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The SAGES Manual Operating Through the Endoscope pp 107–125Cite as

Stricture Management: Interventional Options

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Abstract

Anastomotic stricturing is a reported complication post gastrointestinal surgery and is associated with significant patient morbidity depending on location of the lesion.

Anastomotic diseases can be classified based on location. Esophageal anastomotic strictures, usually after an esophagectomy, are common with an incidence between 5 and 48 %. These strictures are best treated with mechanical esophageal dilation with either rigid or balloon dilators. The main rigid dilators consist of the Maloney, Hurt and the Savary-Gilliard. The other primary option, based mostly on preference, is the balloon dilator. Endoluminal stents, both metal and plastic, are becoming more common and are being trialed as primary therapy for benign disease, rather than just palliative for malignancy. Other treatment modalities, mainly applied as adjunctive procedures, include kenalog injections and electrocautery needle-knife. Gastric anastomotic strictures usually occur after bariatric surgery at the site of the gastrojejunostomy, with an incidence of 0.6–27 %. Balloon dilation is the most common treatment modality with efficacy rates reaching 100 %. Endoluminal stents and Savary-Gilliard dilators have also been reported. Colorectal anastomotic strictures are associated with low anterior resections and sigmoidectomies, with an incidence between 3 and 30 %. The mainstay of therapy remains endoscopic balloon dilation. Through-the-Scope balloon dilation has medium-term successful rates of obstruction resolution, upwards of 86 %, but is associated with high recurrence rates. For colorectal strictures, it appears that the size of the dilator is the most important factor for recurrence, and therefore larger diameters are favored. Small case series have advocated for the double balloon approach, as well as adjuncts including argon plasma coagulation. For failures of balloon dilation, endoscopic transanal resection and stenting have been reported.

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References

  1. Zieren HU, Muller JM, Pichlmaier H. Prospective randomized study of one- or two-layer anastomosis following oesophageal resection and cervical oesophagogastrostomy. Br J Surg. 1993;80(5):608–11.

    Article  CAS  PubMed  Google Scholar 

  2. Briel JW, Tamhankar AP, Hagen JA, DeMeester SR, Johansson J, Choustoulakis E, et al. Prevalence and risk factors for ischemia, leak, and stricture of esophageal anastomosis: gastric pull-up versus colon interposition. J Am Coll Surg. 2004;198(4):536–41. discussion 41–2.

    Article  PubMed  Google Scholar 

  3. Stangl JR, Gould J, Pfau PR. Endoscopic treatment of luminal anastomotic strictures. Tech Gastrointest Endosc. 2006;8(2):72–80.

    Article  Google Scholar 

  4. Serhal L, Gottrand F, Sfeir R, Guimber D, Devos P, Bonnevalle M, et al. Anastomotic stricture after surgical repair of esophageal atresia: frequency, risk factors, and efficacy of esophageal bougie dilatations. J Pediatr Surg. 2010;45(7):1459–62.

    Article  PubMed  Google Scholar 

  5. Ruigomez A, Garcia Rodriguez LA, Wallander MA, Johansson S, Eklund S. Esophageal stricture: incidence, treatment patterns, and recurrence rate. Am J Gastroenterol. 2006;101(12):2685–92.

    Article  PubMed  Google Scholar 

  6. Holm AN, de la Mora Levy JG, Gostout CJ, Topazian MD, Baron TH. Self-expanding plastic stents in treatment of benign esophageal conditions. Gastrointest Endosc. 2008;67(1):20–5.

    Article  PubMed  Google Scholar 

  7. Chung WC, Paik CN, Lee KM, Jung SH, Chang UI, Yang JM. The findings influencing restenosis in esophageal anastomotic stricture after endoscopic balloon dilation: restenosis in esophageal anastomotic stricture. Surg Laparosc Endosc Percutan Tech. 2009;19(4):293–7.

    Article  PubMed  Google Scholar 

  8. Kochhar R, Poornachandra KS. Intralesional steroid injection therapy in the management of resistant gastrointestinal strictures. World J Gastrointest Endosc. 2010;2(2):61–8.

    Article  PubMed Central  PubMed  Google Scholar 

  9. Luechakiettisak P, Kasetsunthorn S. Comparison of hand-sewn and stapled in esophagogastric anastomosis after esophageal cancer resection: a prospective randomized study. J Med Assoc Thai. 2008;91(5):681–5.

    PubMed  Google Scholar 

  10. Muehrcke DD, Kaplan DK, Donnelly RJ. Anastomotic narrowing after esophagogastrectomy with the EEA stapling device. J Thorac Cardiovasc Surg. 1989;97(3):434–8.

    CAS  PubMed  Google Scholar 

  11. Honkoop P, Siersema PD, Tilanus HW, Stassen LP, Hop WC, van Blankenstein M. Benign anastomotic strictures after transhiatal esophagectomy and cervical esophagogastrostomy: risk factors and management. J Thorac Cardiovasc Surg. 1996;111(6):1141–6. discussion 7–8.

    Article  CAS  PubMed  Google Scholar 

  12. Johansson J, Oberg S, Wenner J, Zilling T, Johnsson F, von Holstein CS, et al. Impact of proton pump inhibitors on benign anastomotic stricture formations after esophagectomy and gastric tube reconstruction: results from a randomized clinical trial. Ann Surg. 2009;250(5):667–73.

    Article  PubMed  Google Scholar 

  13. Park JY, Song HY, Kim JH, Park JH, Na HK, Kim YH, et al. Benign anastomotic strictures after esophagectomy: long-term effectiveness of balloon dilation and factors affecting recurrence in 155 patients. AJR Am J Roentgenol. 2012;198(5):1208–13.

    Article  PubMed  Google Scholar 

  14. Law S, Fok M, Chu KM, Wong J. Comparison of hand-sewn and stapled esophagogastric anastomosis after esophageal resection for cancer: a prospective randomized controlled trial. Ann Surg. 1997;226(2):169–73.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  15. Rindani R, Martin CJ, Cox MR. Transhiatal versus Ivor-Lewis oesophagectomy: is there a difference? Aust N Z J Surg. 1999;69(3):187–94.

    Article  CAS  PubMed  Google Scholar 

  16. 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 

  17. Fennerty MB. The continuum of GERD complications. Cleve Clin J Med. 2003;70 Suppl 5:S33–50.

    Article  PubMed  Google Scholar 

  18. El-Serag HB. Temporal trends in new and recurrent esophageal strictures in Department of Veterans Affairs. Am J Gastroenterol. 2006;101(8):1727–33.

    Article  PubMed  Google Scholar 

  19. Committee AT, Siddiqui UD, Banerjee S, Barth B, Chauhan SS, Gottlieb KT, et al. Tools for endoscopic stricture dilation. Gastrointest Endosc. 2013;78(3):391–404.

    Article  Google Scholar 

  20. 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 

  21. 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 

  22. Abele JE. The physics of esophageal dilatation. Hepatogastroenterology. 1992;39(6):486–9.

    CAS  PubMed  Google Scholar 

  23. Kim JH, Shin JH, Song HY. Fluoroscopically guided balloon dilation for benign anastomotic stricture in the upper gastrointestinal tract. Korean J Radiol. 2008;9(4):364–70.

    Article  PubMed Central  PubMed  Google Scholar 

  24. Hordijk ML, van Hooft JE, Hansen BE, Fockens P, Kuipers EJ. A randomized comparison of electrocautery incision with Savary bougienage for relief of anastomotic gastroesophageal strictures. Gastrointest Endosc. 2009;70(5):849–55.

    Article  PubMed  Google Scholar 

  25. London RL, Trotman BW, DiMarino Jr AJ, Oleaga JA, Freiman DB, Ring EJ, et al. Dilatation of severe esophageal strictures by an inflatable balloon catheter. Gastroenterology. 1981;80(1):173–5.

    CAS  PubMed  Google Scholar 

  26. Lin S-C, Sy E, Lin B-W, Lee J-C. Management of colorectal anastomotic strictures using multidiameter balloon dilation. J Soc Colon Rectal Surgeon. 2009;20:62–9.

    Google Scholar 

  27. Di ZH, Shin JH, Kim JH, Song HY. Colorectal anastomotic strictures: treatment by fluoroscopic double balloon dilation. J Vasc Interv Radiol. 2005;16(1):75–80.

    Article  PubMed  Google Scholar 

  28. Ikeya T, Ohwada S, Ogawa T, Tanahashi Y, Takeyoshi I, Koyama T, et al. Endoscopic balloon dilation for benign esophageal anastomotic stricture: factors influencing its effectiveness. Hepatogastroenterology. 1999;46(26):959–66.

    CAS  PubMed  Google Scholar 

  29. Martin RC, Woodall C, Duvall R, Scoggins CR. The use of self-expanding silicone stents in esophagectomy strictures: less cost and more efficiency. Ann Thorac Surg. 2008;86(2):436–40.

    Article  PubMed  Google Scholar 

  30. Repici A, Conio M, De Angelis C, Battaglia E, Musso A, Pellicano R, et al. Temporary placement of an expandable polyester silicone-covered stent for treatment of refractory benign esophageal strictures. Gastrointest Endosc. 2004;60(4):513–9.

    Article  PubMed  Google Scholar 

  31. Cwikiel W, Stridbeck H, Tranberg KG, von Holstein CS, Hambraeus G, Lillo-Gil R, et al. Malignant esophageal strictures: treatment with a self-expanding nitinol stent. Radiology. 1993;187(3):661–5.

    Article  CAS  PubMed  Google Scholar 

  32. Wilson JL, Louie BE, Farivar AS, Vallieres E, Aye RW. Fully covered self-expanding metal stents are effective for benign esophagogastric disruptions and strictures. J Gastrointest Surg. 2013;17(12):2045–50.

    Article  PubMed  Google Scholar 

  33. Committee AT, Varadarajulu S, Banerjee S, Barth B, Desilets D, Kaul V, et al. Enteral stents. Gastrointest Endosc. 2011;74(3):455–64.

    Article  Google Scholar 

  34. Eloubeidi MA, Lopes TL. Novel removable internally fully covered self-expanding metal esophageal stent: feasibility, technique of removal, and tissue response in humans. Am J Gastroenterol. 2009;104(6):1374–81.

    Article  PubMed  Google Scholar 

  35. Buscaglia JM, Jayaraman V, Nagula S. Temporary use of a new fully-covered self-expanding metal stent for the management of post-esophagectomy strictures. Dig Endosc. 2011;23:187–9.

    Article  PubMed  Google Scholar 

  36. Evrard S, Le Moine O, Lazaraki G, Dormann A, El Nakadi I, Deviere J. Self-expanding plastic stents for benign esophageal lesions. Gastrointest Endosc. 2004;60(6):894–900.

    Article  PubMed  Google Scholar 

  37. Pennathur A, Chang AC, McGrath KM, Steiner G, Alvelo-Rivera M, Awais O, et al. Polyflex expandable stents in the treatment of esophageal disease: initial experience. Ann Thorac Surg. 2008;85(6):1968–72. discussion 73.

    Article  PubMed  Google Scholar 

  38. Sanchez Munoz D, Ortiz-Moyano C, Gomez-Rodriguez B. Resolution of a refractory anastomotic stricture with a novel biodegradable esophageal stent. Clin Gastroenterol Hepatol. 2013;11(9):e63.

    Article  PubMed  Google Scholar 

  39. Hindy P, Hong J, Lam-Tsai Y, Gress F. A comprehensive review of esophageal stents. Gastroenterol Hepatol. 2012;8(8):526–34.

    Google Scholar 

  40. Kochhar R, Makharia GK. Usefulness of intralesional triamcinolone in treatment of benign esophageal strictures. Gastrointest Endosc. 2002;56(6):829–34.

    Article  PubMed  Google Scholar 

  41. Miyashita M, Onda M, Okawa K, Matsutani T, Yoshiyuki T, Sasajima K, et al. Endoscopic dexamethasone injection following balloon dilatation of anastomotic stricture after esophagogastrostomy. Am J Surg. 1997;174(4):442–4.

    Article  CAS  PubMed  Google Scholar 

  42. Brandimarte G, Tursi A. Endoscopic treatment of benign anastomotic esophageal stenosis with electrocautery. Endoscopy. 2002;34(5):399–401.

    Article  CAS  PubMed  Google Scholar 

  43. Da Costa M, Mata A, Espinos J, Vila V, Roca JM, Turro J, et al. Endoscopic dilation of gastrojejunal anastomotic strictures after laparoscopic gastric bypass. Predictors of initial failure. Obes Surg. 2011;21(1):36–41.

    Article  PubMed  Google Scholar 

  44. Nguyen NT, Stevens CM, Wolfe BM. Incidence and outcome of anastomotic stricture after laparoscopic gastric bypass. J Gastrointest Surg. 2003;7(8):997–1003. discussion.

    Article  PubMed  Google Scholar 

  45. Carrodeguas L, Szomstein S, Zundel N, Lo Menzo E, Rosenthal R. Gastrojejunal anastomotic strictures following laparoscopic Roux-en-Y gastric bypass surgery: analysis of 1291 patients. Surg Obes Relat Dis. 2006;2(2):92–7.

    Article  PubMed  Google Scholar 

  46. Marcotte E, Comeau E, Meziat-Burdin A, Menard C, Rateb G. Early migration of fully covered double-layered metallic stents for post-gastric bypass anastomotic strictures. Int J Surg Case Rep. 2012;3(7):283–6.

    Article  PubMed Central  PubMed  Google Scholar 

  47. Cusati D, Sarr M, Kendrick M, Que F, Swain JM. Refractory strictures after Roux-en-Y gastric bypass: operative management. Surg Obes Relat Dis. 2011;7(2):165–9.

    Article  PubMed  Google Scholar 

  48. Carter JT, Tafreshian S, Campos GM, Tiwari U, Herbella F, Cello JP, et al. Routine upper GI series after gastric bypass does not reliably identify anastomotic leaks or predict stricture formation. Surg Endosc. 2007;21(12):2172–7.

    Article  CAS  PubMed  Google Scholar 

  49. Caro L, Sanchez C, Rodriguez P, Bosch J. Endoscopic balloon dilation of anastomotic strictures occurring after laparoscopic gastric bypass for morbid obesity. Dig Dis. 2008;26(4):314–7.

    Article  PubMed  Google Scholar 

  50. Eubanks S, Edwards CA, Fearing NM, Ramaswamy A, de la Torre RA, Thaler KJ, et al. Use of endoscopic stents to treat anastomotic complications after bariatric surgery. J Am Coll Surg. 2008;206(5):935–8. discussion 8–9.

    Article  PubMed  Google Scholar 

  51. Csendes A, Burgos AM, Burdiles P. Incidence of anastomotic strictures after gastric bypass: a prospective consecutive routine endoscopic study 1 month and 17 months after surgery in 441 patients with morbid obesity. Obes Surg. 2009;19(3):269–73.

    Article  PubMed  Google Scholar 

  52. Hiranyakas A, Da Silva G, Denoya P, Shawki S, Wexner SD. Colorectal anastomotic stricture: is it associated with inadequate colonic mobilization? Tech Coloproctol. 2013;17(4):371–5.

    Article  CAS  PubMed  Google Scholar 

  53. Suchan KL, Muldner A, Manegold BC. Endoscopic treatment of postoperative colorectal anastomotic strictures. Surg Endosc. 2003;17(7):1110–3.

    Article  CAS  PubMed  Google Scholar 

  54. Lamazza A, Fiori E, Sterpetti AV, Schillaci A, Scoglio D, Lezoche E. Self-expandable metal stents in the treatment of benign anastomotic stricture after rectal resection for cancer. Colorectal Dis. 2014;16(4):O150–3.

    Article  CAS  PubMed  Google Scholar 

  55. Repici A, Pagano N, Rando G, Carlino A, Vitetta E, Ferrara E, et al. A retrospective analysis of early and late outcome of biodegradable stent placement in the management of refractory anastomotic colorectal strictures. Surg Endosc. 2013;27(7):2487–91.

    Article  CAS  PubMed  Google Scholar 

  56. Kim PH, Song HY, Park JH, Kim JH, Na HK, Lee YJ. Safe and effective treatment of colorectal anastomotic stricture using a well-defined balloon dilation protocol. J Vasc Interv Radiol. 2012;23(5):675–80.

    Article  PubMed  Google Scholar 

  57. Werre A, Mulder C, van Heteren C, Bilgen ES. Dilation of benign strictures following low anterior resection using Savary-Gilliard bougies. Endoscopy. 2000;32(5):385–8.

    Article  CAS  PubMed  Google Scholar 

  58. Caruso A, Manno M, Manta R, Bertani H, Mirante VG, Conigliaro R. Alternative management of anastomotic colorectal strictures: our experience with fully covered self-expanding metal stents. Surg Endosc. 2013;27(12):4752–3.

    Article  PubMed  Google Scholar 

  59. Forshaw MJ, Maphosa G, Sankararajah D, Parker MC, Stewart M. Endoscopic alternatives in managing anastomotic strictures of the colon and rectum. Tech Coloproctol. 2006;10(1):21–7.

    Article  CAS  PubMed  Google Scholar 

  60. Sutton CD, Marshall LJ, White SA, Flint N, Berry DP, Kelly MJ. Ten-year experience of endoscopic transanal resection. Ann Surg. 2002;235(3):355–62.

    Article  PubMed Central  PubMed  Google Scholar 

  61. Hunt TM, Kelly MJ. Endoscopic transanal resection (ETAR) of colorectal strictures in stapled anastomoses. Ann R Coll Surg Engl. 1994;76(2):121–2.

    PubMed Central  CAS  PubMed  Google Scholar 

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Authors and Affiliations

  1. Division of General Surgery, University of Alberta Hospital, Edmonton, AB, Canada

    Noah Jacob Switzer B.Sc., M.D.

  2. Center for the Advancement of Minimally Invasive Surgery (CAMIS), Royal Alexandra Hospital, 10240 Kingsway, Edmonton, AB, Canada, T5H 3V9

    Shahzeer Karmali B.Sc., M.D., M.P.H., F.R.C.S.C.

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  1. Noah Jacob Switzer B.Sc., M.D.
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Correspondence to Shahzeer Karmali B.Sc., M.D., M.P.H., F.R.C.S.C. .

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Editors and Affiliations

  1. Cleveland Clinic, Section of Surgical Endoscopy, Cleveland, Ohio, USA

    Matthew Kroh

  2. The Oregon Clinic, Division of Gastrointestinal Surgery, Portland, Oregon, USA

    Kevin M. Reavis

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Switzer, N.J., Karmali, S. (2016). Stricture Management: Interventional Options. In: Kroh, M., Reavis, K. (eds) The SAGES Manual Operating Through the Endoscope. Springer, Cham. https://doi.org/10.1007/978-3-319-24145-6_7

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  • DOI: https://doi.org/10.1007/978-3-319-24145-6_7

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