PROBLEMATIC ESOPHAGEAL STRICTURES

Abstract

Purpose: Self-expandable metal stents (SEMS) are routinely used to palliate dysphagia in the patients with unresectable esophageal carcinoma. However, proximally located malignant strictures and benign strictures refractory to endoscopic dilations remain problematic due to the potential for tracheal compression, foreign body sensation and tissue responses leading to inflammation, necrosis, and ulceration, with eventual fibrosis. The hyperplastic tissue reaction may progress to worsening dysphagia and restenosis. The recently developed self-expandable silicone stents (SESS) have demonstrated some advantages over SEMS because of their better biocompatibility and may circumvent these problems. Case reports: We present two cases with refractory benign stricture and proximally located malignant stricture which were treated with SESS. The first case is an 81-year-old man who underwent an Ivor-Lewis esophagogas-trectomy for distal esophageal adenocarcinoma. Four months after, he developed benign circumferential anastomotic stricture requiring frequent endoscopic dilations every 3–4 weeks. Given its benign nature and long life expectancy, SESS was considered over SEMS to avoid potential complications from long-term implantation. He was followed more than 1 year with complete resolution of dysphagia and no complication. The second case is a 53-year-old man who underwent an Ivor-Lewis esophagogastrectomy for proximally located squamous cell carcinoma (SCC). One year later, dysphagia recurred and progressed to an inability to handle oral secretions. Recurrence of SCC was found at 22 cm from the incisors with liver metastasis. Given the location, SESS was chosen to avoid tracheal compression and foreign body sensation from SEMS. The proximal end was located at 20 cm from the incisors, just below upper esophageal sphincter (UES). He was followed for 3 months without recurrence of symptoms. Discussions: We demonstrate our initial experience in using SESS in the treatment of refractory benign stricture and proximally located malignant stricture near UES. These cases represent some of the more difficult-to-treat esophageal strictures. With the inert property resulting in less tissue reaction, SESS seem to be more appropriate device to use in these situations compared to SEMS. No tissue reaction or recurrent symptoms in our patients with more than 1 year follow-up period confirm the feasibility and safety of long-term SESS implantation.