Endoscopic Incisional Therapy Research Articles

Endoscopic incisional therapy for benign anastomotic strictures after esophagectomy or gastrectomy: a systematic review and meta-analysis.

Studies have evaluated the efficacy of endoscopic incisional therapy (EIT) for benign anastomotic strictures. We performed a systematic review and meta-analysis to evaluate stricture recurrence after EIT following esophagectomy or gastrectomy. A systematic search of databases was performed up to April 2nd, 2023, after selection of key search terms with the research team. Inclusion criteria included human participants undergoing EIT for a benign anastomotic stricture after esophagectomy or gastrectomy, age ≥ 18, and n ≥ 5. Our primary outcome was the incidence of stricture recurrence among patients treated with EIT compared to dilation. Our secondary outcome was the stricture-free duration after EIT and rate of adverse events. Meta-analysis was performed with RevMan 5.4.1 using a Mantel-Haenszel random-effects model. Publication bias was evaluated with funnel plots and the Egger test. A total of 2550 unique preliminary studies underwent screening of abstracts and titles. This led to 33 studies which underwent full-text review and five studies met the inclusion criteria. Meta-analysis revealed reduced odds of overall stricture recurrence (OR 0.35, 95% CI 0.13-0.92, p = 0.03; I2 = 71%) and reduced odds of stricture recurrence among naïve strictures (OR 0.32, 95% CI 0.17-0.59, p = 0.0003; I2 = 0%) for patients undergoing EIT compared to dilation. There was no significant difference in the odds of stricture recurrence among recurrent strictures (OR 0.63, 95% CI 0.12-3.28, p = 0.58; I2 = 81%). Meta-analysis revealed a significant increase in the recurrence-free duration (MD 42.76, 95% CI 12.41-73.11, p = 0.006) among patients undergoing EIT compared to dilation. Current data suggest EIT is associated with reduced odds of stricture recurrence among naïve anastomotic strictures. Large, prospective studies are needed to characterize the safety profile of EIT, address publication bias, and to explore multimodal therapies for refractory strictures.

Sporadic gastrinoma with refractory benign esophageal stricture: A case report

BACKGROUND Gastrinoma is characterized by an excessive release of gastrin, leading to hypersecretion of gastric acid, subsequently resulting in recurrent peptic ulcers, chronic diarrhea, and even esophageal strictures. This case report aims to improve awareness and facilitate early diagnosis and treatment of gastrinoma by presenting a rare case of gastrinoma with refractory benign esophageal stricture (RBES). Additionally, it highlights the persistent challenges that gastroenterologists encounter in managing RBES. CASE SUMMARY This case demonstrates a patient with gastrinoma who developed RBES and complete esophageal obstruction despite management with maximal acid suppressive therapy, multiple endoscopic bougie dilations and endoscopic incisional therapy (EIT). CONCLUSION It is essential to diagnose gastrinoma as early as possible, as inadequately controlled acid secretion over an extended period increases the risk of developing severe esophageal strictures. In patients with esophageal strictures causing complete luminal obstruction, blind reopening EIT presents challenges and carries a high risk of perforation.

Cricopharyngeal septal cyst within a Zenker's diverticulum treated with EUS-FNA and endoscopic incisional therapy.

Cricopharyngeal septal cyst within a Zenker's diverticulum treated with EUS-FNA and endoscopic incisional therapy.

Comparison of the efficacy and complications of endoscopic incisional therapy and balloon dilatation for benign esophageal strictures

Background: Benign esophageal strictures are treated endoscopically, often with balloon dilatation (BD) or bougie dilators. However, recurrent esophageal strictures have been reported after BD, and severe complications sometimes occur. The aim of this study was to compare the efficacy and complications of endoscopic incisional therapy (EIT) and BD for benign esophageal strictures.Methods: We retrospectively reviewed patients who underwent BD or EIT as primary treatment for benign esophageal strictures between July 2014 and June 2021. Technical success was defined as restoration of the lumen diameter with <30% residual stenosis. Clinical success was defined as no recurrence of dysphagia within 1 month after BD or EIT and an increase of 1 grade or more on the Functional Oral Intake Scale.Results: Thirty patients with benign esophageal stricture were enrolled. There were 16 patients in the BD group and 14 patients in the EIT group. No significant differences in technical and clinical success rates were found between the two groups. Furthermore, no significant differences in the re-stricture rate were observed between the groups. There was one complication in the EIT group and three complications in the BD group. Three patients who underwent BD had re-stricture and underwent EIT thereafter, and we regrouped patients who underwent EIT at least once. The clinical success rate was significantly higher in patients regrouped to the EIT group than in patients who underwent BD only.Conclusions: EIT is not inferior to BD as the primary treatment for benign esophageal strictures, especially for recurrent cases.

Benign Esophageal Stricture

Benign esophageal strictures, characterized by fibrotic narrowing of the esophageal lumen, are frequently encountered in clinical practice. Benign esophageal strictures are associated with a multifactorial etiology and may occur across various age and population groups. Common causes of benign esophageal strictures include gastroesophageal reflux disease (peptic stricture), esophageal injury secondary to surgery (anastomotic strictures), radiotherapy, caustic agent ingestion, or endoscopic resection. Benign esophageal strictures are categorized into simple and complex types based on their size, area involved, surface features, extent of luminal narrowing, and margins. Esophageal strictures often present clinically with dysphagia and may lead to severe complications. Regardless of the underlying cause, therapy is aimed at relief of dysphagia and prevention of stricture recurrence. Benign esophageal strictures are commonly treated using endoscopic balloon or bougie dilation, followed by disease-specific approaches to treat underlying inflammation. However, based on the underlying cause, the risk of recurrence of benign esophageal strictures is 10~30%. Therapeutic options for refractory or recurrent esophageal strictures include endoscopic incisional therapy, esophageal stent placement, or intralesional injection of steroids or mitomycin C. The pathophysiology of esophageal strictures is complicated, and thorough understanding and patient cooperation are important for optimal management. Physicians should familiarize themselves with the various dilation strategies available and their application for management of specific types of stenotic lesions. In this article, we review the evaluation and management of patients with esophageal strictures.

Flexible endoscopic incisional therapy for Zenker's diverticulum (FEIT-Z) is an effective treatment for surgical failures or non-operative patients.

Symptomatic Zenker's diverticulum (ZD) occurs mostly in the elderly, who often have significant comorbidities, and poor neck hyperextension, putting them at high risk for surgical management while also increasing the potential of technical failure. Flexible endoscopic incisional therapy for Zenker's diverticulum (FEIT-Z) offers a safe approach to this problem with high technical and clinical success rates. There are limited data on its use following a failed surgical approach or in patients unfit for a surgical approach. The aim of this study was to assess clinical and technical outcomes of FEIT-Z in patients who were non-operative candidates or refused or failed surgical management. Patients who underwent FEIT-Z from January 2015 to February 2019 at a tertiary referral center were included. Patient demographics, prior ZD surgical history, procedural data, dysphagia scores, clinical success, and adverse events (AE) were collected. Univariable analysis was performed to assess differences between pre- and post-FEIT-Z dysphagia scores. 30 patients undergoing FEIT-Z were included. Seven had a prior failed ZD surgical approach, 6 refused surgical management, and 17 were deemed to be non-operative candidates based on medical comorbidities. Mean age was 78.4 (± 12.1) and 36.7% were male. Technical success of FEIT-Z was 96.7%. There was a significant improvement in dysphagia scores after FEIT-Z: 2.3 (± 0.64) vs. before, 0.4 (± 0.76) (p < 0.001). Long-term clinical success was achieved in 73.3% of patients. Adverse events were seen in 23.3% of patients; however, these were graded as mild in 85.7% of patients. One microperforation was managed with antibiotics. FEIT-Z is a safe procedure with low adverse events and a high rate of technical and clinical success. FEIT-Z can be done in patients who fail previous surgical treatment, refuse a surgical approach, or are not surgical candidates due to medical comorbidity or other factors.

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.

Comparison of the Efficacy and Safety of Endoscopic Incisional Therapy and Balloon Dilatation for Esophageal Anastomotic Stricture

BackgroundBenign esophageal anastomotic strictures have typically been treated using endoscopic methods, often with balloon dilatation (BD). However, recurrent esophageal strictures after BD have been reported. We evaluated the efficacy and safety of endoscopic incisional therapy (EIT) and BD for treating an anastomotic stricture after a total gastrectomy. MethodsSubjects who underwent EIT or BD as a first treatment for esophagojejunostomy anastomotic stricture after a total gastrectomy between January 2010 and December 2018 were eligible. The medical records of these cases were retrospectively reviewed. Stricture was defined as an inability to pass a normal diameter endoscope (10.2 mm). The stricture area was incised under direct vision with the nano-insulated-tip knife in a radial fashion parallel to the longitudinal axis of the esophagus. ResultsTwenty-one patients in our database presented with benign anastomotic stricture after a total gastrectomy for advanced gastric cancer. The BD group included 12 patients. The remaining nine patients underwent EIT, and three of these cases received an immediate additional BD. The re-stricture rate was significantly different between the BD and EIT groups (41.7% vs. 0%, respectively; P = 0.045). There were no significant differences in procedure time, interval from surgery to first stricture, hospitalization period, or complication rates between the groups. One patient developed a microperforation during BD and was treated without surgical intervention. ConclusionsEIT is a safe and effective primary treatment modality compared with BD for esophagojejunostomy anastomotic stricture after a total gastrectomy as it shows a significantly lower re-stricture rate.

Utility of repeated therapeutic endoscopies for pediatric esophageal anastomotic strictures.

Anastomotic stricture is a common complication of esophageal atresia (EA) repair. Such strictures are managed with dilation or other therapeutic endoscopic techniques such as steroid injections, stenting, or endoscopic incisional therapy (EIT). In situations where endoscopic therapy is unsuccessful, patients with refractory strictures may require surgical stricture resection; however, the point at which endoscopic therapy should be abandoned in favor of repeat thoracotomy is unclear. We hypothesized that increasing numbers of therapeutic endoscopies are associated with increased likelihood of stricture resection. We retrospectively reviewed the records of patients with EA who had an initial surgery at our institution resulting in an esophago-esophageal anastomosis between August 2005 and May 2019. Up to 2years of post-surgery endoscopy data were collected, including exposure to balloon dilation, intralesional steroid injection, stenting, and EIT. Primary outcome was need for stricture resection. Receiver operating characteristic (ROC) curve analysis and univariate and multivariable Cox proportional hazards regression analyses were performed. There were 171 patients who met inclusion criteria. The number of therapeutic endoscopies was a moderate predictor of stricture resection by ROC curve analysis (AUC = 0.720, 95% CI 0.617-0.823). With increasing number of therapeutic endoscopies, the probability of remaining free from stricture resection decreased. By Youden's J index, a cutoff of ≥7 therapeutic endoscopies was optimal for discriminating between patients who had versus did not have stricture resection, though an absolute majority of patients (≥50%) remained free of stricture resection at each number of therapeutic endoscopies through 12 endoscopies. Significant predictors of needing stricture resection by univariate regression included ≥7 therapeutic endoscopies, Foker surgery for long-gap EA, fundoplication, history of esophageal leak, and length of stricture ≥10mm. Multivariate analysis identified only history of leak as statistically significant, though this regression was underpowered. The utility of repeated therapeutic endoscopies may diminish with increasing numbers of endoscopic therapeutic attempts, with a cutoff of ≥7 endoscopies identified by our single-center experience as our statistically optimal discriminator between having stricture resection versus not; however, a majority of patients remained free of stricture resection well beyond 7 therapeutic endoscopies. Though retrospective, this study supports that repeated therapeutic endoscopies may have clinical utility in sparing surgical stricture resection. Esophageal leak is identified as a significant predictor of needing subsequent stricture resection. Prospective study is needed.

Endoscopic incisional therapy and other novel strategies for effective treatment of congenital esophageal stenosis

Background & aimsCongenital esophageal stenosis (CES) is an inborn condition of the esophagus that can be refractory to endoscopic dilation. Surgical intervention is not curative, with patients experiencing frequent ongoing need for therapy for anastomotic stricture postoperatively.We hypothesized that novel methods of endoscopic CES management including endoscopic incisional therapy (EIT) would lead to less surgical intervention. MethodsWe retrospectively reviewed the medical records of all patients with CES treated by our tertiary care center who had at least one endoscopy between July 2007 and July 2019. Statistical comparison of cohorts who underwent advanced endoscopic therapy involving EIT versus traditional endoscopic therapy with balloon dilation was performed. Primary outcome measure was need for surgical intervention. ResultsThirty-six patients with CES met inclusion criteria. Thirty-four ever had at least one endoscopic intervention such as balloon dilation, steroid injection, stenting, and/or endoscopic incisional therapy (EIT) at their CES. Esophageal vacuum assisted closure (EVAC) was used for treatment or prevention of esophageal leak. Odds of surgical intervention were significantly lower in the group who received therapeutic endoscopy with EIT (odds ratio (OR) 0.1; p = 0.007). Clinical feeding outcomes were similar in the endoscopic and surgical management groups. Odds of complications after therapeutic endoscopies involving EIT were significantly greater than those without EIT (odds ratio 6.39; 95% confidence interval (2.34, 17.44); p < 0.001), though our rates of esophageal leak significantly decreased over time as our use of EVAC increased (Spearman's ρ = −0.884; p = 0.004). ConclusionComplementary endoscopic techniques such as EIT broaden the toolbox of the treating physician and may allow for avoidance of surgery in CES. Level of evidenceLevel III.

2135 A Rare Case of Dysphagia From a Cricopharyngeal Septal Cyst Within a Zenker’s Diverticulum Treated With EUS-FNA and Endoscopic Incisional Therapy

INTRODUCTION: Zenker’s diverticulum (ZD) occurs mostly in elderly patients and may manifest with dysphagia, halitosis, regurgitation, and aspiration. We present a rare cause of esophageal dysphagia from an obstructing cyst on the cricopharyngeal septum within the Zenker’s diverticulum, successfully treated with endoscopic ultrasound guided drainage and endoscopic incisional therapy. CASE DESCRIPTION/METHODS: A 68-year-old female was referred for endoscopic treatment of a suspected Zenker’s diverticulum seen on esophagram. On endoscopic exam, she was found to have an obstructing Zenker’s diverticulum in the proximal esophagus with a cystic structure on the cricopharyngeal septum (image 1). Endoscopic ultrasound exam was done to characterize the cystic lesion which showed a 14 mm anechoic round cyst originating in the deep mucosa (image 2). Color Doppler did not find any significant vascular flow within the cyst, which was then aspirated under EUS guidance and cytology confirmed a benign cyst. After cyst decompression, the Zenker’s diverticulum was successfully treated using flexible endoscopic incisional therapy with the SB knife (image 3). Patient had complete resolution of her dysphagia with no symptom recurrence. DISCUSSION: Zenker’s diverticulum has been successfully treated with surgical and endoscopic techniques, but the presence of incidental cystic or vascular lesions highlight the need for endoscopic evaluation and use of adjunct tools such as endoscopic ultrasound to rule out vascular flow and assist in drainage before endoscopic therapy can be pursued. We report a unique case of cricopharyngeal septal cyst as the cause of symptomatic dysphagia within a Zenker’s diverticulum which was successfully treated with endoscopic interventional tools.

DOZ047.14: Endoscopic incisional therapy and other novel strategies for treatment of congenital esophageal stenosis

Abstract Summary Management of congenital esophageal stenosis (CES) often involves dilation with reversion to myotomy or stricture resection in refractory cases.1,2 However, surgery often fails to produce durable response, with anastomotic strictures requiring ongoing dilation and stenotic symptoms plaguing more than half of the patients in published series.3 Methods In this study, the medical records of all patients with CES treated by our tertiary care center who had at least one endoscopy between July 2007 and October 2018 were retrospectively reviewed. Success was defined as full when the diet included all age-appropriate textures with dysphagia once per month or less, or partial when the diet included most textures with dysphagia at most 1–2 times per week. Results Thirty patients with CES had at least one endoscopic intervention. All patients had balloon dilation(s) and at least one other therapy such as endoscopic incisional therapy (EIT), steroid injection, or stenting. Esophageal vacuum-assisted closure (EVAC) was used for treatment or prevention of esophageal leak. Of patients who had EIT at their CES (N = 18), 14 (77.8%) achieved full (N = 13) or partial (N = 1) success with endoscopic therapy alone; 3 (16.7%) required surgery to achieve full (N = 3) success; 1 nonsurgical patient does not yet eat by mouth due to oral aversion. Of patients who did not undergo EIT at their CES (N = 12), 5 (41.7%) achieved full success with endoscopic therapy alone; 7 (58.3%) required surgery (2 full success, 4 partial success, and 1 does not eat by mouth due to airway comorbidities). The rate of surgical intervention was significantly lower in the group that received EIT (Fisher's exact test, P = 0.045). Twenty-five endoscopies (8.9%) were associated with complications, including esophageal leak (N = 21) or stent migration (N = 4). Of endoscopies with a complication, 16 (64%) involved EIT. Odds of complications after therapeutic endoscopies involving EIT were significantly higher than those without EIT (odds ratio 6.15; 95% CI (2.44, 15.52); P &lt; 0.001). The rates of esophageal leak significantly decreased over time as the use of EVAC increased (P = 0.003). Conclusion EIT shows promise as an alternative to surgery in CES; however, further study is needed. Complementary endoscopic techniques such as injection, stenting, and EIT broaden the toolbox of the treating physician and may allow for avoidance of surgery in CES.

Research progress of benign anastomotic stricture after esophagectomy

Benign anastomotic stricture is one of the most common complications after esophagectomy, which can result in the dysphagia and weight loss of patients. It can severely impair the patient′s quality of life with the progress of the stricture. What is more, refractory benign stricture is a major challenge for physicians and needs repeated treatments, which aggravates the patient′s pain and increases extra costs. Benign anastomo-tic stricture is associated closely with various risk factors, which can be prevented by adopting some measures. Dilation remains the first-line treatment to manage benign anastomotic stricture and it may be effective to combine with drug therapy. Endoscopic incisional therapy is a promising method as a new treatment therapy. The use of various stents fails to improve overall long-term dysphagia-free rate. In addition, stent has a possible risk of migration and hyperplastic tissue growth, which should be used by weighing the pros and cons. Key words: Esophageal neoplasms; Deglutition disorders; Benign anastomotic stricture

Tu1157 Flexible Endoscopic Incisional Therapy for Zenker's Diverticulum Is Cost-Saving Compared to Surgical Approaches

Tu1157 Flexible Endoscopic Incisional Therapy for Zenker's Diverticulum Is Cost-Saving Compared to Surgical Approaches

An Intractable Caustic Esophageal Stricture Successfully Managed with Sequential Treatment Comprising Incision with an Insulated-Tip Knife, Balloon Dilation, and an Oral Steroid.

Bougie or balloon dilation is a good short-term treatment for caustic esophageal strictures, although recurrence after dilation occurs in approximately 30% of these cases. Therefore, long-term treatment options are required in some cases, and endoscopic incisional therapy has been used for patients with an anastomotic stricture in the gastrointestinal tract. A 58-year-old woman presented with severe swallowing difficulty because of a caustic esophageal stricture, which was caused by accidental exposure to anhydrous acetic acid at infancy. She had undergone several previous bougie and balloon dilations but the stricture did not improve. We performed sequential treatment comprising incision with an insulated-tip knife, balloon dilation, and an oral steroid, which resulted in the patient’s symptoms markedly improving. Thus, we report this case of an intractable caustic esophageal stricture, which was successfully treated using combined endoscopic sequential treatment.

Endoscopic incisional therapy for benign esophageal strictures: Technique and results.

Benign esophageal strictures refractory to the conventional balloon or bougie dilatation may be subjected to various adjunctive modes of therapy, one of them being endoscopic incisional therapy (EIT). A proper delineation of the stricture anatomy is a prerequisite. A host of electrocautery and mechanical devices may be used, the most common being the use of needle knife, either standard or insulated tip. The technique entails radial incision and cutting off of the stenotic rim. Adjunctive therapies, to prevent re-stenosis, such as balloon dilatation, oral or intralesional steroids or argon plasma coagulation can be used. The common strictures where EIT has been successfully used are Schatzki's rings (SR) and anastomotic strictures (AS). Short segment strictures (< 1 cm) have been found to have the best outcome. When compared with routine balloon dilatation, EIT has equivalent results in treatment naïve cases but better long term outcome in refractory cases. Anecdotal reports of its use in other types of strictures have been noted. Post procedure complications of EIT are mild and comparable to dilatation therapy. As of the current evidence, incisional therapy can be used for management of refractory AS and SR with relatively short stenosis (< 1 cm) with good safety profile and acceptable long term patency.

Intralesional steroid injection therapy in the management of resistant gastrointestinal strictures

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.

Endoscopic Incisional Therapy with Iso-Tome and Transparent Hood in Patients with Benign Anastomotic Esophageal Stricture

Background: Benign anastomotic stricture of the esophagus following surgical resection has been reported to occur in 5% to 46% of patients. There is a significant recurrence rate in bougie, or balloon dilation, which requires repeated dilation sessions to maintain the patency. Electrocautery treatment was proposed to be a good alternative treatment in several studies. Aim: Our study evaluated the efficacy of endoscopic incisional therapy using an Iso-Tome and an end-viewing endoscope fitted with a transparent hood in patients with benign anastomotic esophageal strictures, prospectively.