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Benign Strictures of the Esophagus and Gastric Outlet: Interventional Management

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Benign Strictures of the Esophagus and Gastric Outlet: Interventional Management Benign Strictures of the Esophagus and Gastric Outlet: Interventional Management Jin Hyoung Kim, MD Ji Hoon Shin, MD Benign strictures of the esophagus and gastric outlet are difficult to manage conservatively and they usually require intervention to relieve dysphagia or to Ho-Young Song, MD treat the stricture-related complications. In this article, authors review the non-sur- gical options that are used to treat benign strictures of the esophagus and gastric outlet, including balloon dilation, temporary stent placement, intralesional steroid injection and incisional therapy. t is not uncommon to encounter benign strictures of the esophagus and gastric outlet in clinical practice (1-4). Any benign process that obstructs I the esophagus or stomach, or that induces inflammatory or fibrotic changes in the esophagus or stomach can result in esophageal strictures and gastric outlet obstruction (1-8). These benign strictures can have a major negative impact on a Index terms: Benign esophageal strictures patient’s well-being, and the complications include malnutrition, aspiration, pain and Benign gastric-outlet strictures respiratory failure (9-11). These strictures are difficult to manage conservatively and Interventional procedure they usually require intervention to relieve the dysphagia or to treat the stricture- Fluoroscopy Endoscopy related complications (12-14). Although the surgical procedures are potentially curative, they are associated with high rates of morbidity and mortality (15-17). DOI:10.3348/kjr.2010.11.5.497 Several non-surgical, minimally invasive options are available to treat benign strictures of the esophagus and gastric outlet. These procedures, which can be performed endoscopically or fluoroscopically, include balloon dilation, temporary Korean J Radiol 2010;11:497-506 Received January 6, 2010; accepted stent placement, intralesional steroid injection and incisional therapy. This article after revision February 16, 2010. reviews the use of these options to treat benign strictures of the esophagus and gastric All authors: Department of Radiology and outlet. Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul 138-736, Benign Esophageal Strictures Korea Corresponding author: Benign esophageal strictures are sequelae of deep esophageal injuries, and these Ho-Young Song, MD, Department of injuries may be due to peptic ulcer disease, surgery, radiation therapy, Schatzki’s ring, Radiology and Research Institute of esophageal webs and corrosive injury (6). These injuries stimulate the overproduction Radiology, University of Ulsan College of Medicine, Asan Medical Center, 86 of fibrotic tissue and this leads to the formation of benign esophageal strictures (18). Asanbyeongwon-gil, Songpa-gu, Seoul These strictures can be divided into two categories, 1) simple and 2) complex, based 138-736, Korea. Tel. (822) 3010-4370 on their length, shape and diameter. Simple esophageal strictures are defined as those Fax. (822) 476-0090 that are focal and straight, with most having a diameter that allows the passage of an e-mail: [email protected] endoscope of normal diameter (3). Simple strictures are usually caused by peptic ulcer disease, Schatzki’s ring or a web (3, 19). Complex esophageal strictures are defined as those that are long (> 2 cm), tortuous or that have a diameter that prevents passage of an endoscope of normal diameter (3). The most common causes of complex strictures Korean J Radiol 11(5), Sep/Oct 2010 497 Kim et al. include corrosive injury, radiation, anastomotic stricture able pain or if a persistent waist remains in the balloon and severe peptic injury (6, 14, 20, 21). even at the maximal inflation pressure (i.e., 6 atm), then the dilation should be stopped (23). Fluoroscopy allows Balloon Dilation complete visual control and so it may help minimize the Balloon dilation under endoscopic or fluoroscopic risk of perforation due to inappropriate advancement of guidance is regarded as a safe, effective initial option for instruments and misplacement of the balloon, which can be treating benign esophageal strictures (1, 3, 4, 12, 14, 15, caused by sliding during inflation, and especially when 19, 22). Balloon dilation is thought to widen the luminal treating complex strictures (1, 4). diameter of the esophagus by circumferential stretching Simple esophageal strictures generally respond well to and/or splitting of the stricture (1, 3). Under endoscopic or balloon dilation. Most patients with simple esophageal fluoroscopic guidance, the middle portion of the balloon is strictures require 1-3 dilations to relieve their symptoms, positioned at the narrowest part of the stricture and then it although 25-35% of patients require repeated dilations is inflated with water or contrast medium until the waist (13). Yet complex esophageal strictures are more difficult deformity created by the stricture disappears from the to treat, and they require at least three dilation sessions to balloon contour or until the patient develops severe pain relieve the obstructive symptoms, and complex esophageal (1, 4). Elimination of the waist is an indicator of successful strictures are associated with high rates of recurrence and dilation. The balloon’s diameter should be progressively perforation (6, 14). For example, 43-46% of patients increased, with starting by performing dilation with a small require repeated balloon dilations for esophageal strictures balloon and progressing to larger sizes to minimize the induced by radiation injury (20, 24) (Fig. 1). Although they chance of perforation (4). The first balloon is often 10-15 are minor complications, type 1 (intramural) and type 2 mm in diameter; if dilation with this sized balloon is easily (transmural without mediastinal spillage) esophageal accomplished and the patient well tolerates the procedure, ruptures were observed after 12 of 25 (48%) balloon then the diameter of the balloon catheter is increased up to dilations for esophageal strictures caused by radiation 20-25 mm. If at any point the patient complains of intoler- injury (20). Moreover, 62% (73 of 117) of patients with ABC Fig. 1. Radiation-induced esophageal stricture. A. Esophagogram shows 5-cm long stricture (arrow) in mid-esophageal area. B. Dilation of stricture using 15-mm-diameter balloon under fluoroscopic guidance. Because dilation was not easily accomplished, caliber of balloon catheter was not increased to 20 mm. C. Esophagogram one month after balloon dilation shows improvement of stricture (arrow). Patient’s symptoms were also resolved, but symptoms recurred two months later. 498 Korean J Radiol 11(5), Sep/Oct 2010 Intervention of Benign Strictures of Esophagus and Gastric Outlet corrosive esophageal strictures required repeated balloon including the development of new strictures caused by dilations owing to recurrence. In addition, esophageal stent-induced granulation tissue, stent migration and ruptures occurred after 52 of 390 balloon dilations (13%), esophageal ulceration (35, 36). However, temporary including 35 type 1, 14 type 2 and three type 3 (transmural placement of retrievable, fully covered stents made of with mediastinal spillage) ruptures. plastic or metal has become a new strategy for treating The patients with type 1 and type 2 esophageal ruptures refractory benign esophageal strictures (10, 11, 37-39) can be managed conservatively. Those patients with type 2 (Fig. 2). The therapeutic concept of temporary stenting is esophageal rupture and who experience persistent extralu- quite attractive because a stent has a persistent dilation minal leakage, even after conservative treatment, can be effect after placement and it can be removed after the treated by insertion of a covered stent to prevent leakage stricture heals or when new strictures or other stent-related (25). Surgery is indicated for the patients with type 3 complications occur. The early experience of temporary esophageal rupture and for patients with progressive stenting for refractory benign esophageal stricture was clinical deterioration (26). favorable (18, 37). In one series (37), 17 of 21 patients Refractory benign esophageal strictures are defined as (81%) showed improvement of dysphagia after a median those that cannot be dilated to an adequate diameter, those of 21 months with no complications. In another series (18), that recur within a short time interval or those that require 12 of 15 patients (80%) showed improvement of dyspha- continuous dilation (27). These resistant strictures may gia after a median of 22.7 months. However, five patients seriously affect a patient’s quality of life owing to compli- (33%) showed recurrent symptoms, four due to formation cations such as aspiration, malnutrition, pain and of granulation tissue and one due to stent migration (18). esophageal perforation (10). Among the methods used to Yet more recent studies have found that the rates of treat refractory benign esophageal strictures are intrale- long-term resolution of dysphagia after temporary stenting sional steroid injection, temporary stenting and incisional were unsatisfactory, with high rates of complications (10, therapy. 11, 38). For example, one study (11) found that only 31% of patients showed long-term relief of symptoms, whereas Intralesional Steroid Injection the rates of complications were high, including the rates of The intralesional injection of corticosteroids has been stent migration (62%), pain (27%) and stent-induced reported to soften scars and keloids (28, 29)
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