esophstrictures chennai
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Europe, USA Delhi,Chandigarh
Peptic 68 - 72% 18 – 32%Post-op 8 - 21% 1 – 13%Caustic 1 - 4% 33 – 42%Radiation 0 - 1% 3 – 27%EST - 2 – 17%Misc 3 - 9% 5 – 7%-------------------------------------------------------------------------- Patterson 1983,Williamson 197 7, Broor1993,Kochhar 2001
• Focal/straight/symmetric• >12 mm• Easy to dilate• rings, webs,peptic
• Long, >2 cms, tortuous• Asymmetrical• <12 mm
• Caustic• Radiation• Anastomotic
Endoscopy 2013; 45: E1–E2
Clin Endosc 2013;46:643-646
• Whale bone – 17th century
• Bougienage – 1821
• Flexible – Maloney, Hurst
Bougie Dilators
Through the scope/ Over the guidewire
-Wire/Non wire guided
Eclipse TTC CRE (Microvasive)
• Both effectively relieved dysphagia.• Stricture recurrence during the I year of follow- up similar • In second year, the risk of recurrence was significantly
lower in balloon group. • Other advantages of balloons
• the need for fewer treatment• sessions to achieve the end-diameter for dilation • less procedural discomfort
Gastrointest Endosc 1995
Dysphagia relief : Diameter > 12mm
Actual diameter : 4-8 mm less
(Bennett . 1985)
Dilating beyond 15 mm : not superior relief
: same recurrence
(Saeed ; Dig Dis Sci 1994)
Intraesophageal pressure: Max for 44 Fr-48 Fr
(Kozarek . Gastroent.1981)
• Webs excellent
• Peptic 60% 1 diln
• Caustic difficult and
resistant
• Radiation risk of perf
• Anastomotic difficult
Poddar et al; GI Endoscopy 2001; 54; 480-4Savary Dilatation : 54 children
Layered Patten LostCorrosive stricture
Layered Patten LostCorrosive stricture
Layered Patten Partially LostPeptic Stricture
Layered Patten Partially LostPeptic Stricture
ParameterWithout
recurrenceWith
recurrence
Layer pattern preserved
8 7
Layer pattern lost 5 20
p value 0.061
Refractory strictures:luminal diameter of 14 mm not achieved
despite five consecutive endoscopic sessions occurring every 2 weeks
Recurrent strictures:luminal patency not maintained for 4
weeks after achieving target diameter of 14 mm diameter
52 patients : 47 available
44(93.6%) successful dilatation
94.4% had recurrence with
55% having 5 recurrences
33% having 10 recurrences
8(18.7%) perforations Broor et al; Gut 1993; 34: 1498-1501
Intralesional steroids
Electrodiathermy incision
Stents
Others
• 1966 - Ketchum ,Griffith -
keloids and scars
Gastrointest Endosc 1999
• N-71• Strictures
• corrosive (29)• peptic (14)• anastomotic (19)• radiation-induced (9)
Gastrointest Endosc 2002
Time to first repeat dilatation
Am J Gastroenterol 2005
• Inhibits collagen synthesis
• Direct application to submucosa at the site of mucosal disruption
Journal of Pediatric Surgery 2008
Metal stents
Plastic stents
Biodegradable stents
• Indications : refractory or recurrent strictures
• Continuous dilatation by indwelling prosthesis
• Akin to frequent dilatation
• Remodelling of lumen after removal of stent
Gastrointest Endosc. 2004 Dec;60(6):894-900
• 9 studies : 162 pts : Anast (50), Peptic (27), Caustic (26)
• Outcome:
• Tissue overgrowth : 18%
• Migration : 47%
• Complications : 6%
• Long term relief : 39%
(Siersema Endoscopy 2009;41:363)
Completely covered even at flanges - Tissue reaction minimized
Special SEMS – Double covering both inside & outside
First use 1993 Cwikiel. 5 patients (Radiology 1993, 187,667)
Till 2009 : 12 studies: 168 patients : 50% achalasia
Uncovered 34: not removed
Covered 134: 18 not removed
Overall : Migration 14%
Tissue hyperplasia 17%
Long term data : 14/30 (47%) benefit
Synthetic biodegradable material polylactide
Self disintegration
Biocompatible - Minimal tissue reaction
Projected biologic life 3-6 mo
Loss of mech strength 4-8 wk
2 wks 4 wks
(Jahangeer Endoscopy 2013 )
13 patients
Dysphagia free @ 3 months : 4 patients
Dysphagia free @ 6 months : 3 patients
Dysphagia free @ 12 months : 2 patients
Follow up 3 years - 3 Surgery
- 3 Free of dysphagia
- 7 dilatation infrequent
(Kochhar ,Reddy,Choudhury OESO 2012)
Characteristic BD stent (n 18) SEPS (n 20) p value
Technically successful sent placement, n(%)
16(85) 19(95) 0.49
Median follow-up, d 166(21-559) 385(77-924) 0.23
Clinical success, n(%) 6(33) 6(30) 0.83
Mean number of reinterventions, per stent placed (SD)
0.8(0.6) 1.3(0.4) 0.03
NOTE: Values in bold indicate statistical significance
Clinical Gastroenterology and Hepatology 2011;9:653-659
Overall efficacy of stents 30-40%
SEMS Tissue hyperplasia
Polyflex Migration
Biodegradable Recurrence
SURGERY
Corrosive 15-18%
Peptic , anastomotic, radiation : rare
(Shah GL Endo 2007, Siersema Endo 2009)
StrictureDilatation : Bougie / Balloon
StrictureDilatation : Bougie / Balloon
No response : 3 sessionsNo response : 3 sessions
Complex strictureComplex stricture
2 more sessions : No response
2 more sessions : No response
Add : Steroid injectionAdd : Steroid injection
No response in 5 sessionsNo response in 5 sessions
Refractory strictureRefractory stricture
Incisional therapy + DilationIncisional therapy + Dilation Temporary SEMSTemporary SEMS SurgerySurgery
8 studies : 199 patients : 84 corrosives
Relief in dysphagia : Polyflex 55%
Nitinol 37%
83% of Nitinol group had corrosive strictures
vs 14% of polyflex
(Thomas et al Endoscopy 2011;43:386)
Conclusion:
Efficacy of SERS - 46.2 %
Migration rate - 26.4 %
Successful removal - 87%
SEPS better primary outcome than Nitinol stents
Heterogeneity of data – Subgroups non comparable
Nitinol group – 83% corrosives, Median length > 7cm
Polyflex group – 14% corrosives, Median length < 5cm
Corrosive strcitures - Extensive fibrotic scar tissue formation, hence more resistant to even sustained dilation by stents
8 studies : 199 patients : 84 corrosives
Relief in dysphagia : Polyflex 55%
Nitinol 37%
83% of Nitinol group had corrosive strictures
vs 14% of polyflex
Overall : Etiology, site, length, time to removal had no effect on outcome
(Thomas et al Endoscopy 2011;43:386)
6 studies (> 10pts ) : 119 patients
Dysphagia improvement : 53%
Migration : 30%
(Thomas Endoscopy 2011;43:386)
2 studies : 80 patients : Korea (67 corrosive)
Sustained benefit : 36.7%
Migration : 21.8%
(Thomas Endoscopy 2011;43:386)
8 studies : 199 patients : 84 corrosives
Relief in dysphagia : Polyflex 55%
Nitinol 37%
83% of Nitinol group had corrosive strictures
vs 14% of polyflex
(Thomas et al Endoscopy 2011;43:386)
2 centers in Europe - 21 patients
Technical success - 100%
Stent migration in 7 wks - 9.5%
Fragmentation - 3 months
Median follow-up - 53 wks
Dysphagia free - 45%
No major complication
Gastrointest Endosc. 2010 Nov;72(5):927-34
2 wks 4 wks
8 studies
Polyflex – 6
Nitinol - 2
Endoscopy 2011; 43: 386 –393
• Dysphgia improvement– Polyflex better – 55% vs 37%
• Migration rate – - Similar- 30% vs 22%
8 corrosivesSuccess – 1, Failure - 7
Characteristic BD stent (n 18) SEPS (n 20) p value
Technically successful sent placement, n(%)
16(85) 19(95) 0.49
Median follow-up, d 166(21-559) 385(77-924) 0.23
Clinical success, n(%) 6(33) 6(30) 0.83
Mean number of reinterventions, per stent placed (SD)
0.8(0.6) 1.3(0.4) 0.03
NOTE: Values in bold indicate statistical significance
Clinical Gastroenterology and Hepatology 2011;9:653-659
Ultraflex, Z-stent, Polyflex, Niti-S stent, Choo stent, and Bonastent
In refractory strictures or recurrent strictures
Not responding to intralesional steroids or needle knife
incision
May consider early
• Successful placement : 38/40 : 94%• Successful removal : 31/33 : 94%• Overall changed outcome : 66%• FU : 53 wk• 12 (40%) dysphagia free• 10 opted for long-term stenting• 4 Repeated dilatation• 3 Surgery • 1 Needle knife
• (Dua et al AJG 2008;103:2988)
No of stents
1 2 3
No 28 13 7
Cl. Success 25% 15% 0
Major compl. 29% 8% 29%
Dysphagia free days
90 55 106
• Incidence 9%
• Perforation 3
• Trach compr 1
• Gran tissue 2
• Bleed 3
• TOF 1
(Eloubeidi GIE 2011;73:673)
• 10 studies : 130 patients
• FU 10 months
• Overall success 52%
• Migration 23%
•
(Repici APT 2010;31:1268)
(Shah GL Endo 2007, Siersema Endo 2009)
Dilatation : Bougie / Balloon
Dilatation : Bougie / Balloon
No response : 3 sessionsNo response : 3 sessions
Complex strictureComplex stricture
2 more sessions : No response
2 more sessions : No response
Steroid injection Steroid injection
No response in 5 sessionsNo response in 5 sessions
Refractory strictureRefractory stricture
Incisional therapy + DilationIncisional therapy + Dilation TemporaryStent TemporaryStent SurgerySurgery
• Granulation tissue 56%
• Reactive hyperplasia 22%
• Fibrosis 22%
(Eloubeidi GIE 2011;73:673)
28 patients
First stent
15 13 second stent
7 improved 8 ? 10 3Restricture
Improved
7 Third stent
All recurred
(Shah GL Endo 2007, Siersema Endo 2009)
StrictureDilatation : Bougie / Balloon
StrictureDilatation : Bougie / Balloon
No response : 3 sessionsNo response : 3 sessions
Complex strictureComplex stricture
2 more sessions : No response
2 more sessions : No response
Add : Steroid injectionAdd : Steroid injection
No response in 5 sessionsNo response in 5 sessions
Refractory strictureRefractory stricture
Incisional therapy + DilationIncisional therapy + Dilation Temporary SEMSTemporary SEMS SurgerySurgery
Gastrointest Endosc. 2004 Dec;60(6):894-900
Am J Gastroenterol 2008
• n-40• SEPS for 4 wk (95%)• Removal (94%)• Follow up- 53wk• 12 (40%) dysphagia
free
Migration 8 (22%)
Severe pain 4 (11%)
Bleeding 3 (8%)
Perf 2 (5.5%)
Inability to remove 2 (5.5%)
(Dua et al AJG 2008;103:2988)
10 studies : 130 patients
FU 10 months
Overall success 52%
Migration 23%
(Repici APT 2010;31:1268)
Incidence 9%
Perforation 3
Trach compr 1
Gran tissue 2
Bleed 3
TOF 1
(Eloubeidi GIE 2011;73:673)
21 patients : 62 stents
Migration : 64%
Prox : 68%
Distal : 70%
Mid : 30%
Tissue hyperplasia : 17%
Overall response : 18%
(Holm GIE 2008;67:20)
Completely covered even at flanges - Tissue reaction minimized
Special SEMS – Double covering both inside & outside
• Polyester• Inner lining of silicone• Upper and lower ends
smoothened with silicone membrane
• REMOVED after 4+weeks
First use 1993 Cwikiel. 5 patients (Radiology 1993,
187,667)
Till 2009 : 12 studies: 168 patients : 50% achalasia
Uncovered 34: not removed
Covered 134: 18 not removed
Overall : Migration 14%
Tissue hyperplasia 17%
Long term data : 14/30 (47%) benefit
Two US centers: 35 pts. : 19 strictures
Alimaax stent : fully covered
Removed : ? In all 64 ± 74D
Migration 37%
Long term outcome : 21%
(Eloubeidi GIE 2011;73:673)
Granulation tissue 56%
Reactive hyperplasia 22%
Fibrosis 22%
(Eloubeidi GIE 2011;73:673)
Post-operative; China
Stent removal 8 weeks
12 mo FU : Response 66%
Recurrence 33%
Migration 1/29 stents
(Lie et al Dhsphagia 2012;27:260)
Ther Adv Gastroenterol (2013) 6(5) 365–370
Strength : 10,20,40 mg/ml
Strength dose used :
8 mg/ml - 1 study
10 mg/ml - 4 studies
20 mg/ml - 1 study
40 mg/ml - 1 study
Effective dose :
8 mg/ml - 1 study
10 mg/ml - 1 study
28 mg/ml - 1 study
40 mg/ml - 3 studies
80 mg/ml - 1 study
• Dead space of bougies -Children -Small stomach -Multiple strictures -Caustic gastric
involvement -Anastomotic -Location-small bowel.
colon
Bougie dilator
• Radial & shearing force• Dilation “felt”• Best suited for simple
strictures
Balloon dilators
• dilating force is radial • Simultaneously over the
entire length• Safer with multiple,
tortuous strictures
Outcome is worse for :
Patients with stomach involvement
Patients requiring more no of dilatations to reach 15mm
Multiple strictures required more dilatations to reach 15mm
Parameters which did not influence outcome
Site of stricture
Acid vs Alkali
Major success – 62.5%, Partial success – 19%Major success – 62.5%, Partial success – 19%
