Radiation-induced Strictures Research Articles

NSAID enteropathy: appearance at CT and MR enterography in the age of multi-modality imaging and treatment.

CT and MR enterography and capsule endoscopy are increasingly used as routine diagnostic tests for patients with potential small bowel disorders and obscure gastrointestinal bleeding. Non-steroidal anti-inflammatory drugs (NSAIDs) are commonly used drugs that disrupt prostaglandin synthesis and result in a variety of localized complications within the small bowel ranging from ulcer formation to characteristic circumferential strictures, or diaphragms. NSAID enteropathy encompasses this spectrum of acute and chronic inflammatory sequelae, and is associated with typical findings at capsule endoscopy and surgery. Herein we review the typical clinical presentation of NSAID enteropathy, in addition to its endoscopic appearances, focusing on imaging findings at cross-sectional enterography. Multiple, short-segment strictures are the hallmarks of imaging diagnosis. Strictures may have minimal hyperenhancement or wall thickening, but these findings are typically symmetric and circumferential with respect to the bowel lumen. Multifocal Crohn's strictures, and occasionally radiation-induced strictures or adhesions, will mimic NSAID diaphragms. Multi-phase or multi-sequence imaging at CT and MR enterography increase diagnostic confidence in stricture presence. Strategies for subsequent workup and therapy after enterography are also discussed. Given the frequent use of NSAIDs and typical appearance of these strictures, knowledge of characteristic imaging findings can be particularly useful when evaluating patients with anemia and recurrent small bowel obstruction.

Management of radiation-induced urethral strictures.

Radiation as a treatment option for prostate cancer has been chosen by many patients. One of the side effects encountered are radiation-induced urethral strictures which occur in up to 11% of patients. Radiation damage has often left the irradiated field fibrotic and with poor vascularization which make these strictures a challenging entity to treat. The mainstay of urologic management remains an urethroplasty procedure for which several approaches exist with variable optimal indication. Excision and primary anastomoses are ideal for shorter bulbar strictures that comprise the majority of radiation-induced urethral strictures. One advantage of this technique is that it does not require tissue transfers and success rates of 70-95% have consistently been reported. Substitution urethroplasty using remote graft tissue such as buccal mucosa are indicated if the length of the stricture precludes a tension-free primary anastomosis. Despite the challenge of graft survival in radiation-damaged and poorly vascularized recipient tissue, up to 83% of patients have been treated successfully although the numbers described in the literature are small. The most extensive repairs involve the use of tissue flaps, for example gracilis muscle, which may be required if the involved periurethral tissue is unable to provide sufficient vascular support for a post-operative urethral healing process. In summary, radiation-induced urethral strictures are a challenging entity. Most strictures are amenable to excision and primary anastomosis (EPA) with encouraging success rates but substitution urethroplasty may be indicated when extensive repair is needed.

Treatment of Urethral Strictures from Irradiation and Other Nonsurgical Forms of Pelvic Cancer Treatment.

Radiation therapy (RT), external beam radiation therapy (EBRT), brachytherapy (BT), photon beam therapy (PBT), high intensity focused ultrasound (HIFU), and cryotherapy are noninvasive treatment options for pelvic malignancies and prostate cancer. Though effective in treating cancer, urethral stricture disease is an underrecognized and poorly reported sequela of these treatment modalities. Studies estimate the incidence of stricture from BT to be 1.8%, EBRT 1.7%, combined EBRT and BT 5.2%, and cryotherapy 2.5%. Radiation effects on the genitourinary system can manifest early or months to years after treatment with the onus being on the clinician to investigate and rule-out stricture disease as an underlying etiology for lower urinary tract symptoms. Obliterative endarteritis resulting in ischemia and fibrosis of the irradiated tissue complicates treatment strategies, which include urethral dilation, direct-vision internal urethrotomy (DVIU), urethral stents, and urethroplasty. Failure rates for dilation and DVIU are exceedingly high with several studies indicating that urethroplasty is the most definitive and durable treatment modality for patients with radiation-induced stricture disease. However, a detailed discussion should be offered regarding development or worsening of incontinence after treatment with urethroplasty. Further studies are required to assess the nature and treatment of cryotherapy and HIFU-induced strictures.

Risk of recurrent or refractory strictures and outcome of endoscopic dilation for radiation-induced esophageal strictures

Radiation therapy for head, neck, and esophageal cancer can result in esophageal strictures that may be difficult to manage. Radiation-induced esophageal strictures often require repeat dilation to obtain relief of dysphagia. This study aimed to determine the long-term clinical success and rates of recurrent and refractory stenosis in patients with radiation-induced strictures undergoing dilation. Retrospective cohort study of patients with radiation-induced strictures who underwent endoscopic dilation by a single provider from October 2007-October 2012. Outcomes measured included long-term clinical efficacy, interval between sessions, number of dilations, and proportion of radiation strictures that were recurrent or refractory. Risk factors for refractory strictures were assessed. 63 patients underwent 303 dilations. All presented with a stricture >30 days after last radiation session. Clinical success to target diameter was achieved in 52 patients (83%). A mean of 3.3 (±2.6) dilations over a median period of 4 weeks was needed to achieve initial patency. Recurrence occurred in 17 (33%) at a median of 22 weeks. Twenty-seven strictures (43%) were refractory to dilation therapy. Fluoroscopy during dilation (OR 22.88; 95% CI 3.19-164.07), severe esophageal stenosis (lumen <9 mm) (OR 10.51; 95% CI 1.94-56.88), and proximal location with prior malignancy extrinsic to the lumen (OR 6.96; 95% CI 1.33-36.29) were independent predictors of refractory strictures in multivariate analysis. (1) Radiation-induced strictures have a delayed onset (>30 days) from time of radiation injury. (2) Endoscopic dilation can achieve medium-term luminal remediation but the strictures have a high long-term recurrence rate of up to 33%. (3) Remediation of radiation strictures following laryngectomy can be achieved but require frequent dilations. (4) Clinical and procedural predictors may identify patients at high risk of refractory strictures. (5) The optimal strategy in highly selected refractory patients is not clear.

Esophagus.

Esophagus.

Urethral strictures and the cancer survivor.

Urethral stricture disease is poorly understood in prostate cancer survivors who have undergone radiation or ablative treatments. We review the cause and incidence of urethral strictures (excluding bladder neck contracture) in this setting, as well as risk factors and treatment options. Stricture rates differ for various modalities of radiation therapy, with the highest rate in high-dose-rate brachytherapy. Risk factors include higher dose of radiation delivered to prostate apex, radiation delivered per treatment, and prior transurethral resection of prostate. Cryoablation and high-intensity focused ultrasound of the prostate also carry high risk of urethral stricture formation, particularly in the salvage setting. Dilation or direct vision incision of the urethra can be utilized as a temporizing technique, with frequent recurrence. Urethral stenting is also an option; however, this is associated with a high rate of incontinence. Urethroplasty has durable outcomes for radiation-induced strictures, with a preference for excision and primary anastomosis because of the bulbomembranous location and relatively short length of these strictures. Salvage radical prostatectomy has been described in a small series as treatment for posterior urethral strictures and bladder neck contractures resulting from ablative therapies. Prostate cancer survivors treated with radiation or ablative therapies are at risk for urethral stricture formation. Urethroplasty is a feasible and durable treatment option and should be considered in the appropriate patient.

Tu1378 Clinical and Procedural Predictors of Refractory Anastomotic and Radiation-Induced Strictures

more routinely. Perforation caused by endoscopic removal of foreign bodies is much rarer than has been described in the historical literature.

Su1826 Efficacy and Safety of EndoMAXX™, A New Non-Foreshortening Fully Covered Nitinol Esophageal Stent

transesophageal prosthesis). No perforations occurred. Endoscopic injection of steroids did not accelerate remediation compared to patients who did not receive injected steroids [median 24 (IQR 8, 38.5) weeks, mean 7.5 (+/-2.6) dilations vs. median 11 (IQR 2, 14) weeks, mean 3.8 (+/-2.3) dilations, p=0.16 and p=0.007]. Conclusions: 1. Radiation-induced strictures appear to have a delayed onset from time of injury. 2. Endoscopic dilation can achieve medium-term luminal remediation but has a high long-term recurrence rate. 3. Endoscopically injected steroids do not promote remediation of radiation strictures.

Su1823 Risk of Recurrence and Outcomes for Endoscopic Dilation of Radiation-Induced Esophageal Strictures

Su1823 Risk of Recurrence and Outcomes for Endoscopic Dilation of Radiation-Induced Esophageal Strictures

Adverse events of upper GI endoscopy

Adverse events of upper GI endoscopy

944P - Comparative Evaluation of Radiation-Induced Damages in Prostate Cancer Patients after Intratissue Radiation Therapy Using I-125 Seeds and External Beam Radiation Therapy

ABSTRACT Purpose To compare complications of external beam radiation therapy (EBRT) and brachytherapy for prostate cancer. Materials and methods We performed a comparative evaluation of radiation-induced damages of the small pelvis organs in 46 patients with prostate cancer. The first group consisted of 24 patients who received EBRT to a total tumor dose of 65-72 Gy. In the second group (22 patients), standard brachytherapy procedures were carried out. Results The patients were distributed according to the type of radiation-induced complications (Table 1). Table 1 Distribution of patients according to the type of radiation-induced complications. Group No. Cystitis Bladder ulcer Rectitis Rectal ulcer Combined damages (rectitis, rectal ulcer) Group 1 (24) 8 (33.3%) 2 (8.3%) 7 (29.2%) 3 (12.5%) 4 (16.7%) Group 2 (22) 4 (18.2%) 0 13 (59%) 2 (9.1%) 3 (13.7%) Thus, the rate of rectal complications was higher in the brachytherapy group compared with the EBRT group. Radiation cystitis occurred more frequently in patients with bladder lesions of group 1. It is worth noting that the severity of radiation-induced damage appeared to be more marked in group 2. Radiation-induced strictures of the posterior urethra were detected in 2 (8.3%) patients of group 1 and in 5 (22.7%) patients of group 2. More serious complications associated with functional disturbances of organs (microcystitis, rectovesical fistula, rectal stricture) occurred only in patients who had undergone external beam radiation therapy. Conclusions Our study suggests that radiation-induced damages of the rectum and posterior urethra occur more often after brachytherapy. EBRT can result in radiation cystitis. It should be pointed out that EBRT can produce more severe lesions of the pelvic organs including complications associated with physical disability. Disclosure All authors have declared no conflicts of interest.

Editorial Comment

The authors describe a large (29 patients) single-surgeon series of urethroplasty for radiation induced urethral strictures. With more prostate cancers detected every year, the rate of radiation-induced strictures will increase over time. First, the authors should be congratulated for achieving a high rate of success (90%). This rate is comparable with a previous multi-institutional series that reported a success rate >80% with reconstruction.1 There is now evidence that it is possible to reconstruct these very challenging surgical patients.

Urethroplasty After Radiation Therapy for Prostate Cancer

To report urethroplasty outcomes in men who developed urethral stricture after undergoing radiation therapy for prostate cancer. Our urethroplasty database was reviewed for cases of urethral stricture after radiation therapy for prostate cancer between June 2004 and May 2010. Patient demographics, prostate cancer therapy type, stricture length and location, and type of urethroplasty were obtained. All patients received clinical evaluation, including imaging studies post procedure. Treatment success was defined as no need for repeat surgical intervention. Twenty-nine patients underwent urethroplasty for radiation-induced stricture. Previous radiation therapy included external beam radiotherapy (EBRT), radical prostatectomy (RP)/EBRT, EBRT/brachytherapy (BT) and BT alone in 11 (38%), 7 (24%), 7 (24%), and 4 (14%) patients, respectively. Mean age was 69 (±6.9) years. Mean stricture length was 2.6 (±1.6) cm. Anastomotic urethroplasty was performed in 76% patients, buccal mucosal graft in 17%, and perineal flap repair in 7%. Stricture was localized to bulbar urethra in 12 (41%), membranous in 12 (41%), vesicourethra in 3 (10%), and pan-urethral in 2 (7%) patients. Overall success rate was 90%. Median follow-up was 40 months (range 12-83). Time to recurrence ranged from 6-16 months. Multiple forms of urethroplasty appear to be viable options in treating radiation-induced urethral stricture. Future studies are needed to examine the durability of repairs.

Success and complications associated with placement of fully covered removable self-expandable metal stents for benign esophageal diseases (with videos)

Fully covered esophageal self-expandable metal stents (FCSEMSs) are thought to induce less mucosal hyperplasia and are potentially removable. They may constitute an attractive alternative for the treatment of benign esophageal diseases. To evaluate the efficacy and safety of FCSEMSs in the treatment of benign esophageal diseases. Patients referred for management of benign esophageal disease underwent placement of an FCSEMS and were entered into a prospective database and analyzed retrospectively for clinical response, efficacy, and morbidity. Two tertiary care centers with long-standing experience in the management of benign esophageal strictures. Between January 2006 and September 2007, 35 patients (mean age 61 years, range 20-85 years) underwent FCSEMS placement for benign esophageal diseases at 2 tertiary academic medical centers. There were 19 patients with benign esophageal strictures and 16 patients with leaks/perforations. Temporary placement of FCSEMS until stricture resolution. Clinical response, efficacy, and morbidity. Indications for stent placement were esophageal leak/fistulae (n = 12), refractory benign strictures (n = 10), anastomotic strictures (n = 7), perforations (n = 4), and radiation-induced strictures (n = 2). Immediate complications were chest pain (2 patients), stent migration (2 patients), dysphagia (1 patient), respiratory compromise (1 patient), and arrhythmia (1 patient). Long-term complications included recurrent dysphagia (6 patients), aspiration pneumonia (2 patients), globus sensation (2 patients), abdominal pain (2 patients), and fever (1 patient). Stent migration was observed in 12 patients (34%). After placement, dysphagia scores at 1 month improved significantly from 3.1 ± 1.0 to 1.2 ± 1.3 (P < .0001). A total of 11 of 35 patients (31%) were treated successfully. Specifically, 21% of patients with refractory strictures and 44% of patients with leaks/fistulae had successful long-term outcomes without any need for reinterventions. All stents were retrieved successfully, except for 1 stent, which fractured and was retrieved in 2 pieces without any complications. Use of FCSEMSs for benign esophageal conditions was associated with frequent stent migration and long-term improvement in only one third of patients. Further investigation is required before recommending FCSEMS placement to treat benign diseases of the esophagus and to further characterize the subgroup that might benefit from these interventions.

Dose–response relations for stricture in the proximal oesophagus from head and neck radiotherapy

Background and purpose Determination of the dose–response relations for oesophageal stricture after radiotherapy of the head and neck. Material and methods In this study 33 patients who developed oesophageal stricture and 39 patients as controls are included. The patients received radiation therapy for head and neck cancer at Karolinska University Hospital, Stockholm, Sweden. For each patient the 3D dose distribution delivered to the upper 5 cm of the oesophagus was analysed. The analysis was conducted for two periods, 1992–2000 and 2001–2005, due to the different irradiation techniques used. The fitting has been done using the relative seriality model. Results For the treatment period 1992–2005, the mean doses were 49.8 and 33.4 Gy, respectively, for the cases and the controls. For the period 1992–2000, the mean doses for the cases and the controls were 49.9 and 45.9 Gy and for the period 2001–2005 were 49.8 and 21.4 Gy. For the period 2001–2005 the best estimates of the dose–response parameters are D 50 = 61.5 Gy (52.9–84.9 Gy), γ = 1.4 (0.8–2.6) and s = 0.1 (0.01–0.3). Conclusions Radiation-induced strictures were found to have a dose response relation and volume dependence (low relative seriality) for the treatment period 2001–2005. However, no dose response relation was found for the complete material.

Fluoroscopically Guided Balloon Dilation of the Esophagus

Balloon dilation has become a common method for treating a variety of esophageal conditions. When properly performed, it is an effective procedure with a high rate of success. Fluoroscopically guided balloon dilation offers distinct advantages over endoscopically performed balloon dilation or blindly performed bougienage, as it allows for better visual control of the procedure and morbidity is low. In our experience, fluoroscopically guided esophageal balloon dilation is safe and easy to perform, provided that the operators are aware of the potential complications and the procedure is properly tailored to the patient's underlying condition. At our institution, over the course of 25 years we have performed more than 2300 fluoroscopically guided esophageal balloon dilations to treat a multitude of disorders including strictures of benign and malignant etiology, anastomotic strictures, radiation-induced strictures, tight gastric fundoplication wraps, esophageal webs and rings, achalasia, and anastomotic leaks. Over the years that we have performed the procedure, we have adapted our technique to maximize postprocedural outcomes and utilize available technology. In this article, we describe our current technique, present the various conditions amenable to balloon dilation, and emphasize modifications for each condition. We also discuss potential problems and complications that we have experienced in our practice.

Outcomes of a combined antegrade and retrograde approach for dilatation of radiation-induced esophageal strictures (with video)

Treatment of head, neck, and esophageal cancers with radiation therapy can lead to esophageal strictures. In some cases, these can progress to complete esophageal obstruction, precluding typical antegrade endoscopic dilation. The aim of this study was to review our experience with a combined antegrade/retrograde technique for dilation of complete esophageal strictures. Case series. Tertiary-care referral center. Twelve patients with complete esophageal radiation-induced strictures. In collaboration with otolaryngologists who performed direct antegrade esophagoscopy, retrograde endoscopy via gastrostomy was simultaneously performed. While visualizing the stricture from both sides and transilluminating, it was recannulated with use of a biliary or spring-tipped guidewire, and then dilated. Dilation method, complications, and postdilation oral intake. Combined antegrade and retrograde dilation was technically possible in 10 of the 12 patients (83%). Two cases were unsuccessful due to an inability to achieve transillumination. The only significant complication was a contained esophageal perforation that was managed nonoperatively. The mean number of repeat dilations was 7 (range, 1-22); none were complicated by perforation. Esophageal patency allowing at least some oral intake and tolerance of secretions was ultimately successful in 8 patients (67%). Retrospective, single center. A combined antegrade/retrograde approach for dilation of complete esophageal radiation-induced strictures in collaboration with colleagues from otolaryngology is a viable treatment option. The procedure is technically feasible, effective, and well tolerated, although there may be an increased risk of esophageal perforation. This strategy may obviate a more invasive surgical approach.

The Role of Pretreatment Percutaneous Endoscopic Gastrostomy in Facilitating Therapy of Head and Neck Cancer and Optimizing the Body Mass Index of the Obese Patient

Chemoradiation of head and neck cancer induces severe dysphagia and malnutrition, which may lead to interruptions in therapy and reduction in its efficacy. Percutaneous endoscopic gastrostomy (PEG) feedings bypass the oropharynx, allowing administration of nutrients and medications into the stomach, thus preventing malnutrition, dehydration, and treatment interruption. Medical records of 161 patients treated for head and neck cancer who had PEGs placed prior to chemoradiation and 2 PEGs placed during chemoradiation were reviewed from the date of PEG placement throughout treatment and utilization. The objective was to determine the contribution of pretreatment PEGs to the therapy of patients with head and neck cancer and to optimize their body mass index. Severe chemoradiation-induced dysphagia developed in 160 patients (98%), necessitating PEG utilization for feeding and hydration. PEGs were used for a mean 251 +/- 317 days. Significant complications related to PEG placement and utilization were infrequent. PEG feeding allowed chemoradiation to continue without interruption in 93% of patients. Individualized feeding regimens optimized body mass index in obese and overweight patients with a decline from 33.0 +/- 3.4 to 28.4 +/- 4.8 kg/m(2) (P < .001) and 27.3 +/- 1.5 to 24.6 +/- 2.7 kg/m(2) (P < .001), respectively. Radiation-induced strictures developed in 12% of patients, requiring endoscopic dilatation. Enteral feeding through prechemoradiation-placed PEGs is an effective and safe method for nutrition and hydration of patients with head and neck cancer undergoing chemoradiation. PEGs allowed chemoradiation to proceed with minimal interruptions despite severe dysphagia, which excluded oral intake for prolonged periods.

Intestinal Radiation-Induced Stricture Favours Small Bowel Obstruction by Phytobezoar: Report of a Case

Bezoars represent the fifth most frequent cause of acute small bowel obstruction. Phytobezoar is the most common type of bezoar. It is a concretion of undigestible fibers derived from ingested vegetables and fruits. We report a case of a woman with a 1-year history of recurrent epigastric and periumbilical abdominal pain with intermittent vomiting caused by phytobezoar of the terminal ileum. After careful investigation of the case and review of literature, we identified the factor involved in bezoar formation as radiation-induced ileal stenosis due to previous treatment for a pelvic tumour. This report provides evidence to consider phytobezoar as a possible cause of small bowel obstruction in patients previously treated with abdominal radiotherapy.

Fully Covered Removable Nitinol Self Expandable Metal Stents (SEMS) in Benign Esophageal Diseases: A Multicenter Analysis

Background: Fully covered esophageal stents are thought to induce less mucosal hyperplasia and are potentially removable, and therefore have been considered as an attractive alternative for the treatment of benign esophageal diseases. However, large scale studies with long-term data on their effectiveness, safety and removability are lacking. Aim: To evaluate the efficacy and safety of fully covered removable Nitinol esophageal SEMS in the treatment of benign esophageal diseases. Materials and Methods: Between January 06 and September 07, 35 patients (18 males with mean age 61 years, range 20-85 years) underwent SEMS placement (ALIMAXX, Alveolus) (18 or 22 × 70, 100 or 120 mm) for benign esophageal strictures at two tertiary academic medical centers. Response to treatment as well as short and long-term complications were documented. Results: Indication for stent placement was: Esophageal leak/fistulae (n = 12), refractory benign strictures (including reflux disease, pill and lye induced) (n = 10), anastomotic strictures (n = 7), perforations (n = 4), and radiation-induced strictures (n = 2). All SEMS placements were successful. Technical problems encountered during deployment included 4 partial invaginations (11%). Immediate complications were chest pain (2), stent migration (2) dysphagia (1), respiratory compromise (1) and arrhythmia (1). Long-term complications included recurrent dysphagia (6), aspiration pneumonia (2), globus sensation (2), abdominal pain (2) and fever (1). Stent migration was observed in 12 patients (34%), and was more frequent in distal (5/9, 56%) and upper (4/11, 36%) compared with mid esophageal (3/15, 20%) stents. Migration was more frequent in stents placed for strictures (7/19 stents, 37%), and fistulae/leak (4/12 stents, 33%) compared with perforation (1/4 stents, 25%) with p values of 0.614 and 0.339 respectively. Post placement, dysphagia scores at one month improved significantly from 3.1 ± 1.0 (range: 0-4) to 1.2 ± 1.3 (range: 0-4), p value < 0.0001. A total of 11/35 patients (31%) had successful treatment defined as resolution of presenting symptoms with sustained response after stent removal. All stents were retrieved successfully. One stent was fractured and retrieved completely in two pieces. Conclusion: Use of SEMS for benign esophageal conditions resulted in frequent stent migration and long-term improvement in a third of patients. Further investigation is required before universally recommending SEMS in the treatment of benign diseases of the esophagus. The subset of patients that can benefit from stent placement for benign esophageal disorders requires further investigation and definition.