Treatment Of Benign Esophageal Strictures Research Articles

Paclitaxel-coated balloon catheter for benign esophageal stenosis in a rabbit model

Most patients with benign esophageal stenosis require multiple or even continuous balloon dilation treatments to achieve symptom relief. In this study, eighteen rabbits were used to establish an esophageal benign stenosis model and were divided into a control group (n = 6), a balloon group (n = 6) and a PTX-coated balloon group (n = 6) to evaluate the feasibility and effectiveness of paclitaxel (PTX)-coated balloons for the rabbit esophageal benign stenosis model. The weight and esophageal diameter were recorded every 2 weeks until 8 weeks post-surgery. Hematoxylin–eosin staining, Masson’s trichrome staining and immunohistochemical staining were performed for pathological analysis. Four weeks post-operation, there was a significant difference in weight between the control group and the balloon group (p = 0.01) and between the control group and the PTX balloon group (p = 0.01). There was a significant difference in the esophageal diameter between the balloon group and the PTX balloon group at 8 weeks post-operation (p = 0.02). Four weeks post-operation, the degree of inflammatory cell infiltration in the PTX balloon group was significantly lower than that in the control group (p = 0.002) and balloon group (p = 0.001). The degree of collagen deposition in the PTX balloon group was significantly lower than that in the control group (p = 0.002) and balloon group (p = 0.03). Eight weeks post-operation, the percentage of cells positive for TGF-β (p < 0.001), the degree of inflammatory cell infiltration (p = 0.02) and the degree of collagen deposition (p = 0.02) in the PTX balloon group were significantly lower than those in the balloon group. Therefore, PTX-coated balloons may alleviate the local inflammatory response and collagen deposition when used during dilation treatment of benign esophageal stenosis.

Is a higher frequency of esophageal dilations more effective in treating benign esophageal strictures? Retrospective, multicenter study.

Background and study aims There is still a lack of evidence-based recommendations concerning endoscopic bougienage in benign esophageal strictures. Our study aimed to assess the relevance of the time interval between endoscopic dilation (ED) sessions with regard to endoscopic and clinical response. Patients and methods We performed a retrospective study including patients treated with endoscopic bougienage for a benign esophageal stricture in two German centers. Primary endpoint was the number of ED until freedom from dysphagia was achieved. Secondary endpoints were analyses on reaching a diameter of 15 mm and on achieving clinical freedom from symptoms. Results Between April 2014 and March 2020, bougienage was used as the primary treatment for benign esophageal strictures in 238 patients (194 patients in Center 1; 44 patients in Center 2). Both centers differed in their endoscopic bougienage regime: Center 1 was characterized by a higher frequency of interventions compared to Center 2 (median: 2 days [range 1-28] vs. 10 days [range 1-41]; P <0.001). Clinical response was achieved significantly earlier using the high-frequency regimen in all patients except for those with post-radiogen strictures, who clinically benefited from a low-frequency ED program. Accordingly, patients receiving higher-frequency ED reached a significantly larger post-dilation diameter and considerably larger diameter differences. Conclusions The results of our study demonstrate that a treatment concept consisting of higher-frequency bougienages seems to be more effective in treating most types of esophageal stricture. Radiogenic strictures were the only types of stenoses that benefited from a lower frequency ED program.

Dilation of benign esophageal strictures with balloon/bougie; a single center experience

Objective: Narrowing in the esophagus caused by benign conditions such as peptic injury, surgical anastomosis, radiation therapy, Schatzki rings, esophageal webs, erosive injury and eosinophilic esophagitis are called benign esophageal strictures. In the treatment of benign esophageal stricture, endoscopic dilation with balloon or bougie is the first priority. Method: The study included a total of 96 patients who were diagnosed with a benign stricture at the gastroenterology clinic of our university from May 2009 to October 2023. All patients were symptomatic, and their main complaint was dysphagia. The benign stricture was diagnosed through clinical examination, radiological imaging and endoscopy. Patient data were scanned retrospectively. The dilation method (bougie, balloon), the number of times the procedure was permormed and any potential complications were recorded. Stents were applied to patients who did not provide adequate dilatation. Results: A total of 96 patients were included in the study. 47 (49%) of them were women and 49 (51%) were men. The average age was 48±17 years (the youngest was 18, the oldest was 81). A total of 198 dilation procedures were performed on 96 patients. The average follow-up period was 79±54 (1-179) months. Srictures were divided into 4 groups according to etiology as anastomotic stricture, peptic stricture, caustic stricture and post-radiotherapy stricture. Of the cases with stricture, 76 (79.2%) underwent bougie dilation, 26 (27.1%) underwent balloon dilation, 5 (5.2%) underwent bougie and then balloon dilation, and in 5 (5.2%) cases, metallic stent was placed due to failed dilations. Conclusion: This study shows the effectiveness of bougie and/or balloon dilation in treating most of the patients with benign esophageal strictures, with a low complication rate. It is less invasive, comfortable and cost-effective than the alternative surgical approach.

Esophageal dilation through bouginage or balloon catheters in children, as the treatment of benign esophageal strictures: results, considering the etiology, and the methods.

Corrosive substance ingestion, history of esophageal surgery, and reflux esophagitis are the main causes of benign esophageal strictures in children. Esophageal dilation is the first treatment option. Bougies and balloons are the most frequently used dilation tools. The literature record on esophageal dilation methods and their results is mostly composed of data gathered from adults, who differ from children in many terms, including etiology, indications, and results. This study aims to evaluate esophagial dilation in children; comparing the two mentioned modalities; and considering the impact of different diseases on dilation success. The benign esophageal stricture cases who had undergone esophageal dilation between 2001 and 2009, at two tertiary health-care centers of a university were evaluated retrospectively with regard to stricture etiology, treatment methods, and their results. In addition, balloon and bougie dilations were compared. Fifty-four cases were dilated in 447 sessions. The strictures were due to corrosive ingestion or anastomoses in 72.2% of the cases. Of the dilation sessions, 52.6% were performed with Savary-Gilliard bougies, and the rest with balloon dilators. No guidewire was needed in 53.2% of the bougie sessions. Fluoroscopy was used during balloon dilation sessions as a routine part of the method, while it was needed only to check the guide location when needed during the bougie dilation sessions. The complication rates of balloon and bougie dilation sessions were 2.4% and 2.1%, respectively. The mean session length was 26.2±11.8 and 42.6±13.7 min, for bougie and balloon, respectively. Success rate was 93.7% for the balloon, while 98.2% of the bougie sessions. Balloon catheters used were disposable. Savary-Gilliard bougies have advantages over balloon catheters with less need of fluoroscopy, shorter duration of sessions, and lower cost. Both methods are equivalently safe with close complication rates.

Which endoscopic treatment is effective for the treatment of benign esophageal stricture: balloon or incision?

Which endoscopic treatment is effective for the treatment of benign esophageal stricture: balloon or incision?

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 &lt;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.

Fluoroscopy-guided balloon dilatation of benign esophageal strictures in children: 11-year experience.

The esophageal stricture is an important clinical problem in children, and the treatment is difficult. To evaluate the results of fluoroscopy-guided balloon dilatation of benign pediatric esophageal strictures and to suggest a safety range for balloon diameters. We retrospectively reviewed the medical records of children who underwent fluoroscopy-guided esophageal balloon dilatation for treatment of benign esophageal stricture from February 2008 to July 2019. We recorded the demographic data of the children, technical details of each procedure, balloon diameter, number of repeated procedures, clinical and technical success rates, complications and follow-up period. Technical success was defined as the disappearance of the waist formation on the balloon catheter, and clinical success was defined as no need for re-dilation or other treatment methods during the 1-year follow-up after the procedure. These children were divided into groups and evaluated according to esophageal stricture etiology. Technically successful procedures included 375 balloon dilatations in 116 patients (67 boys; age range: 1month to 18years; mean age: 4.3 ± 4.8 standard deviation [SD] years at the initial dilatation). The follow-up period was 1-138months (median: 41months; mean: 44months) since the last dilatation. In this study, the clinical success rate was 34% per procedure (120 of 353 procedures) and 85% per patients (91 of 107 patients). The total complication rate per procedure was 0.5%, and the perforation rate was 0.25% per session. Fluoroscopy-guided esophageal balloon dilatation is an effective and reliable method for treating benign esophageal strictures in children.

Contactless Measurement of Integrity of Silicone Coating on Self-Expandable Esophageal Nitinol Stents.

A stent is a mesh tube inserted into a natural passage in the body to prevent disease induction. Self-expandable esophageal nitinol stents such as SX-ELLA Stent Esophageal HV (HV Stent Plus) can be indicated for palliation of malignant esophageal strictures, for the treatment of benign esophageal strictures that are refractory to standard therapy and for the treatment of esophago-respiratory fistulas. A silicone-stent coating is used for tumor in-growth prevention and esophago-respiratory fistula occlusion. The thickness of the stent and the overall integrity of the silicone coating of all wires indicate the overall mechanical properties of the esophageal stent and the resistance to external adverse events such as corrosion and mechanical and chemical resistance. The polymer multicomponent epoxy resin - a mixture of Epon and Durcupan - was used as a method for robust sample stabilization. A cutting system using a thin water beam with a powder (Blue Line) was chosen as the best variant to obtain 6 samples for both-sided measurement (10 measuring sides). The optical microscopic reflective light method was used to examine wire crossing points in the sections. Fifty values were measured on either sample side for the internal, external and mesh thickness of the silicone stent layer. The wire crossing points were selected so that the silicone layer structure could be clearly seen, and the wires approached each other most closely. Only approximately 4 to 8 crossing points in each section could be measured when applying this approach. The resolution of the microscope and calibration (based on the camera used) was 0.677 μm/pixel. Additional data could be obtained on 8 planes. Two boundary samples were destroyed by the cutting process. Whole coating of the stent was around all mesh wires, especially in areas with higher mechanical stress (wire crossing). The minimum detectable and admissible value determined for all 3 measuring areas (internal, external, mesh) on the wire crossings was 6.77 μm, i.e., 10 pixels, based on the microscope resolution and manufacturer's methodology. The results were characterized by p < 0.001 for all 3 parameters. We tested opposite samples in each section to verify the section quality and data consistency. For the 4 areas, the data were significantly different, but the thickness differences were only on the order of units percent, so the measurements were not appreciably affected. We assume that the material cutting loss, making up 1-2 mm, contributed to the differences in the sections. We examined the overall integrity of the silicone coating of the esophageal stent. The method of HV stent anchoring in a polymeric bath followed by cutting with a waterjet and sample measurement under an optical microscope proved to be very simple and reliable. Sufficient thicknesses of the silicone layer on the wire cross sections were verified. The coated silicone layer thickness appeared to be significantly different along the stent from the proximal part to the distant part, presumably due to the manufacturing technology.

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.

Эндоскопическое стентирование при рефрактерных доброкачественных стриктурах пищевода (обзор)

Despite the fact that the overwhelming majority of benign esophageal strictures, although long-term, but effectively stop with the help of endoscopic recanalization, 10% of them recur. Such strictures are a major problem in thoracic surgery. Disabled surgical methods of treatment are associated with a sufficiently high mortality rate and do not guarantee the formation of new anastomotic strictures. Esophageal stenting against the background of a limited endoscopic arsenal of methods for recanalization of benign strictures is the last option. A lot of different models of esophageal stents with their own individual characteristics and features have appeared since the introduction of the first stents in clinical practice. All were investigated in an attempt to identify the optimal stent type and design for the treatment of refractory benign strictures. The review is devoted to the current state of stenting in recurrent benign esophageal stenosis. The review reflects the efficacy and disadvantages of various types of stents and their comparison with a focus on new biodegradable stents used in the treatment of benign esophageal strictures.

Novel Biodegradable PTX-PLGA-Coated Magnesium Stent for Benign Esophageal Stricture: An Experimental Study

Metal or plastic stent implantation is the most common treatment for benign esophageal stricture. Biodegradable stents, with unsatisfied radial force, can degrade step by step and thereby avoiding secondary surgical removal compared with metal stents. Herein, a novel biodegradable composite stent, with poly(lactic-co-glycolic acid) (PLGA) containing paclitaxel (PTX) coated the surface of the magnesium (Mg)-based braided stent, was designed and tested. By adding this drug-loaded polymer coating, the radial force of the stent increased from 32.56 Newton (N) to 82.64 N. PTX continuously released as the stent degraded, and the in vitro cumulative drug release in phosphate buffer saline for 28 days were 114.52 ± 13.47 μg/mL (pH = 7.4) and 176.10 ± 11.95 μg/mL (pH = 4.0). There was no statistically significant difference in the viability of fibroblasts of stent extracts with different concentration gradients (P > 0.05), while the PTX-loaded stents effectively promoted fibroblast apoptosis. In animal experiment, the stents were able to maintain the esophageal patency during the 3-week follow-up and to reduce infiltration of the inflammatory cells and the amount of fibrous tissue. These results showed that the PTX-PLGA-coated Mg stent has the potential to be a safe and effective approach for benign esophageal stricture.

PS01.095: BENIGN ESOPHAGEAL STRICTURE: A RECAP OF OUR EXPERIENCE

Abstract Background Caustic injury remains the commonest cause of benign esophageal strictures in Asia. Others include gastroesophageal reflux, iatrogenic, radiation, autoimmune or idiopathic causes. Treatment goals are relief of dysphagia and prevention of recurrence. This study aims to evaluate the experience with benign esophageal stricture in Penang Hospital, a tertiary hospital in Northern region of Malaysia. Methods A retrospective review of 12 patients with benign esophageal strictures between year 2012 - 2017. Results The mean age was 53.5 and two thirds were female. Half of these patients were of Chinese ethnicity while the other half were Indian. The commonest cause was caustic ingestion (41.7%), followed by reflux stricture (25%) and anastomotic stricture (25%). There was one case of dystrophic epidermolysis bullosa. More than half of the patients had complex and multiple strictures. 41.7% of patients had proximal strictures that were located within 20cm from the incisors. Endoscopic dilatation was the first line treatment with either Savary Gilliard or balloon dilators. A total of 97 dilatation sessions were done with a mean dilatation frequency of 2.3 ± 1.5 times for anastomotic strictures, 8 ± 8.2 times for reflux strictures and 8.0 ± 6.6 times for corrosive strictures. The mean dilatation interval was 2.5 ± 1.2 weeks. 58.3% of patients had successful endoscopic treatment. The success rate was higher in non-corrosive stricture (83% vs 40%). There was one dilatation related complication in which the patient had pneumomediastinum without overt mediastinitis. This however, resolved with conservative management. 41.7% of patients had refractory strictures that failed endoscopic dilatation. Surgery including esophagectomy (40%), revision of anastomosis (20%) and gastrostomy (40%) were done for this group of patients. Proximal strictures, complex strictures and multiple strictures were associated with failed endoscopic dilatation (P &lt; 0.05). Conclusion Endoscopic dilatation is the first line treatment for benign esophageal strictures. Surgery is reserved for refractory strictures with failed endoscopic treatment. Predictor scoring systems for refractory stricture and individualized approaches are the key to success. Disclosure All authors have declared no conflicts of interest.

Efficacy observation of local injection of mitomycin under endoscope for treatment of benign esophageal stricture

目的 观察内窥镜下狭窄部位局部注射丝裂霉素（MMC）治疗食管癌术后吻合口狭窄或食管内窥镜黏膜下剥离术（ESD）的疗效和安全性。 方法 选取食管狭窄患者48例，分组给予扩张联合放射状切开结合或不结合局部注射MMC，评估治疗前后食管直径改善情况，同时对MMC治疗组和对照组之间的疗效进行比较。 结果 ESD术后狭窄中，MMC组治疗后狭窄部位直径由（0.26±0.14）cm增至（1.07±0.12）cm，与对照组[治疗后（0.25±0.13）cm增至（0.78±0.07）cm]比较，差异有统计学意义（t=5.63，P 0.05）。其中MMC组有2例患者出现食管瘘，分别置入支架。 结论 局部注射MMC对食管ESD术后狭窄的疗效显著，但需谨慎操作，避免并发症的发生。

Endoscopic Incision Therapy (EIT) for Benign Esophageal Strictures

Benign esophageal strictures are conventionally managed by dilation and response is based on the etiology of the stricture. Most patients often need multiple sessions of dilations. Directed mucosal incision can have the advantage of focusing on the site of narrowing and potentially decreasing the number of endoscopic therapies needed. The aim of this pilot study is to evaluate the safety and efficacy of endoscopic incision therapy for benign esophageal strictures. Five consecutive patients with benign esophageal strictures were treated with EIT. Site and etiology of the stricture is described in Table 1. These patients underwent endoscopic incision therapy with an insulated tip endoscopic submucosal dissection knife. Patient A had Savary dilation one month prior to the incision therapy. Patients B and C had no prior treatment of the strictures. Patient D had previously undergone Savary dilation and through-the-scope balloon dilation with partial response. Patient E had multiple dilations in the past including steroid injection and stent placement with recurrence of the stricture. Four of the five patients required one endoscopic incision therapy, while patient D underwent a total of three incision therapies within a period of 5 months with significant gradual improvement in symptoms. Patients A and C required one endoscopic incision therapy with complete resolution of their symptoms. Patient B had structural improvement but had persistent dysphagia due to a motility disorder. Patient D had significant structural resolution at follow up four months after the initial incision therapy with improvement in dysphagia. Patient E had structural improvement as well as significant improvement of dysphagia at the 6 week follow-up. There were no complications in this series. Our case series demonstrates that endoscopic incision therapy is effective and safe for treatment of benign esophageal strictures as either the initial form of treatment or in refractory cases. There is a potential to reduce the number of endoscopic procedures required for desired clinical efficacy. Further long-term studies are needed to establish the role of EIT.Figure

Can mitomycin facilitate endoscopic dilatation treatment of benign oesophageal stricture?

A best evidence topic in cardiothoracic surgery was written according to a structured protocol. The question addressed was 'Can mitomycin facilitate endoscopic dilatation treatment of benign esophageal stricture (mainly including caustic and anastomotic esophageal stricture)?' Altogether, 115 papers were found using the reported search, of which 6 represented the best evidence to answer the clinical question, which included 1 randomized controlled trial, 1 systematic review and 4 cohort studies. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Mytomicin was topically applied as an adjunct to endoscopic dilatation with a concentration of 0.1-1 mg/ml in those included studies. Most of the studies reported that topical application of mitomycin could augment the effect of endoscopic dilatation treatment to achieve less dilatation number and significant improvement of dysphagia in patients suffering benign oesophageal stricture, and would not increase the risk of complications. These satisfying adjunct effects were observed in both child patients and adult patients. Therefore, we conclude that mitomycin can serve as a useful adjunct to endoscopic dilatation for benign oesophageal stricture. On the basis of our evidence, we strongly believe that topical application of mitomycin would augment the efficacy of endoscopic dilatation of benign oesophageal stricture.

Fabrication of a Delaying Biodegradable Magnesium Alloy-Based Esophageal Stent via Coating Elastic Polymer.

Esophageal stent implantation can relieve esophageal stenosis and obstructions in benign esophageal strictures, and magnesium alloy stents are a good candidate because of biodegradation and biological safety. However, biodegradable esophageal stents show a poor corrosion resistance and a quick loss of mechanical support in vivo. In this study, we chose the elastic and biodegradable mixed polymer of Poly(ε-caprolactone) (PCL) and poly(trimethylene carbonate) (PTMC) as the coated membrane on magnesium alloy stents for fabricating a fully biodegradable esophageal stent, which showed an ability to delay the degradation time and maintain mechanical performance in the long term. After 48 repeated compressions, the mechanical testing demonstrated that the PCL-PTMC-coated magnesium stents possess good flexibility and elasticity, and could provide enough support against lesion compression when used in vivo. According to the in vitro degradation evaluation, the PCL-PTMC membrane coated on magnesium was a good material combination for biodegradable stents. During the in vivo evaluation, the proliferation of the smooth muscle cells showed no signs of cell toxicity. Histological examination revealed the inflammation scores at four weeks in the magnesium-(PCL-PTMC) stent group were similar to those in the control group (p > 0.05). The α-smooth muscle actin layer in the media was thinner in the magnesium-(PCL-PTMC) stent group than in the control group (p < 0.05). Both the epithelial and smooth muscle cell layers were significantly thinner in the magnesium-(PCL-PTMC) stent group than in the control group. The stent insertion was feasible and provided reliable support for at least four weeks, without causing severe injury or collagen deposition. Thus, this stent provides a new stent for the treatment of benign esophageal stricture and a novel research path in the development of temporary stents in other cases of benign stricture.

シンポジウム2「食道狭窄に対する新しい治療：予防治療も含めて」司会者のまとめ

シンポジウム2「食道狭窄に対する新しい治療：予防治療も含めて」司会者のまとめ

Modified continuous balloon dilatation substituting stenting in the treatment of benign esophageal stenosis in children

Objective To explore the feasibility of using the modified continuous balloon dilatation substituting the traditional membrane-covered stent in the treatment of benign esophageal stenosis in children. Methods A retrospective analysis of the clinical data of 25 cases with esophageal stenosis from January,2012 to February,2014 was conducted. Preoperative esophageal stenosis was confirmed by angiography, and the expansion of the stenosis segment was examined after 2-4 weeks postoperatively. According to the age and the location of the esophageal stricture, 25 cases were classified into two groups. Twelve cases of group A without obvious contraindications were treated by continuous balloon dilatation, while 13 cases of group B with age of less than 3 years or upper esophageal stenosis, retrievable stent implantation was performed. All cases were followed up from 6 months to 2 years. Clinical symptoms, swallowing fluency and the degree of esophageal stricture were followed up at 1, 3, and 6 months postoperatively, and the effect of treatment was evaluated. Results Two groups of patients were successfully treated, and the stents were removed successfully after 2-4 weeks. The average diameter of the stenosis was significantly increased after treatment, swallowing was improved obviously, with no perforation, hematemesis and melena and other serious complications. The balloon moved down happened in one case, which was adjusted under perspective observation. One case in group A underwent colonic interposition for esophageal replacement because of recurrence of restenosis. The balloon dilatation was effective in 10 cases. In Group B, 5 patients had stent migration or displacement, 3 cases had recurrent esophageal stricture, and the treatment was effective in 5 cases. There was significant difference in complications between the group A and B (χ2=5.23,P<0.05). Conclusions Continuous balloon dilatation is a simple, effective procedure with fewer complications in the treatment of children with benign esophageal stenosis. In addition to stenting, it may be another ideal choice for benign esophageal stenosis in children. Key words: Esophageal stenosis; Stents; Child

Endoscopic balloon dilatation for benign esophageal stricture after endoscopic submucosal dissection for early esophageal neoplasms

The aim of this study was to evaluate the safety and efficacy of endoscopic balloon dilatation (EBD) for benign esophageal strictures after ESD for early esophageal neoplasms. Data of 335 patients who were treated with ESD for early esophageal neoplasms from October 2006 to August 2012 were retrospectively reviewed. The characteristics of the patients who underwent EBD for post-ESD stricture were analyzed. A total of 117 dilatation procedures were performed in 29 patients with post-ESD esophageal stricture. The mean number of EBD sessions was 4.0 (range 1-15) and no complications occurred during the procedures. The median follow-up period for the 29 patients since their last session of EBD was 20 months (range 1-48 months). Of the 28 patients who were followed up for more than 3 months after achieving dysphagia relief, two had recurrent dysphasia and EBD was reintroduced. The treatment success rate was 92.9% (26/28). EBD is a safe and effective modality for the treatment of benign esophageal stricture after ESD for early esophageal neoplasms.

Obliteration of Schatzki Rings in Patients with Refractory Dysphagia Utilizing Multiple Standard Endoscopic Biopsies

Purpose: The Schatzki ring, a benign lower esophageal structural anomaly, is one of the most common causes of dysphagia and intermittent food impaction. Therapy for Schatzki rings has traditionally utilized esophageal dilation with either bougienage or balloon dilators. No clear advantage has been demonstrated between these dilator types and both are associated with recurrent dysphagia. Alternatively, endoscopic electrosurgical incision of the fibrous, elastic core of Schatzki rings has been shown to be an efficacious treatment modality ever since it was first described almost 30 years ago in two patients who did not respond to conventional bougienage. However, the needle knife is not commonly employed during upper endoscopy, and its use in the treatment of benign esophageal strictures is likely to be technically difficult among most gastroenterologists with a risk of serious complications. In a fashion similar to that of electrosurgical incision, direct disruption of Schatzki rings may be more feasibly achieved with standard endoscopic biopsy forceps. To our knowledge, no study or case series has described ring obliteration by endoscopic biopsy forceps in patients who have refractory dysphagia after Savary dilation or through-the-scope balloon dilation. In our case series, we describe three individuals who underwent Schatzki ring obliteration utilizing multiple biopsies with standard forceps after undergoing conventional esophageal dilation that did not relieve their dysphagia. In the presence of acid suppression, obliteration was performed by obtaining four to five circumferential biopsies from various points of the Schatzki ring; no complications were encountered and dilation was immediately confirmed by the passage of a 13.5 or 15 millimeter through-the-scope balloon without resistance. Two of the patients reported no symptoms of dysphagia at follow-up 6-8 months later. The third patient had recurrent dysphagia that was later discovered to have an oropharyngeal etiology. Based on these outcomes, we suggest that multiple standard biopsies performed at equidistant sites around the Schatzki ring “break” the ring and relieve refractory dysphagia in a manner that is comparatively safer, more cost-effective, and more widely accepted in routine practice than electrosurgical incision.