Endoscopic Management of Postoperative Esophageal Strictures

Edip Akpinar, MD, Sheila C. Marmalojes, MD, Mohamed S. Alshal, MD, Jc Jimenez, MD, D Horkan, MD, Ja Astudillo, MD, Jose M. Martinez, MD, FACS. Department of LaparoEndoscopic Surgery, University of Miami, Miami, FL.

Background: Postoperative esophageal strictures may happen in 30% of patients at the anastomotic site following reconstruction for esophagectomy using gastric or colonic conduit. Those strictures must be treated in order to resume diet in this population.

Patients and methods: Patients that were referred to our surgical endoscopy unit because of swallowing problems after esophageal surgery were retrospectively studied. Endoscopy was performed using mostly conscious sedation and sometimes using general anesthesia in non-tolerant cases. Various sizes of endoscopes were utilized based on the degree of the stricture. Once the stricture is located and assessed the dilation procedure was performed using balloon dilation. Fluoroscopy guidance was used when needed. If required, subsequent serial dilations were performed using either balloon or Savary-Gilliard dilators employing mainly direct visualization technique without fluoroscopy. The procedure was performed on outpatient basis and the patients were kept in the recovery room for a couple of hours after the procedure and they were allowed to resume diet at the same day. They were instructed to call back only if they re-develop dysphagia. Data were presented in median (min-max) format unless otherwise stated. Nonparametric statistics were used when needed.

Results: A total of 62 patients were treated between March 2009 and May 2013 because of postoperative esophageal strictures. Forty four pts were male and 18 were female and their median age was 65 (21-84). All had stricture at the anastomotic site. While 33 pts (53%) required only 1 session of dilation, 10 pts required 2 (16%), 3 patients required 3 (5%), 3 pts required 4 (5%), 5 pts required 5 (8%), 2 pts required 6 (3%), 1 pt required 7 (2%), 1 pt required 8 (2%), and 4 pts required more than 10 (6%) sessions of dilation respectively. Overall, 3 different patterns emerged in terms of response to treatment. First pattern was the good responder group that needed only 3 or less dilations (75%) and it constituted the biggest group. Second group was the medium responder group that needed between 4 to 7 dilations (19%).  The third group was the poor responder group (6%) that needed more than 7 dilations which was the smallest group. Poor responders tended to have frequent recurrences and some needed up to 25 or more sessions of dilations over a year or longer time with no definitive palliation.

Conclusion: Postoperative esophageal strictures at the anastomotic level can effectively and safely be managed by serial endoscopic dilations and good response can be obtained in 94% of patients. The number of poor responders is 6% and we think that their resistance to treatment needs to be addressed with alternative methods.

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