Benign Strictures

As dilatation has been available for almost two decades, most of the series attesting to its efficacy in 80 to 90% of patients are older (Kozarek et al, 1990). Nevertheless, several issues deserve mention. On the one hand, it is important to recognize that extrinsic lesions, including annular pancreas as well as malignancies, cause proximal C loop obstruction, and other abdominal imaging procedures (eg, CT scan) should be considered before treatment in all but the most obvious cases of proximal gastric outlet obstruction. On the other hand, there are certain situations in which dilatation is much less likely to be successful. The latter include long, acutely angulated stenoses and situations in which ongoing intestinal insult occurs. Occasionally the consequence of ongoing acid secretion surreptitious NSAID use is actually a considerably more common cause. Finally, from a technical standpoint, taking a 2 mm stricture to 15 to 20 mm in a single dilatating session seems risky and is likely to increase the 1 to 5% perforation rate quoted by most authors. As such, multiple dilatating sessions over a period of weeks or even months, perhaps accompanied by four quadrant steroid injections, seems preferable to perforation (Miyashita et al, 1997). By way of example, a recent publication by Solt and colleagues (2003) reported 177 dilatation procedures in 72 patients with benign disease. At a mean follow-up of 98 months, symptomatic relief was noted in 80%, and 70% maintained that relief at 3 months. There were two perforations and one case of procedure-related bleeding, and approximately one-quarter of patients developed recurrent stenosis requiring repeat dilatation.

TABLE 85-3. Endoscopic Therapies Available for Benign Intestinal and Colonic Strictures

Upper intestinal tract Prevention

NSAID interdiction, chronic ulcer disease Acid suppression, pylorus-preserving Whipple Dilatation

Balloon; eg, TTS/CRE Corticosteroid injection into stricture Surgery Mid-distal small bowel/colon Dilatation

Savary versus balloon type ± Corticosteroid injection Radial incisions SEMS Surgery

CRE = continuous radial expansion; NSAID = nonsteroidal anti-inflammatory drug; SB = small bowel; SEMS = self-expandable metallic stent; TTS = through-the-scope.

Constipation Prescription

Constipation Prescription

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