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Management of Chronic Refractory Oesophageal Strictures

  • Esophagus (P Iyer, Section Editor)
  • Published:
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Abstract

Purpose of review

Benign oesophageal strictures are commonly encountered in endoscopy. Although most strictures are successfully treated with endoscopic dilatation, up to 40% of patients may develop refractory strictures which require repeated long-term endoscopic intervention with an adverse impact on their quality of life. This review summarises the current evidence-based treatment options available for these patients including preliminary data on novel interventions for this difficult to treat cohort of patients.

Recent findings

Only one-third of patients with refractory oesophageal strictures are able to escape the need for repeated long-term endoscopic dilatation. It has been shown however that dilatation up to a target diameter of 16–18 mm can reduce the need for further dilatations. Incisional therapy is a useful alternative treatment option for anastomotic strictures as is temporary placement of a lumen-apposing metal stent. Although biodegradable stents appear promising in the short-term, longer-term data and pain may limit their use. Self-dilatation appears to be a useful approach for motivated patients with short, proximal strictures.

Summary

Although refractory oesophageal strictures are challenging to treat, numerous endoscopic treatment options are now available that usually prevent patients needing more radical surgical intervention.

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References and Recommended Reading

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. •• Sami SS, Haboubi HN, Ang Y, Boger P, Bhandari P, de Caestecker J, et al. UK guidelines on oesophageal dilatation in clinical practice. Gut. 2018;67(6):1000–23 The most up-to-date guidelines on oesophageal dilatation from a wide-ranging team of internal experts in the field.

    Article  PubMed  Google Scholar 

  2. Patterson DJ, Graham DY, Smith JL, Schwartz JT, Alpert E, Lanza FL, et al. Natural history of benign esophageal stricture treated by dilatation. Gastroenterology. 1983;85(2):346–50.

    Article  CAS  PubMed  Google Scholar 

  3. Spechler SJ. American gastroenterological association medical position statement on treatment of patients with dysphagia caused by benign disorders of the distal esophagus. Gastroenterology. 1999;117(1):229–33.

    Article  CAS  PubMed  Google Scholar 

  4. •• Repici A, Small AJ, Mendelson A, Jovani M, Correale L, Hassan C, et al. Natural history and management of refractory benign esophageal strictures. Gastrointestinal endoscopy. 2016;84(2):222–8 A much needed long-term follow-up on the natural history and management of patients with refractory benign oesophageal struictures which revealed that only 31.4% of patients with RBES achieve clinical stricture resolution.

    Article  PubMed  Google Scholar 

  5. •• Kochman ML, McClave SA, Boyce HW. The refractory and the recurrent esophageal stricture: a definition. Gastrointest Endosc. 2005;62(3):474–5 The first definition of refrcatory or recurrent oesophageal strictures which is still widely accepted and use in most studies to date.

    Article  PubMed  Google Scholar 

  6. Siersema PD. Management of refractory benign esophageal strictures. Gastroenterol Hepatol. 2018;14(3):189–91.

    Google Scholar 

  7. Pereira-Lima JC, Ramires RP, Zamin I Jr, Cassal AP, Marroni CA, Mattos AA. Endoscopic dilation of benign esophageal strictures: report on 1043 procedures. Am J Gastroenterol. 1999;94(6):1497–501.

    Article  CAS  PubMed  Google Scholar 

  8. Ogilvie AL, Dronfield MW, Ferguson R, Atkinson M. Palliative intubation of oesophagogastric neoplasms at fibreoptic endoscopy. Gut. 1982;23(12):1060–7.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  9. Lal N, Bhasin DK, Malik AK, Gupta NM, Singh K, Mehta SK. Optimal number of biopsy specimens in the diagnosis of carcinoma of the oesophagus. Gut. 1992;33(6):724–6.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  10. Boyce HW. Dilation of difficult benign esophageal strictures. Am J Gastroenterol. 2005;100(4):744–5.

    Article  PubMed  Google Scholar 

  11. Cox JG, Winter RK, Maslin SC, Dakkak M, Jones R, Buckton GK, et al. Balloon or bougie for dilatation of benign esophageal stricture? Dig Dis Sci. 1994;39(4):776–81.

    Article  CAS  PubMed  Google Scholar 

  12. Saeed ZA, Winchester CB, Ferro PS, Michaletz PA, Schwartz JT, Graham DY. Prospective randomized comparison of polyvinyl bougies and through-the-scope balloons for dilation of peptic strictures of the esophagus. Gastrointest Endosc. 1995;41(3):189–95.

    Article  CAS  PubMed  Google Scholar 

  13. Scolapio JS, Pasha TM, Gostout CJ, Mahoney DW, Zinsmeister AR, Ott BJ, et al. A randomized prospective study comparing rigid to balloon dilators for benign esophageal strictures and rings. Gastrointest Endosc. 1999;50(1):13–7.

    Article  CAS  PubMed  Google Scholar 

  14. Egan JV, Baron TH, Adler DG, Davila R, Faigel DO, Gan SL, et al. Esophageal dilation. Gastrointest Endosc. 2006;63(6):755–60.

    Article  PubMed  Google Scholar 

  15. Riley SA, Attwood SE. Guidelines on the use of oesophageal dilatation in clinical practice. Gut. 2004;53(Suppl 1(Suppl 1)):i1-6.

    PubMed  Google Scholar 

  16. Grooteman KV, Wong Kee Song LM, Vleggaar FP, Siersema PD, Baron TH. Non-adherence to the rule of 3 does not increase the risk of adverse events in esophageal dilation. Gastrointest Endosc. 2017;85(2):332-7.e1.

    Article  Google Scholar 

  17. Walter B, Schmidbaur S, Rahman I, Albers D, Schumacher B, Meining A. The BougieCap - a new method for endoscopic treatment of complex benign esophageal stenosis: results from a multicenter study. Endoscopy. 2019;51(9):866–70.

    Article  PubMed  Google Scholar 

  18. Raymondi R, Pereira-Lima JC, Valves A, Morales GF, Marques D, Lopes CV, et al. Endoscopic dilation of benign esophageal strictures without fluoroscopy: experience of 2750 procedures. Hepato-gastroenterology. 2008;55(85):1342–8.

    PubMed  Google Scholar 

  19. • Vermeulen BD, de Zwart M, Sijben J, Soons E, van der Weerd L, Arese D, et al. Risk factors and clinical outcomes of endoscopic dilation in benign esophageal strictures: a long-term follow-up study. Gastrointest Endosc. 2020;91(5):1058–66 Long-term follow of patients with refractory benign oesophageal strictures which demonstrated that dilatation to a target diameter of 16-18mm significantly reduced the number of repeated endoscopic dilatations needed compared to 13-15mm.

    Article  PubMed  Google Scholar 

  20. Honda M, Nakamura T, Hori Y, Shionoya Y, Nakada A, Sato T, et al. Process of healing of mucosal defects in the esophagus after endoscopic mucosal resection: histological evaluation in a dog model. Endoscopy. 2010;42(12):1092–5.

    Article  CAS  PubMed  Google Scholar 

  21. Ashcraft KW, Holder TM. The expeimental treatment of esophageal strictures by intralesional steroid injections. J Thoracic Cardiovasc Surg. 1969;58(5):685–91 passim.

  22. Ramage JI Jr, Rumalla A, Baron TH, Pochron NL, Zinsmeister AR, Murray JA, et al. A prospective, randomized, double-blind, placebo-controlled trial of endoscopic steroid injection therapy for recalcitrant esophageal peptic strictures. Am J Gastroenterol. 2005;100(11):2419–25.

    Article  CAS  PubMed  Google Scholar 

  23. Hirdes MM, van Hooft JE, Koornstra JJ, Timmer R, Leenders M, Weersma RK, et al. Endoscopic corticosteroid injections do not reduce dysphagia after endoscopic dilation therapy in patients with benign esophagogastric anastomotic strictures. Clinical gastroenterology and hepatology : the official clinical practice journal of the American Gastroenterological Association. 2013;11(7):795-801.e1.

    Article  CAS  Google Scholar 

  24. Hanaoka N, Ishihara R, Motoori M, Takeuchi Y, Uedo N, Matsuura N, et al. Endoscopic balloon dilation followed by intralesional steroid injection for anastomotic strictures after esophagectomy: a randomized controlled trial. Am J Gastroenterol. 2018;113(10):1468–74.

    Article  PubMed  Google Scholar 

  25. Szapáry L, Tinusz B, Farkas N, Márta K, Szakó L, Meczker Á, et al. Intralesional steroid is beneficial in benign refractory esophageal strictures: a meta-analysis. World J Gastroenterol. 2018;24(21):2311–9.

    Article  PubMed  PubMed Central  Google Scholar 

  26. Henskens N, Wauters L, Vanuytsel T. Intralesional steroid injections in addition to endoscopic dilation in benign refractory esophageal strictures : a systematic review. Acta Gastro-Enterol Belg. 2020;83(3):432–40.

    CAS  Google Scholar 

  27. Shi Q, Ju H, Yao LQ, Zhou PH, Xu MD, Chen T, et al. Risk factors for postoperative stricture after endoscopic submucosal dissection for superficial esophageal carcinoma. Endoscopy. 2014;46(8):640–4.

    Article  PubMed  Google Scholar 

  28. Abe S, Iyer PG, Oda I, Kanai N, Saito Y. Approaches for stricture prevention after esophageal endoscopic resection. Gastrointest Endosc. 2017;86(5):779–91.

    Article  PubMed  Google Scholar 

  29. van de Ven SEM, Snijders M, Bruno MJ, Koch AD. Effectiveness of topical budesonide in preventing esophageal strictures after endoscopic resection of esophageal cancer. Endoscopy international open. 2020;8(12):E1795–e803.

    Article  PubMed  PubMed Central  Google Scholar 

  30. Iizuka T, Kikuchi D, Yamada A, Hoteya S, Kajiyama Y, Kaise M. Polyglycolic acid sheet application to prevent esophageal stricture after endoscopic submucosal dissection for esophageal squamous cell carcinoma. Endoscopy. 2015;47(4):341–4.

    PubMed  Google Scholar 

  31. Sakaguchi Y, Tsuji Y, Ono S, Saito I, Kataoka Y, Takahashi Y, et al. Polyglycolic acid sheets with fibrin glue can prevent esophageal stricture after endoscopic submucosal dissection. Endoscopy. 2015;47(4):336–40.

    PubMed  Google Scholar 

  32. Sakaguchi Y, Tsuji Y, Fujishiro M, Kataoka Y, Takeuchi C, Yakabi S, et al. Triamcinolone injection and shielding with polyglycolic acid sheets and fibrin glue for postoperative stricture prevention after esophageal endoscopic resection: a pilot study. Am J Gastroenterol. 2016;111(4):581–3.

    Article  CAS  PubMed  Google Scholar 

  33. Burdick JS, Venu RP, Hogan WJ. Cutting the defiant lower esophageal ring. Gastrointest Endosc. 1993;39(5):616–9.

    Article  CAS  PubMed  Google Scholar 

  34. DiSario JA, Pedersen PJ, Bichiş-Canoutas C, Alder SC, Fang JC. Incision of recurrent distal esophageal (Schatzki) ring after dilation. Gastrointest Endosc. 2002;56(2):244–8.

    Article  PubMed  Google Scholar 

  35. Lee TH, Lee SH, Park JY, Lee CK, Chung IK, Kim HS, et al. Primary incisional therapy with a modified method for patients with benign anastomotic esophageal stricture. Gastrointest Endosc. 2009;69(6):1029–33.

    Article  PubMed  Google Scholar 

  36. Pih GY, Kim DH, Na HK, Ahn JY, Lee JH, Jung KW, et al. Comparison of the efficacy and safety of endoscopic incisional therapy and balloon dilatation for esophageal anastomotic stricture. Journal of gastrointestinal surgery : official journal of the Society for Surgery of the Alimentary Tract. 2020.

  37. van Halsema EE, van Hooft JE. Clinical outcomes of self-expandable stent placement for benign esophageal diseases: a pooled analysis of the literature. World journal of gastrointestinal endoscopy. 2015;7(2):135–53.

    Article  PubMed  PubMed Central  Google Scholar 

  38. Fuccio L, Hassan C, Frazzoni L, Miglio R, Repici A. Clinical outcomes following stent placement in refractory benign esophageal stricture: a systematic review and meta-analysis. Endoscopy. 2016;48(2):141–8.

    PubMed  Google Scholar 

  39. Canena JM, Liberato MJ, Rio-Tinto RA, Pinto-Marques PM, Romão CM, Coutinho AV, et al. A comparison of the temporary placement of 3 different self-expanding stents for the treatment of refractory benign esophageal strictures: a prospective multicentre study. BMC Gastroenterol. 2012;12:70.

    Article  PubMed  PubMed Central  Google Scholar 

  40. Spaander MC, Baron TH, Siersema PD, Fuccio L, Schumacher B, Escorsell À, et al. Esophageal stenting for benign and malignant disease: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline. Endoscopy. 2016;48(10):939–48.

    Article  PubMed  Google Scholar 

  41. Hirdes MM, Siersema PD, Houben MH, Weusten BL, Vleggaar FP. Stent-in-stent technique for removal of embedded esophageal self-expanding metal stents. Am J Gastroenterol. 2011;106(2):286–93.

    Article  CAS  PubMed  Google Scholar 

  42. Bakken JC. Wong Kee Song LM, de Groen PC, Baron TH. Use of a fully covered self-expandable metal stent for the treatment of benign esophageal diseases. Gastrointest Endosc. 2010;72(4):712–20.

    Article  PubMed  Google Scholar 

  43. Eloubeidi MA, Talreja JP, Lopes TL, Al-Awabdy BS, Shami VM, Kahaleh M. Success and complications associated with placement of fully covered removable self-expandable metal stents for benign esophageal diseases (with videos). Gastrointest Endosc. 2011;73(4):673–81.

    Article  PubMed  Google Scholar 

  44. Watanabe K, Hikichi T, Nakamura J, Takagi T, Suzuki R, Sugimoto M, et al. Feasibility of esophageal stent fixation with an over-the-scope-clip for malignant esophageal strictures to prevent migration. Endoscopy international open. 2017;5(11):E1044–e9.

    Article  PubMed  PubMed Central  Google Scholar 

  45. Wright A, Chang A, Bedi AO, Wamsteker EJ, Elta G, Kwon RS, et al. Endoscopic suture fixation is associated with reduced migration of esophageal fully covered self-expandable metal stents (FCSEMS). Surg Endosc. 2017;31(9):3489–94.

    Article  PubMed  Google Scholar 

  46. Law R, Prabhu A, Fujii-Lau L, Shannon C, Singh S. Stent migration following endoscopic suture fixation of esophageal self-expandable metal stents: a systematic review and meta-analysis. Surg Endosc. 2018;32(2):675–81.

    Article  PubMed  Google Scholar 

  47. Adler DG. Lumen-apposing metal stents for the treatment of refractory benign esophageal strictures. Am J Gastroenterol. 2017;112(3):516–7.

    Article  PubMed  Google Scholar 

  48. Mizrahi M, Fahmawi Y, Merritt L, Kumar M, Tharian B, Khan SA, et al. Luminal-apposing stents for benign intraluminal strictures: a large United States multicenter study of clinical outcomes. Ann Gastroenterol. 2021;34(1):33–8.

    PubMed  Google Scholar 

  49. Siersema PD. How to approach a patient with refractory or recurrent benign esophageal stricture. Gastroenterology. 2019;156(1):7–10.

    Article  PubMed  Google Scholar 

  50. Fry SW, Fleischer DE. Management of a refractory benign esophageal stricture with a new biodegradable stent. Gastrointest Endosc. 1997;45(2):179–82.

    Article  CAS  PubMed  Google Scholar 

  51. Repici A, Vleggaar FP, Hassan C, van Boeckel PG, Romeo F, Pagano N, et al. Efficacy and safety of biodegradable stents for refractory benign esophageal strictures: the BEST (Biodegradable Esophageal Stent) study. Gastrointest Endosc. 2010;72(5):927–34.

    Article  PubMed  Google Scholar 

  52. Hirdes MM, Siersema PD, van Boeckel PG, Vleggaar FP. Single and sequential biodegradable stent placement for refractory benign esophageal strictures: a prospective follow-up study. Endoscopy. 2012;44(7):649–54.

    Article  CAS  PubMed  Google Scholar 

  53. van Boeckel PG, Vleggaar FP, Siersema PD. A comparison of temporary self-expanding plastic and biodegradable stents for refractory benign esophageal strictures. Clinical gastroenterology and hepatology : the official clinical practice journal of the American Gastroenterological Association. 2011;9(8):653–9.

    Article  Google Scholar 

  54. Dhar A, Close H, Viswanath YK, Rees CJ, Hancock HC, Dwarakanath AD, et al. Biodegradable stent or balloon dilatation for benign oesophageal stricture: pilot randomised controlled trial. World J Gastroenterol. 2014;20(48):18199–206.

    Article  PubMed  PubMed Central  Google Scholar 

  55. Gkolfakis P, Siersema PD, Tziatzios G, Triantafyllou K, Papanikolaou IS. Biodegradable esophageal stents for the treatment of refractory benign esophageal strictures. Ann Gastroenterol. 2020;33(4):330–7.

    PubMed  PubMed Central  Google Scholar 

  56. • Walter D, van den Berg MW, Hirdes MM, Vleggaar FP, Repici A, Deprez PH, et al. Dilation or biodegradable stent placement for recurrent benign esophageal strictures: a randomized controlled trial. Endoscopy. 2018;50(12):1146–55 The largest multicentre trial to date comparing biodegradable stents (BDS) versus endoscopic dilatation for BES demonstrating that BDS were associated significantly fewer endoscopic dilatations after the first 3 months.

    Article  PubMed  Google Scholar 

  57. Yano T, Yoda Y, Nomura S, Toyosaki K, Hasegawa H, Ono H, et al. Prospective trial of biodegradable stents for refractory benign esophageal strictures after curative treatment of esophageal cancer. Gastrointest Endosc. 2017;86(3):492–9.

    Article  PubMed  Google Scholar 

  58. Bick BL, Song LM, Buttar NS, Baron TH, Nichols FC, Maldonado F, et al. Stent-associated esophagorespiratory fistulas: incidence and risk factors. Gastrointest Endosc. 2013;77(2):181–9.

    Article  PubMed  Google Scholar 

  59. Debourdeau A, Gonzalez JM, Dutau H, Benezech A, Barthet M. Endoscopic treatment of nonmalignant tracheoesophageal and bronchoesophageal fistula: results and prognostic factors for its success. Surg Endosc. 2019;33(2):549–56.

    Article  PubMed  Google Scholar 

  60. Silon B, Siddiqui AA, Taylor LJ, Arastu S, Soomro A, Adler DG. Endoscopic management of esophagorespiratory fistulas: a multicenter retrospective study of techniques and outcomes. Dig Dis Sci. 2017;62(2):424–31.

    Article  PubMed  Google Scholar 

  61. Benson AA, Hakimian D, Jacob H, Boškoski I. Closure of a chronic complex tracheoesophageal fistula by using endoscopic suturing. VideoGIE : an official video journal of the American Society for Gastrointestinal Endoscopy. 2021;6(3):119–21.

    Article  Google Scholar 

  62. Smallwood NR, Fleshman JW, Leeds SG, Burdick JS. The use of endoluminal vacuum (E-Vac) therapy in the management of upper gastrointestinal leaks and perforations. Surg Endosc. 2016;30(6):2473–80.

    Article  PubMed  Google Scholar 

  63. van Twisk JJ, Brummer RJ, Manni JJ. Retrograde approach to pharyngo-esophageal obstruction. Gastrointest Endosc. 1998;48(3):296–9.

    Article  PubMed  Google Scholar 

  64. Kos MP, David EF, Mahieu HF. Anterograde-retrograde rendezvous approach for radiation-induced complete upper oesophageal sphincter stenosis: case report and literature review. J Laryngol Otol. 2011;125(7):761–4.

    Article  CAS  PubMed  Google Scholar 

  65. Kozarek RA. Endoscopic approach to reopening a completely obstructed esophagus. Gastroenterol Hepatol. 2015;11(8):565–8.

    Google Scholar 

  66. Francis DO, Hall E, Dang JH, Vlacich GR, Netterville JL, Vaezi MF. Outcomes of serial dilation for high-grade radiation-related esophageal strictures in head and neck cancer patients. Laryngoscope. 2015;125(4):856–62.

    Article  PubMed  Google Scholar 

  67. Chapuy CI, Annino DJ, Tishler RB, Haddad RI, Snavely A, Goguen LA. Success of endoscopic pharyngoesophageal dilation after head and neck cancer treatment. Laryngoscope. 2013;123(12):3066–73.

    Article  PubMed  PubMed Central  Google Scholar 

  68. Babich JP, Diehl DL, Entrup MH. Retrograde submucosal tunneling technique for management of complete esophageal obstruction. Surgical laparoscopy, endoscopy & percutaneous techniques. 2012;22(4):e232–5.

    Article  Google Scholar 

  69. Gilmore IT, Sheers R. Oesophageal self-bougienage. Lancet. 1982;319(8272):620–1.

    Article  Google Scholar 

  70. Dzeletovic I, Fleischer DE, Crowell MD, Pannala R, Harris LA, Ramirez FC, et al. Self-dilation as a treatment for resistant, benign esophageal strictures. Dig Dis Sci. 2013;58(11):3218–23.

    Article  PubMed  Google Scholar 

  71. van Halsema EE. t Hoen CA, de Koning PS, Rosmolen WD, van Hooft JE, Bergman JJ. Self-dilation for therapy-resistant benign esophageal strictures: towards a systematic approach. Surg Endosc. 2018;32(7):3200–7.

    Article  PubMed  PubMed Central  Google Scholar 

  72. Dzeletovic I, Fleischer DE, Crowell MD, Kim HJ, Harris LA, Burdick GE, et al. Self dilation as a treatment for resistant benign esophageal strictures: outcome, technique, and quality of life assessment. Dig Dis Sci. 2011;56(2):435–40.

    Article  PubMed  Google Scholar 

  73. Qin Y, Sunjaya DB, Myburgh S, Sawas T, Katzka DA, Alexander JA, et al. Outcomes of oesophageal self-dilation for patients with refractory benign oesophageal strictures. Aliment Pharmacol Ther. 2018;48(1):87–94.

    Article  CAS  PubMed  Google Scholar 

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  1. Department of Gastroenterology and Endoscopy, University College London Hospitals NHS Foundation Trust, Ground Floor West, 250 Euston Road, London, NW1 2PG, UK

    Vinay Sehgal MBChB, MRCP, PhD & Sarmed Sami MBChB, MRCP, PhD

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  1. Vinay Sehgal MBChB, MRCP, PhD
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  2. Sarmed Sami MBChB, MRCP, PhD
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Correspondence to Vinay Sehgal MBChB, MRCP, PhD.

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Sehgal, V., Sami, S. Management of Chronic Refractory Oesophageal Strictures. Curr Treat Options Gastro 19, 443–458 (2021). https://doi.org/10.1007/s11938-021-00352-z

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