Esophageal Stricture Treatment & Management

Traditionally, more emphasis has been placed on mechanical dilatation, and coexistent esophagitis has been relatively ignored. However, several studies have demonstrated that aggressive acid suppression using PPIs is extremely beneficial in the initial treatment of esophageal stricture, as well as long-term management.

• A dysphagia score developed by Dakkak et al in a study of 64 patients revealed that the stricture diameter only contributed to 30% of the dysphagia score and that esophagitis and other factors accounted for 70% of the score.^[8] A linear association existed between the dysphagia score only when the luminal diameter was less than 5 mm. Overall, the degree of dysphagia was worse with increasing esophagitis independent of the degree of stenosis.^[8]
• Smith et al showed in a randomized study of 366 patients that omeprazole 20 mg/d was superior to ranitidine 300 mg twice a day in preventing stricture recurrence with redilation rates of 30% and 46%, respectively, at 12 months (P < 0.01).^[9]
• Marks et al showed that the redilation rate in patients treated with omeprazole 20-40 mg/d was 41% versus 73% in patients treated with ranitidine 150-300 mg twice per day and almost reached significance (P < 0.07).^[10] However, the omeprazole group showed higher rates of dysphagia relief and healing of esophagitis when compared with histamine 2 (H2) blockers.
• In contrast, 2 other studies by Swarbrick et al^[11] and Silvis et al^[12] did not show any significant differences in the redilation rates at 12 and 10 months, respectively.
• PPI treatment of patients with esophageal stricture is also more cost effective than H2 blocker therapy. Marks et al found that over a 6-month period, the cost of omeprazole therapy was $1744 compared with $2957 with H2 blockers.^[10]
• H2 blockers have not been shown to be any better than placebo in various trials, and no reliable data on prokinetic agents exist.

The following discussion concerns the endoscopic and surgical modalities employed for the management of peptic esophageal stricture. The choice of dilator and technique is dependent on many factors, the most important being stricture characteristics. It is also based on other factors, including patient tolerance, operator preference, and experience. No clear consensus on the optimal end point exists. In summary, dilation therapy should be tailored individually.

• Endoscopic dilation dates to the 16th century, when physicians used wax wands for esophageal dilation.^{[13, 14]} The word bougie is derived from Boujiyah, an Algerian city that was the center of the medieval candle trade. The following 3 types of dilators are used:

  • Mercury-filled bougies - Maloney or Hurst dilators
    • These dilators are indicated in uncomplicated strictures with diameters greater than 10-12 mm.
    • They are inexpensive and simple to perform without fluoroscopic guidance.
    • Minimal or no sedation is necessary.
    • Self-bougienage may be performed at home.
  • Wire-guided polyvinyl bougies - Savary-Gilliard and American dilators
    • These dilators are relatively stiff and better suited to longer, tighter, and irregular strictures.
    • The need for fluoroscopy is variable.
    • The range is 5-20 mm, and these dilators are reusable.
    • Drawbacks include trauma to the laryngeal wall and patient discomfort.
    • American dilators are shorter, less tapered, and impregnated with barium for better fluoroscopic visualization.
  • Through-the-scope (TTS) balloon dilators
    • These dilators are used through the endoscope, and they allow for direct visualization.
    • These are relatively expensive and not reusable.
    • Fluoroscopy is not mandatory, but it is useful in difficult cases.
    • Studies conflict about the benefits of balloon dilators compared with Savary dilators.
• A prospective, randomized study with 17 patients in each arm comparing balloon dilators with Savary dilators was performed by Saeed et al over a 2-year period, with the end point being 45F.^[15]

  • Stricture recurrence was similar in the first year but lower in the second year for balloons.
  • Fewer sessions were needed for balloons, 1.1 sessions +/- 0.1 versus 1.7 sessions +/- 0.2, and less procedural discomfort occurred (P < 0.05).
  • Both devices were effective in relieving dysphagia.
• Another prospective, randomized study by Scolapio et al included 251 patients with peptic strictures.^[16] Schatzki rings did not show any differences in complications, the degree of immediate relief, or the time to recurrent dysphagia.
• General rules of esophageal dilation

  • Many authors have questioned the need for mandatory fluoroscopy, and no published data exist to advocate safety of fluoroscopy. However, one may consider using fluoroscopy in complicated strictures, especially in guiding the blind passage of a guidewire.
  • Rule of 3s: The first bougie passed should be approximately equal to the estimated diameter of the stricture. Pass no more than 3 consecutive bougies of progressively increasing size after the first one that meets moderate resistance during any one dilation session. The rule of 3s has been questioned because of a lack of data verifying the increased efficacy or safety if one adheres to this rule. This rule was formulated for dilation using mercury-filled bougies resulting in dilation no greater than 1.3 mm in one session. However, polyvinyl dilators may not provide adequate tactile perception to follow this rule.
  • A study by Kozarek et al showed only one perforation in 400 patients dilated with polyvinyl dilators to greater than 2 mm in one session.^[17]
  • Balloon dilators frequently dilate greater than that prescribed by the rule of 3s without any increased risk of complications.
• No consensus exists regarding the end point of esophageal dilation for peptic strictures.

  • Most patients experience complete relief when dilated to 40-54F. Therefore, using this end point as a benchmark is recommended.
  • In summary, the extent of the dilatation should be individualized based on symptomatic response and technical difficulty encountered during therapy.
• Intralesional steroid injection

  • Limited anecdotal data exist showing that intralesional steroid injection of peptic strictures may be beneficial. The mechanism is unclear; it may inhibit collagen formation and enhance collagen degradation, thus increasing stricture compliance.^[18]
  • Triamcinolone 10 mg/mL in 0.5 mL aliquots was injected in 4 quadrants in 2 patients with a successful outcome as reported by Kirsch et al.^[19]
  • Lee at al showed a higher rate of achieving greater luminal diameters and duration between dilations in a nonrandomized cohort of patients with strictures of varying etiologies.^[20] Similar results were obtained by Kochhar et al in 71 patients, although 8 injections of 20 mg of triamcinolone in 0.5-mL aliquots were given at the proximal margin and into the stricture itself.^[21]
  • A randomized prospective trial of Savary dilation with or without intralesional steroids was conducted in 42 patients by Dunne et al^[22] ; it demonstrated a decreased need for second dilations in the steroid group (1.95 vs 5.5) at 1 year. Similar results were seen in a study by Ramage et al in 30 patients, but the latter study was also double blinded with a sham group.^[23] Two patients (13%) in the steroid group and 9 patients (60%) in the sham group needed repeat dilation over a 12-month period.
  • Therefore, a trial of steroid injection may be reasonable in patients with benign strictures who experience no significant relief of dysphagia despite repeated dilations and aggressive antireflux therapy. Hishiki et al reported the use of repeated endoscopic dilatation with systemic steroids in a child with severe esophageal anastomotic stricture that did not respond to endoscopic dilatation and local steroid injection of the stricture.^[24] At 18 months follow-up,the child remained asymptomatic without any further endoscopic dilations.
• Endoscopic stricturoplasty: Two case series described a technique using a needle knife to make 4 quadrant incisions followed by Savary dilation. This was successful in 8 of 8 patients as reported by Raijman et al^[25] and 5 of 6 patients as reported by Hagiwara et al.^[26]
• Pharyngoesophageal puncture is a term recently coined by Tang et al to describe the technique of endoscopic dilation of radiation-induced severe or complete pharyngoesophageal strictures.^[27] A combination of guide wires, endoscopic balloons, puncture and techniques learned from ERCP were successfully applied to 3 patients with severe/complete stenosis.
• Expandable polyester silicone-covered stent: Repici et al presented a case series of 15 patients whose condition had failed endoscopic therapy.^[28] A temporary placement of a stent for 6 weeks was successful in 12 patients over a long-term period (mean follow-up, 22.7 [2.6] mo). However, the exact duration for stent placement remains unclear, as strictures can recur following stent removal.^[29] Furthermore, a variety of complications have been described following stent deployment.^{[30, 31]} More recently, biodegradable stents have shown some promise in animal studies and were used to treat severe corrosive esophageal stenosis in a child.^[32]
• The role of surgical treatment in peptic stricture remains in dispute. Indications include failed aggressive medical therapy or an unsuitable candidate for aggressive medical therapy. This is usually a rare occurrence in the era of PPI therapy. Various procedures advocated include the following:

  • Esophageal-sparing procedures - Standard antireflux surgery (Nissen total or Belsey partial fundoplication), esophageal lengthening with antireflux surgery (Collis-Nissen or Belsey gastroplasty)
  • Esophageal resection and reconstruction - Gastric or colon interposition or jejunal segment
• If the benign peptic stricture is dilatable, an esophageal-sparing operation is performed.

  • If the length of the esophagus is normal, standard antireflux surgery and postoperative dilation as necessary is recommended.
  • If the esophagus is short, performing Collis gastroplasty and postoperative dilation as necessary is recommended.
  • If the stricture is undilatable, esophageal resection and interposition is recommended.
• In the literature, some anecdotal reports exist of minimally invasive surgery, including laparoscopic transhiatal esophagectomy and laparoscopic Collis gastroplasty with Nissen fundoplication. With continuing advances in technology, whether or not minimally invasive surgery would play a major role in the surgical management of peptic stricture remains to be determined.

• Surgical consultation is indicated for esophageal stricture if aggressive medical therapy fails or the patient is an unsuitable candidate for aggressive medical therapy.
• Surgical consultation is also indicated if the stricture is malignant and amenable to curative or palliative resection.

The usual antireflux precautions and lifestyle modifications should be reinforced, although no published data exist showing that these measures are efficacious in peptic strictures.

• Patients are told to avoid fatty and spicy foods, alcohol, tobacco, chocolate, and peppermint.
• Patients should eat smaller meals, avoid eating in a hurried fashion, and chew their food well.
• Patients should be encouraged not to eat at least 2-3 hours before bedtime.
• Weight reduction should be encouraged.
• Ill-fitting dentures or poor dentition should be corrected if possible.

No specific limitation in activity exists.