Refractory Benign Esophageal Strictures Research Articles

Efficacy and safety of radial incision and cutting for nonsurgical refractory benign esophageal stricture.

Background and study aims Radial incision and cutting (RIC) was established to improve refractory esophageal anastomotic strictures but its efficacy and safety for nonsurgical refractory strictures remain unclear. To evaluate the usefulness of RIC in nonsurgical refractory strictures, we retrospectively compared outcomes between nonsurgical and surgical strictures. Patients and methods We retrospectively studied 54 consecutive patients who were initially treated with RIC for refractory benign esophageal stricture. The study variables included dysphasia score improvement rate, frequency of repeated RIC, cumulative patency rate, cumulative stricture improved rate, and adverse events(AEs), which were compared between nonsurgical (n = 21) and surgical (n = 33) stricture groups. Results Immediately after RIC, 90.5% of patients in the nonsurgical group and 84.8% of patients in the surgical group had improvement in dysphagia ( P = 0.69). The frequency of intervening repeated RIC was 42.9% in the nonsurgical group and 42.4% in the surgical group ( P = 0.98). During median follow-up of 22.3 months (range, 1.0-175.0), the cumulative patency rate ( P = 0.23) and cumulative stricture improvement rate ( P = 0.14) but there was not statistical difference between the two groups. Despite a low cumulative stricture improvement rate (9.5%) at 6 months after the first RIC in the nonsurgical group, 57.7% of patients no longer required endoscopic balloon dilatation at 2 years. The cumulative stricture improvement rate was significantly lower in patients with a history of radiation therapy. No severe AEs were observed in the nonsurgical group. Conclusions RIC for nonsurgical refractory benign esophageal stricture is an effective and safe treatment option.

Esophageal Self-Dilation in Benign Refractory Esophageal Strictures: Outcomes from a Randomized Controlled Trial and a Prospective Observational Study

BackgroundPatients with benign esophageal strictures may not maintain a response to endoscopic dilation, stenting, incisional or injectional therapies. For patients with these refractory esophageal strictures, esophageal self-dilation therapy (ESDT), performed to maintain luminal patency, may provide persistent symptomatic benefit while reducing patients’ reliance on healthcare services and the risk associated with repeated endoscopic procedures.AimsThe aim of this study was to evaluate the efficacy and safety of EDST in a randomized controlled trial and prospective observational study.MethodsTwenty-five patients with refractory benign esophageal strictures were recruited at two esophageal clinics between November 2018 and June 2021. Twelve patients participated in the randomized trial and 13 in the prospective observational study. The number of endoscopic dilations, impact of therapy on dysphagia, adverse events, and complications were recorded.ResultsIn the randomized study, 50% of patients performing ESDT and 100% of controls required endoscopic dilation during follow-up (P = 0.02). In the observational study, the median (IQR) number of endoscopic dilations fell from 7 [7–10] in the 6 months prior to commencing ESDT to 1 [0–2] in the 6 months after (P < 0.0001). Most patients (22/25) were able to learn self-dilation. Few serious adverse events were noted. Dysphagia severity remained unchanged or improved.ConclusionsESDT appears to be a safe effective therapy for benign esophageal strictures refractory to endoscopic treatment.Clinical Trial NumberNCT03738566.

Update on applications of endoscopic cryotherapy in the gastrointestinal tract.

Endoscopic cryotherapy has emerged as a minimally invasive procedure for targeted tissue ablation within the gastrointestinal tract. This review aims to provide a comprehensive overview of current clinical applications of EC with a review of the pertinent literature. Endoscopic cryotherapy has demonstrated safety and efficacy for various gastrointestinal conditions. Recent studies have highlighted the efficacy of endoscopic cryotherapy, including both liquid nitrogen-based spray cryotherapy and the novel cryoballoon focal ablation system, in achieving complete eradication of dysplasia and neoplasia in Barrett's esophagus. Endoscopic cryotherapy has also shown promise as a second-line treatment option for patients with dysplastic Barrett's esophagus refractory to radiofrequency ablation and as an alternative to surgical resection for duodenal adenomas, when endoscopic resection is not feasible. Innovative applications for the treatment of gastrointestinal bleeding and management of benign refractory esophageal strictures have also been reported. Endoscopic cryotherapy represents a safe, effective, and well tolerated therapeutic option for various clinical scenarios in gastrointestinal endoscopy, including challenging disease states such as refractory Barrett's esophagus and advanced esophageal cancer. Advancements in cryotherapy technology and ongoing research continue to explore additional clinical indications and expand the role of endoscopic cryotherapy in patient care with an aim toward improved patient outcomes.

A novel self-inflatable balloon for treating refractory benign esophageal strictures: a prospective, single-arm, multicenter study.

Current treatments for refractory benign esophageal strictures (BESs) often take several years and have poor effects. The authors propose a novel method of self-help inflatable balloon (SHIB) and evaluate its efficacy and safety. A prospective, multicenter study was conducted from January 2019 to March 2022. All enrolled patients were diagnosed with refractory BESs and received SHIB. The primary endpoint was the clinical success rate at 12 months after removing SHIB. The secondary endpoints were the number of days of placing SHIB, and changes from baseline in BMI and health-related quality of life at 1, 3, 6, and 12 months. The clinical success rate was 51.2% (21/41) with the median days of placing SHIB being 104.0 days (range: 62.0-134.5 days), which was higher in the endoscopic group compared to the caustic and surgery groups (63.3 vs. 28.6% vs. 0, P=0.025). All patients (100%) showed significant improvement in dysphagia scores during placing SHIB. Although 20 patients (48.8%) experienced recurrent stricture, the median stricture length was decreased (P<0.001) and the median intervention-free interval was prolonged (P<0.001). In all patients, the mean BMI at and health-related quality of life at 1, 3, 6, and 12 months were significantly increased compared with baseline (P<0.05). On multivariate analysis, stricture etiology and wearing time were independent predictors of recurrent stricture. The SHIB has high efficacy and safety in treating refractory BESs of different origins, especially for endoscopic resection. Stricture etiology and wearing time were independent predictors of recurrent stricture.

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.

RISK FACTORS FOR REFRACTORY BENIGN ESOPHAGEAL STRICTURES

Background: The management of patients with refractory benign esophageal stricture is time-consuming and challenging. Dilation is the classic treatment for esophageal strictures, expressed primarily as dysphagia, which can significantly impair quality of life.Our objective is to report the results of dilatation, as well as the different risk factors of refractory benign esophageal strictures. Methods: This is a single-center retrospective study. Thirty-three patients with benign esophageal strictures were treated by dilation between 2016 and 2021. Refractory stenosis was defined as the inability to maintain esophageal caliber at 14 mm diameter over 5 dilatation sessions, or the inability to maintain satisfactory luminal diameter for 4 weeks once a 14 mm diameter was achieved. Results: 12 patients had refractory strictures. All patients had dysphagia.After univariate analysis, refractory strictures were associated with the presence of a peptic stenosis (p=0.002) and dilatations of caliber less than 16 mm (p=0.012), after multivariate analysis only peptic stenosis was associated with refractory stenosis (p=0.034). Conclusion: In our series, refractory stenosis was present in 38.7%. Peptic stenosis was statistically significantly associated with refractory esophageal stenosis.

Validity and Reliability of the European Organization Research and Treatment of Cancer Quality of Life Questionnaire-Oesophagogastric 25 in Indian Patients With Corrosive-Induced Benign Refractory Esophageal Strictures.

Background The European organization Research and Treatment of Cancer Quality of Life Questionnaire-Oesophagogastric 25 (EORTC QLQ-OG 25) is designed for patients with esophagogastric cancer. Its performance has never been tested with benign disorders. A health-related quality-of-life questionnaire does not exist for patients with benign corrosive-induced esophageal strictures. Hence, we evaluated the EORTC QLQ-OG 25 in Indian patients with corrosive strictures. Methods The English or Hindi version of QLQ-OG 25 was administered to 31 adult patients undergoing outpatient esophageal dilation at GB Pant hospital, New Delhi. These patients had refractory or recurrent esophageal strictures due to corrosive ingestion and had not undergone reconstructive surgery. Score distribution was analyzed, and item performance was determined based on floor and ceiling effects. Convergent validity, discriminant validity, and internal consistency were checked. Results The average time to finish the questionnaire was 6.70 minutes. Most scales fulfilled convergent validity (corrected item-total correlation >0.4), barring the Odynophagia scale and one item of the Dysphagia scale. Most scales exhibited divergent validity except for odynophagia and one item of dysphagia. Cronbach's alpha was >0.70 for all scales except odynophagia. Responses to questions evaluating taste, cough, swallowing saliva, and talking were highly skewed and had prominent floor effects. Overall, the questionnaire demonstrated good internal consistency, convergent validity, and divergent validity in benign corrosive-induced refractory esophageal strictures patients. Conclusion The EORTC QLQ-OG 25 can be satisfactorily used in patients with benign esophageal strictures to assess health-related quality of life.

Efficacy and safety of repeated endoscopic radial incision and cutting procedure for benign esophageal stricture.

Background and study aims: Radial incision and cutting (RIC) is indicated for refractory benign esophageal strictures after curative treatment for esophageal cancer and has shown favorable short-term outcomes. However, re-stricture after RIC may occur in the long term, and RIC is performed repeatedly in such cases, but the efficacy and safety of repeated RIC are unclear. Therefore, we aimed to demonstrate the efficacy and safety of the repeated RIC for refractory benign esophageal strictures after surgical and non-surgical treatment. Patients and methods: Between April 2008 and September 2019, we enrolled patients who were treated with the first RIC for benign esophageal strictures. The RIC was indicated for the refractory stricture and repeatedly performed for re-refractory esophageal stricture after RIC. We retrospectively evaluated the 6-month refractory stricture-free rate, and adverse events (AEs) in the first RIC and repeated RICs. Results: Forty-six patients (39 men, 7 women; median age, 71 years, range 49-85) were included. RIC was performed once in 24 patients (non-repeated RIC group) and two or more times in 22 patients (repeated RIC group). In all patients, the 6-month refractory stricture-free rate after the first RIC were 42.3 %. In the repeated RIC group, the 6-month refractory stricture-free rate after the first and repeated RICs were 18.2 % vs 18.2 %, respectively. No AEs were noted. Conclusions: Repeated RIC could be effective in the short-term and safe even for patients with refractory benign esophageal stricture after the first RIC. However, it cannot be considered curative treatment for refractory stricture because of poor long-term results.

Endoscopic radial incision versus endoscopic balloon dilation as initial treatments of benign esophageal anastomotic stricture.

We aim to evaluate the efficacy and safety of endoscopic radial incision (ERI) versus endoscopic balloon dilation (EBD) treatment of naïve, recurrent, and refractory benign esophageal anastomotic strictures. One hundred and one ERI, 145 EBD, and 42 ERI combined with EBD sessions were performed in 136 consecutive patients with benign esophageal anastomotic stricture after esophagectomy at Zhongshan Hospital from January 2016 to August 2021. Baseline characteristics, operational procedures, and clinical outcomes data were retrospectively evaluated. Parameters and recurrence-free survival (RFS) were compared between ERI and EBD in patients with naïve or recurrent or refractory strictures. Risk factors for re-stricture after ERI were identified using univariate and multivariate analyses. Twenty-nine ERI versus 68 EBD sessions were performed for naïve stricture, 26 ERI versus 60 EBD for recurrent strictures, and 46 ERI versus 17 EBD for refractory stricture. With comparable baseline characteristics, RFS was greater in the ERI than the EBD group for naïve strictures (P=0.0449). The ERI group had a lower 12-month re-stricture rate than the EBD group (37.9% vs 61.8%, P=0.0309) and a more prolonged patency time (181.5±263.1 vs 74.5±82.0, P=0.0233). Between the two interventions, recurrent and refractory strictures had similar RFS (P=0.0598; P=0.7668). Multivariate analysis revealed initial ERI treatment was an independent predictive factor for lower re-stricture risk after ERI intervention (odds ratio=0.047, P=0.001). Few adverse events were observed after ERI or EBD (3.0% vs 2.1%, P=0.6918). ERI is associated with lower re-stricture rates with better patency and RFS compared with EBD for naive strictures.

S2259 The Efficacy and Safety of Treatment Outcomes for Refractory Benign Esophageal Strictures Using a Novel Combination of Needle-Knife Stricturoplasty, Balloon Dilation, and Steroid Injection

Introduction: Benign esophageal strictures that are refractory to standard endoscopic techniques can significantly impair a patient’s quality of life leading to complications such as malnutrition and weight loss. When repeat dilations fail to achieve an adequate luminal diameter or resolve dysphagia, further therapy with needle knife or steroid injections are needed. However, patients can still clinically fail. In an effort to manage such strictures we employed a novel triple combination of needle-knife stricturoplasty, balloon dilation, and steroid injection to assess clinical outcomes and safety. Case Description/Methods: This was a single center retrospective study of all adult patients with benign strictures that were refractory to conventional endoscopic therapy and removable self-expanding metal stenting. The triple therapy consisted of at least 4 longitudinal needle knife incision followed by balloon dilation and then targeted 4 quadrant intralesional steroid injections (Figure). Primary success was defined as a 50% reduction in repeat endoscopic therapy needed. Secondary outcomes included periodic dilation index, esophageal diameter changes, technical success, and complications. Four patients (average age 49.7 years, average body mass index 22.8 kg/m2) underwent endoscopic therapy for complex benign strictures using our triple therapy technique (Table). Stricture etiologies included peptic strictures (n= 3) and an anastomotic stricture (n=1). All patients previously required esophageal stenting (range 1-3). There was 100% technical success rate with no adverse events. The average diameter of the esophagus before and after triple therapy was 4.2 ± 1.63 mm and 13 ± 1.36 mm, respectively. The periodic dilation index was 6.3 (range 12-2) before and 1.5 (range 5–0) after triple therapy. The mean length of follow up was 316 days (range 116-425). Discussion: Triple combination therapy may be useful in benign strictures that are refractory to standard techniques. We do recommend needle knife before dilation to enhance the efficacy of steroid injections. In light of our findings, this method should be considered when strictures are refractory after 2-3 dilation sessions and/or stent therapy. Larger studies are needed to validate these findings and identify predictive factors that can enhance clinical success using this novel combination.Figure 1.: Esophageal stricture (A) that was treated with needle knife (B), balloon dilation (C) and then steroid injections (D). Table 1. - Patient characteristics and clinical outcomes Patient Age/Sex Stricture Etiology Initial stricture diameter Stricture diameter after triple therapy Number of triple therapy procedures Length of follow up (days) 1 30/Male GERD 7 mm 13.5 mm 1 425 2 59/Male Anastomotic 3 mm 15 mm 2 421 3 57/Male GERD 3 mm 11.5 mm 4 304 4 53/Male GERD 4 mm 12 mm 2 116

ИНТРАМУРАЛЬНЫЕ ИНЪЕКЦИИ ТРИАМЦИНОЛОНА (КЕНАЛОГ) В ЭНДОСКОПИЧЕСКОМ ЛЕЧЕНИИ СЛОЖНЫХ РУБЦОВЫХ СТРИКТУР ПИЩЕВОДА И АНАСТОМОЗОВ

Abstract. Approximately one third of patients with complex strictures of the esophagus and esophageal anastomoses develop restenosis after a course of endoscopic bougienage. To prevent this, we have developed a tactic of long-term planned maintenance bougienage for 6-24 months, which is successfully used in the clinical practice of the endoscopy department of the Petrovsky National Research Center of Surgery for many years. Recently, to improve the results of endoscopic bougienage of refractory benign esophageal and esophageal anastomotic strictures and strictures with the tendency to restenosis or recurrence, we have been using intramural steroid injections according to our scheme. To date, the technique has been applied in 65 patients (esophageal strictures — 44, strictures of esophageal anastomoses — 21). Comparison of the immediate results of endoscopic bougienage, supplemented by the introduction of Dexamethasone and Kenalog, showed the advantage of the latter. There were no complications of intramural steroid therapy in the course of endoscopic bougienage. Our still little experience with the use of intramural injections of triamcinolone acetate (Kenalog) in the course of long-term planned endoscopic bougienage of complex recurrent and refractory strictures of the esophagus and esophageal anastomoses indicates that this technique is promising.

Individually designed fully covered self-expandable metal stents for pediatric refractory benign esophageal strictures

To share our institutional experience of placing individually designed fully covered self-expandable metal stents (FCSEMSs) for the treatment of refractory benign esophageal strictures (RBESs) in pediatric patients. A 10-year retrospective study between May 2009 and July 2020 that includes 14 children with RBESs who were treated with individually designed FCSEMSs. Patients were followed-up regularly after stent placement to observe the improvement of vomiting and dysphagia, changes in stenosis diameter and complications. A total of 20 stents were successfully placed in 14 patients. During a follow-up period ranging from 5 to 83 months, except for one 4-year-old child who could not endure chest pain, the remaining 13 patients all benefited from stenting. Their Ogilvie & Atkinson scores improved from grade III–IV to grade 0-I, and the diameters of the stenosis’ were enlarged from 2–5 mm to 9–14 mm. Two patients developed restenosis and granulation tissue hyperplasia was found in 2 patients and stent migration and malapposition in 2 patients with esophageal perforations that required further endoscopic intervention. The use of FCSEMS for RBES is safe and effective in selected pediatric patients. Rationally designed stents and timely management of postoperative complications are critical to ensure the success of this new method.

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.

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 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.

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

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

The management of esophageal strictures by using self-expanding metallic stents

Esophageal stents are an important tool for palliative treatment of inoperable or recurrent esophageal cancer; and broncho-esophageal fistula; to bypass refractory benign stenosis. Our work aims are to study the indication of self-expanding metallic stents for esophageal strictures, as well as the challenges, and complications of their placement. Between May 2016 and November 2019, 10 esophageal stents placement procedures were performed on 9 patients. The placement of the esophageal stent was performed by using a guidewire. Radioscopic control has been systematically carried out, and all patients were monitored 24 hours after the procedure. Nine patients were included in this study, 77.7% (n=7) were male and 22.3% (n=2), were female, the average age was 54 years (18-67 years). All stents have been successfully placed. The average follow-up for the procedures was 24 weeks. 33.33% (n=3) of the patients had a stent migration treated by the placement of another stent in 11.1% (n=1). No stent occlusion and no complications were noted. The food recovery was again possible in all cases. The evolution was marked by the death in 33.3 % (n=3), fistula closure in 22.2% (n= 2) and persistent of stricture in 11.1% (n=1). Esophageal stents remain an important tool for the management of malignant esophageal diseases and refractory benign esophageal stricture. The simplicity and the functional success of the majority of cases, make them highly recommended as palliative treatment, as the success rate in our study was 66.7% (n=7).

Sa2002 THE CLINICAL EFFICACY OF ENDOSCOPIC POSTDILATION INTRALESIONAL INJECTION OF MITOMYCIN-C IN ADULT PATIENTS WITH REFRACTORY BENIGN ESOPHAGEAL STRICTURE

Refractory benign esophageal stricture (RBES) still remains as a clinical challenge, even though repeated endoscopic therapies with bougie or balloon dilation has clinically been tried. Intralesional Mitomycin-C (MMC) injection has recently been introduced to resolve it mostly in children. The aim of this study was to evaluate the clinical efficacy of endoscopic postdilation intralesional injection of MMC in adult patients with RBES. The patients who had RBES even after five or more sessions of bougination were prospectively enrolled. A submucosal needle injection of 4mL of a MMC preparation (0.5mg/mL) was endoscopically done with a 0.5mL of eight each injection mainly into the tearing esophageal wall, after esophageal bougie dilation had done up to 14mm in diameter. Additional therapy of bougination alone or combined with MMC injection was done, if dysphagia symptoms recurred with dysphagia score 3 or more. It was considered as treatment failure if there was no clinical improvement even after 3 additional MMC injections with the interval of 8 weeks. Initial and overall clinical success rates were evaluated with drug- and procedure-related complication rates during the follow-up period of at least 12 months after last MMC injection. Thirteen of 16 patients enrolled in this study were evaluated except 3 patients who had been dropped out. The causes of esophageal stricture were post-operative stricture in 6, corrosive in 5, post-ESD in 1, and peptic in 1 patient. The lengths of stricture were less than 1cm in 5 and longer than 5cm in 2 patients. In 7 patients, GOOSS scores were significantly improved after single MMC injection and consistently kept without further treatments during follow-up period (median, 369 days) with 53.8 % (7/13) of initial clinical success rate. Of the remaining 6 patients, additional MMC injections were performed once more in 3, 2 more in 1, and 3 more times in 2 patients during follow-up, resulting in significant improvement of dysphagia in 4 patients out of them with 84.6% (11/13) of overall clinical success rate. Two patients who failed in achieving overall clinical success after 3 more MMC injections had longer stricture than 5cm in length. The major drug- and procedure-related complications did not occur in any patients during follow-up. Endoscopic postdilation intralesional injection of MMC was safe and effective in adult patients with RBES, especially whom shorter length (<5cm) of esophageal stricture exist.

Biodegradable esophageal stents for the treatment of refractory benign esophageal strictures.

This review attempts to present the available evidence regarding the use of biodegradable stents in refractory benign esophageal strictures, especially highlighting their impact on clinical success and complications. A comprehensive literature search was conducted in PubMed, using the terms “biodegradable” and “benign”; evidence from cohort and comparative studies, as well as data from one pooled analysis and one meta-analysis are presented. In summary, the results from these studies indicate that the effectiveness of biodegradable stents ranges from more than one third to a quarter of cases, fairly similar to other types of stents used for the same indication. However, their implementation may reduce the need for re-intervention during follow up. Biodegradable stents also seem to reduce the need for additional types of endoscopic therapeutic modalities, mostly balloon or bougie dilations. Results from pooled data are consistent, showing moderate efficacy along with a higher complication rate. Nonetheless, the validity of these results is questionable, given the heterogeneity of the studies included. Finally, adverse events may occur at a higher rate but are most often minor. The lack of high-quality studies with sufficient patient numbers mandates further studies, preferably randomized, to elucidate the exact role of biodegradable stents in the treatment of refractory benign esophageal strictures.

1828 CryoDilation: A Novel Treatment for Benign Esophageal Strictures Using Liquid Nitrogen Spray Cryotherapy

INTRODUCTION: Liquid nitrogen spray cryotherapy (SCT) was developed for endoscopic treatment of Esophageal Cancer and Barrett’s Esophagus. It has been shown to be a safe and effective therapy. Pulmonologists and thoracic surgeons have used SCT for treatment of benign tracheal strictures and stenoses with reduced severity of airway narrowing and symptomatic improvement. We describe the successful use of SCT in a recurrent, benign esophago-gastric anastomotic stricture, highlighting its potential as a new alternative treatment modality. CASE DESCRIPTION/METHODS: A 52-year-old female with stage T1 esophageal adenocarcinoma status-post laparoscopic thoracoscopic Ivor-Lewis esophagectomy presented to clinic 3 months following surgery for dysphagia. An esophagogastroduodenoscopy (EGD) revealed an esophago-gastric anastomotic stricture. Over the next 4 years, the stricture recurred despite monthly EGDs with dilations, steroid injections, and stent placement. Her course was complicated by dysphagia, food impactions, and severe protein-calorie malnutrition requiring total parenteral nutrition (TPN). The decision was made to perform Cryodilation. The patient then underwent seven EGDs with cryodilation over seven months. During the procedure, liquid nitrogen spray was administered for 20 seconds, followed by 60 seconds of thaw time, for a total of three freeze-thaw cycles and stricture then dilated up to 18mm. Prior to the first EGD with cryoablation, she recorded her lowest weight within 5 years at 49.4 kg (BMI 16.4). After initiating these procedures, the patient experienced marked functional and clinical improvement. After only three cycles, she began eating soft foods again. After five cycles, her weight peaked at 58.9 kg (BMI 19.7), which she maintained for 8 months. After six cycles of therapy she was able to discontinue TPN. Since cryodilation, she has had no further weight loss nor episodes of food impaction and the time between endoscopic dilation procedures has lengthened considerably. DISCUSSION: This case demonstrates a severe recurrent esophago-gastric anastomotic stricture which was unresponsive to aggressive, frequent traditional management. This novel and previously unreported method of serial cryotherapy with dilation greatly improved this patient’s symptoms and functional status. This method is a potential safe and effective primary treatment or adjunct modality for refractory benign esophageal strictures.