25 Benign Esophageal Strictures and Esophageal Narrowing Including Eosinophilic Esophagitis
Peter D. Siersema
Benign esophageal strictures and narrowing are commonly seen in daily endoscopic practice. The cornerstone of the management of benign strictures is endoscopic dilation therapy. A subgroup of strictures is refractory or recurs repeatedly after initial dilation. For these so-called difficult strictures alternative treatment modalities are available, that is, steroid injections into the stricture combined with dilation, incisional therapy for refractory anastomotic strictures, stent placement, self-bougienage, or surgery as salvage treatment. The scientific background for these treatments is largely based on case series and only a few randomized studies have compared different treatment modalities.
In this chapter, the most frequently used endoscopic treatment modalities for benign strictures and narrowing are discussed and practical information for the management of some specific causes of esophageal stricturing and narrowing, that is, eosinophilic esophagitis (EoE) and post–endoscopic resection (ER) of premalignant stages and early-stage malignancies, is presented.
25.2 Diagnostic Approaches
25.2.1 General Approach Including Causes, Symptoms, and Diagnosis
Benign esophageal strictures and narrowing are caused by a variety of esophageal disorders or injuries, including gastroesophageal reflux disease (GERD), radiation therapy, or ingestion of a corrosive substance. They also occur at the anastomotic site after esophageal resection. Two relatively new kids on the block include EoE, which may lead to focal or diffuse esophageal narrowing, and stricturing due to ER or ablative therapy in the esophagus.
Dysphagia is the most common symptom in patients with a benign esophageal stricture and narrowing. Interestingly, most patients with a benign stricture do not experience severe weight loss, as is often seen in malignant esophageal strictures. Some patients have symptoms of odynophagia, mostly as a result of radiotherapy and severe reflux esophagitis. The first presentation in EoE is frequently food bolus obstruction, but patients may also have symptoms of regurgitation and sometimes aspiration (pneumonia).
Barium swallow can detect these esophageal strictures; however, most cases are nowadays detected by upper endoscopy. If the stricture diameter does not allow introduction of a normal-cali-ber endoscope, one should consider using a small-caliber endoscope. A combined anterograde and retrograde dilation (CARD) or rendezvous approach is useful for the treatment of a completely obstructed esophagus. 1 It should be considered to take biopsies in case malignancy is suspected and to confirm EoE.
25.3 Classification System
Benign esophageal strictures can be subdivided into simple and complex strictures. Simple strictures are short, focal, straight, and frequently allow passage of a normal-diameter endoscope. Examples include Schatzki’s rings, esophageal webs, and most peptic strictures. 2 Overall, one to three dilations are sufficient to relieve dysphagia in simple strictures. Only 25 to 35% of patients require additional sessions, with a maximum of five dilations in more than 95% of patients. 3
Complex strictures are usually longer (> 2 cm), angulated, irregular, or have a severely narrowed diameter. These strictures are more difficult to treat and have a tendency to be refractory or to recur despite dilation therapy. 2 Etiologies of complex strictures include anastomotic strictures, radiation-induced strictures, and caustic strictures. When strictures are refractory or recur frequently, dilation therapy alone is usually not sufficient to relieve dysphagia. According to the Kochman criteria, refractory or recurrent strictures are defined as an anatomical restriction because of persistent or recurrent fibrosis. This may occur as the result of either an inability to successfully remediate the anatomical problem to a diameter of at least 14 mm over five sessions at 2-week intervals (refractory); or as a result of an inability to maintain a satisfactory luminal diameter for 4 weeks once the target diameter of 14 mm has been achieved (recurrent). 2 In these cases, repeated dilations are indicated, or one of the alternative techniques described under the section Variations of standard techniques could be considered.
25.4 Therapeutic Approaches
25.4.1 Standard Technique
Endoscopic Dilation with an Inflatable Balloon or Bougie Dilator
Treatment aims to relieve dysphagia, with the avoidance of complications and the prevention of recurrences. In most cases this can be achieved by endoscopic dilation with an inflatable balloon or a (Savary) bougie dilator, both introduced over a guidewire (▶Fig. 25.1). No differences have been shown between balloon and bougie dilation in safety and efficacy. For strictures in the proximal esophagus, especially for anastomotic strictures, wire-guided bougie dilators can be used as these allow sensing the degree of resistance during dilation, which may help in deciding whether further dilation with larger-diameter bougies should be considered. The most frequently reported complications associated with esophageal dilation include perforation, hemorrhage, and bacteremia. The reported rates of perforation vary between 0.1 and 0.4% and are mostly seen with complex strictures. 4
It is advised to start endoscopic dilation at a balloon or bougie size that is 1 to 2 mm larger than the estimated stricture diameter and to limit initial dilation to a diameter of 8 to 12 mm. If strictures cannot be traversed with a standard endoscope, the next step is to use a small-caliber endoscope. If still not possible to traverse, it is advised to advance the guidewire under fluoroscopy. In some cases, especially when the stricture has already been dilated several times, one may consider to traverse the guidewire and the balloon or bougie “blind,” that is, not using fluoroscopy.
It is generally accepted that the risk of perforation is minimal when “the rule of three” is applied, meaning that the maximum dilation diameter should not increase greater than 3 mm per session. A recent study by Grooteman et al 5 has questioned the rule of three and suggested that more than three dilation steps may be considered in benign esophageal strictures. Caution is, however, needed with the dilation of malignant strictures, as the authors found an increased risk of perforations and adverse events when the rule of three was not applied.
25.4.2 Variations of Standard Techniques
Endoscopic Dilation Combined with Steroid Injection
Endoscopic dilation combined with steroid injection has been reported to prevent stricture recurrence. Unfortunately, randomized trials are limited and mostly not adequately powered. Camargo et al randomized 14 patients with corrosive strictures between steroid injections or placebo, both combined with dilation. 6 They found no difference in dilation frequency or recurrent dysphagia between the two groups. Ramage et al. randomized 30 patients with peptic strictures with recurrent dysphagia after at least one dilation session to dilation with or without intralesional four-quadrant injections of triamcinolone. 7 It was concluded that dilation combined with steroid injection reduced the number of repeat dilations and increased the dysphagia-free period, with redilation rates of 13% in the steroid group versus 60% in the control group (p = 0.01). Finally, Hirdes et al randomized 60 patients with untreated cervical anastomotic esophageal strictures after esophagostomy with gastric tube interposition and dysphagia for at least solid food to dilation with or without four-quadrant triamcinolone injections. 8 They concluded that adding intralesional steroid injections to Savary dilation in patients with benign anastomotic esophageal strictures did not result in a clinically significant benefit. The authors also noted an increased incidence of candida esophagitis in the remaining esophagus in the steroid group.
It can be concluded that steroid injection combined with dilation seems to reduce the risk of recurrent dysphagia in benign esophageal strictures of peptic origin. However, in other stricture types no significant effect was found, probably related to the underlying cause of stricturing. It is advised to repeat steroid injection up to a maximum of three sessions. Nonetheless, the optimal injection dose, technique, and frequency remain to be determined.
Incisional therapy with a needle–knife was first reported for the treatment of Schatzki rings. 9 This was followed by incisional therapy for anastomotic strictures of the esophagus. In our practice, we place a transparent hood on the tip of the endoscope to enhance control and safety when performing incisional therapy. For cutting, we use a bimodal blended electrocautery current (ERBE Electromedizin GmbH, Tübingen, Germany) with software-controlled fractionated cuts (Endocut). The effective cutting power is maximized at 120 W for 50 ms. The maximum coagulation power during the forced coagulation mode is 45 W for 750 ms. With the needle–knife catheter under direct vision, longitudinal incisions are made around the circumference of the stenotic ring. The required length of the cut is chosen according to the length of the fibrotic stricture as endoscopically determined. The depth of the incision, estimated by comparison with the length of the needle–knife, is not more than 4 mm (▶Fig. 25.2).
Hordijk et al treated 24 patients with endoscopic incisional therapy using an endoscopic retrograde cholangiopancreatography (ERCP) needle–knife. After 2 years of follow-up, more than 85% of the patients were still dysphagia-free after one session. 10 This was followed by another study by the same group, in which 62 patients with a primary anastomotic stricture after esophagectomy (which were not previously treated with dilation therapy) were randomized to Savary dilation or incisional therapy using a needle–knife. No significant difference was found in the mean number of dilations (2.9; 95% confidence interval [CI], 2.7–4.1 vs. 3.3; 95% CI, 2.3–3.6l; p = 0.46) or success rate (80.6 vs. 67.7%, p = 0.26) between the incisional and dilation therapy arms, respectively. 11 No complications were observed after incisional therapy.
From these results, it can be concluded that incisional therapy can be considered as an alternative treatment in patients with a (relatively) short stenosis. Incisional therapy should, however, only be used in esophageal strictures that consist of elevated strictures based on fibrous or scar-like tissue, such as Schatzki’s rings and anastomotic strictures.