Esophageal strictures: Management beyond dilation

Table 1 It enumerate various benign causes of esophageal stricture

Intrinsic esophageal disorders	Iatrogenic or accidental
Peptic esophagitis	Postsurgical-anastomotic
Eosinophilic esophagitis	Post-radiation therapy
Miscellaneous disorders of the squamous epithelium (e.g., scleroderma, epidermolysis bullosa dystrophica, pemphigus and pemphigoid, lichen planus)	Endoscopic therapy; post endoscopic resection-endoscopic mucosal resection/endoscopic submucosal dissection; radiofrequency ablation; variceal band ligation
Motility disorders (e.g., achalasia)	Long-term nasogastric feeding tubes
Rings and webs (e.g., Schatzki ring)	Caustic ingestion

Table 2 Difference between simple and complex stricture

Feature	Simple stricture	Complex stricture
Length	Usually less than 2 cm	Often more than 2 cm
Shape	Straight	Angulated and/or tortuous
Lumen diameter	≥ 10-12 mm	< 10 mm
Endoscope passage	Usually, possible	Often impossible
Number	Usually, single	Single or multiple
Response to dilation	Good, 1-2 sessions are often enough	Recurrent, requires multiple sessions
Cause	Peptic stricture, esophageal web, Schatzki ring, etc.	Caustic strictures, radiation stricture, eosinophilic esophagitis, etc.

Table 3 Difference between refractory and recurrent esophageal stricture

Feature	Refractory stricture	Recurrent stricture
Lumen diameter achieved	Never reaches a diameter of ≥ 14 mm after 5 sessions of dilation performed at a short interval	Reaches ≥ 14 mm but later narrows again
Symptom pattern	Persistent dysphagia	Symptom-free interval followed by recurrence
Typical cause	Severe fibrosis, unresponsive inflammation	Incomplete disease control or complex anatomy

Table 4 It enumerates the difference between bougie and balloon dilators

Feature	Bougie dilators	Balloon dilators
Mechanism of action	Apply axial/shearing force as they are pushed through the stricture	Apply radial/centrifugal force by expanding within the stricture
Force distribution	Longitudinal, may be uneven and less controlled	Radial and uniform, leading to symmetrical expansion
Need for endoscopic visualization	Not essential	Requires endoscopic access (TTS) or fluoroscopy
Need for guidewire	Required	May or may not require, depending on the type of balloon dilator
Cost	Generally lower (reusable)	Higher (disposable or limited reuse)
Procedure time	Shorter procedure time	Longer procedure time due to multistep inflation
Types	Savary-Gilliard (wire-guided)	TTS balloon

TTS: Through-the-scope.

Table 5 Characteristics of the studies that evaluated the effect of intralesional steroid in treatment naïve esophageal strictures

Ref.	Study type and number of patients	Etiology of stricture	Dilator used	Steroid application	Outcome
Miyashita et al[24], 1997	Case series, n = 11	Anastomotic: 11	Balloon	2 mg dexamethasone into each quadrant (post-dilation). After dilation. Unclear repeating schedule	The mean number of dilations decreases significantly after steroid injection (1.1 vs 4.7, P < 0.05)
Orive-Calzada et al[25], 2012	Case series, n = 9	Anastomotic: 2; corrosive: 4; peptic: 3	NA	NA	No difference in mean number of dilations after steroid injection (3.33 vs 3, P = 0.673)
Hirdes et al[21], 2013	RCT, n = 29 in steroid arm	Anastomotic: 29	Bougie	20 mg triamcinolone into each quadrant (pre-dilation). Repeated up to 3 times	The number of patients dysphagia-free at 6 months was not different in the steroid and control group (45% vs 36%, P = 0.46)
Pereira-Lima et al[22], 2015	RCT, n = 10 (steroid arm)	Anastomotic: 10	Bougie	NA	The number of patients dysphagia-free at 6 months was higher in the steroid arm than the control group (62% vs 0%, P = 0.009)
Altintas et al[26], 2004	RCT, n = 10 (steroid arm)	Anastomotic: 1; corrosive: 2; peptic 6; radiation: 1	Bougie	8 mg triamcinolone into each quadrant (post-dilation). Only the first time	Mean periodic dilation index decreases significantly after steroid injection (0.193 vs 0.597, P < 0.05)

NA: Not available; RCT: Randomised controlled trial.

Table 6 Characteristics of the studies that evaluated the effect of intralesional steroid in refractory esophageal strictures

Ref.	Study type and number of patients	Etiology of stricture	Dilator used	Steroid application	Outcome
Ramage et al[23], 2005	Randomised controlled trial, n = 15 (steroid arm)	Peptic: 15	Balloon	20 mg triamcinolone into each quadrant at the narrowest part (pre-dilation) With each dilation	Number of follow-up dilations, time to first repeat dilation was not different among the two groups (P > 0.05)
Ahn et al[27], 2015	Case series, n = 25	Anastomotic: 1, eosinophilic esophagitis: 3, peptic: 17, radiation: 4	Bougie or balloon	10 mg triamcinolone into each quadrant at the proximal margin and into the stricture segment (post-dilation) with each dilation	Mean PDI decreases significantly after steroid injection (0.58 vs 0.28, P < 0.05)
Kochhar et al[28], 1999	Case series, n = 17	Corrosive: 17	Bougie	10-15 mg triamcinolone at the proximal margin and into the stricture (pre-dilation in 13 patients and post-dilation in 4 patients). Injections repeated if no subjective response at subsequently scheduled session (maximum: 3)	Median PDI decreases significantly after steroid injection (1.67 vs 0.32, P < 0.01)
Kochhar et al[29], 2002	Case series, n = 71	Anastomotic: 19, corrosive: 29, peptic: 14, radiation: 9	Bougie	10 mg triamcinolone into each quadrant at the proximal margin and into the strictured segment (pre-dilation in 63 patients and post-dilation in 8 patients). Injections repeated if no subjective response at subsequently scheduled session (maximum: 4)	Mean PDI decreases significantly after steroid injection (1.24 vs 0.51, P < 0.001)
Lee et al[30], 1995	Case series, n = 31	Anastomotic: 8, corrosive: 1, peptic: 12, pill esophagitis: 1, radiation: 6, sclerotherapy: 1	Bougie or balloon	28 mg triamcinolone into each quadrant at the narrowest region of the stricture (post-dilation) with each dilation	The mean number of dilations significantly reduced with steroid injection (P < 0.05)
Nijhawan et al[31], 2016	Case series, n = 11	Caustic: 11	Bougie	10 mg triamcinolone into the proximal margin of the stricture and the strictured segment (if long stricture) (post-dilation), weekly for 5 weeks	Mean PDI decreases significantly after steroid injection (2.54 vs 0.19, P < 0.001)

PDI: Periodic dilation index.

Table 7 Characteristics of the studies (with at least 5 patients) that evaluated the effect of mitomycin application for refractory esophageal strictures, n (%)

Ref.	Study type and number of patients	Etiology of stricture	Number of applications	Outcome
Rosseneu et al[37], 2007	Prospective clinical trial, n = 15	Caustic: 9, anastomotic: 9, peptic: 2, Crohn’s: 1, and dystrophic epidermolysis bullosa: 1	Median: 2	Stricture resolution: Complete: 10, partial: 2, no improvement: 3
Gillespie et al[38], 2007	Case series, n = 12	Radiation: 11 and anastomotic: 1	Mean: 1	Stricture resolution: Complete: 11 (91.7), partial: 1 (8.3) and required two additional sessions
Coopman et al[39], 2009	Case series, n = 6	Caustic: 3 and esophageal atresia: 3	Mean: 1.5	All have clinical and endoscopic improvement
Machida et al[40], 2012	Case series, n = 5	Post endoscopic submucosal dissection: 5	Mean: 1.6	All have resolution of symptoms without further dilations
El-Asmar et al[34], 2013	RCT, n = 20 (mitomycin arm)	Caustic: 20	Median: 1	Stricture resolution in 80%
El-Asmar et al[41], 2013	Prospective clinical trial, n = 16	Caustic: 16	Mean: 2.4	Stricture resolution in 81.2%
Nagaich et al[42], 2014	Prospective study, n = 12	Caustic: 12	Mean: 4.75	Increased interval for dilations in all
Sweed et al[35], 2015	RCT, n = 18 (mitomycin arm)	Caustic: 18	Median: 1	Dysphagia resolved in all patients
Bartel et al[43], 2016	Case series, n = 9	Anastomotic: 3, radiation: 3, caustic: 2, anastomotic + radiation: 1	Not available	Mean periodic dilation index decreased from 1.53 to 0.39, P = 0.01
Ghobrial et al[33], 2018	RCT, n = 60 (mitomycin arm)	Caustic: 60	Mean: 3.25	Stricture resolution in 81.6% patients compared to only 40% in the control arm (P < 0.0001)

RCT: Randomised controlled trial.

Table 8 Studies that evaluated the incisional therapy for esophageal strictures

Ref.	Number of patients	Etiology of stricture	Clinical success at follow-up	Follow-up duration (months)
Treatment naïve
Burdick et al[44], 1993	7	Schatzki ring	85.7%	36
Disario et al[45], 2002	11	Schatzki ring	36%	72
Schubert et al[46], 2003	15	Anastomotic strictures	93%	23
Hordijk et al[47], 2009	31	Anastomotic strictures	67.7%	6
Lee et al[48], 2009	24	Anastomotic strictures	87.5%	24
Treatment refractory
Brandimarte et al[49], 2002	6	Anastomotic strictures	36%	24
Simmons et al[50], 2006	9	Anastomotic strictures	44.4%	14
Hordijk et al[51], 2006	20	Anastomotic strictures	60%	12
Muto et al[52], 2012	32	Anastomotic strictures	62%	12
Tan and Liu[53], 2016	13	Anastomotic strictures	60%	24

Table 9 Studies (with at least 5 patients) that evaluated the self-expandable metal stents in benign esophageal strictures, n (%)

Ref.	Study type, number of patients	Etiology of stricture	Median duration of stent (days)	Clinical success	Complication rates
Song et al[55], 2000	Prospective, n = 25	Peptic: 1 (4), caustic: 22 (88), radiotherapy: 1 (4), other: 1 (4)	29	12 (48)	17 (68)
Kim et al[56], 2009	Retrospective, n = 51	Peptic: 1 (2), caustic: 44 (86), radiotherapy: 2 (4), anastomotic: 2 (4), other: 3 (6)	56	13 (26)	14 (27)
Bakken et al[57], 2010	Retrospective, n = 25	Peptic: 7 (28), radiotherapy: 8 (32), anastomotic: 10 (40)	67 (0-279)	13 (52)	5 (20)
Eloubeid et al[58], 2011	Retrospective, n = 19	Peptic: 4 (21), caustic: 2 (11), radiotherapy: 2 (11), anastomotic: 9 (47), other: 2 (11)	64 (6-300)	4 (21)	5 (26)
Hirdes et al[59], 2012	Prospective, n = 15	Peptic: 6 (40), caustic: 3 (20), radiotherapy: 2 (13), other: 4 (27)	61 (13-222)	0	5 (33)
Liu et al[60], 2012	Retrospective, n = 24	Anastomotic	74 (63-84)	18 (75)	0
Canena et al[61], 2012	Prospective, n = 30	Peptic: 7 (23), caustic: 3 (10), radiotherapy: 2 (7), anastomotic: 13 (43), other: 5 (17)	90	8 (27)	2 (7)
Chaput et al[62], 2013	Prospective, n = 41	Peptic: 16 (39), caustic: 3 (7), radiotherapy: 8 (20), anastomotic: 12 (29), other: 2 (5)	58 (20-140)	21 (51)	5 (12)
Dan et al[63], 2014	Retrospective, n = 17	Peptic: 2 (12), radiotherapy: 3 (18), anastomotic: 9 (52), other: 3 (18)	71 (1-65)	5 (29)	0
Yang et al[64], 2017	Retrospective, n = 5	Peptic stricture: 2, anastomotic stricture: 3	60 (40-90)	5 (100)	1 (20)
Santos-Fernandez et al[65], 2017	Retrospective, n = 9	Caustic: 2, radiation/anastomotic: 7	67.6 (mean)	3 (33)	2 (22.2)
Lu et al[66], 2019	Retrospective, n = 20	Peptic, caustic, radiotherapy, anastomotic	29 (7-67)	7 (35)	9 (47)
Mahmoud et al[67], 2023	Retrospective, n = 15	Peptic: 4, radiation: 3, anastomotic: 8	119 (49.5-352)	14 (93)	Not available

Table 10 Studies that evaluated the biodegradable stents in benign esophageal strictures, n (%)

Ref.	Study type, number of patients	Etiology of stricture	Technical success	Clinical success	Complication rates
Repici et al[68], 2010	Prospective, n = 21	Peptic: 7 (33), caustic: 2 (10), radiotherapy: 5 (24), anastomotic: 5 (24), other: 2 (10)	21 (100)	9 (43) at 1 year	3 (14)
van Boeckel et al[69], 2011	Prospective, n = 18	Peptic: 6 (33), caustic: 2 (11), radiotherapy: 2 (11), anastomotic: 5 (27), others: 3 (16)	15 (85)	6 (33) at 3 months	6 (33)
van Hooft et al[70], 2011	Prospective, n = 10	Anastomotic: 10 (100)	10 (100)	6 (60) at 6 months	6 (60)
Hirdes et al[71], 2012	Prospective, n = 28	Peptic: 9 (32), caustic: 2 (7), radiotherapy: 3 (11), anastomotic: 7 (25), others: 7 (25)	28 (100)	7 (25) at 6 months	8 (29)
Karakan et al[72], 2013	Prospective, n = 7	Caustic: 7 (100)	7 (100)	2 (29) at 60 weeks	3 (43)
Kochhar et al[73], 2017	Prospective, n = 11	Caustic: 13 (100)	13 (100)	2 (15.4) at 1 year	7 (54)