|Year : 2016 | Volume
| Issue : 1 | Page : 1-5
Refractory benign esophageal strictures
Gopal Goyal, Surender Sultania, Babulal Meena, Sandeep Nijhawan
Department of Gastroenterology, Sawai Man Singh Medical College, Jaipur, Rajasthan, India
|Date of Web Publication||12-Apr-2016|
Department of Gastroenterology, Sawai Man Singh Medical College, J L N Marg, Jaipur - 302 004, Rajasthan
Source of Support: None, Conflict of Interest: None
Refractory benign esophageal stricture (RBES) is a frequently encountered problem worldwide. These strictures arise from various causes such as corrosive injury, radiation therapy, peptic origin, ablative therapy, and after surgery. Most strictures can be treated successfully with endoscopic dilatation using bougies or balloons, with only a few complications. Those patients who fail after serial dilatation with bougies or balloons will come to the category of refractory strictures. Dilatation combined with intralesional steroid injections can be considered for peptic strictures, whereas incisional therapy has been demonstrated to be effective for short anastomotic strictures. When these therapeutic options do not resolve the stenosis, stent placement should be considered. Self-bougienage can be proposed to a selected group of patients with a proximal stenosis. Most of the patients of RBES respond to above-mentioned treatment and occasional patient may require surgery as the final treatment option. This review aims to provide a comprehensive approach toward endoscopic management of RBESs based on current literature and personal experience.
Keywords: Biodegradable stent, dilatation, dysphagia, incisional therapy, refractory benign esophageal strictures, self-expandable metal stent, self-expandable plastic stent
|How to cite this article:|
Goyal G, Sultania S, Meena B, Nijhawan S. Refractory benign esophageal strictures. J Dig Endosc 2016;7:1-5
| Introduction|| |
Refractory benign esophageal stricture (RBES) is a frequently encountered problem, which negatively affects patient's quality of life and has significant complications such as malnutrition, weight loss, and aspiration pneumonia.  Typical benign esophageal strictures are characterized by a cicatricial, anatomic narrowing of the esophagus, which define as either simple or complex strictures. Simple strictures are short (<2 cm) focal, straight, and can be traversed with an adult endoscope prior to dilatation and are mostly caused by Schatzki rings, esophageal webs, or peptic injury. In contrast, complex strictures are long (>2 cm), irregular, angulated, or difficult to traverse with an endoscope and mainly caused by surgery, radiotherapy, or corrosive injury.  Peptic strictures are common in Western countries and usually respond to few sessions of dilatation. Corrosive strictures are common in developing countries and require repeated sessions of endoscopic dilatation. ,,
Refractory esophageal strictures are the ones which require more than five sessions of dilatation at 2 weeks interval to achieve a diameter of 14 mm in the absence of endoscopic evidence of inflammation. Inability to maintain the satisfactory esophageal lumen for 4 weeks after achieving a 14 mm diameter is a recurrent stricture. 
The extent of fibrosis of the esophageal wall is an important determinant of stricture severity, maximum wall thickness of 9 mm, or more require a higher number of dilatation sessions than those with <9 mm on computed tomography scan [Figure 1].  Endoscopic ultrasonography gives more detailed examination of the full thickness of the esophageal wall, the maximum wall thickness has been found to be greater in patients with corrosive and postradiation strictures as compared to patients with peptic strictures. Those patients with involvement of muscularis propria require more sessions of dilatation as compared to patients having involvement of mucosa and submucosa [Figure 2]. 
|Figure 1: Computed tomography Images of esophageal wall thickness in benign esophageal stricture reproduced from Lahoti et al. (a) Normal esophageal wall (arrow). (b) Mid increase in esophageal wall thickness (arrow). (c) Marked increase in esophageal wall thickness note the esophageal lumen (long arrow) and the outer limit of thickened esophageal wall (short arrow)|
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|Figure 2: Endoscopic ultrasonography images of benign esophageal stricture reproduced from Rana et al. (a) Endoscopic ultrasonography in a patient with peptic stricture showing the involvement of the mucosa and submucosa. Muscularis propria is seen as hypoechoic layer (arrows). (b) Endoscopic ultrasonography in a patient with corrosive stricture showing involvement of the muscularis propria of esophagus with thickened esophageal wall. (c) Endoscopic ultrasonography in a patient with postradiation stricture showing involvement of all the layers of esophagus with thickened esophageal wall|
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Serial endoscopic dilatation with bougies or balloons has been the standard treatment for esophageal strictures. In patients with benign simple strictures, dilatation gives good relief in 85-93% of cases.  Dilatation appears less effective in those with radiation- or corrosive-induced complex strictures. The recurrence rate reaches to 30-40% during long-term follow-up, especially in complex strictures. 
Those patients who fail after serial dilatation with bougies or balloons will come to the category of refractory strictures. Adding local steroid injection followed by dilatation is found to decrease the number and frequency of dilatation in peptic strictures [Table 1]. , Intralesional steroid injection followed by dilatation has been found to be useful in patients with corrosive strictures in nonrandomized trial, , but its usefulness could not be proved in a randomized controlled trial [Table 2].  Similarly, adding local steroid injection to dilatation did not result in clinical benefit in patients of anastomotic strictures.  Incisional therapy can be performed for short strictures (<1 cm) using needle knife or tip of the polypectomy snare. It has been found to be useful and safe in short anastomotic strictures, the results are comparable to dilatation. 
|Table 1: Results of steroid injection therapy in peptic and anastomotic esophageal strictures|
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|Table 2: Results of steroid injection therapy in corrosive esophageal strictures|
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Self-expandable stents work on the principle of persistent dilatation till the inflammation subsides. The advantage is avoiding repeated sessions of dilatations. Uncovered self-expandable metal stents (SEMS) have a high complication rate (up to 80%) due to hyperplasic tissue in growth; therefore, fully covered SEMS (FCSEMS) are preferable but studies with FCSEMS showed high migration rate with lower clinical success [Table 3]. ,,,,,
|Table 3: Results of self-expanding metal stents in benign esophageal strictures|
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To overcome the problem of hyperplastic tissue reaction, self-expandable plastic stents (SEPS) were introduced. A meta-analysis concluded SEPS to be technically successful in 98% with 50% clinical success and 9% major complications.  Another review showed similar technical and clinical success but stent migration in one-third of patients [Table 4]. ,,,,,,,,,,,,
|Table 4: Results of self-expandable plastic stents in refractory benign esophageal strictures|
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Biodegradable stents (BD) are the alternative to SEPS, they are either Polydioxanone BD stent or Poly-L-lactic acid BD stent. Their degradation occurs by hydrolysis, which starts after 4-5 weeks and dissolves over a period of 2-3 months. Limitations of BD stents are low radial force contributing to early stricture recurrence and their high cost. Sequential BD stent placement is an effective alternative to avoid the burden of frequent dilatation.
The technical success rate of BD stents in various studies ranges from 85 to 100% with median 96% and clinical success rate ranges from 25 to 100% with median 47% [Table 5]. ,,,,,,,,, A study comparing SEPS and BD stents showed clinical relief of dysphagia in 30% and 33% patients, respectively, of patients with RBES.  A prospective multicenter study compared temporary placement of three different SEPS (FCSEMS, SEPS, BD) for the treatment of RBES. These stents were placed for 12 weeks. Short-term benefit was comparable for all three stents at 8-9 weeks, long-term benefit could be achieved with BD and FCSEMS but not with SEPS.  The technical success was 100% among all 3 stents long-term clinical success was higher with FCSEMS (40%) than BD stents (30%) and least with SEPS (10%). The migration rates of SEPS, FCSEMS, and BD were 18%, 9%, and 6%, respectively.
The cost of BD stent is an important issue, especially in developing countries. Cost of FCSEMS and SEPS are 1000$ (USD) and 400$ (USD), respectively, whereas the cost of BD stent is around 900£ (pound).
The duration of stent placement in RBES is till the inflammation subsides. Strictures longer than 5 cm may require longer duration of stenting. The duration of stent placement ranges from 12 to 16 weeks. The other factors such as the etiology of stricture and severity of inflammation also affect the outcome of stent placement.
| Summary|| |
All patients of RBESs except anastomotic stricture after the failure of conventional dilatation treatment should be subjected to three sessions of dilatation with intralesional four quadrant triamcinolone injections. Incisional therapy (maximum three sessions) is recommended for short (<1 cm) anastomotic strictures. Temporary placement of fully covered metallic stent should be tried if the above treatment fails and BD stent may be an option in these cases. Occasional patients with proximal esophageal refractory strictures may do self-bougienage when all these above treatment options fail. Most of the patients of RBES respond to above-mentioned treatment and occasional patient may require surgery as the final treatment option. An algorithm for the management of RBES is given in [Figure 3].
|Figure 3: Algorithm for management of refractory benign esophageal strictures (original) FCSEMS: Fully covered self-expandable metallic stents; BD: Biodegradable stents SEPS: Self-expandable plastic stents|
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]