pISSN 1229-6929
eISSN 2005-8330
Open Access, Peer-reviewed
    Korean J Radiol. 2010 Sep-Oct;11(5):497-506. English.
    Published online Aug 27, 2010.
    https://doi.org/10.3348/kjr.2010.11.5.497
    Copyright © 2010 The Korean Society of Radiology
    Review

    Benign Strictures of the Esophagus and Gastric Outlet: Interventional Management

    Jin Hyoung Kim, MD, Ji Hoon Shin, MD and Ho-Young Song, MD
      • Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul 138-736, Korea.
    • Corresponding author: Ho-Young Song, MD, Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 86 Asanbyeongwon-gil, Songpa-gu, Seoul 138-736, Korea. Tel. (822) 3010-4370, Fax. (822) 476-0090, Email: hysong@amc.seoul.kr
    Received January 06, 2010; Accepted February 16, 2010.

    This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

    Abstract

    Benign strictures of the esophagus and gastric outlet are difficult to manage conservatively and they usually require intervention to relieve dysphagia or to treat the stricture-related complications. In this article, authors review the non-surgical 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.

    Keywords
    Benign esophageal strictures; Benign gastric-outlet strictures; Interventional procedure; Fluoroscopy; Endoscopy

    It is not uncommon to encounter benign strictures of the esophagus and gastric outlet in clinical practice (1-4). Any benign process that obstructs 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 patient's well-being, and the complications include malnutrition, aspiration, pain and respiratory failure (9-11). These strictures are difficult to manage conservatively and they usually require intervention to relieve the dysphagia or to treat the stricture-related complications (12-14). Although the surgical procedures are potentially curative, they are associated with high rates of morbidity and mortality (15-17).

    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 stent placement, intralesional steroid injection and incisional therapy. This article reviews the use of these options to treat benign strictures of the esophagus and gastric outlet.

    Benign Esophageal Strictures

    Benign esophageal strictures are sequelae of deep esophageal injuries, and these injuries may be due to peptic ulcer disease, surgery, radiation therapy, Schatzki's ring, esophageal webs and corrosive injury (6). These injuries stimulate the overproduction of fibrotic tissue and this leads to the formation of benign esophageal strictures (18). These strictures can be divided into two categories, 1) simple and 2) complex, based on their length, shape and diameter. Simple esophageal strictures are defined as those that are focal and straight, with most having a diameter that allows the passage of an 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 include corrosive injury, radiation, anastomotic stricture and severe peptic injury (6, 14, 20, 21).

    Balloon Dilation

    Balloon dilation under endoscopic or fluoroscopic guidance is regarded as a safe, effective initial option for treating benign esophageal strictures (1, 3, 4, 12, 14, 15, 19, 22). Balloon dilation is thought to widen the luminal diameter of the esophagus by circumferential stretching and/or splitting of the stricture (1, 3). Under endoscopic or fluoroscopic guidance, the middle portion of the balloon is positioned at the narrowest part of the stricture and then it is inflated with water or contrast medium until the waist deformity created by the stricture disappears from the balloon contour or until the patient develops severe pain (1, 4). Elimination of the waist is an indicator of successful dilation. The balloon's diameter should be progressively increased, with starting by performing dilation with a small balloon and progressing to larger sizes to minimize the chance of perforation (4). The first balloon is often 10-15 mm in diameter; if dilation with this sized balloon is easily accomplished and the patient well tolerates the procedure, then the diameter of the balloon catheter is increased up to 20-25 mm. If at any point the patient complains of intolerable pain or if a persistent waist remains in the balloon even at the maximal inflation pressure (i.e., 6 atm), then the dilation should be stopped (23). Fluoroscopy allows complete visual control and so it may help minimize the risk of perforation due to inappropriate advancement of instruments and misplacement of the balloon, which can be caused by sliding during inflation, and especially when treating complex strictures (1, 4).

    Simple esophageal strictures generally respond well to balloon dilation. Most patients with simple esophageal strictures require 1-3 dilations to relieve their symptoms, although 25-35% of patients require repeated dilations (13). Yet complex esophageal strictures are more difficult to treat, and they require at least three dilation sessions to relieve the obstructive symptoms, and complex esophageal strictures are associated with high rates of recurrence and perforation (6, 14). For example, 43-46% of patients require repeated balloon dilations for esophageal strictures induced by radiation injury (20, 24) (Fig. 1). Although they are minor complications, type 1 (intramural) and type 2 (transmural without mediastinal spillage) esophageal ruptures were observed after 12 of 25 (48%) balloon dilations for esophageal strictures caused by radiation injury (20). Moreover, 62% (73 of 117) of patients with corrosive esophageal strictures required repeated balloon dilations owing to recurrence. In addition, esophageal ruptures occurred after 52 of 390 balloon dilations (13%), including 35 type 1, 14 type 2 and three type 3 (transmural with mediastinal spillage) ruptures.

    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.

    The patients with type 1 and type 2 esophageal ruptures can be managed conservatively. Those patients with type 2 esophageal rupture and who experience persistent extraluminal leakage, even after conservative treatment, can be treated by insertion of a covered stent to prevent leakage (25). Surgery is indicated for the patients with type 3 esophageal rupture and for patients with progressive clinical deterioration (26).

    Refractory benign esophageal strictures are defined as those that cannot be dilated to an adequate diameter, those that recur within a short time interval or those that require continuous dilation (27). These resistant strictures may seriously affect a patient's quality of life owing to complications such as aspiration, malnutrition, pain and esophageal perforation (10). Among the methods used to treat refractory benign esophageal strictures are intralesional steroid injection, temporary stenting and incisional therapy.

    Intralesional Steroid Injection

    The intralesional injection of corticosteroids has been reported to soften scars and keloids (28, 29) owing to the local inhibition of inflammatory responses, which results in the reduction of fibrotic tissue (30). Intralesional steroid injections have been increasingly used over the past decade to treat refractory benign esophageal strictures (30-32). This approach usually involves endoscopic intralesional injections of triamcinolone acetonide (40 mg/mL, diluted 1:1 with saline solution) into all four quadrants of the strictures, and this is most often done in combination with balloon dilation (30-32). The combination of intralesional steroid injection and balloon dilation has been shown to increase the intervals between dilations and to decrease their frequency (30-32). However, this therapy seems to be inadequate to treat long strictures. Furthermore, the optimal injection technique and the frequency and dose of triamcinolone injections have not yet been established (1).

    Stent Placement

    Stent placement is a commonly used, minimally invasive method to treatment unresectable malignant strictures and fistulas (33, 34). However, permanent stenting of benign esophageal strictures in patients with a relatively long life expectancy has not yet reached widespread acceptance owing to the late adverse events of stent placement, including the development of new strictures caused by stent-induced granulation tissue, stent migration and esophageal ulceration (35, 36). However, temporary placement of retrievable, fully covered stents made of plastic or metal has become a new strategy for treating refractory benign esophageal strictures (10, 11, 37-39) (Fig. 2). The therapeutic concept of temporary stenting is quite attractive because a stent has a persistent dilation effect after placement and it can be removed after the stricture heals or when new strictures or other stent-related complications occur. The early experience of temporary stenting for refractory benign esophageal stricture was favorable (18, 37). In one series (37), 17 of 21 patients (81%) showed improvement of dysphagia after a median of 21 months with no complications. In another series (18), 12 of 15 patients (80%) showed improvement of dysphagia after a median of 22.7 months. However, five patients (33%) showed recurrent symptoms, four due to formation of granulation tissue and one due to stent migration (18).

    Fig. 2
    Corrosive esophageal stricture.

    A. Esophagogram shows focal stricture (arrow) at distal esophageal level.

    B. Severe tight stricture precluded dilation with 10-mm-diameter balloon.

    C. Placement of retrievable covered metallic stent (arrowheads) at stricture.

    D. Esophagogram immediately after stent placement shows good contrast passage through stent.

    E. Esophagogram five years after temporary stenting for two months shows stricture improvement was maintained (arrow).

    Yet more recent studies have found that the rates of long-term resolution of dysphagia after temporary stenting were unsatisfactory, with high rates of complications (10, 11, 38). For example, one study (11) found that only 31% of patients showed long-term relief of symptoms, whereas the rates of complications were high, including the rates of stent migration (62%), pain (27%) and stent-induced formation of granulation tissue (17%). Another study (38) found that only 30% of patients (intention to treat) were dysphagia-free after a median follow-up of 12.3 months, with high rates of complications, including stent migration (22%), severe chest pain (11%), bleeding (8%), perforation (6%), gastroesophageal reflux (6%), impaction (6%) and new fistula (3%), and one patient died of massive bleeding.

    A third study (10) also showed that temporary metallic stenting for refractory benign esophageal strictures achieved discouraging results. During a mean follow-up period of 38 months, only 31% of patients showed long-term relief of obstructive symptoms. The most common complications were granulation tissue formation (31%), severe pain (24%) and stent migration (25%). The rates of maintained patency after temporary metallic stenting at 1, 3 and 6 months and 1, 2 and 4 years were 58%, 43%, 38%, 33%, 26% and 21%, respectively (10). An increased stricture length was found to be a significant predictor of stricture recurrence (10).

    Temporary stenting does have several benefits. For example, temporary stent placement should be considered during the early chronic stage (3 weeks to 6 months after ingestion of a corrosive agent) for patients with corrosive strictures because these patients are highly prone to recurrence and rupture after dilation (6). In addition, temporary stent placement can serve as an effective bridge to surgery for patients who require a considerable time before surgery. Furthermore, stent placement may be the only option for patients with severe stenosis that prevents adequate balloon dilation.

    Efforts are underway to decrease the rates of stent-related complications, including formation of granulation tissue and stent migration. An in vivo animal study showed that compared with conventional metallic stents, drug-eluting (paclitaxel) stents induced little tissue reaction around the esophageal mucosa, and the drug-eluting (paclitaxel) stents were easily separated from esophageal tissue, which allows easy retrievability (40). In addition, a new esophageal stent has been developed with an anti-migration design, a double-layer configuration (inner covered and outer uncovered parts) and an outer uncovered nitinol wire tube, which allows the stent to fix itself in the esophageal wall (41). These new stents provided good symptom relief with low rates of recurrent dysphagia and stent migration (41). Because recurrent dysphagia is often due to the formulation of granulation tissue and stent migration, drug-eluting or anti-migration stents may be a good alternative in the management of refractory benign esophageal strictures.

    In summary, temporary stenting for refractory benign esophageal strictures may be effective during the period of stent placement. Yet following stent removal, the symptom-free period rapidly decreases over time, and particularly in patients with long strictures. Temporary stenting is associated with high complication rates and so it should only be considered in carefully selected patients.

    Incisional Therapy

    Incisional therapy using electrocautery, with or without argon plasma coagulation or endoscopic scissors, has been successful in patients with Schatzki's rings or circular anastomotic strictures that are refractory to dilations (42-44). For instance, evaluation of the efficacy of electrocautery needle-knife treatment in 20 patients with refractory anastomotic strictures of the esophagus showed that 12 patients with strictures < 1 cm remained dysphagia-free for 12 months after a single treatment (42). In contrast, dysphagia recurred in eight patients who had long-segment strictures (1.5-5 cm), and these patients required a mean of three treatments (42).

    Incisional therapy has been also used as the primary treatment for patients with Schatzki's rings and anastomotic strictures after gastroesophageal surgery (8, 9). For example, a randomized, prospective trial that compared electrosurgical incision combined with acid suppression treatment and bougie dilation combined with acid suppression treatment in 25 patients with symptomatic Schatzki's rings found that the symptom-free period was significantly longer in the incision group than in the bougie dilation group (7.99 vs. 5.86 months, p = 0.03) and that the addition of acid suppression treatment reduced the gastroesophageal reflux-related symptoms, regardless of the primary treatment (8).

    In summary, incisional therapy may be a good alternative for the treatment of resistant or non-resistant anastomotic strictures of the esophagus and Schatzki's ring. However, incisional therapy is not appropriate for patients with long esophageal strictures.

    Benign Gastric Outlet Strictures

    Benign strictures of the gastric outlet are not uncommon in clinical practice and these may have several etiologies, including anastomotic strictures after gastric surgery, peptic ulcer, corrosive injury, strictures secondary to intervention, and rarely, Crohn's disease (2, 4, 5, 7, 15, 16, 45). These strictures may result in prolonged vomiting and nutritional deficiencies (46). Surgical revision is indicated for the patients with benign gastric outlet strictures and who do not respond to conservative medical treatment (47, 48). However, surgery is associated with high rates of morbidity and mortality, and particularly in patients with high risk factors, including an advanced age, a poor nutritional status or combined disease (49).

    Balloon Dilation

    Endoscopically or fluoroscopically guided balloon dilation is a safe and effective alternative to surgery for patients with benign strictures of the gastric outlet (2, 4, 5, 7, 15, 16, 45). It is considered to be a more rapid treatment and more cost effective than surgery.

    Balloon dilation has been widely used for treating patients with peptic ulcer-related gastric outlet obstruction (Fig. 3), but the long-term outcomes were found to widely vary, from 16-100% (50-53). Yet more recently, balloon dilation combined with antisecretory therapy and removal of the etiologic factors (e.g., Helicobacter pylori) was shown to achieve long-term resolution of symptoms in 85-100% of patients with peptic ulcer-related gastric outlet obstruction (2, 54).

    Fig. 3
    Peptic ulcer-induced duodenal stricture.

    A. Upper gastrointestinal series shows peptic ulcer-induced stricture (arrow) in second portion of duodenum.

    B-E. Under fluoroscopic guidance, stricture was initially dilated with 8-mm-diameter balloon. Because dilation was easily achieved, caliber of balloon catheter was increased to 15 mm.

    F. Upper gastrointestinal series one year after balloon dilation shows improvement of luminal diameter (arrow).

    Benign anastomotic strictures occur in 3-13% of patients after gastric surgery, and usually within the first three months (7, 55). Obesity has become a major health problem, leading to an increase in performing restrictive gastric surgery for morbidly obese patients worldwide. Several studies have assessed the efficacy of balloon dilation for treating benign gastric outlet stricture after restrictive surgery for morbid obesity (7, 16, 55, 56). For example, one or two endoscopic balloon dilations resulted in symptom resolution without any major complications in 93% (40 of 43) of patients with gastrojejunostomy strictures after Roux-en-Y gastric bypass for obesity during the first year. In addition, fluoroscopically guided balloon dilation relieved the obstructive symptoms in 50% (12 of 24) of the patients who had gastric outlet strictures after surgery for morbid obesity after a mean follow-up of 29 months (16). Fluoroscopically guided balloon dilation also led to symptom resolution in 16 of 17 (84%) patients who were treated for benign strictures that were caused by Billroth I (gastroduodenostomy) or Billroth II (gastrojejunostomy) reconstruction for malignancy or gastric ulcer, with no major complications, over a mean of 14 months (57). An interval of two or three weeks has been suggested as the minimum 'safe' time between surgery and dilation of an anastomotic stricture (21, 58).

    Gastric outlet stricture can also result from the ingestion of caustic substances. However, only six of 17 (35%) patients with caustic strictures responded to balloon dilation, compared with a 70% response rate for the patients with peptic strictures (52). Furthermore, the patients with caustic strictures required more dilations than those with peptic ulcer-related strictures (53). Yet more recently, repeated balloon dilations (mean: 5.8 sessions) were found to achieve long-term resolution (symptom free for 18 to 58 months) in 95% (39 of 41) of the patients with short-segment (< 2.5 cm), caustic-induced gastric outlet strictures (5).

    Strictures occurring at the gastric outlet should be sufficiently dilated to prevent symptoms of obstruction, but not so much as to increase the risk of perforation. Thus, it is important to determine the optimal diameter of dilation. The optimal diameter may depend on the type of stricture (i.e., anastomotic vs. non-anastomotic stricture). For anastomotic strictures, a diameter of 20 mm may prevent symptoms of obstruction with no major complications (57). Yet for non-anastomotic strictures, a maximal diameter of 15 mm may be sufficient to relieve obstructive symptoms (2, 5). Balloons of larger diameter (> 15 mm) may increase the risk of perforation during the treatment of non-anastomotic strictures. For example, dilation with 20-mm balloons caused perforations in two of three patients with peptic pyloric strictures (51), and dilations to 18 mm caused perforations in two patients with peptic pyloroduodenal strictures (59). Following laparotomy, 21% of the patients with gastric outlet strictures and who were dilated to 20 mm experienced perforations, compared with none of those patients whose strictures were dilated to 15 mm (60-62).

    Other Options

    Severely angulated, tortuous or edematous benign gastric outlet strictures are usually refractory to balloon dilation (21, 56, 57). Resistance to initial balloon dilation may result in poor long-term results, and early surgical revision has been recommended for these patients (63, 64), but several non-surgical options are available to treat these strictures.

    Metallic stents are safe and effective for patients with malignant gastric outlet obstruction (65, 66) and metallic stents have been used in selected patients with benign gastric outlet strictures that are refractory to balloon dilation (Fig. 4). For example, temporary placement of a covered retrievable metallic stent for two months to treat a patient with a benign anastomotic duodenojejunal stricture that was resistant to repeated balloon dilations resulted in a favorable outcome at up to six months after stent removal (67). Stent placement in seven patients with resistant benign anastomotic strictures after gastric surgery showed benefit for five patients (71%), regardless of whether the stent placement was temporary (two patients) or permanent (three patients) (21). However, owing to the high risk of migration, stents should be used only in selected patients with resistant benign gastric outlet strictures (21).

    Fig. 4
    Benign anastomotic stricture at gastroduodenostomy.

    A, B. Endoscopic image (arrowhead) and upper gastrointestinal series (arrow) show severe anastomotic stricture upon gastroduodenostomy.

    C. Because stricture was resistant to repeated balloon dilation, retrievable covered metallic stent (arrow) was inserted.

    D, E. Three months after stent placement, stent was endoscopically removed using rat-tooth forceps (arrowhead). Endoscopic image immediately after stent removal showed improvement of stricture (arrowheads).

    Electrosurgical incision, with or without balloon dilation, has been successful in a small numbers of patients (< 5) with refractory benign gastric outlet strictures (68, 69). In addition, intralesional steroid injections have been used to augment the effect of balloon dilation in three patients with corrosive-induced pyloric stenosis (70).

    Summary

    Balloon dilation is a safe, effective initial option in the treatment of benign strictures of the esophagus and gastric outlet. Intralesional steroid therapy, electrosurgical incision or stent placement can be effective in selected patients with strictures that are resistant to balloon dilation.

    References

      1. Siersema PD, de Wijkerslooth LR. Dilation of refractory benign esophageal strictures. Gastrointest Endosc 2009;70:1000–1012.
      1. Cherian PT, Cherian S, Singh P. Long-term follow-up of patients with gastric outlet obstruction related to peptic ulcer disease treated with endoscopic balloon dilatation and drug therapy. Gastrointest Endosc 2007;66:491–497.
      1. Lew RJ, Kochman ML. A review of endoscopic methods of esophageal dilation. J Clin Gastroenterol 2002;35:117–126.
      1. Kim JH, Shin JH, Song HY. Fluoroscopically guided balloon dilation for benign anastomotic stricture in the upper gastrointestinal tract. Korean J Radiol 2008;9:364–370.
      1. Kochhar R, Dutta U, Sethy PK, Singh G, Sinha SK, Nagi B, et al. Endoscopic balloon dilation in caustic-induced chronic gastric outlet obstruction. Gastrointest Endosc 2009;69:800–805.
      1. Kim JH, Song HY, Kim HC, Shin JH, Kim KR, Park SW, et al. Corrosive esophageal strictures: long-term effectiveness of balloon dilation in 117 patients. J Vasc Interv Radiol 2008;19:736–741.
      1. Peifer KJ, Shiels AJ, Azar R, Rivera RE, Eagon JC, Jonnalagadda S. Successful endoscopic management of gastrojejunal anastomotic strictures after Roux-en-Y gastric bypass. Gastrointest Endosc 2007;66:248–252.
      1. Wills JC, Hilden K, Disario JA, Fang JC. A randomized, prospective trial of electrosurgical incision followed by rabeprazole versus bougie dilation followed by rabeprazole of symptomatic esophageal (Schatzki's) rings. Gastrointest Endosc 2008;67:808–813.
      1. Hordijk ML, van Hooft JE, Hansen BE, Fockens P, Kuipers EJ. A randomized comparison of electrocautery incision with Savary bougienage for relief of anastomotic gastroesophageal strictures. Gastrointest Endosc 2009;70:849–855.
      1. Kim JH, Song HY, Choi EK, Kim KR, Shin JH, Lim JO. Temporary metallic stent placement in the treatment of refractory benign esophageal strictures: results and factors associated with outcome in 55 patients. Eur Radiol 2009;19:384–390.
      1. Holm AN, de la Mora Levy JG, Gostout CJ, Topazian MD, Baron TH. Self-expanding plastic stents in treatment of benign esophageal conditions. Gastrointest Endosc 2008;67:20–25.
      1. Cho YK, Shin JH, Kim BS, Yook JH, Song HY, Kim JH, et al. Fluoroscopically guided balloon dilation of anastomotic strictures after total gastrectomy: long-term results. AJR Am J Roentgenol 2007;188:647–651.
      1. Jha S, Levine MS, Rubesin SE, Dumon K, Kochman ML, Laufer I, et al. Detection of strictures on upper gastrointestinal tract radiographic examinations after laparoscopic Roux-en-Y gastric bypass surgery: importance of projection. AJR Am J Roentgenol 2006;186:1090–1093.
      1. Siersema PD. Treatment options for esophageal strictures. Nat Clin Pract Gastroenterol Hepatol 2008;5:142–152.
      1. Kim JH, Shin JH, Di ZH, Ko GY, Yoon HK, Sung KB, et al. Benign duodenal strictures: treatment by means of fluoroscopically guided balloon dilation. J Vasc Interv Radiol 2005;16:543–548.
      1. Vance PL, de Lange EE, Shaffer HA Jr, Schirmer B. Gastric outlet obstruction following surgery for morbid obesity: efficacy of fluoroscopically guided balloon dilation. Radiology 2002;222:70–72.
      1. Little AG, Naunheim KS, Ferguson MK, Skinner DB. Surgical management of esophageal strictures. Ann Thorac Surg 1988;45:144–147.
      1. Repici A, Conio M, De Angelis C, Battaglia E, Musso A, Pellicano R, et al. Temporary placement of an expandable polyester silicone-covered stent for treatment of refractory benign esophageal strictures. Gastrointest Endosc 2004;60:513–519.
      1. Pereira-Lima JC, Ramires RP, Zamin I Jr, Cassal AP, Marroni CA, Mattos AA. Endoscopic dilation of benign esophageal strictures: report on 1043 procedures. Am J Gastroenterol 1999;94:1497–1501.
      1. Choi GB, Shin JH, Song HY, Lee YS, Cho YK, Bae JI, et al. Fluoroscopically guided balloon dilation for patients with esophageal stricture after radiation treatment. J Vasc Interv Radiol 2005;16:1705–1710.
      1. Kim JH, Song HY, Park SW, Yoon CJ, Shin JH, Yook JH, et al. Early symptomatic strictures after gastric surgery: palliation with balloon dilation and stent placement. J Vasc Interv Radiol 2008;19:565–570.
      1. Ferguson DD. Evaluation and management of benign esophageal strictures. Dis Esophagus 2005;18:359–364.
      1. McLean GK, Cooper GS, Hartz WH, Burke DR, Meranze SG. Radiologically guided balloon dilation of gastrointestinal strictures. Part I. Technique and factors influencing procedural success. Radiology 1987;165:35–40.
      1. Swaroop VS, Desai DC, Mohandas KM, Dhir V, Dave UR, Gulla RI, et al. Dilation of esophageal strictures induced by radiation therapy for cancer of the esophagus. Gastrointest Endosc 1994;40:311–315.
      1. Schubert D, Scheidbach H, Kuhn R, Wex C, Weiss G, Eder F, et al. Endoscopic treatment of thoracic esophageal anastomotic leaks by using silicone-covered, self-expanding polyester stents. Gastrointest Endosc 2005;61:891–896.
      1. Kang SG, Song HY, Lim MK, Yoon HK, Goo DE, Sung KB. Esophageal rupture during balloon dilation of strictures of benign or malignant causes: prevalence and clinical importance. Radiology 1998;209:741–746.
      1. Siersema PD, Hirdes MM. What is the optimal duration of stent placement for refractory, benign esophageal strictures? Nat Clin Pract Gastroenterol Hepatol 2009;6:146–147.
      1. Ketchum LD, Smith J, Robinson DW, Masters FW. The treatment of hypertrophic scar, keloid and scar contracture by triamcinolone acetonide. Plast Reconstr Surg 1966;38:209–218.
      1. Griffith BH. The treatment of keloids with triamcinolone acetonide. Plast Reconstr Surg 1966;38:202–208.
      1. Ramage JI Jr, Rumalla A, Baron TH, Pochron NL, Zinsmeister AR, Murray JA, et al. A prospective, randomized, double-blind, placebo-controlled trial of endoscopic steroid injection therapy for recalcitrant esophageal peptic strictures. Am J Gastroenterol 2005;100:2419–2425.
      1. Kochhar R, Makharia GK. Usefulness of intralesional triamcinolone in treatment of benign esophageal strictures. Gastrointest Endosc 2002;56:829–834.
      1. Altintas E, Kacar S, Tunc B, Sezgin O, Parlak E, Altiparmak E, et al. Intralesional steroid injection in benign esophageal strictures resistant to bougie dilation. J Gastroenterol Hepatol 2004;19:1388–1391.
      1. Shin JH, Song HY, Ko GY, Lim JO, Yoon HK, Sung KB. Esophagorespiratory fistula: long-term results of palliative treatment with covered expandable metallic stents in 61 patients. Radiology 2004;232:252–259.
      1. Kim JH, Song HY, Shin JH, Kim TW, Kim KR, Kim SB, et al. Palliative treatment of unresectable esophagogastric junction tumors: balloon dilation combined with chemotherapy and/or radiation therapy and metallic stent placement. J Vasc Interv Radiol 2008;19:912–917.
      1. Cwikiel W, Willén R, Stridbeck H, Lillo-Gil R, von Holstein CS. Self-expanding stent in the treatment of benign esophageal strictures: experimental study in pigs and presentation of clinical cases. Radiology 1993;187:667–671.
      1. Tan BS, Kennedy C, Morgan R, Owen W, Adam A. Using uncovered metallic endoprostheses to treat recurrent benign esophageal strictures. AJR Am J Roentgenol 1997;169:1281–1284.
      1. Evrard S, Le Moine O, Lazaraki G, Dormann A, El Nakadi I, Devière J. Self-expanding plastic stents for benign esophageal lesions. Gastrointest Endosc 2004;60:894–900.
      1. Dua KS, Vleggaar FP, Santharam R, Siersema PD. Removable self-expanding plastic esophageal stent as a continuous, non-permanent dilator in treating refractory benign esophageal strictures: a prospective two-center study. Am J Gastroenterol 2008;103:2988–2994.
      1. Song HY, Jung HY, Park SI, Kim SB, Lee DH, Kang SG, et al. Covered retrievable expandable nitinol stents in patients with benign esophageal strictures: initial experience. Radiology 2000;217:551–557.
      1. Jeon SR, Eun SH, Shim CS, Ryu CB, Kim JO, Cho JY, et al. Effect of drug-eluting metal stents in benign esophageal stricture: an in vivo animal study. Endoscopy 2009;41:449–456.
      1. Verschuur EM, Homs MY, Steyerberg EW, Haringsma J, Wahab PJ, Kuipers EJ, et al. A new esophageal stent design (Niti-S stent) for the prevention of migration: a prospective study in 42 patients. Gastrointest Endosc 2006;63:134–140.
      1. Hordijk ML, Siersema PD, Tilanus HW, Kuipers EJ. Electrocautery therapy for refractory anastomotic strictures of the esophagus. Gastrointest Endosc 2006;63:157–163.
      1. Schubert D, Kuhn R, Lippert H, Pross M. Endoscopic treatment of benign gastrointestinal anastomotic strictures using argon plasma coagulation in combination with diathermy. Surg Endosc 2003;17:1579–1582.
      1. Beilstein MC, Kochman ML. Endoscopic incision of a refractory esophageal stricture: novel management with an endoscopic scissors. Gastrointest Endosc 2005;61:623–625.
      1. Tsunada S, Ogata S, Mannen K, Arima S, Sakata Y, Shiraishi R, et al. Case series of endoscopic balloon dilation to treat a stricture caused by circumferential resection of the gastric antrum by endoscopic submucosal dissection. Gastrointest Endosc 2008;67:979–983.
      1. Byrne TK. Complications of surgery for obesity. Surg Clin North Am 2001;81:1181–1193.
      1. Kretzschmar CS, Hamilton JW, Wissler DW, Yale CE, Morrissey JF. Balloon dilation for the treatment of stomal stenosis complicating gastric surgery for morbid obesity. Surgery 1987;102:443–446.
      1. Buckwalter JA, Herbst CA Jr. Perioperative complications of gastric restrictive operations. Am J Surg 1983;146:613–618.
      1. Hewitt PM, Krige JE, Funnell IC, Wilson C, Bornman PC. Endoscopic balloon dilatation of peptic pyloroduodenal strictures. J Clin Gastroenterol 1999;28:33–35.
      1. Kuwada SK, Alexander GL. Long-term outcome of endoscopic dilation of nonmalignant pyloric stenosis. Gastrointest Endosc 1995;41:15–17.
      1. Lau JY, Chung SC, Sung JJ, Chan AC, Ng EK, Suen RC, et al. Through-the-scope balloon dilation for pyloric stenosis: long-term results. Gastrointest Endosc 1996;43:98–101.
      1. Solt J, Bajor J, Szabó M, Horváth OP. Long-term results of balloon catheter dilation for benign gastric outlet stenosis. Endoscopy 2003;35:490–495.
      1. Kochhar R, Sethy PK, Nagi B, Wig JD. Endoscopic balloon dilatation of benign gastric outlet obstruction. J Gastroenterol Hepatol 2004;19:418–422.
      1. Lam YH, Lau JY, Fung TM, Ng EK, Wong SK, Sung JJ, et al. Endoscopic balloon dilation for benign gastric outlet obstruction with or without Helicobacter pylori infection. Gastrointest Endosc 2004;60:229–233.
      1. Ahmad J, Martin J, Ikramuddin S, Schauer P, Slivka A. Endoscopic balloon dilation of gastroenteric anastomotic stricture after laparoscopic gastric bypass. Endoscopy 2003;35:725–728.
      1. Sataloff DM, Lieber CP, Seinige UL. Strictures following gastric stapling for morbid obesity. Results of endoscopic dilatation. Am Surg 1990;56:167–174.
      1. Kim JH, Shin JH, Bae JI, Di ZH, Lim JO, Kim TH, et al. Gastric outlet obstruction caused by benign anastomotic stricture: treatment by fluoroscopically guided balloon dilation. J Vasc Interv Radiol 2005;16:699–704.
      1. de Lange EE, Shaffer HA Jr. Anastomotic strictures of the upper gastrointestinal tract: results of balloon dilation. Radiology 1988;167:45–50.
      1. DiSario JA, Fennerty MB, Tietze CC, Hutson WR, Burt RW. Endoscopic balloon dilation for ulcer-induced gastric outlet obstruction. Am J Gastroenterol 1994;89:868–871.
      1. McMahon MJ, Greenall MJ, Johnston D, Goligher JC. Highly selective vagotomy plus dilatation of the stenosis compared with truncal vagotomy and drainage in the treatment of pyloric stenosis secondary to duodenal ulceration. Gut 1976;17:471–476.
      1. Johnston D, Lyndon PJ, Smith RB, Humphrey CS. Highly selective vagotomy without a drainage procedure in the treatment of haemorrhage, perforation, and pyloric stenosis due to peptic ulcer. Br J Surg 1973;60:790–797.
      1. Delaney P. Preoperative grading of pyloric stenosis: a long term clinical and radiological follow-up of patients with severe pyloric stenosis treated by highly selective vagotomy and dilatation of the stricture. Br J Surg 1978;65:157–160.
      1. Perng CL, Lin HJ, Lo WC, Lai CR, Guo WS, Lee SD. Characteristics of patients with benign gastric outlet obstruction requiring surgery after endoscopic balloon dilation. Am J Gastroenterol 1996;91:987–990.
      1. Holt PD, de Lange EE, Shaffer HA Jr. Strictures after gastric surgery: treatment with fluoroscopically guided balloon dilatation. AJR Am J Roentgenol 1995;164:895–899.
      1. Kim JH, Song HY, Shin JH, Choi E, Kim TW, Jung HY, et al. Metallic stent placement in the palliative treatment of malignant gastroduodenal obstructions: prospective evaluation of results and factors influencing outcome in 213 patients. Gastrointest Endosc 2007;66:256–264.
      1. Kim JH, Song HY, Shin JH, Hu HT, Lee SK, Jung HY, et al. Metallic stent placement in the palliative treatment of malignant gastric outlet obstructions: primary gastric carcinoma versus pancreatic carcinoma. AJR Am J Roentgenol 2009;193:241–247.
      1. Bae JI, Shin JH, Song HY, Lee GH. Treatment of a benign anastomotic duodenojejunal stricture with a polytetrafluoroethylene-covered retrievable expandable nitinol stent. J Vasc Interv Radiol 2004;15:769–772.
      1. Boron B, Gross KR. Successful dilatation of pyloric stricture resistant to balloon dilatation with electrocautery using a sphincterotome. J Clin Gastroenterol 1996;23:239–241.
      1. Hagiwara A, Sonoyama Y, Togawa T, Yamasaki J, Sakakura C, Yamagishi H. Combined use of electrosurgical incisions and balloon dilatation for the treatment of refractory postoperative pyloric stenosis. Gastrointest Endosc 2001;53:504–508.
      1. Kochhar R, Sriram PV, Ray JD, Kumar S, Nagi B, Singh K. Intralesional steroid injections for corrosive induced pyloric stenosis. Endoscopy 1998;30:734–746.
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    MeSH Terms
    Radiography, Interventional*
    Balloon Dilation
    Electrocoagulation
    Endoscopy, Gastrointestinal
    Esophageal Stenosis/therapy*
    Gastric Outlet Obstruction/therapy*
    Humans
    Injections, Intralesional
    Stents
    Steroids/administration & dosage
    Metrics
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