Natural history and management of refractory benign esophageal strictures

doi:10.1016/j.gie.2016.01.053

Gastrointestinal Endoscopy

Volume 84, Issue 2, August 2016, Pages 222-228

https://doi.org/10.1016/j.gie.2016.01.053 Get rights and content

Background and Aims

The natural history of refractory benign esophageal strictures (RBES) is unclear, and surgery or percutaneous endoscopic gastrostomy (PEG) may be the only viable long-term options. The aim of the present study was to assess the long-term outcomes of patients with RBES.

Methods

Clinical data of consecutive patients with RBES treated in the previous 15 years in 2 tertiary-care referral academic centers with specialized interest in esophageal stricture management were retrospectively analyzed. RBES was defined as the persistence and/or recurrence of dysphagia despite at least 5 dilation sessions and/or cycles with dilation to at least 14 mm. Information regarding the use of dilation or stents and the dysphagia-free period between subsequent interventions and adverse events was collected. Clinical success was defined as no need for endoscopic interventions for at least 6 months; unfavorable outcomes were defined as the need for endoscopic treatment at the end of follow-up, surgery, or percutaneous endoscopic gastrostomy (PEG). Predictors of unfavorable outcomes were assessed by multivariate analysis. A linear mixed-effect model was used to measure dysphagia-free period changes over time.

Results

Overall, 70 patients with RBES (46 male; mean age 60 years) were followed for a mean of 43.9 months (range 3.7-157 months). Caustic, postradiotherapy, surgical, mixed, and postinflammatory etiology accounted for 10%, 14.3%, 31.4%, 40%, and 4.3% of causes, respectively. All patients underwent sequential sessions of pneumatic or bougie dilation, with a median of 15.5 dilation sessions per patient. Self-expandable metal stents (SEMSs) and biodegradable stents were placed in 18 (25.7%) and 14 (20%) patients, respectively. RBES resolution was achieved in only 22 of 70 (31.4%) patients. Two deaths (3%) were related to RBES. The success rate was lower in those who also were treated with endoprosthetics (odds ratio [OR] 3.7; 95% confidence interval [CI], 1.01-18.0). The mean dysphagia-free period was 3.3 months (95% CI, 2.4-4.1) for patients treated with dilation and 2.4 months (95% CI, 1.2-3.6) for those treated with stents (P = .062). Over time, the total dysphagia-free period increased at a rate of 4.1 days (95% CI, 1.7-6.4) per dilation. There was no difference in the rate of change across groups defined by sex (P = .976), age (P = .633), or endoscopic treatment (P = .267).

Conclusions

Our multicenter series showed a disappointing long-term outcome for RBES, with only 1 of 3 achieving clinical resolution. The dysphagia-free period was relatively short, affecting the quality of life. Endoprosthetics did not appear to affect the natural history of RBES.

Section snippets

Patients and data collection

Clinical charts of patients who were managed over the previous 15 years in 2 tertiary-care referral academic centers (Humanitas Research Hospital, Milan, Italy, and Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA) were retrospectively reviewed, and patients who had a diagnosis of refractory or recurrent esophageal strictures, defined as the persistence or recurrence of dysphagia despite at least 5 endoscopic treatment sessions, were selected. Data were retrieved from

Study population

Overall, 70 patients were identified and included for analysis (46 male; median age at diagnosis 60 years, range 23-81 years). Nineteen and 51 patients were managed at the Humanitas Research Hospital and the Hospital of the University of Pennsylvania, respectively. Esophageal strictures were caused by caustic injury in 7 patients (10%), radiation therapy in 10 (14.3%), surgery in 22 (31.4%), a mixture of these etiologies in 28 (40%), and by fibrosis related to previous inflammatory processes in

Discussion

We have shown that the long-term outcome of endoscopic treatment for RBES is unfavorable, with less than one-third of the patients achieving resolution of dysphagia, and the majority still requiring continuous endoscopic dilation at the end of follow-up. The addition of endoprosthetic placement to dilation therapy did not significantly affect the long-term outcome of patients with RBES.

The findings of our study are relevant for several reasons. First, we restricted our cohort only to patients

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Citation Excerpt :
In 2005, Kochman et al20 proposed a refractory BES definition to achieve uniformity among clinical studies. Since then, this definition has only been used in 1 study that investigated risk factors for refractory BES6 but not in other studies.7,21 Second, the varying results may also be related to the relatively small sample size of previous studies (range, 63-87 patients), which may have resulted in poor adjustment for confounding (eg, type of BES) in the multivariate analysis.6-8
Endoscopic dilation (ED) is still the mainstay of therapeutic management of benign esophageal strictures (BESs). This study aimed to establish risk factors for refractory BESs and assess long-term clinical outcomes of ED.
We performed a retrospective study in 891 patients who underwent ED from 2003 to 2018 for BESs. We searched electronic medical records in 6 tertiary care centers in the Netherlands for data on clinical outcome of ED. Median follow-up was 39 months. The primary endpoint was risk factors for refractory BESs, defined as factors associated with an increased number of ED sessions during follow-up. Secondary endpoints were time from first to last ED session and adverse events.
Dilation up to 13 to 15 mm was associated with a higher number of ED sessions than dilation up to 16 to 18 mm (5.0 vs 4.1; hazard ratio [HR], 1.4; P = .001). Compared with peptic strictures, anastomotic (4.9 vs 3.6; HR, 2.1; P < .001), radiation (5.0 vs 3.6; HR, 3.0; P < .001), caustic (7.2 vs 3.6; HR, 2.7; P < .001), and postendotherapy (3.9 vs 3.6; HR, 1.8; P = .005) strictures were associated with a higher number of ED sessions. After 1 year of follow-up, the proportions of patients who remained free of ED was 75% in anastomotic, 71% in radiation, 70% in peptic, 83% in postendotherapy, and 62% in caustic strictures. Esophageal perforation occurred in 23 ED sessions (.4%) in 22 patients (2.4%).
More than 60% of patients with BESs remain free of ED after 1 year of follow-up. Because dilation up to 16 to 18 mm diameter was associated with fewer ED sessions during follow-up, we suggest that clinicians should consider dilation up to at least 16 mm to reduce the number of ED sessions in these patients.
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: DISCLOSURE: All authors disclosed no financial relationships relevant to this publication.

: If you would like to chat with an author of this article, you may contact Dr Repici at [email protected].

: See CME section; p. 329.

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Original articleClinical endoscopyNatural history and management of refractory benign esophageal strictures

Background and Aims

Methods

Results

Conclusions

Section snippets

Patients and data collection

Study population

Discussion

Gastroenterology

Gastrointest Endosc Clin N Am

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Clin Gastroenterol Hepatol

Am J Gastroenterol

Gastrointest Endosc

Ann Thorac Surg

Original article
Clinical endoscopy
Natural history and management of refractory benign esophageal strictures