Management Of Benign Esophageal Strictures Research Articles

Management of a refractory benign esophageal stricture with a new biodegradable stent

Palliation of malignant esophageal obstruction and/or esophagorespiratory fistula has been accompushed with both plastic stents (PS) and self-expanding metal stents (SEMS). The role of endoprostheses in the management of benign esophageal strictures has been limited because (1) most benign strictures can be managed with medication or dilation, (2) esophageal stents are generally not removable and most physicians would not accept that restriction for benign disease, and (3) the safety of an indwelling esophageal foreign body for long periods of time is not established. Both PS and SEMS have been utilized for benign esophageal strictures, but to a very limited degree, and primarily in patients who are poor surgical candidates or have a limited life expectancy. 1 The delivery system for PS is awkward and the insertion process generally requires esophageal dilation of 15 to 18 mm prior to insertion, with an associated risk for perforation of 5% to 8%. 2 The PS have been prone to migration, especially when an adequate tumor shelf does not exist, as is the case with benign strictures. Noncoated SEMS have had less tendency to migrate due in part to their persistent radial force as well as tumor ingrowth. The more recently developed coated SEMS have thwarted tumor ingrowth but have been limited by a tendency to migrate. 1 Both PS and SEMS can be associated with an unpleasant foreign body sensation or even frank retrosternal chest pain, food impaction, and pressure necrosis, therefore making them unappealing for long-term management of benign esophageal strictures. Once SEMS are deployed, endoscopic removal is either very difficult or impossible and may require surgery. Temporary placement of plastic biliary stents for benign biliary strictures has been successful in some instances, allowing for the eventual removal after remodeling of the fibrotic stenoses. 3 Applying this con

A comparison of omeprazole and ranitidine in the prevention of recurrence of benign esophageal stricture

Background/Aims: Dilatation combined with subsequent pharmacological control of gastroesophageal reflux represents a logical but poorly documented approach to the management of benign esophageal stricture. This large trial (366 patients) aimed to assess whether omeprazole as the most effective available medication for gastroesophageal reflux disease prevents recurrent stricture formation. Methods: Patients (n = 366) were randomized in a double-blind study to undergo either omeprazole (20 mg once daily; 180 evaluable patients) or ranitidine therapy (150 mg twice daily; 185 evaluable patients) for 1 year after dilatation to 12–18-mm diameter (36–54F gauge). Subsequently, endoscopy and dilatation were performed when clinically indicated and endoscopy on completion. Symptoms were assessed at clinic visits every 3 months and using weekly diary cards. Results: Fewer patients undergoing omeprazole therapy required redilatation compared with those on ranitidine (43 of 143 [30%] vs. 66 of 143 [46%] by 12 months; P < 0.01), and patients in the omeprazole group needed fewer redilatations during the year (0.48 vs. 1.08; P < 0.01). On completion, symptom relief favored omeprazole: 76% of patients in the omeprazole group were free of dysphagia (compared with 64% in the ranitidine group; P < 0.05); 83% were able to accept a normal diet (69%; P < 0.01); and 65% were completely asymptomatic (43%; P < 0.001). Conclusions: Omeprazole, 20 mg once daily, was more effective than ranitidine, 150 mg twice daily, as prophylaxis against stricture recurrence and in providing symptom relief.

The incidence of bacteremia after outpatient Hurst bougienage in the management of benign esophageal stricture.

Transient bacteremia occurs in a variety of gastrointestinal procedures. Of 13 patients with a benign esophageal stricture treated as out-patients by the passage of Hurst mercury bougies only one developed transient bacteremia which occurred five minutes after dilation. We do not therefore recommend routine antibiotic prophylaxis for patients undergoing this type of management. Attention should be given to the manner in which dilators are cleaned and stored.

Clinical course of esophageal stricture managed by bougienage.

To define the clinical course of patients with benign esophageal stricture treated with bougienage, we received the records of 76 patients undergoing dilatation. Patients with the diagnosis of scleroderma and those with previous hiatal hernia repair or gastric surgery were excluded. Initial evaluation included contrast study, esophagoscopy, and biopsy. Patients underwent a series of dilatations until a 44-Fr or larger bougie was passed. Patients were then instructed to return for recurrence of dysphagia. In this group, mean duration of follow-up from the first dilatation was 21.1 months. A total of 569 dilatations were performed with one major complication and no mortality. Benign esophageal stricture recurred in 65% of patients. After two or more recurrences, the likelihood of requiring an additional dilatation was 86--94% after each recurrence. The interval between required dilatations was variable; however, after 8 dilatations, it approximated once monthly. The shorter mean follow-up time of patients requiring a single dilatation (9.7 months) compared to those requiring multiple dilatations (28.8 months) suggests that the recurrence rates noted in this study are underestimations. In spite of high recurrence rates and short recurrence intervals, the low morbidity and absent mortality over long-term follow-up suggests that repeated bougienage is an effective modality for the management of benign esophageal stricture.