3218-3223Crossref PubMed Scopus (18) Google Scholar The study found an astounding difference in the average number of EGD dilations per year before and after the initiation of self-dilation: 21.7 versus 1.0, respectively (P < .0001), with a reported 90% success rate in the treatment of RBES. No adverse events were observed. We use this strategy routinely in our clinical practice with excellent outcomes. Esophageal self-dilation appears to be an underused tool in the treatment of RBES, and it warrants both mention and further study. All authors disclosed no financial relationships relevant to this publication. Natural history and management of refractory benign esophageal stricturesGastrointestinal EndoscopyVol. 84Issue 2PreviewThe natural history of refractory benign esophageal strictures (RBES) is unclear, and surgery or percutaneous endoscopic gastrostomy (PEG) may be the only viable long-term options. The aim of the present study was to assess the long-term outcomes of patients with RBES. Full-Text PDF Treatment of refractory benign esophageal strictures: it is all about being “patient”Gastrointestinal EndoscopyVol. 84Issue 2PreviewBenign esophageal strictures are seen frequently and are caused by a variety of esophageal injuries, such as gastroesophageal reflux, radiotherapy, corrosive substance ingestion, eosinophilic esophagitis, after esophageal resection, and as an adverse event of ablation. Most benign strictures are effectively treated by bougie or balloon dilation, which usually takes 1 or only a few sessions.1 However, in a small subset of patients (<10%), at least 5 dilations to at least 14 mm fail to establish adequate and persistent food passage. Full-Text PDF