Recurrence of Esophageal Strictures

The treatment of esophageal strictures with dilatation has had a major impact on relieving symptoms of dysphagia. On the other hand, recurrence of strictures after initial dilatation has proved to be a major problem. The 1-year recurrence rate for strictures is approximately 60%, with only 40% of patients remaining symptom-free (Ogilvie et al, 1980; Patterson et al, 1983). Studies have looked at different characteristics that may play a role in subsequent need for repeat dilatations. Factors such as cause of stricture, severity of stricture, presence of esophagitis or initial diameter of dilatation have not consistently correlated with stricture recurrence. Recently it has been shown that weight loss or lack of heartburn correlate with need for repeat dilatation but this has yet to be reconfirmed (Agnew et al, 1996). Other factors, such as nonsteroidal anti-inflammatory drug use, have revealed conflicting data.

Acid Suppression

One treatment that has consistently shown to reduce the number of stricture dilatations is acid suppression therapy. Acid suppression therapy has been shown to reduce the 1-year recurrence rate to 30% (Lundell, 1992). An added effect has been shown with the use of PPIs over histamine receptor antagonists. One randomized prospective study comparing postdilatation use of omeprazole (Prilosec) 20 mg daily to ranitidine (Zantac) 150 mg twice daily revealed a significant lower need for redilatation and improved dysphagia in the omeprazole group at 1 year (Smith et al, 1994). Another study using the same medications showed a significant decrease in stricture recurrence at 10 months as judged by radiologic and endoscopic criteria (Silvis et al, 1996). Therefore, acid suppression therapy with PPIs is recommended in the treatment of benign esophageal strictures.

Intralesional Steriod Injections intralesional steroid injections may help reduce the number of dilatation sessions needed for patients with refractory benign strictures. This adjuvant therapy has allowed for greater achievable dilator sizes as well as increased symptom-free intervals between dilatation sessions with negligible complications or side effects (Zein et al, 1995; Kirsch et al, 1991). Steroid injections work by suppressing collagen formation and subsequent fibrosis and may be effective without coinciding dilatation. in fact, by decreasing the need for repetitive dilatations, this modality may prove to lower the overall risk of complications behind frequent dilatation sessions. This intervention may be most successful and cost effective among those forms of strictures that are highly relapsing. Studies suggest that placement of the steroid injections in the thickest part of the stricture is optimal. Endoscopic ultrasound guided injection may be the most precise manner in which to insure adequate placement of steroids into the stricture (Bhutani et al, 1997). Although intralesional steroid injections have shown promise, there is no consistent guideline for their use in esophageal strictures.

Temporary Stents

Temporarily placed nitinol stents may increase the interval between esophageal dilatation sessions for recurrent benign strictures. These expandable wire mesh stents are most frequently used in aggressive strictures, such as those resulting from radiation therapy or corrosive substances. Although the optimal duration that these stents should remain in place is not well established, they have been shown to have an excellent safety profile (Song et al, 2000). Presently, a biodegradable stent that maintains its integrity and allows for remodeling of the esophageal stricture without the dangers of a long term foreign body is being developed (Fry and Fleischer, 1997).

Novel Dilatation Techniques/Self Dilatations

Over the past decade, a number of innovative approaches have been devised for the management of complicated or highly relapsing strictures that are poorly amenable to medical or surgical interventions. one method involves dedication from the patients to dilate their own strictures. This technique is best reserved for chronic upper to mid-esophageal strictures such as those resulting from corrosive or pill esophagitis (Robinson and Gear, 1991). In this technique, the patient is instructed to swallow a catheter coated with a steroid paste. A balloon at the end of the catheter is inflated allowing the stricture to stretch. The patient then pulls out the apparatus completing the procedure. The patient repeats this dilatation technique frequently over several months until complete relief is achieved.

Combined Approach

Another clever technique that has been designed to safely dilate nearly obstructed or fistulizing esophageal strictures, is the combined antegrade and retrograde dilatation procedure (Bueno et al, 2001). In this technique, an endoscope is inserted through a preexisting or newly placed gastrostomy tube, in an effort to pass a guidewire through the distal aspect of the stricture. A guidewire is fluoroscopically passed through the stricture and captured by a peroral endoscope. This is followed by antegrade Savary dilatation of the complicated stricture. other endoscopists have documented variations of this technique (Lew and Kochman, 2002).

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