Topical Mitomycin Application Can Improve the Outcome of Recurrrent Benign Esophageal Strictures

Abstract

Introduction: Recurrent benign esophageal strictures represent a subset of complex esophageal strictures. Application of Mitomycin C (MMC) was shown recently in small case series to improve the outcome of complex benign strictures; however these studies were mainly limited to pediatric populations. The aim of this study is to investigate and update our outcome of topical MMC application for recurrent benign esophageal strictures which failed prior standard dilation.Figure 1Figure 2Methods: Prospectively collected data was abstracted by retrospective chart review of all patients who underwent topical MMC application for recurrent benign esophageal strictures between 2008 and 2015. All patients underwent balloon dilation followed by topical MMC application over 2-3 minutes (0.4mg/ml). The primary endpoint was to demonstrate an improvement in the periodic dilation index (PDI) and dysphagia score. The secondary endpoint was to determine complication rates. Results: 12 patients (mean age 70 years, SD 11.6; 42% male) with 5 anastomotic (41%), 2 radiationinduced (17%), 2 combined anastomotic and radiation-induced (17%), 2 caustic (17%), and 1 peptic (8%) stricture were included. Strictures had a mean length of 13mm (SD 6.7) and mean diameter of 8.1mm (SD 2.6). Prior to topical MMC application, all patients required an average of 8.5 dilations (SD 5) over 6.7 months (SD 3.7). Additionally, patients had a median dysphagia score of 3, SD 1 (Table 1). At the index dilation with MMC application, strictures were dilated to a mean diameter of 14.1mm (SD 2.2). One patient had concomitant stent placement and 6 patients underwent additional needle knife incision prior to balloon dilation. During follow up (10 months, SD 8.7) 10 patients developed recurrent stricture verified by EGD, however PDI improved from 1.5 (SD 0.9) to PDI 0.3 (SD 0.3) following MMC application (p=0.022). In addition to dilation patients with recurrent strictures underwent repeat MMC application or incisional therapy or stent placement (Table 2). The dysphagia score decreased from a median of 3 to 2 (p=0.046). One patient developed vocal cord paralysis following MMC application; however it was considered unrelated to treatment. No other complications were recorded. Conclusion: MMC application in conjunction with dilation decreases the frequency of esophageal dilations in patients with highly recurrent benign esophageal strictures, although strictures continue to form. Not all patients benefit from MMC treatment, as 2 patients required esophagectomy.