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A new simple endoscopic incision therapy for refractory benign oesophageal anastomotic stricture
  1. Jeongmin Choi and
  2. Soo In Choi
  1. Department of Internal Medicine, Inje University Sanggye Paik Hospital, Nowon-gu, Korea
  1. Correspondence to Dr Jeongmin Choi; doct00{at}hanmail.net

Abstract

Oesophageal anastomotic stricture is a frequent complication after esophagectomy. In most cases, endoscopic bougination or balloon dilation usually resolves anastomotic stricture. However, some refractory oesophageal strictures remain difficult to treat and cause significant morbidity. Recently, successful treatment using endoscopic incisional therapy has been reported in several cases. We report a case of refractory benign oesophageal anastomotic stricture after oesophagectomy. A 72-year-old man underwent three consecutive bouginations. However, he developed progressive stricture. Stricture was successfully treated with an endoscopic knife incision. We performed only three incisions without a cutting method, which was new compared with previous reports. A new simple endoscopic incision technique is effective and safe for stricture management. In conclusion, endoscopic incisional therapy may be recommended as a salvage treatment for properly selected patients with refractory benign stricture who do not respond to conventional therapy.

  • endoscopy
  • oesophageal cancer

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Background

Oesophageal cancer is the ninth most common cancer and the sixth most common cause of cancer deaths worldwide.1 Oesophagectomy is the mainstay of treatment for early stage oesophageal cancer. Anastomotic stricture is a frequent complication after oesophagectomy, with mean prevalence rate of 30% (range: 9%–48%).2 In most cases, endoscopic bougination or balloon dilation usually resolve oesophageal anastomotic stricture. However, some refractory strictures do not respond to repeated dilatation and causes significant morbidity to patients such as dysphagia and weight loss.3

Various treatment options for refractory strictures have been reported, including oesophageal stent placement, intralesional steroid injection or mitomycin C, or combination therapy.4

Recently, endoscopic incisional therapy has been an effective treatment for anastomotic strictures refractory to endoscopic balloon dilation.5 Successful incisional treatment has been reported in several cases.5 6

We present a case of refractory benign anastomotic stricture after oesophagectomy, which was treated with an endoscopic incision therapy. Finally, we recommend treatment options for refractory benign oesophageal stricture.

Case presentation

A 72-year-old man underwent a minimally invasive Ivor-Lewis oesophagectomy for early oesophageal cancer. Six months later, the patient visited our department presenting with progressive dysphagia and weight loss of 8 kg. Initial oesophagogastroduodenoscopy (EGD) showed anastomotic stricture of the mid oesophagus. The endoscopic biopsy showed no evidence of cancer recurrence. Patient underwent three consecutive bouginations every 2 months with 15-mm diameter Savary Gilliard dilators (Cook, USA). However, he developed progressive stricture 2–4 weeks after each bougination.

Differential diagnosis

We considered this case as a benign refractory anastomotic stricture. Possible differential diagnosis for this patient may be oesophageal cancer recurrence or candida infection. EGD found fibrotic stricture without mucosal abnormality in the anastomosis (figure 1A), and endoscopic biopsy revealed no cancer or candida infection.

Figure 1

Endoscopic incisional therapy for recurrent oesophageal anastomotic stricture. (A) Oesophagogastroduodenoscopy (EGD) showed a semicircular oesophageal anastomotic stricture (arrows) with a 3-mm luminal opening without ulceration. (B) First incision by pulling the insulated tipped knife carefully to the oesophagus (arrow). (C) Dilated lumen after the first incision and proper muscle layer was identified. (D) Additional incision in a different direction (arrow). (E) Incisional therapy was completed and the EGD scope reached the stomach. (F) A 2-month follow-up EGD showed a wide lumen of 11 mm.

Treatment

Therapeutic options for refractory strictures after oesophagectomy include endoscopic incisional therapy and placement of oesophageal stent. Since anastomotic stricture is a short segment of the oesophagus, oesophagectomy and colonic interposition are rarely performed. The patient was informed of treatment options regarding efficacy and safety. He was reluctant to receive oesophageal stent insertion due to concerns about stent migration. We decided endoscopic incisional therapy as a salvage therapy.

A transparent hood (cap) and carbon dioxide insufflation were used for the procedure. EGD showed a semicircular (from 5 o’clock to 10 o’clock direction) stricture with a 3-mm luminal opening without ulceration (figure 1A). The scope attached to the cap was placed very close to the stricture for direct endoscopic view. An insulated tipped (IT) knife (Olympus, Korea) was used for incision. The electrosurgical unit was VIO 300 (ERBE, Germany) and the Endocut I mode (effect 2, duration 2, interval 3) was used.

The first incision was made at the 7 o’clock position by pulling the IT knife carefully into the oesophageal lumen (figure 1B). The incision was stopped when the IT knife reached the surface of the proper muscle layer (figure 1C). The second incision was made at the 6 o’clock position (figure 1D), and the third incision at 9 o’clock position. After the incision therapy, the endoscope was able to reach the stomach without resistance (figure 1E). Total procedure time was 20 min and there was no procedure-related complications.

Outcome and follow-up

The patient was discharged 2 days after the procedure and was able to eat a solid diet. Two months after discharge, EGD showed a wide lumen of 11 mm (figure 1F). CT of the chest showed the opening of the oesophageal lumen after the procedure (figure 2). The patient gained 5 kg weight. After 2 years of follow-up, the anastomotic stricture recurred, and the patient was successfully treated again with the incision therapy in the same manner. He had no recurrence at 3-year endoscopic follow-up (figure 3).

Figure 2

CT of the chest. (A) Oesophageal obstruction before endoscopic incisional therapy (arrow). (B) Oesophageal luminal opening after incisional therapy (arrow).

Figure 3

Oesophagogastroduodenoscopy showed a wide oesophageal lumen at 3-year follow-up.

Discussion

Endoscopic incisional therapy for anastomotic stricture was first reported in 1977 by Weiss et al.7 Ten patients with anastomotic stricture after total gastrectomy had been treated with an unopened diathermy snare tip. With the advent of endoscopic devices, various treatments for oesophageal anastomotic strictures have been developed.

Our patient underwent three consecutive endoscopic balloon dilations, but failed to maintain oesophageal lumen every 2–4 weeks. By definition, benign refractory stricture or recurrent oesophageal stricture is a failure to maintain a diameter of 14 mm over 5 sessions at 2-week intervals (refractory) or inability to maintain for 4 weeks (recurrent).8 In practice, this means that the patient has undergone numerous sequential dilations at short intervals.8

Therapeutic options for refractory oesophageal strictures include endoscopic incisional therapy, oesophageal stent insertion or combination therapy.4

Endoscopic incisional therapy has been an effective treatment for strictures refractory to endoscopic balloon dilation.5 It is also effective for Schatzki’s ring (oesophageal web-like stenotic lesion)4 or refractory oesophageal stricture after endoscopic submucosal dissection of oesophageal cancer.6 To date, a small number of cases have been reported since incisional therapy is a novel technique.5 9 10

Incisional therapy has favourable efficacy in the short term, but retreatment is needed to maintain long-term lumen patency. Reported perforation rate ranges from 0% to 3.5%,4 so endoscopic incisional therapy is a safe option for stricture management. However, endoscopists should be familiar with fibrotic tissue of the anastomotic site, otherwise there is a risk of oesophageal rupture or incomplete incisions.

Some study proposed an endoscopic ‘radial incisions and cutting’ method to prevent recurrence of anastomotic stricture,5 which means 6–9 radial incisions parallel to the longitudinal axis of the oesophagus and cut-off all stenotic tissue rim in a circular manner.5 In the present study, only three incisions were sufficient to complete the release of the stricture because stricture involved semicircular area of the oesophageal lumen. Cutting off the stenotic rim was not performed in this study, which was different from the previous reports. ‘Incision only’ technique is simple, so this procedure could be performed by less experienced endoscopists. The incision was made very carefully, but the total procedure time was relatively short (20 min). However, the long-term efficacy of the incision only technique should be validated in subsequent studies. In the present study, the stricture recurred 2 years after the procedure and was managed with the same technique.

Incisional therapy should be considered for short segment stricture. In the case of refractory stricture after chemoradiotherapy for oesophageal cancer, incisional therapy showed unfavourable long-term lumen patency. Obviously, longer (>2 cm) oesophageal segment involvement and severe stricture resulted in unsuccessful outcome.11

Another approach to refractory oesophageal stricture is stent placement. In a systematic review, including 18 studies, overall success rate was 40.5%.12 However, adverse event was 20%, including severe chest pain, migration, perforation and bleeding. Success rate was not different among self-expanding metal stent, plastic stent and biodegradable stent.12

Patient who do not respond to endoscopic incisional therapy requires combination therapy. One study reported a combination therapy of endoscopic incision and balloon dilation for refractory oesophageal stricture.13 The stricture was successfully treated with an endoscopic incision, balloon dilation and oral steroids.13 In a randomised study, combination therapy of balloon dilation and intralesional steroid injections had a lower recurrence rate of stricture than balloon dilation only in patients with oesophageal stricture.14

In conclusion, refractory benign anastomotic stricture is recurrent and causes severe morbidity. We report a case of refractory oesophageal anastomotic stricture that was successfully treated with endoscopic incisional therapy. We performed only three incisions without cutting technique, which was new compared with previous reports. Our case showed that simple incision technique can be effective and safe for stricture management. Therefore, endoscopic incisional therapy may be recommended as a salvage treatment for properly selected patients with refractory benign stricture who do not respond to conventional therapy.

Learning points

  • Refractory benign oesophageal anastomotic stricture after oesophagectomy remains difficult to treat and causes severe morbidity.

  • Our case showed endoscopic incisional therapy was effective and safe for refractory oesophageal stricture.

  • In this case, a new simple incision technique can be effective and safe for stricture management.

  • Endoscopic incisional therapy may be recommended as rescue treatment for properly selected patients who do not respond to conventional therapy.

References

Footnotes

  • Twitter @sooin

  • Contributors JC and SIC contributed to this manuscript regarding data acquisition, analysis, drafting and critical revision.

  • Funding This study was funded by Inje University (20190001).

  • Competing interests None declared.

  • Patient consent for publication Obtained.

  • Provenance and peer review Not commissioned; externally peer reviewed.