A randomized prospective study comparing rigid to balloon dilators for benign esophageal strictures and rings

The Effect of Laparoscopic Gastric Ischemic Preconditioning Prior to Esophagectomy on Anastomotic Stricture Rate and Comparison with Esophagectomy-Alone Controls

BACKGROUND

Benign anastomotic stricture is a recognized complication following esophagectomy. Laparoscopic gastric ischemic preconditioning (LGIP) prior to esophagectomy has been associated with decreased anastomotic leak rates; however, its effect on stricture and the need for subsequent endoscopic intervention is not well studied.

METHODS

This was a case-control study at an academic medical center using consecutive patients undergoing oncologic esophagectomies (July 2012-July 2022). Our institution initiated an LGIP protocol on 1 January 2021. The primary outcome was the occurrence of stricture within 1 year of esophagectomy, while secondary outcomes were stricture severity and frequency of interventions within the 6 months following stricture. Bivariable comparisons were performed using Chi-square, Fisher's exact, or Mann-Whitney U tests. Multivariable regression controlling for confounders was performed to generate risk-adjust odds ratios and to identify the independent effect of LGIP.

RESULTS

Of 253 esophagectomies, 42 (16.6%) underwent LGIP prior to esophagectomy. There were 45 (17.7%) anastomotic strictures requiring endoscopic intervention, including three patients who underwent LGIP and 42 who did not. Median time to stricture was 144 days. Those who underwent LGIP were significantly less likely to develop anastomotic stricture (7.1% vs. 19.9%; p = 0.048). After controlling for confounders, this difference was no longer significant (odds ratio 0.46, 95% confidence interval 0.14-1.82; p = 0.29). Of those who developed stricture, there was a trend toward less severe strictures and decreased need for endoscopic dilation in the LGIP group (all p < 0.20).

CONCLUSION

LGIP may reduce the rate and severity of symptomatic anastomotic stricture following esophagectomy. A multi-institutional trial evaluating the effect of LGIP on stricture and other anastomotic complications is warranted.

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.

The Triple-S Advantage of Endoscopic Management in Gastrointestinal Surgery Complications: Safe, Successful, and Savings-Driven

Despite advances in gastrointestinal (GI) surgery, post-operative complications are not entirely avoidable [...].

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.

Interventional functional diagnostics in gastrointestinal endoscopy: Combining diagnostic and therapeutic tools in the endoscopy suite with the functional lumen imaging probe

With technical progress of gastrointestinal functional testing, there has been a demand for more comprehensive examination of esophageal physiology and pathophysiology beyond high-resolution manometry. A new interventional technology based on impedance planimetry, the functional lumen imaging probe (FLIP), enables intraluminal measurement of distensibility and compliance of hollow organs. EndoFLIP uses balloon catheters to measure diameter and distension pressure to calculate cross-sectional area and distensibility in different organs (mostly esophagus, stomach, anorectal region) and can be used in wide variety of indications (diagnostics, pre- and post-treatment evaluation) and currently serves as a helpful adjunctive tool in ambiguous clinical cases. EsoFLIP is a therapeutic variation that uses a stiffer balloon catheter allowing for dilation. The trend to simplify the clinical process from diagnosis to treatment tends to a one-session procedure combining diagnostics and therapeutic interventions. In specified conditions like e.g. achalasia or gastroparesis, a combination of EndoFLIP and EsoFLIP procedures may therefore be useful. The aim of this narrative review is to introduce the clinical use of FLIP and its potential benefit in combined diagnostic-therapeutic procedures.

The utility of intraoperative endoscopy in esophagogastric surgery

Flexible endoscopy (FE) plays a major role in the diagnosis and treatment of gastrointestinal disease. Although its intraoperative use has spread over the years, its use by surgeons is still limited in our setting. FE training opportunities are different among many institutions, specialties, and countries. Intraoperative endoscopy (IOE) presents peculiarities that increase its complexity compared to standard FE. IOE has a positive impact on surgical results, due to increased safety and quality, as well as a reduction in the complications. Due to its innumerable advantages, its intraoperative use by surgeons is currently a current project in many countries and is part of the near future in others because of the creation of better structured training projects. This manuscript reviews and updates the indications and uses of intraoperative upper gastrointestinal endoscopy in esophagogastric surgery.

Expert Consensus Statement: Management of Dysphagia in Head and Neck Cancer Patients

OBJECTIVE

To develop an expert consensus statement (ECS) on the management of dysphagia in head and neck cancer (HNC) patients to address controversies and offer opportunities for quality improvement. Dysphagia in HNC was defined as swallowing impairment in patients with cancers of the nasal cavity, paranasal sinuses, nasopharynx, oral cavity, oropharynx, larynx, or hypopharynx.

METHODS

Development group members with expertise in dysphagia followed established guidelines for developing ECS. A professional search strategist systematically reviewed the literature, and the best available evidence was used to compose consensus statements targeted at providers managing dysphagia in adult HNC populations. The development group prioritized topics where there was significant practice variation and topics that would improve the quality of HNC patient care if consensus were possible.

RESULTS

The development group identified 60 candidate consensus statements, based on 75 initial proposed topics and questions, that focused on addressing the following high yield topics: (1) risk factors, (2) screening, (3) evaluation, (4) prevention, (5) interventions, and (6) surveillance. After 2 iterations of the Delphi survey and the removal of duplicative statements, 48 statements met the standardized definition for consensus; 12 statements were designated as no consensus.

CONCLUSION

Expert consensus was achieved for 48 statements pertaining to risk factors, screening, evaluation, prevention, intervention, and surveillance for dysphagia in HNC patients. Clinicians can use these statements to improve quality of care, inform policy and protocols, and appreciate areas where there is no consensus. Future research, ideally randomized controlled trials, is warranted to address additional controversies related to dysphagia in HNC patients.

Endoscopic Management of Congenital Esophageal Defects and Associated Comorbidities

The endoscopist plays a critical role in the management of patients with congenital esophageal defects. This review focuses on esophageal atresia and congenital esophageal strictures and, in particular, the endoscopic management of comorbidities related to these conditions, including anastomotic strictures, tracheoesophageal fistulas, esophageal perforations, and esophagitis surveillance. Practical aspects of endoscopic techniques for stricture management are reviewed including dilation, intralesional steroid injection, stenting, and endoscopic incisional therapy. Endoscopic surveillance for mucosal pathology is essential in this population, as patients are at high risk of esophagitis and its late complications such as Barrett's esophagus.

Efficacy of bougie dilation for normal diet in benign esophageal stricture

OBJECTIVES

Bougination is one of the first-line treatments in benign esophageal stricture (BES). The aim of the study was to identify clinical and endoscopic factors affecting the achievement of a normal diet with only bougie dilation in patients with BES.

PATIENTS AND METHODS

Patients treated with only bougination for BES at three hospitals were retrospectively investigated. Data including patient demographics, stricture and procedural characteristics were collected. Clinical success was defined as normal diet without additional procedures for two months after bougination. Clinical success rate and associated factors were assessed.

RESULTS

A total of 121 patients with BES were included. The most common cause of BES was post-operative stricture (n = 55). Finally, 43 (36%) patients were able to eat a normal diet with only bougination. Of these patients, 42 (97.7%) achieved clinical success in the first three sessions or less. Among causes of stenosis, corrosive injury had the lowest success rate (9/40, 22.5%). Clinical success rate was significantly higher for those with the length of stricture of less than 2 cm (47.2%), those with pre-procedural dysphagia of semi-solid or soft diet (51.3%) and those with dilation of 13 mm or more (46.1%). However, the duration of symptom, the number of previous endoscopic treatments and the location of stenosis were not related to clinical success.

CONCLUSIONS

Normal diet is possible in one-third of BES after bougination alone. Predictable factors for achieving a normal diet were less than four sessions of dilation, short length of stricture, pre-procedural dysphagia status and diameter of dilator.

Endoscopic radial incision versus endoscopic balloon dilation as initial treatments of benign esophageal anastomotic stricture

BACKGROUND AND AIM

We aim to evaluate the efficacy and safety of endoscopic radial incision (ERI) versus endoscopic balloon dilation (EBD) treatment of naïve, recurrent, and refractory benign esophageal anastomotic strictures.

METHODS

One hundred and one ERI, 145 EBD, and 42 ERI combined with EBD sessions were performed in 136 consecutive patients with benign esophageal anastomotic stricture after esophagectomy at Zhongshan Hospital from January 2016 to August 2021. Baseline characteristics, operational procedures, and clinical outcomes data were retrospectively evaluated. Parameters and recurrence-free survival (RFS) were compared between ERI and EBD in patients with naïve or recurrent or refractory strictures. Risk factors for re-stricture after ERI were identified using univariate and multivariate analyses.

RESULTS

Twenty-nine ERI versus 68 EBD sessions were performed for naïve stricture, 26 ERI versus 60 EBD for recurrent strictures, and 46 ERI versus 17 EBD for refractory stricture. With comparable baseline characteristics, RFS was greater in the ERI than the EBD group for naïve strictures (P = 0.0449). The ERI group had a lower 12-month re-stricture rate than the EBD group (37.9% vs 61.8%, P = 0.0309) and a more prolonged patency time (181.5 ± 263.1 vs 74.5 ± 82.0, P = 0.0233). Between the two interventions, recurrent and refractory strictures had similar RFS (P = 0.0598; P = 0.7668). Multivariate analysis revealed initial ERI treatment was an independent predictive factor for lower re-stricture risk after ERI intervention (odds ratio = 0.047, P = 0.001). Few adverse events were observed after ERI or EBD (3.0% vs 2.1%, P = 0.6918).

CONCLUSIONS

ERI is associated with lower re-stricture rates with better patency and RFS compared with EBD for naive strictures.

Efficacy and Safety of Endoscopic Esophageal Dilatation in Pediatric Patients with Esophageal Strictures

Materials and Methods

In this retrospective cross-sectional single center study, records of patients with esophageal strictures presented to the pediatric department, Salmaniya Medical Complex, Bahrain, in the period between 1995 and 2019 were reviewed. Demographic data, indications of endoscopic dilatations, the procedure success rate, and possible complications were assessed.

Results

Forty-six children were found to have esophageal strictures. Twenty-five (54.3%) patients were males. Most patients presented during infancy (86.5%, 32/37 patients). Twenty-six (56.5%) patients required 88 dilatation sessions, while the remaining 20 (43.5%) patients did not require dilatations. The median number of dilatation sessions per patient was three (interquartile range = 2-5). Savary-Gilliard bougienages were the main dilators used (80.8%, 21/26 patients). Anastomotic stricture (post esophageal atresia/tracheoesophageal fistula repair) was the main cause of esophageal strictures and was found in 35 (76.1%) patients. Patients with nonanastomotic strictures had more frequent dilatations compared to those with anastomotic strictures (P = 0.007). The procedure success rate was 98.8%. Yet, it was operator dependent (P = 0.047). Complete response to dilatation was found in 18 (69.2%) patients, satisfactory in seven (26.9%), and an inadequate response in one (3.9%). Those with satisfactory responses still require ongoing dilatations based on their symptoms and radiological and endoscopic findings. No perforation or mortality was reported. Patients with dilatations had more recurrent hospitalization (P < 0.0001), more dysphagia (P = 0.001), but shorter hospital stay (P = 0.046) compared to those without dilatations. Surgical intervention was required in one patient with caustic strictures. The median follow-up period was six years (interquartile range = 2.25-9.0).

Conclusions

Endoscopic esophageal dilatation in children with esophageal strictures is effective and safe. Yet, it was operator dependent. Nonanastomotic strictures require more dilatations compared to anastomotic strictures. Findings of this study are comparable to those reported worldwide.

Biopsy forceps disruption paired with bougie dilation of esophageal strictures lengthens time to repeat intervention

Esophageal strictures commonly cause dysphagia and require treatment with endoscopic dilation using balloons or bougies. We aimed to determine whether biopsy forceps disruption of strictures at time of dilation increases time to repeat intervention or duration of intervention-free follow-up. We performed a retrospective analysis of 289 adults (age 61.0 ± 0.8 years, 66.4% female) who underwent dilation of an esophageal stricture at our tertiary care center between 2014 and 2016. Exclusions consisted of endoscopic intervention within the preceding 6 months, prior foregut neoplasia, achalasia, radiofrequency ablation, endoscopic mucosal resection, endoscopic submucosal dissection, or foregut surgery. Demographics, clinical presentation, dilation technique, and follow-up were abstracted from electronic medical records. We compared time to repeat dilation and duration of intervention-free follow-up between treatment subgroups. Balloon dilation was performed more often than bougie dilation (76.8 vs. 17.6%); biopsy forceps disruption was performed in 23.2%. Over a median follow-up of 52.9 months, 135 patients (46.7%) underwent repeat dilation. Age, body mass index, gender, and use of antisecretory medications did not influence need for repeat dilation (P = ns for each). Bougie dilation with biopsy forceps disruption prolonged time to repeat dilation in all patients (P ≤ 0.02), particularly in those with gastroesophageal reflux disease (P ≤ 0.03), compared with bougie dilation alone and balloon dilation with or without disruption. On Kaplan-Meier analysis, bougie dilation with biopsy forceps resulted in longer intervention-free follow-up compared with dilation alone (P = 0.03). We conclude that stricture disruption with biopsy forceps increases time to repeat intervention with bougie but not balloon dilation.

Self-dilatation of benign oesophageal strictures: a literature review

BACKGROUND

Benign oesophageal strictures can have several aetiologies and often require serial endoscopic dilatation. The aim of this study was to review the existing literature regarding the efficacy of self-dilatation for benign oesophageal strictures.

METHODS

This study presents the results of a systematic review that was performed on the available literature using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Full-text articles from Medline, PubMed and Embase were used, as well as associated reference lists. This study systematically reviews the literature to present the efficacy and different outcome measurements associated with self-dilatation of benign oesophageal strictures.

RESULTS

This study identified 13 articles with 274 participants.

CONCLUSION

Self-dilatation for refractory benign oesophageal strictures is effective regardless of aetiology. It is well tolerated, safe and leads to lasting symptom resolution in the majority of patients.

Appropriate duration of endoscopic dilation for postoperative benign esophageal strictures

BACKGROUND

Benign esophageal strictures are a frequent complication after esophageal surgery or extensive endoscopic submucosal dissection. Endoscopic dilation is the preferred treatment in clinical practice. However, the allocation of time for each dilation is unclear. The aim of this study was to evaluate the appropriate duration of endoscopic dilation for benign esophageal strictures after esophageal surgery or endoscopic submucosal dissection.

METHODS

Patients with benign esophageal strictures after esophageal surgery or endoscopic submucosal dissection between July 2010 and July 2018 were retrospectively included in this study. According to the dilation time (1, 3, 5 min), patients were divided into three groups. The clinical effects and adverse events were compared among the three groups.

RESULTS

Altogether, 57 patients, including 21 in the 1-min group, 18 in the 3-min group and 18 in the 5-min group, were included. All patients underwent endoscopic treatment successfully. The stricture recurrence rate was 76.19% in the 1-min group, 55.56% in the 3-min group and 61.11% in the 5-min group. The median overall dysphagia-free period was 2.60 (range, 0.80-12.00) months in the 1-min group, 6.60 (range, 1.80-12.00) months in the 3-min group and 6.25 (range, 2.40-12.00) months in the 5-min group (P < 0.05). For patients who developed stricture recurrence, the mean dysphagia-free periods were 2.26  ±  1.27 months, 4.00  ±  1.76 months and 4.23  ±  1.63 months, respectively (P < 0.05). The dysphagia-free periods were comparable between the 3- and 5-min groups and were longer than those in the 1-min group. Muscle layer damage occurred in two patients (11.11%) in the 5-min group and in no patients in the other two groups.

CONCLUSION

Three minutes was considered a safe and effective dilation duration for benign esophageal strictures after esophageal surgery or endoscopic submucosal dissection.

Endoscopic management of benign recalcitrant esophageal strictures

Benign esophageal strictures are one of the common clinical conditions managed by endoscopists. Nearly 90% of the benign esophageal strictures respond to endoscopic dilation. However, a small percentage of patients progress to recalcitrant strictures. The benign recalcitrant esophageal strictures are difficult to manage both medically and endoscopically as they do not respond to conventional treatment with proton pump inhibitors and esophageal dilations. Patients with benign recalcitrant esophageal strictures are at a high risk of developing debilitating malnutrition and morbidity due to severe dysphagia. This condition is associated with psychological trauma to patients as treatments are usually prolonged with poor outcomes. Also, this can be a financial burden on the healthcare industry due to several sessions of treatment. In this article, we discuss the classification of benign esophageal strictures, evidence-based treatment strategies, endoscopic procedural techniques, and complications of endoscopic interventions. We aim to guide providers in managing benign esophageal strictures with a focus on endoscopic management of benign recalcitrant esophageal strictures.

Outcomes of Combined Antegrade-Retrograde Dilations for Radiation-Induced Esophageal Strictures in Head and Neck Cancer Patients

The purpose of this study is to analyze outcomes of combined antegrade-retrograde dilations (CARD). This retrospective study was conducted on 14 patients with a history of head and neck cancer, treated with radiation therapy that was complicated by either complete or near-complete esophageal stenosis. All patients had minimal oral intake and depended on a gastrostomy tube for nutrition. Swallow function before and after CARD was assessed using the Functional Oral Intake Scale, originally developed for stroke patients and applied to head and neck cancer patients. Patients undergoing CARD demonstrated a quantifiable improvement in swallow function (p = 0.007) that persisted at last known follow-up (p = 0.015) but only a minority (23.1%) achieved oral intake sufficient to obviate the need for tube feeds. Complication rates were 24% per procedure or 36% per patient, almost all complications required procedural intervention, and all complications occurred in patients with complete stenosis. Our study suggests further caution when considering CARD, careful patient selection, and close post-operative monitoring.

Endoscopic Equipment-From Simple to Advanced

Flexible endoscopic procedures, such as esophagogastroduodenoscopies and colonoscopies, allow for diagnosis and treatment of numerous gastrointestinal disorders. Advanced endoscopic procedures, such as endoscopic ultrasounds, endoscopic retrograde cholangiopancreatography, and balloon enteroscopies, offer therapeutic options that are minimally invasive and effective. As technology advances, the equipment and tools in an endoscopist's armamentarium continue to grow. This article highlights key endoscopic equipment and supplies, from simple to advanced.

Use of the Functional Lumen Imaging Probe in Clinical Esophagology

The functional lumen imaging probe (FLIP) measures luminal dimensions using impedance planimetry, performed most often during sedated upper endoscopy. Mechanical properties of the esophageal wall and opening dynamics of the esophagogastric junction (EGJ) can be objectively evaluated in esophageal motor disorders, eosinophilic esophagitis, esophageal strictures, during esophageal surgery and in postsurgical symptomatic states. Distensibility index, the ratio of EGJ cross sectional area to intraballoon pressure, is the most useful FLIP metric. Secondary peristalsis from balloon distension can be displayed topographically as repetitive anterograde or retrograde contractile activity in the esophageal body, similar to high-resolution manometry. Real-time interpretation and postprocessing of FLIP metadata can complement the identification of esophageal outflow obstruction and achalasia, especially when findings are inconclusive from alternate esophageal tests in symptomatic patients. FLIP can complement the diagnosis of achalasia when manometry and barium studies are inconclusive or negative in patients with typical symptoms. FLIP can direct adequacy of disruption of the EGJ in achalasia when used during and immediately after myotomy and pneumatic dilation. Lumen diameter measured using FLIP in eosinophilic esophagitis and in complex strictures can potentially guide management. An abbreviated modification of the Grading of Recommendations Assessment, Development, and Evaluation was used to determine the quality of available evidence and recommendations regarding FLIP utilization. FLIP metrics that are diagnostic or suggestive of an abnormal motor pattern and metrics that define normal esophageal physiology were developed by consensus and are described in this review.

An international survey on anastomotic stricture management after esophageal atresia repair: considerations and advisory statements

Background

Endoscopic dilatation is the first-line treatment of stricture formation after esophageal atresia (EA) repair. However, there is no consensus on how to perform these dilatation procedures which may lead to a large variation between centers, countries and doctor’s experience. This is the first cross-sectional study to provide an overview on differences in endoscopic dilatation treatment of pediatric anastomotic strictures worldwide.

Methods

An online questionnaire was sent to members of five pediatric medical networks, experienced in treating anastomotic strictures in children with EA. The main outcome was the difference in endoscopic dilatation procedures in various centers worldwide, including technical details, dilatation approach (routine or only in symptomatic patients), and adjuvant treatment options. Descriptive statistics were performed with SPSS.

Results

Responses from 115 centers from 32 countries worldwide were analyzed. The preferred approach was balloon dilatation (68%) with a guidewire (66%), performed by a pediatric gastroenterologist (n = 103) or pediatric surgeon (n = 48) in symptomatic patients (68%). In most centers, hydrostatic pressure was used for balloon dilatation. The insufflation duration was standardized in 59 centers with a median duration of 60 (range 5–300) seconds. The preferred first-line adjunctive treatments in case of recurrent strictures were intralesional steroids and topical mitomycin C, in respectively 47% and 31% of the centers.

Conclusions

We found a large variation in stricture management in children with EA, which confirms the current lack of consensus. International networks for rare diseases are required for harmonizing and comparing the procedures, for which we give several suggestions.

Electronic supplementary material

The online version of this article (10.1007/s00464-020-07844-6) contains supplementary material, which is available to authorized users.

EsoFLIP for esophageal dilation: proposed advantages

PURPOSE OF REVIEW

The EsoFLIP integrates impedance planimetry technology into a dilator balloon capable of dilating from diameters between 10 and 30 mm via controlled volumetric distension while providing real-time visualization and objective measurement during the dilation procedure, potentially negating the need for fluoroscopy. This review aims to describe the use and application of EsoFLIP and the potential advantages this novel technology may afford.

RECENT FINDINGS

Small pilot and retrospective studies demonstrate EsoFLIP feasibility and safety, but larger studies are needed to understand its impact on clinical outcomes.

SUMMARY

EsoFLIP is an appealing new technology that offers advantages in therapeutic dilation of the lower esophageal sphincter in achalasia or of esophageal strictures because of previous surgery, gastroesophageal reflux disease, or radiation.

Esophageal Dysphagia in the Elderly

PURPOSE OF REVIEW

With a globally aging population, dysphagia is a growing health concern among elderly. Increasing reflux disease has contributed to an increased prevalence of dysphagia from peptic strictures and esophageal cancer. Dysphagia can lead to malnutrition and aspiration pneumonia, causing considerable morbidity and mortality. This review article focuses on recent advances in the approach and management of esophageal dysphagia.

RECENT FINDINGS

Endoscopic functional luminal imaging probe is a novel test that complements upper endoscopy, esophagram, and esophageal manometry for evaluation of esophageal dysphagia. Opioid induced esophageal dysfunction (OIED) is an emerging clinical entity that can mimic achalasia. Strictures refractory to dilation can be treated with intralesional steroid injections, electrosurgical incision, or esophageal stents. Peroral endoscopic myotomy (POEM) is gaining in popularity for treatment of achalasia and other spastic disorders of esophagus. Treatment of esophageal dysphagia may include proton pump inhibitors, endoscopic dilation, or surgery and requires a personalized approach based on risks and benefits. POEM is a valuable therapy for achalasia, but further studies are needed to evaluate its use, and other alternatives, for treatment of OIED and spastic esophageal disorders.

Outcomes of Endoscopic Dilation in Patients with Esophageal Anastomotic Strictures: Comparison Between Different Etiologies

BACKGROUND AND AIMS

This retrospective study was aimed at assessing the efficacy of endoscopic dilation for esophageal anastomotic strictures, and to compare response between caustic anastomotic strictures (CAS) and non-caustic anastomotic strictures (NCAS).

MATERIALS AND METHODS

Patients with anastomotic strictures (enrolled during January 1996-December 2015) were analyzed. Short- and long-term outcomes of dilation, in terms of clinical success, refractory, and recurrent strictures were compared between NCAS and CAS. Patients with refractory and recurrent strictures were managed with adjunctive therapy including intralesional steroids. Factors predicting refractoriness at start of dilation and reasons for more than ten lifetime dilations were also evaluated.

RESULTS

Of the 142 patients, 124 (mean age-44.02; males-74) underwent dilation. Clinical success was achieved in 113 (91.3%) patients requiring a median [Interquartile range (IQR)] of 4 (2-10) sessions. The number of dilations to achieve clinical success, refractory strictures, and recurrent strictures, and the use of adjunctive therapy were significantly higher for CAS than for NCAS. Intralesional steroid use decreased periodic dilation index (PDI) significantly in CAS. Caustic etiology and starting dilation diameter of < 10 mm were found to be predictors of refractoriness, with the former alone being an independent predictor of more than ten lifetime dilations. No patient had free perforation; however, five required revision surgery.

CONCLUSION

Patients with CAS fared worse than those with NCAS in terms of number of dilations, refractoriness, recurrence of strictures, and need of adjunctive therapy. Endoscopic dilation can successfully ameliorate dysphagia due to anastomotic strictures in a majority of patients.

Factors associated with complications during endoscopic esophageal dilation

BACKGROUND

endoscopic dilation is considered as the treatment of choice for esophageal strictures. However, there are no studies in our region that have assessed the safety of the procedure.

OBJECTIVE

to assess the safety of esophageal dilation and the factors associated with the development of complications.

MATERIALS AND METHODS

a retrospective cohort was studied. All patients referred for esophageal dilation between January 2015 and June 2017 were included in the study. A complication rate was obtained and the association between nonadherence to the "rule of 3" and the development of complications was determined. Other predictive factors associated with complication development were also analyzed.

RESULTS

a total of 164 patients that underwent 474 dilations were included in the study. Surgical anastomosis stricture was the most prevalent etiology. A total of six complications occurred, including three perforations (0.63%), two bleeding events (0.42%) and one episode of significant pain that required post-procedure observation (0.21%). Endoscopic esophageal dilation without adherence to the "rule of 3" was not associated with a higher risk of complications. Balloon dilation was the only predictive factor for complications.

CONCLUSIONS

esophageal dilation is a safe procedure. Nonadherence to the "rule of 3" does not appear to be associated with a higher risk of complications, including esophageal perforation.

Role of endoscopy in caustic injury of the esophagus

Caustic injury of the esophagus is a problematic condition challenging endoscopists worldwide. Although the caustic agents and motives are different among countries and age groups, endoscopy still plays an invaluable role in diagnosis and treatment. Endoscopy can determine the severity of caustic ingestion which is of great importance in choosing appropriate treatment. However, some aspects of endoscopy in diagnosis of caustic injury remain controversial. Whether or not all patients need endoscopy, when to perform endoscopy and how to assess the severity are just some examples of these controversies. Due to lack of randomized controlled trials, many findings and suggestions are inconclusive. Computerized tomography scan of the chest and abdomen gains popularity in assessing the severity of caustic injury and avoiding unnecessary surgery. If esophageal stricture eventually develops, endoscopic dilatation is a mainstay. Maneuvers such as steroid injection and esophageal stent may be used in a refractory stricture. Nevertheless, some patients have to undergo surgery in spite of vigorous attempts with esophageal dilatation. To date, caustic injury remains a difficult situation. This article reviews all aspects of caustic injury of the esophagus focusing on endoscopic role. Pre-endoscopic management, endoscopy and its technique in acute and late phase of caustic injury including the endoscopic management of refractory stricture, and the treatment outcomes following each endoscopic intervention are thoroughly discussed. Finally, the role of endoscopy in the long term follow-up of patients with esophageal caustic injury is addressed.

Endoscopic balloon dilation and submucosal injection of triamcinolone acetonide in the treatment of esophageal stricture: A single-center retrospective study

Effect and prognosis of endoscopic balloon dilatation combined with submucosal triamcinolone acetonide on treating benign esophageal lesions were explored. This retrospective study included patients with esophageal stricture treated in the Department of Gastroenterology, the Third Affiliated Hospital of Soochow University from March 2012 to March 2015. Enrolled patients were divided into the treatment and control group depending on the therapy differences. Endoscopic balloon dilation combined with submucosal injection of triamcinolone acetonide was performed in the treatment group and the endoscopic balloon dilatation was performed in the control group. In addition, the treatment group was further divided into the <16- and >16-mm subgroup according to the degree of balloon dilatation. During 1-year follow-up, changes of esophageal stenosis, esophageal stenosis recurrence rate, postoperative complications and adverse reactions were observed and analyzed. The improvement of esophageal stenosis of the treatment group was significantly superior to that of the control group at 2 and 4 months after operation, respectively (P=0.002, 0.013). The esophageal stenosis recurrence rate was 62.2 and 77.2% in the treatment and control group, respectively (P=0.027); the recurrence time of stenosis was 101.4±8.6 days in the treatment group and 75.4±5.2 days in the control group (P=0.006). Additionally, the recurrence time of esophageal stenosis was significantly shorter in the >16-mm subgroup compared with that of the <16-mm subgroup (P<0.001). Endoscopic balloon dilatation combined with local injection of triamcinolone acetonide in the treatment of esophageal stricture had a better therapeutic effect than that of the simple balloon dilatation, which was more effective when the balloon dilatation was >16 mm. It could significantly prolong the recurrence time of esophageal stricture.

Long-Term Outcomes of Caustic Esophageal Stricture with Endoscopic Balloon Dilatation in Chinese Children

Caustic esophageal stricture (CES) in children still occurs frequently in developing countries. We aimed to evaluate the long-term outcomes of endoscopic balloon dilatation (EBD) in treating CES in children and the influencing factors associated with outcome. We retrospectively reviewed the data of all patients who had a diagnosis of CES and underwent EBD from August 1, 2005, to December 31, 2014. The primary outcome was EBD success, which was defined as the maintenance of dysphagia-free status for at least 12 months after the last EBD. The secondary outcome was to analyze influencing factors associated with EBD success. Forty-three patients were included for analysis (29 males; mean age at first dilatation 44 months with range 121 months). 26 (60.5%) patients had long segment (>2 cm) stricture. A total of 168 EBD procedures were performed. Twenty-six (60.5%) patients were considered EBD success. Seventeen (39.5%) patients failed EBD and required stent placement and/or surgery. Patients in the EBD success group had significantly shorter stricture segments when compared to the EBD failure group (t = 2.398, P = 0.018, OR = 3.206, 95% OR: 1.228-8.371). Seven (4.4%) esophageal perforations occurred in 6 patients after EBD. Stents were placed in 5 patients, and gastric tube esophagoplasty was performed in 14 patients. In conclusion, 26 (60.5%) of 43 children with CES had EBD success. Length of stricture was the main influencing factor associated with EBD treatment outcome.

Endoscopic Dilation with Bougies versus Balloon Dilation in Esophageal Benign Strictures: Systematic Review and Meta-Analysis

Background

The use of bougies and balloons to dilate benign esophageal strictures (BES) is a consolidated procedure. However, the amount of evidence available in scientific literature supporting which is the best technique is very low, despite the great prevalence and importance of such pathology. This systematic review with meta-analysis aims at comparing both techniques, providing good quality of evidence.

Methods

We searched for randomized clinical trials (RCTs) published from insertion to November 2017, using MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, LILACS, and grey literature. After the data extraction, a meta-analysis was performed. The main outcomes were symptomatic relief and recurrence rate. The secondary outcomes were bleeding, perforation, and postprocedure pain.

Results

We included 5 randomized clinical trials (RCTs), totalizing 461 patients. Among them, 151 were treated with bougie dilation and 225 underwent balloon dilation. Regarding symptomatic relief, recurrence, bleeding, and perforation rates, there were no differences between the methods. Concerning postprocedure pain, patients submitted to balloon dilation had less intense pain (RD 0.27, 95% IC -0.42 to -0.07, P = 0.007).

Conclusion

We conclude that there is no difference between bougie and balloon dilation of BESs regarding symptomatic relief, recurrence rate at 12 months, bleeding, and perforation. Patients undergoing balloon dilation present less severe postprocedure pain.

UK guidelines on oesophageal dilatation in clinical practice

These are updated guidelines which supersede the original version published in 2004. This work has been endorsed by the Clinical Services and Standards Committee of the British Society of Gastroenterology (BSG) under the auspices of the oesophageal section of the BSG. The original guidelines have undergone extensive revision by the 16 members of the Guideline Development Group with representation from individuals across all relevant disciplines, including the Heartburn Cancer UK charity, a nursing representative and a patient representative. The methodological rigour and transparency of the guideline development processes were appraised using the revised Appraisal of Guidelines for Research and Evaluation (AGREE II) tool.Dilatation of the oesophagus is a relatively high-risk intervention, and is required by an increasing range of disease states. Moreover, there is scarcity of evidence in the literature to guide clinicians on how to safely perform this procedure. These guidelines deal specifically with the dilatation procedure using balloon or bougie devices as a primary treatment strategy for non-malignant narrowing of the oesophagus. The use of stents is outside the remit of this paper; however, for cases of dilatation failure, alternative techniques-including stents-will be listed. The guideline is divided into the following subheadings: (1) patient preparation; (2) the dilatation procedure; (3) aftercare and (4) disease-specific considerations. A systematic literature search was performed. The Grading of Recommendations Assessment, Develop-ment and Evaluation (GRADE) tool was used to evaluate the quality of evidence and decide on the strength of recommendations made.

Endoscopic Dilation of Pharyngoesophageal Strictures: There Are More Dimensions than a Diameter

Background/Aims

Dysphagia due to benign pharyngoesophageal strictures (PES) often requires repeated dilations; however, a uniform definition for the therapeutic efficacy of this technique has not been yet established. We aimed to assess the overall efficacy of endoscopic dilation of pharyngoesophageal anastomotic or post-radiotherapy (post-RT) strictures.

Methods

The data of 48 patients with post-RT (n = 29) or anastomotic PES (n = 19) submitted to endoscopic dilation during a 3-year period were retrospectively assessed. The Kochman criteria were used to determine refractoriness and recurrence. Patients were asked to answer a questionnaire determining prospectively the dilation program efficacy as (a) dysphagia improvement, (b) dysphagia resolution, (c) need for further dilations, or (d) percutaneous endoscopic gastrostomy (PEG) during the previous 6 months. Need for additional therapy was considered an inefficacy criterion.

Results

The median number of dilations per patient was 4 (total of 296 dilations) with a median follow-up of 29 months. The mean predilation dysphagia Mellow-Pinkas score was 3 and the initial stenosis diameter was 7 mm. Fifteen and 29% of patients presented with the Kochman criteria for refractory and recurrent strictures, respectively. Moreover, 96 and 60% showed dysphagia improvement and resolution, respectively. Seventy-five-percent did not require dilations during 6 months, and 89% did not require PEG. From the patients' perspective, overall efficacy was achieved in 58% of cases. Nine additional therapies were required. Number of dilations (OR 0.7), stricture diameter (OR 2.2), and nonrecurrence criteria (OR 14.2) appeared as significant predictors of overall efficacy, whereas refractory stenosis criteria did not.

Conclusions

Endoscopic dilation seems to be effective for patients with dysphagia after RT or surgery, especially when assessed as patient perception of improvement. Narrow strictures, recurrent ones, and strictures requiring a higher number of dilations may predict worse outcomes.

Key Message

Health professionals should establish well-defined efficacy criteria for dilations and base their decision beyond exclusively objective measurements.

Self-dilation for therapy-resistant benign esophageal strictures: towards a systematic approach

BACKGROUND

Patients with therapy-resistant benign esophageal strictures (TRBES) suffer from chronic dysphagia and generally require repeated endoscopic dilations. For selected patients, esophageal self-dilation may improve patient's autonomy and reduce the number of endoscopic dilations. We evaluated the clinical course and outcomes of patients who started esophageal self-dilation at our institution.

METHODS

This study was a retrospective case series of patients with TRBES who started esophageal self-dilation between 2012 and 2016 at the Academic Medical Center Amsterdam. To learn self-dilation using Savary-Gilliard bougie dilators, patients visited the outpatient clinic on a weekly basis where they were trained by a dedicated nurse. Endoscopic dilation was continued until patients were able to perform self-bougienage adequately. The primary outcome was the number of endoscopic dilation procedures before and after initiation of self-dilation. Secondary outcomes were technical success, final bougie size, dysphagia scores, and adverse events.

RESULTS

Seventeen patients started with esophageal self-dilation mainly because of therapy-resistant post-surgical (41%) and caustic (35%) strictures. The technical success rate of learning self-bougienage was 94% (16/17). The median number of endoscopic dilation procedures dropped from 17 [interquartile range (IQR) 11-27] procedures during a median period of 9 (IQR 6-36) months to 1.5 (IQR 0-3) procedures after the start of self-dilation (p < 0.001). The median follow-up after initiation of self-dilation was 17.6 (IQR 11.5-33.3) months. The final bougie size achieved with self-bougienage had a median diameter of 14 (IQR 13-15) mm. All patients could tolerate solid foods (Ogilvie dysphagia score ≤ 1), making the clinical success rate 94% (16/17). One patient (6%) developed a single episode of hematemesis related to self-bougienage.

CONCLUSIONS

In this small case series, esophageal self-dilation was found to be successful 94% of patients when conducted under strict guidance. All patients performing self-bougienage achieved a stable situation where they could tolerate solid foods without the need for endoscopic dilation.

Complementary roles of interventional radiology and therapeutic endoscopy in gastroenterology

Acute upper and lower gastrointestinal bleeding, enteral feeding, cecostomy tubes and luminal strictures are some of the common reasons for gastroenterology service. While surgery was initially considered the main treatment modality, the advent of both therapeutic endoscopy and interventional radiology have resulted in the paradigm shift in the management of these conditions. In this paper, we discuss the patient’s work up, indications, and complementary roles of endoscopic and angiographic management in the settings of gastrointestinal bleeding, enteral feeding, cecostomy tube placement and luminal strictures. These conditions often require multidisciplinary approaches involving a team of interventional radiologists, gastroenterologists and surgeons. Further, the authors also aim to describe how the fields of interventional radiology and gastrointestinal endoscopy are overlapping and complementary in the management of these complex conditions.

Clinical Outcomes of Dilation Therapy for Anastomotic Esophageal Stricture

Background/Aims

Benign esophageal stricture after esophagectomy is not an infrequent complication. Anastomotic esophageal stricture requires frequent multiple dilations. We aimed to evaluate the clinical outcomes of dilation therapies using an endoscopic balloon or bougie dilator and analyzed the risk factors associated with refractory stricture.

Methods

Between January 2009 and May 2016, the medical records of 21 patients treated with endoscopic balloon dilation or bougie dilation for esophageal anastomotic strictures were retrospectively reviewed.

Results

During the study periods, a total of 21 patients were diagnosed with esophageal anastomotic stricture and included for analysis (17 male; mean age, 68.2±7.2 years at the first procedure). The mean stricture length was 6.4±8.1 mm. The refractory stricture was found in 28.6% of patients, and successful relief of dysphagia was achieved in 71.4% of patients. The major complication associated with dilations was absent. Factors associated with refractory stricture were stricture length (> 10 mm, p<0.049) and diabetes mellitus (p=0.035). Additive bougie dilations achieved clinical success in 4 out of 7 patients.

Conclusions

Dilation with endoscopic balloon or bougie dilator was an effective and safe procedure for benign anastomotic esophageal strictures of less than 10 mm in length.

Non-adherence to the rule of 3 does not increase the risk of adverse events in esophageal dilation

BACKGROUND AND AIMS

Although the rule of 3 is recommended to minimize the risk of perforation when esophageal dilation is performed using bougie dilators, there are no data to validate its use. Our aim was to investigate the association between the rule of 3 and adverse events (AEs) in esophageal dilation.

METHODS

A retrospective chart review in patients who underwent esophageal bougie or balloon dilation between December 1991 and February 2013 at a tertiary hospital was performed. Data collection included patient demographics, stricture and procedural characteristics, AEs, and follow-up. Univariate logistic regression models were used to assess the risk of AEs and perforations.

RESULTS

A total of 297 patients (median age, 63 years; 60% men) underwent 2216 esophageal bougie or balloon dilations. Major AEs occurred in 22 (1%) dilation sessions, including 11 (0.5%) perforations, 4 (0.2%) fistulas, 3 (0.1%) hospitalizations for pain management, 2 (0.09%) clinically significant hemorrhages, 1 (0.04%) fever, and 1 (0.04%) tracheoesophageal voice prosthesis leak. Mean duration of treatment was 43.2 months (standard deviation, 47.7 months). Most strictures were benign (n = 275; 93%) and complex in nature (n = 198; 67%). Non-adherence to the rule of 3 occurred in 190 (13%) dilations with bougie dilators. Non-adherence was not associated with a higher rate of major AEs (1/190, 0.5% vs 15/953, 1.6%; P = .18) and perforations (0/190, 0% vs 7/952, 0.7%; P = .18). Gender, complex strictures, location of the stricture, type of dilator, and additional interventions were also not associated with major AEs or perforations. However, malignant strictures were associated with an increased risk of major AEs (odds ratio, 3.5; 95% confidence interval, 1.1-12.0) and perforations (odds ratio, 8.3; 95% confidence interval, 2.2-31.9).

CONCLUSIONS

Non-adherence to the rule of 3 does not appear to increase the risk of AEs, particularly perforation, after esophageal dilation using bougie dilators. Caution is needed with the dilation of malignant strictures, as there is an increased risk of perforations and AEs. However, large prospective studies are needed to verify the results of this study.

Anastomotic Strictures after Esophageal Atresia Repair: Incidence, Investigations, and Management, Including Treatment of Refractory and Recurrent Strictures

Improved surgical techniques, as well as preoperative and postoperative care, have dramatically changed survival of children with esophageal atresia (EA) over the last decades. Nowadays, we are increasingly seeing EA patients experiencing significant short- and long-term gastrointestinal morbidities. Anastomotic stricture (AS) is the most common complication following operative repair. An esophageal stricture is defined as an intrinsic luminal narrowing in a clinically symptomatic patient, but no symptoms are sensitive or specific enough to diagnose an AS. This review aims to provide a comprehensive view of AS in EA children. Given the lack of evidence-based data, we critically analyzed significant studies on children and adults, including comments on benign strictures with other etiologies. Despite there is no consensus about the goal of the luminal diameter based on the patient's age, esophageal contrast study, and/or endoscopy are recommended to assess the degree of the narrowing. A high variability in incidence of ASs is reported in literature, depending on different definitions of AS and on a great number of pre-, intra-, and postoperative risk factor influencing the anastomosis outcome. The presence of a long gap between the two esophageal ends, with consequent anastomotic tension, is determinant for stricture formation and its response to treatment. The cornerstone of treatment is endoscopic dilation, whose primary aims are to achieve symptom relief, allow age-appropriate capacity for oral feeding, and reduce the risk of pulmonary aspiration. No clear advantage of either balloon or bougie dilator has been demonstrated; therefore, the choice is based on operator experience and comfort with the equipment. Retrospective evidences suggest that selective dilatations (performed only in symptomatic patients) results in significantly less number of dilatation sessions than routine dilations (performed to prevent symptoms) with equal long-term outcomes. The response to dilation treatment is variable, and some patients may experience recurrent and refractory ASs. Adjunctive treatments have been used, including local injection of steroids, topical application of mitomycin C, and esophageal stenting, but long-term studies are needed to prove their efficacy and safety. Stricture resection or esophageal replacement with an interposition graft remains options for AS refractory to conservative treatments.

Endoscopic treatment of benign esophageal strictures: a literature review

Benign esophageal strictures arise from various etiologies and are frequently encountered. Although endoscopic dilation is still the first-line therapy, recurrent strictures do occur in approximately 10% of the cases and remains a challenge to gastroenterologists. Areas covered: A literature search was performed using PubMed and Google Scholar databases for original and review articles on endoscopic treatment of benign esophageal strictures. This review outlines the main available treatment options and its controversies in the management of refractory benign esophageal strictures. Expert commentary: Adding local steroid injections to dilation can be effective for peptic stenosis and strictures after endoscopic submucosal dissection, but remains uncertain for anastomotic strictures. Intralesional injections of mitomycin-C could be useful in corrosive strictures. Incisional therapy can be a reliable alternative in Schatzki rings and in anastomotic strictures, in experienced hands. By contrast, long-term outcome with endoprosthetic treatment is disappointing, and stent placement should be carefully considered and individualized.

Endoscopic dilation of benign esophageal anastomotic strictures over 16 mm has a longer lasting effect

Background

The optimal target of endoscopic dilation of postsurgical esophageal strictures is unknown. Our aim was to compare the dilation-free period of patients who underwent dilation up to 16 mm with patients who were dilated up to 17 or 18 mm.

Methods

We retrospectively analyzed adult patients who received bougie/balloon dilation for a benign anastomotic stricture after esophagectomy. An anastomotic stricture was defined as dysphagia in combination with a luminal diameter of ≤13 mm at endoscopy. We analyzed the dilation-free period using Kaplan–Meier and multivariable Cox regression analysis.

Results

Eighty-eight patients were dilated up to a maximum diameter of 16 mm and 91 patients to a diameter >16 mm. The stricture recurrence rate was 79.5 % in the 16 mm group and 68.1 % in the >16 mm group (p = 0.083). The overall dilation-free period had a median of 41.5 (range 8–3233) days and 92 (range 17–1745) days, respectively (p < 0.001). For patients who developed a stricture recurrence, the median dilation-free period was 28 (range 8–487) days and 63 (range 17–1013) days, respectively (p = 0.001). Cox regression analysis showed a reduced risk of stricture recurrence for patients who were dilated up to >16 mm: crude hazard ratio (HR) 0.57 (95 % confidence interval (CI) 0.41–0.81) and adjusted HR 0.48 (95 % CI 0.33–0.70).

Conclusions

Endoscopic dilation over 16 mm resulted in a significant prolongation of the dilation-free period in comparison with dilation up to 16 mm in patients with benign anastomotic strictures after esophagectomy.

Electronic supplementary material

The online version of this article (doi:10.1007/s00464-016-5187-0) contains supplementary material, which is available to authorized users.

An Intractable Caustic Esophageal Stricture Successfully Managed with Sequential Treatment Comprising Incision with an Insulated-Tip Knife, Balloon Dilation, and an Oral Steroid

Bougie or balloon dilation is a good short-term treatment for caustic esophageal strictures, although recurrence after dilation occurs in approximately 30% of these cases. Therefore, long-term treatment options are required in some cases, and endoscopic incisional therapy has been used for patients with an anastomotic stricture in the gastrointestinal tract. A 58-year-old woman presented with severe swallowing difficulty because of a caustic esophageal stricture, which was caused by accidental exposure to anhydrous acetic acid at infancy. She had undergone several previous bougie and balloon dilations but the stricture did not improve. We performed sequential treatment comprising incision with an insulated-tip knife, balloon dilation, and an oral steroid, which resulted in the patient’s symptoms markedly improving. Thus, we report this case of an intractable caustic esophageal stricture, which was successfully treated using combined endoscopic sequential treatment.

Endoscopic Management of Anastomotic Esophageal Strictures Secondary to Esophageal Atresia

The reported incidence of anastomotic stricture after esophageal atresia repair has varied in case series from as low as 9% to as high as 80%. The cornerstone of esophageal stricture treatment is dilation with either balloon or bougie. The goal of esophageal dilation is to increase the luminal diameter of the esophagus while also improving dysphagia symptoms. Once a stricture becomes refractory to esophageal dilation, there are several treatment therapies available as adjuncts to dilation therapy. These therapies include intralesional steroid injection, mitomycin C, esophageal stent placement, and endoscopic incisional therapy.

Evaluation of efficacy of endoscopic incision method in postoperative benign anastomotic strictures of gastrointestinal system

INTRODUCTION

Postoperative benign anastomotic strictures (POBAS) which develop after surgical resections of the gastrointestinal system (GIS) present with symptoms depending on location of the stricture. Diagnosis is confirmed by endoscopic and radiological methods. Although bougie or balloon dilatation is preferred in management, the endoscopic incision method (EIM) is also used with considerable success. In this trial, we aimed to evaluate EIM, which is one of the endoscopic dilatation techniques used in postoperative anastomotic stricture of GIS.

MATERIAL AND METHODS

A total of 20 POBAS patients, 12 men and 8 women, subjected to EIM intervention for strictures, were enrolled in the trial. The number of patients with upper GIS strictures was 6 (30%), while the number of cases with lower GIS strictures was 14 (70%).

RESULTS

Dilatation of the stricture was achieved in 15 (75%) patients with one treatment session, while more than one session of EIM was needed in 5 (25%) cases. Mean duration of follow-up of patients was 10.65 ±5.86 (0-25) months. Procedure-related complications developed in 8 patients. Among them, 7 were minor complications and improved without any treatment. In only 1 (5%) patient, perforation was observed as a major complication. Following EIM, recurrence of POBAS was observed in 5 (25%) patients. The following parameters were found to have an impact on successful outcome in EIM: presence or absence of a tortuous lumen in POBAS (p = 0.035) and length of stricture (p = 0.02), complications during the procedure (if any), and presence of single or multiple strictures.

CONCLUSIONS

Endoscopic incision method may be regarded as a favorable approach among first choice treatment alternatives in uncomplicated anastomotic strictures of GIS, or it may be used as an adjunctive dilatation method.

Foregut caustic injuries: results of the world society of emergency surgery consensus conference

INTRODUCTION

Lesions of the upper digestive tract due to ingestion of caustic agents still represent a major medical and surgical emergency worldwide. The work-up of these patients is poorly defined and no clear therapeutic guidelines are available.

PURPOSE OF THE STUDY

The aim of this study was to provide an evidence-based international consensus on primary and secondary prevention, diagnosis, staging, and treatment of this life-threatening and potentially disabling condition.

METHODS

An extensive literature search was performed by an international panel of experts under the auspices of the World Society of Emergency Surgery (WSES). The level of evidence of the screened publications was graded using the Oxford 2011 criteria. The level of evidence of the literature and the main topics regarding foregut caustic injuries were discussed during a dedicated meeting in Milan, Italy (April 2015), and during the 3rd Annual Congress of the World Society of Emergency Surgery in Jerusalem, Israel (July 2015).

RESULTS

One-hundred-forty-seven full papers which addressed the relevant clinical questions of the research were admitted to the consensus conference. There was an unanimous consensus on the fact that the current literature on foregut caustic injuries lacks homogeneous classification systems and prospective methodology. Moreover, the non-standardized definition of technical and clinical success precludes any accurate comparison of therapeutic modalities. Key recommendations and algorithms based on expert opinions, retrospective studies and literature reviews were proposed and approved during the final consensus conference. The clinical practice guidelines resulting from the consensus conference were approved by the WSES council.

CONCLUSIONS

The recommendations emerging from this consensus conference, although based on a low level of evidence, have important clinical implications. A world registry of foregut caustic injuries could be useful to collect a homogeneous data-base for prospective clinical studies that may help improving the current clinical practice guidelines.

Techniques and principles of endoscopic treatment of benign gastrointestinal strictures

PURPOSE OF REVIEW

The fundamental goal of treating any stenosis is luminal enlargement to ameliorate the underlying obstructive symptoms. Symptoms depend on the etiology and the site of the stricture and may include dysphagia, nausea and vomiting, abdominal pain, obstipation, or frank bowel obstruction. This article compares the various current technologies available for the treatment of gastrointestinal stenoses with regard to ease and site of application, patient tolerance, safety and efficacy data, and cost-benefit ratio.

RECENT FINDINGS

Recent studies indicate that gastrointestinal dilation and stenting have evolved to a point at which in many if not most situations they can be the first line therapy and potentially the final therapy needed to treat the underlying condition.

SUMMARY

Following techniques and principles in the management of gastrointestinal strictures would allow for the well tolerated and effective treatment of most patients with the tools currently available today.