Incisional endoscopic therapy as a therapeutic alternative in esophageal anastomotic strictures refractory to conventional treatment

Risk factors of refractory post-endoscopic submucosal dissection esophageal strictures

INTRODUCTION

our aim was to comparatively assess the treatment outcomes of endoscopic dilatation in Barrett's neoplasia and squamous cell carcinoma (SCC) post-endoscopic submucosal dissection (ESD) strictures, and to determine the risk or factors associated to refractory strictures.

METHODS

an observational study. All consecutive patients presenting with a post-ESD stricture in 2007-2016 who underwent dilation therapy were included. Clinical, morphological, and technical features were assessed to determine the risk factors of refractory strictures.

RESULTS

of 414 consecutive patients treated by ESD, 83 (mean age: 65 ± 10 years, 76 % men) with 254 dilations (median: 3, range: 1-27) were considered. Barrett's neoplasia and SCC were the indications in 58 (69.9 %) and in 25 (30.1 %) cases, respectively. Clinical success was achieved in 84.3 % with a median of 3 sessions (range: 1-22), with a higher rate in Barrett's neoplasia (89.7 % vs. 72 %, p = 0.042). Circumferential resection in one single procedure (13.2 %) was associated with the need for a higher number of dilation sessions. By multivariate analysis, upper-esophageal location (OR: 11.479 [95 % CI: 2.058-64.043], p = 0.005), recurrent strictures (OR: 17.252 [95 % CI: 2.833-105.069], p = 0.002), and dilation-related complications (OR: 26.420 [95 % CI: 1.736-401.966], p = 0.018) were risk factors of refractory stenosis.

CONCLUSION

patients presenting with SCC located in the upper superior esophagus, intra-procedural perforation, and recurrent strictures are at higher risk of developing refractory strictures.

Managing esophageal strictures following endoscopic resection of superficial neoplastic lesions

Over the last few years early esophageal tumors, whether squamous-cell or associated with Barrett's esophagus, have been excised using endoscopic resection techniques, primarily endoscopic submucosal dissection (ESD). Esophageal surgery-associated morbidity and mortality are thus avoided with similar oncologic outcomes. ESD is not without complications, many of which arise and are endoscopically solved during the procedure itself (bleeding, perforation, etc.). Other complications develop within days or weeks after resection, these including mainly esophageal stricture. Esophageal strictures following ESD are initially managed with endoscopic balloon dilation (EBD). Preventive measures have been suggested to alleviate this complication, primarily by using local or systemic steroids in association with early dilation. Even so, not always may they be prevented. Such complications are called refractory strictures, which require either esophageal stents (in a majority of cases) or surgery.