Benign Esophageal Strictures Research Articles

Side-overlap esophagogastric tube (SO-EG) reconstruction after minimally invasive Ivor Lewis esophagectomy or laparoscopic proximal gastrectomy for cancer of the esophagogastric junction.

Both laparoscopic proximal gastrectomy with lower esophagectomy (extended LPG) and minimally invasive Ivor Lewis esophagectomy (MIILE) are acceptable treatments for adenocarcinoma of the esophagogastric junction (AEG), but the optimal reconstruction technique for mediastinal esophagogastrostomy (one that provides adequate reflux prevention) has not been established. We devised a novel side-overlap esophagogastric-tube (SO-EG) reconstruction. We performed a retrospective review of patient records after LPG or MIILE. In each patient, we created a 3-cm wide gastric tube, overlapping the esophagus by 5 cm. A linear stapler was inserted into the left side of the esophageal stump and the anterior gastric wall along the greater curvature. The entry hole was closed to make a slit-like anastomosis, and the right side of the esophageal wall was fixed to the anterior gastric wall. Ten consecutive patients underwent this procedure between June 2020 and July 2021. Five patients had Siewert type II AEG: 4 with lower thoracic esophageal cancer and 1 with benign lower esophageal stenosis. A total of 3 patients underwent extended LPG, and 7 underwent MIILE. The median operative time was 352 min (range, 221-556 min). The postoperative course was uneventful in 9 patients; a single patient developed pneumonia. Seven patients underwent follow-up endoscopy at 6 months. One patient with anastomotic stenosis and 2 with mild reflux esophagitis were treated conservatively. Our novel SO-EG reconstruction is simple and feasible, with acceptable results for preventing reflux esophagitis. This technique can be performed with either extended LPG or MIILE.

S2071 Refractory Benign Esophageal Stricture - Management Dilemma

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.

Integrative analysis of miRNA-mRNA expression profiles in esophageal fibrosis after ESD.

The incidence of esophageal fibrosis and benign esophageal stricture (BES) has increased in recent years due to the curative therapy for early-stage esophageal carcinoma, including partial esophagectomy and esophageal endoscopic submucosal dissection (ESD). The aim of the present study was to identify key genes and associated pathways of esophageal fibrosis after the ESD procedure. During the esophageal ESD procedure, the esophageal tissue in the remaining submucosal layer, referred to as normal esophageal (NE) tissue, was collected, and 1 week thereafter, post-operative esophageal (PE) tissue was obtained. High-throughput sequencing was used to identify dysregulated microRNAs (miRNAs/miRs) between NE and PE tissues. According to the differentially expressed (DE) miRNAs, putative target genes were predicted. Gene Ontology, Kyoto Encyclopedia of Genes and Genomes enrichment analysis and DEmiRNA interaction network analysis were performed. Reverse transcription-quantitative PCR (RT-qPCR) was performed to validate the RNA-sequencing results. A total of 199 miRNAs were determined to be DE between NE and PE tissues. Compared with the expression in the NE group, 83 miRNAs were significantly upregulated, while 116 miRNAs were significantly downregulated. According to these DE miRNAs, forkhead box O1 (FOXO1), paired box 6 (PAX6), phosphatidylinositol-4,5-bisphosphate 3-kinase catalytic subunit alpha (PIK3CA) and adrenoceptor β1 (ADRB1) were DE genes regulated by five DE miRNAs, including miR-223-3p, miR-142-5p, miR-582-5p, miR-21-3p and miR-218-5p. The results suggested that certain pathways were markedly dysregulated, including FOXO, MAPK, AMP-activated protein kinase and signaling pathways regulating the pluripotency of stem cells and proteoglycans in cancer. According to the RT-qPCR results, the expression levels of FOXO1, PAX6, ADRB1, miR-223-3p, miR-582-5p, miR-21-3p and miR-218-5p were consistent with the integrated analysis. In conclusion, FOXO1, PAX6, PIK3CA and ADRB1 may have a role in esophageal fibrosis, regulated by miR-223-3p, miR-142-5p, miR-582-5p, miR-21-3p and miR-218-5p. The present results provided an improved understanding of the changes in the microenvironment during the process of esophageal fibrosis, as well as novel potential targets for the treatment of esophageal fibrosis and BES.

THERAPEUTIC TACTICS FOR PEPTIC STRICTURES OF THE ESOPHAGUS. LITERATURE REVIEW

The work is based on the analysis of literature data devoted to the choice of treatment for peptic esophageal strictures. The main goal of this review is to identify treatment tactics for patients with stenosing reflux esophagitis. Researchers point out that the main causes of GERD are a decrease in pressure in the lower esophageal sphincter, the action of the damaging properties of the refluctant. Untimely treatment of GERD can lead to complications such as peptic stricture, Barrett's esophagus. The appearance of GERD stricture is most often promoted by: persistent heartburn after bougienage, erosion of the lower third of the esophagus, shortening of the II degree esophagus, and inadequate antisecretory therapy.Various methods of treatment at all stages of the appearance of peptic stricture are presented, depending on the degree of dysphagia and the length of the stricture, the use of adequate conservative therapy regimens for PPIs, bougienage, as well as a description of various methods of antireflux operations. Endoscopic dilation is the first treatment option for all symptomatic benign esophageal strictures. There are treatments for benign refractory esophageal strictures such as endoscopic dilatation with intraluminal steroid injection, endoscopic postoperative therapy or stricturoplasty, esophageal stenting, self-bougienage, as well as surgery - antireflux surgery, esophagectomy with replacement of the esophagus by the stomach or colon [1].The main goal in the treatment of peptic esophageal strictures, according to most authors, is to eliminate the progression of GERD, conduct bougienage or balloon dilatation, and select the optimal antireflux surgery. Treatment for peptic strictures should minimize the risk of re-stricture of the esophagus.

New therapies for esophageal strictures in children.

The present review aims at describing recent advances in therapeutic strategies for the treatment of benign esophageal strictures in children. We discuss current knowledge and practice on esophageal dilations, which are still the mainstream of treatment. We present new evidence about adjuvant treatments for recurrent and refractory strictures, including endoscopic incisional therapy, esophageal stenting, intralesional or topical mytomicin C and intralesional, systemic or topical steroids. Current evidence on esophageal dilations is not sufficient to establish superiority of one of the available techniques, especially the use of balloon or bougie dilators, but a prospective international cohort study on anastomotic stricture in esophageal atresia is underway to address this issue. Recurrent and refractory strictures still represent a challenge, since none of the adjuvant pharmacological and mechanical interventions has shown to be enough feasible, effective and safe to revolutionize clinical practice. In the last couple of years, several encouraging results have been published on management of esophageal strictures in children. Further research is needed, hopefully directed toward secure, easily reproducible and minimally invasive measures.

A case report of endovascular management of delayed upper gastrointestinal bleeding after open esophagectomy for a benign esophageal stricture.

IntroductionDelayed upper gastrointestinal (GI) bleeding is a rare complication of esophagectomy and can be difficult to manage.PresentationA 76-year-old female represented 17 days post open esophagectomy with an unstable upper GI bleed. When control could not be achieved endoscopically, she was transferred to the Radiology Department where a triphasic CT angiogram confirmed active contrast extravasation into the gastric tube. She proceeded to the Interventional Radiology suite where a thoracic angiogram revealed an active arterial bleed from a branch of the thyrocervical trunk. The bleeding vessel was successfully embolised with coils and haemostasis was achieved.DiscussionManagement options for upper GI bleeding post esophagectomy include medical, endoscopic and endovascular approaches.ConclusionOur case represents a rare example of delayed bleeding into a gastric conduit post open esophagectomy for a benign stricture. The case reinforces:a)The management options available for controlling an acute upper GI bleed.b)The value of a CT angiogram in identifying the site of bleeding and mapping the relevant vascular anatomy prior to embolization.c)How endovascular embolization is a minimally invasive and potentially life-saving intervention for bleeds that cannot be controlled endoscopically.

A patient-like swine model of gastrointestinal fibrotic strictures for advancing therapeutics

Gastrointestinal (GI) strictures are difficult to treat in a variety of disease processes. Currently, there are no Food and Drug Administration (FDA) approved drugs for fibrosis in the GI tract. One of the limitations to developing anti-fibrotic drugs has been the lack of a reproducible, relatively inexpensive, large animal model of fibrosis-driven luminal stricture. This study aimed to evaluate the feasibility of creating a model of luminal GI tract strictures. Argon plasma coagulation (APC) was applied circumferentially in porcine esophagi in vivo. Follow-up endoscopy (EGD) was performed at day 14 after the APC procedure. We noted high grade, benign esophageal strictures (n = 8). All 8 strictures resembled luminal GI fibrotic strictures in humans. These strictures were characterized, and then successfully dilated. A repeat EGD was performed at day 28 after the APC procedure and found evidence of recurrent, high grade, fibrotic, strictures at all 8 locations in all pigs. Pigs were sacrificed and gross and histologic analyses performed. Histologic examination showed extensive fibrosis, with significant collagen deposition in the lamina propria and submucosa, as well as extensive inflammatory infiltrates within the strictures. In conclusion, we report a porcine model of luminal GI fibrotic stricture that has the potential to assist with developing novel anti-fibrotic therapies as well as endoscopic techniques to address recurring fibrotic strictures in humans.

Outcome of dogs and cats with benign oesophageal strictures after balloon dilatation or stenting: 27 cases (2002-2019).

Acquired oesophageal strictures remain challenging to manage in canine and feline patients. The aims of this study were to describe the treatment, complications, short-term outcome and long-term follow-up of benign oesophageal strictures treated by balloon dilatation or stenting in dogs and cats and to describe adjunctive techniques to minimise the complication rate of stent placement. Retrospective analysis of medical records of dogs and cats with benign oesophageal stricture diagnosed under endoscopy between 2002 and 2019. Eighteen dogs and nine cats were included, representing 39 strictures. Balloon dilatation was used as first-line therapy, with a good outcome in 59% of cases. Stents were placed in eight cases due to stricture recurrence; 88% had a long-term satisfactory outcome. Short-term complications occurred in six of eight cases; migration and aberrant mucosal reaction were uncommon. In three cases, progressive mesh cutting during follow-up reduced discomfort and trichobezoars formation and improved long-term stent tolerance. Overall median survival time was 730 days. Long-term prognosis of balloon dilatation as a first-line therapy for esophageal strictures and of stenting as a rescue therapy was considered satisfactory. Although discomfort associated with stenting was frequent, tolerability might be improved by per-endoscopic adjunctive techniques.

Mitomycin C Inhibits Esophageal Fibrosis by Regulating Cell Apoptosis and Autophagy via lncRNA-ATB and miR-200b.

Benign esophageal strictures (BESs) frequently results from esophageal fibrosis. The transformation of fibroblasts into fibrocyte is an important cause of fibrosis. The treatment of fibrosis is challenging. Some previous studies have indicated the antifibrotic effect of mitomycin C (MMC). However, the mechanism of action of MMC and its optimal dose for treatment remains unclear. In the present study, the role of MMC in fighting fibrosis and its mechanism was investigated. Human esophageal fibroblast cells (HEFs)were treated without or with MMC, at 2, 5, 10 μg/ml, combining with mimic lncRNA-ATB, miR-200b inhibitor, rapamycin (RAPA), and 3-Methyladenine (3-MA). The cell viability, and cell apoptosis were evaluated. In addition, expression of apoptosis related proteins (caspase8 and caspase3), autophagy related proteins (LC3II and ATG5) and fibrosis related proteins (α-SMA collagen-1 and TGF-β) were also evaluated. Furthermore, autophagosome was observed by transmission electron microscope. Results showed that the expression of lncRNA-ATB was down-regulated and miR-200b was up-regulated after treated with MMC. And MMC induced cell apoptosis and inhibited cell autophagy. On the other hand, RAPA, mimic lncRNA-ATB and miR-200b inhibitor reduced fibrogenic effect of MMC on HEFs. Collectively, this study suggests that MMC inhibited esophageal fibrosis by regulating cell apoptosis and autophagy via downregulating lncRNA-ATB and upregulating miR-200b.

Self-dilatation of benign oesophageal strictures: a literature review.

Benign oesophageal strictures can have several aetiologies and often require serial endoscopic dilatation. The aim of this study was to review the existing literature regarding the efficacy of self-dilatation for benign oesophageal strictures. This study presents the results of a systematic review that was performed on the available literature using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Full-text articles from Medline, PubMed and Embase were used, as well as associated reference lists. This study systematically reviews the literature to present the efficacy and different outcome measurements associated with self-dilatation of benign oesophageal strictures. This study identified 13 articles with 274 participants. Self-dilatation for refractory benign oesophageal strictures is effective regardless of aetiology. It is well tolerated, safe and leads to lasting symptom resolution in the majority of patients.

Esophageal stenting for benign and malignant disease: European Society of Gastrointestinal Endoscopy (ESGE) Guideline – Update 2021

1: ESGE recommends placement of partially or fully covered self-expandable metal stents (SEMSs) for palliation of malignant dysphagia over laser therapy, photodynamic therapy, and esophageal bypass.Strong recommendation, high quality evidence. 2 : ESGE recommends brachytherapy as a valid alternative, alone or in addition to stenting, in esophageal cancer patients with malignant dysphagia and expected longer life expectancy.Strong recommendation, high quality evidence. 3: ESGE recommends esophageal SEMS placement for sealing malignant tracheoesophageal or bronchoesophageal fistulas. Strong recommendation, low quality evidence. 4 : ESGE does not recommend SEMS placement as a bridge to surgery or before preoperative chemoradiotherapy because it is associated with a high incidence of adverse events. Other options such as feeding tube placement are preferable. Strong recommendation, low quality evidence. 5: ESGE recommends against the use of SEMSs as first-line therapy for the management of benign esophageal strictures because of the potential for adverse events, the availability of alternative therapies, and their cost. Strong recommendation, low quality evidence. 6: ESGE suggests consideration of temporary placement of self-expandable stents for refractory benign esophageal strictures. Weak recommendation, moderate quality evidence. 7: ESGE suggests that fully covered SEMSs be preferred over partially covered SEMSs for the treatment of refractory benign esophageal strictures because of their very low risk of embedment and ease of removability. Weak recommendation, low quality evidence. 8: ESGE recommends the stent-in-stent technique to remove partially covered SEMSs that are embedded in the esophageal wall. Strong recommendation, low quality evidence. 9: ESGE recommends that temporary stent placement can be considered for the treatment of leaks, fistulas, and perforations. No specific type of stent can be recommended, and the duration of stenting should be individualized. Strong recommendation, low quality of evidence. 10 : ESGE recommends considering placement of a fully covered large-diameter SEMS for the treatment of esophageal variceal bleeding refractory to medical, endoscopic, and/or radiological therapy, or as initial therapy for patients with massive bleeding. Strong recommendation, moderate quality evidence.

Endoscopic Management of Refractory Benign Esophageal Strictures.

Benign esophageal strictures are commonly encountered in clinical practice. The principal etiologies of benign esophageal strictures include long term acid reflux, caustic injuries, eosinophilic esophagitis, anastomotic strictures or endoscopic therapy. Dysphagia is most prominently present in esophageal strictures along with a variety of other symptoms which depend on the stricture etiology. Benign esophageal strictures can be categorized into two groups: simple or complex depending on their structure. Most strictures can be treated successfully with endoscopic dilation by bougies or balloons dilators. In some cases, treatment is more challenging, involving a higher risk of the patient developing recurrent or refractory strictures. To improve symptoms in these patients, other endoscopic treatments such as steroid injection, incisional therapy and stent placement should be considered. In this manuscript, we provide a comprehensive review of the main treatment options currently available to manage recurrent benign esophageal strictures.

Appropriate duration of endoscopic dilation for postoperative benign esophageal strictures.

Benign esophageal strictures are a frequent complication after esophageal surgery or extensive endoscopic submucosal dissection. Endoscopic dilation is the preferred treatment in clinical practice. However, the allocation of time for each dilation is unclear. The aim of this study was to evaluate the appropriate duration of endoscopic dilation for benign esophageal strictures after esophageal surgery or endoscopic submucosal dissection. Patients with benign esophageal strictures after esophageal surgery or endoscopic submucosal dissection between July 2010 and July 2018 were retrospectively included in this study. According to the dilation time (1, 3, 5min), patients were divided into three groups. The clinical effects and adverse events were compared among the three groups. Altogether, 57 patients, including 21 in the 1-min group, 18 in the 3-min group and 18 in the 5-min group, were included. All patients underwent endoscopic treatment successfully. The stricture recurrence rate was 76.19% in the 1-min group, 55.56% in the 3-min group and 61.11% in the 5-min group. The median overall dysphagia-free period was 2.60 (range, 0.80-12.00) months in the 1-min group, 6.60 (range, 1.80-12.00) months in the 3-min group and 6.25 (range, 2.40-12.00) months in the 5-min group (P < 0.05). For patients who developed stricture recurrence, the mean dysphagia-free periods were 2.26 ± 1.27months, 4.00 ± 1.76months and 4.23 ± 1.63months, respectively (P < 0.05). The dysphagia-free periods were comparable between the 3- and 5-min groups and were longer than those in the 1-min group. Muscle layer damage occurred in two patients (11.11%) in the 5-min group and in no patients in the other two groups. Three minutes was considered a safe and effective dilation duration for benign esophageal strictures after esophageal surgery or endoscopic submucosal dissection.

Assessment of long-term results of repeated dilations and impact of a scheduled program of dilations for refractory esophageal strictures: a retrospective case-control study.

In patients with benign and refractory esophageal strictures (BES), repeating initial dilations in short intervals could be recommended, but little data are available to validate this strategy. Our aim was to evaluate long-term results of a scheduled program of repeated and sustained esophageal dilations in patients with refractory strictures. Patients with BES requiring five or more dilations were retrospectively included and divided in two groups for analysis: a SCHEDULED group (SDG) where patients were systematically rescheduled for the 5 first dilations; ON-DEMAND group (ODG) where patients were dilated only in case of recurrence of the dysphagia. Comparison between SDG and ODG was done with a 1:1 matching analysis and etiology of stricture. Clinical success was defined as the absence of dysphagia for more than a year. 39 patients with refractory BES were included with post-operative stenosis in 51.2% and post-caustic injury 28.2%; 10 were in SDG and 29 in ODG. In overall analysis (39 patients), the follow-up was 64.4 ± 32months, success rate was 79.5% and duration of treatment was 27.3 ± 20months, and mean number of dilations was 11.7 per patient. The need for dilations decreased significantly after 18months of treatment with an average of 0.56 dilations per semester. Self-expandable metallic stent insertion was associated with an increased rate of complications (5.9% vs 59.1% p = 0.001). In matched analysis (10 ODG vs 10 SDG patients), the duration of treatment was lower in SDG (18.8 vs 41.4months, p = 0,032) with a higher probability of remission (survival analysis, Log-rank: p = 0,019) and the success rate did not differ between ODG and SDG patients (80% vs 90%; NS). Overall, long-term esophageal dilations resulted in a 79.5% success rate and the need for further dilatations decreased significantly in both groups after 18-month follow-up. A scheduled dilation program was associated with a higher probability of final success and lower treatment duration.

Endoscopic Management of Dysphagia

Dysphagia is difficulty in swallowing that can be caused by a number of disorders that involve either the oropharynx or the esophagus. Specific endoscopic treatment for dysphagia depends on its etiology, whether the dysphagia is caused by mechanical narrowing or a motor disorder. Variable endoscopic treatment strategies can be used to manage dysphagia. Patient with dysfunction of the upper esophageal sphincter may benefit from esophageal dilationor injection of botulinum toxin. Pneumatic balloon dilation, injection of botulinum toxin, peroral endoscopic myotomy can be considered as treatment options for esophageal motility disorders. Endoscopic dilation is the treatment choice of esophageal stricture, while intraluminal steroid injection and temporary stent can be considered in refractory benign esophageal stricture. Self-expandable metal stent insertion can be considered for dysphagia with malignant cause.

Utilization of 3D-Printed Polymer Stents for Benign Esophageal Strictures in Patients with Caustic Ingestion

Aim: This study aimed to introduce a 3D printed, flexible esophageal stent, which is useful in personalized treatment of patients with esophageal strictures and also reduce the adverse effects of the existing esophageal stent. Materials &amp; methods: Bio-grade polylactic acid (PLA), bio-grade transparent thermoplastic polyurethane and bio-grade polyvinyl alcohol (PVA) granules were purchased. The dichloromethane (DCM) and dimethylformamide (DMF), and the double distilled water were used as the solvent for PLA, thermoplastic polyurethane and PVA, respectively. The stent was designed by Solidworks software and subsequently printed by a 3D bioprinter (Mobio Tech V1.2). The biocompatibility, self-expansion, anti-inflammation and cytotoxicity of the printed stent were assessed in an in vitro and in vivo normal canine esophagus. An individualized 3D-printed flexible polymer stent was also implemented for a 16-year-old boy who presented with esophageal stricture following ingestion of corrosive chemicals. The patient was followed for 2 months with further endoscopic and pathology evaluations. Results: Several tests were performed before and after the stent placement. Mechanical tests showed that the nature and behavior of the polymeric materials used in the esophagus stent did not change significantly along treatment. Pathology results further indicated that the polymer stent did not have major inflammatory effects and cytotoxicity. Conclusion: The results show that the individualized 3D printed Biocompatible polymeric stent has potential applications in treating esophageal strictures.

Management of Iatrogenic tracheoesophageal fistula in a patient with dyskeratosis congenita

: The management of benign esophageal strictures pose a challenging problem for general thoracic surgeons. The optimal timing of operative intervention is determined on a case by case basis. We present a case of benign esophageal stricturing secondary to dyskeratosis congenita (DKC). This was initially managed non-operatively with esophageal stenting. This led to the development of a tracheoesophageal fistula necessitating an emergent esophagectomy and tracheal repair. Esophageal manifestations of DKC are excessively rare. However, in patients with a genetic predisposition to esophageal stricturing esophagectomy as first line treatment may be warranted.

Large‐bore suctioning for esophageal clearance under endoscopic vision

Dear Editor, Esophageal food residue may play a critical role in the induction of ventilatory adverse events during an upper endoscopy. While concepts similar to bolus obstruction and/or foreign body removal are well established to this effect, here, I present a novel easy-to-implement emergency approach as large-bore suctioning for esophageal clearance under endoscopic vision. A 64-year-old, mentally impaired patient presented for implantation of a biodegradable esophageal stent due to a benign high-grade esophageal stricture related to refractory esophagitis dissecans. During introduction of the 9.2 mm standard-size upper endoscope into the esophagus under deep sedation using midazolam and propofol, a solid food residue was observed in the upper sphincter most likely representing parts of an orange (Figure 1A,B). Prior to proceeding with stent implantation, removal was considered indicated to circumvent aspiration. To this end, the 25-Fr suction unit was detached from the endoscope and inserted along the scope axis into the esophagus without suction. After adequate contact with the food residue, maximum suction was applied. (Figure 1C) Given a diameter mismatch, the food residue could not be suctioned through, but it was instead carefully withdrawn together with the endoscope orally while maintaining suction (Figure 1D). Unlike a similar approach introduced for advanced achalasia, taping the suction tube to the scope's tip, the presented ad hoc applicable technique circumvents repeated esophageal intubation and might, thus, be more instrumental in rapid esophageal food residue clearance, blocking, and safeguarding the route to the airway.1 The procedure time was estimated at <5 minutes, and no adverse events such as mucosal erythema, bleeding, and/or perforation occurred. The author declares no conflict of interest.

Bilateral balloon expandable biodegradable stent (Y-stent) for postcholecystectomy perihilar biliary stricture.

Bilateral balloon expandable biodegradable stent (Y-stent) for postcholecystectomy perihilar biliary stricture.

Endoscopic management of benign recalcitrant esophageal strictures.

Benign esophageal strictures are one of the common clinical conditions managed by endoscopists. Nearly 90% of the benign esophageal strictures respond to endoscopic dilation. However, a small percentage of patients progress to recalcitrant strictures. The benign recalcitrant esophageal strictures are difficult to manage both medically and endoscopically as they do not respond to conventional treatment with proton pump inhibitors and esophageal dilations. Patients with benign recalcitrant esophageal strictures are at a high risk of developing debilitating malnutrition and morbidity due to severe dysphagia. This condition is associated with psychological trauma to patients as treatments are usually prolonged with poor outcomes. Also, this can be a financial burden on the healthcare industry due to several sessions of treatment. In this article, we discuss the classification of benign esophageal strictures, evidence-based treatment strategies, endoscopic procedural techniques, and complications of endoscopic interventions. We aim to guide providers in managing benign esophageal strictures with a focus on endoscopic management of benign recalcitrant esophageal strictures.