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

Abstract

Background

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.

Methods

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.

Results

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.

Conclusions

(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.

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Acknowledgements

This work was supported by the NIH/NIDDK T32 DK007740 (Clinical Epidemiology Training in Gastroenterology) and the NIH/NIDDK P30DK050306 Center for Molecular Studies in Digestive and Liver Diseases. This work was also supported by the Wilmott Center for Endoscopic Innovation, Research, and Training.

Disclosures

Dr. Kochman is a consultant for Boston Scientific Company, Cook Medical Inc., and Olympus Inc. Drs. Agarwalla, Small, Mendelson, and Scott have no financial interest in any products mentioned in this manuscript.

Author information

Correspondence to Aaron J. Small.

Additional information

Drs. Agarwalla and Small contributed equally to this article.

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Agarwalla, A., Small, A.J., Mendelson, A.H. et al. Risk of recurrent or refractory strictures and outcome of endoscopic dilation for radiation-induced esophageal strictures. Surg Endosc 29, 1903–1912 (2015) doi:10.1007/s00464-014-3883-1

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Keywords

  • Esophageal stricture
  • Recurrent
  • Refractory
  • Endoscopic dilation
  • Radiation
  • Risk factors