Stent thực quản

Ann. N.Y. Acad. Sci.
ISSN 0077-8923
A N N A L S O F T H E N E W Y O R K A C A D E M Y O F SC I E N C E S
Issue: The 11th OESO World Conference: Reflux Disease
Stents for benign and malignant esophageal strictures

Eduardo Guimarães Hourneaux de Moura,1 Kengo Toma,1 Khean-Lee Goh,2 Ronald Romero,2
Kulwinder S. Dua,3 Valter Nilton Felix,1 Marc S. Levine,4,5 Rakesh Kochhar,6
Sreekanth Appasani,6 and Carla Cristina Gusmon7
1
Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil. 2 Division of Gastroenterology and GI Endoscopy,
University of Malaya, Kuala Lumpur, Malaysia. 3 Division of Gastroenterology and Hepatology, Department of Medicine,
Medical College of Wisconsin, Milwaukee, Wisconsin. 4 Department of Gastrointestinal Radiation, University of Pennsylvania
Medical Center, Philadelphia, Pennsylvania. 5 Department of Radiology, Perelman School of Medicine at the University of
Pennsylvania, Philadelphia, Pennsylvania. 6 Department of Gastroenterology, Post Graduate Institute of Medical Education
and Research, Chandigarh, India. 7 Endoscopy Unit, Hospital das Clı́nicas da Faculdade de Medicina da Universdade de São
Paulo, São Paulo, Brazil
Address for correspondence: annals@nyas.org
This paper presents commentaries on endotherapy for esophageal perforation/leaks; treatment of esophageal per-
foration; whether esophageal stents should be used for treating benign esophageal strictures; what determines the
optimal stenting period in benign esophageal strictures/leaks; how to choose an esophageal stent; how a new fistula
secondary to an esophageal stent should be treated; which strategy should be adopted when a fistula of a cervi-
cal anastomosis occurs; intralesional steroids for refractory esophageal strictures; balloon and bougie dilators for
esophageal strictures and predictors of response to dilation; whether refractory strictures from different etiologies
respond differently to endotherapy; surgical therapy of benign esophageal strictures; and whether stenoses following
severe esophageal burns should be treated by esophageal resection or esophageal bypass.
Keywords: stent; anastomic leak; stricture formation; neoesophagus; esophageal perforation
Concise summaries r For cervical perforations, endoscopic therapy

with clipping is possible, but visualization of
r Esophageal perforations and leaks remain the area may be difficult and endoscopic stent
complications of high morbidity and mortal- placement may not be feasible. Most cervical
ity. Surgical procedures are still considered as perforations have a good outcome with conser-
the gold standard for some authors, especially vative treatment with intravenous antibiotics
in septic patients or with large esophageal le- and nil per orally. Treatment of thoracic per-
sions. It covers several techniques, all aimed at forations depends very much on the size of the
the repair, removal, or exclusion of the lesion. perforation: small perforations can be treated
Endoscopic therapy has increasingly become conservatively whereas larger perforations can
a viable alternative, and the use of stents has be treated with stent placement if the dehis-
increased in recent years: there is no difference cence of the lumen circumference does not ex-
in efficacy between different types of stents, ceed 70%. Migration is a particular problem
and the choice should be based on the chance with fully covered stents. Surgery is mandatory
of occurrence of complications. Anchorage of in any part of the esophagus when the perfora-
the stent flare top completely covered with the tion is large or when patients do not improve
endoscopic clip is viable and significantly re- with conservative or endoscopic treatment.
duces its migration. Application of fibrin glue, r Refractory benign esophageal strictures
cyanoacrylate, and endoscopic clip may be suf- (RBESs) are not only difficult to dilate (higher
ficient for minor injuries. Endoscopic suturing complication rate) but also tend to recur
is technically a more complex procedure. within weeks. Self-expandable esophageal
doi: 10.1111/nyas.12242
Ann. N.Y. Acad. Sci. 1300 (2013) 119–143
C 2013 New York Academy of Sciences. 119
Stents for benign and malignant strictures; and benign esophageal stenosis Hourneaux de Moura et al.
stents can maintain luminal patency while the stent after 4–6 weeks, by which time the ef-
simultaneously stretching the stricture. fect of chemoradiation/brachytherapy would
However, unlike malignant strictures, they have shrunken the tumor.
will need to be removed at some point. The r Stent failure can be attributable to mechanical
uncovered segments at the upper and the factors such as esophageal leak of the proximal
lower ends allow for better anchoring and cervical esophagus, esophageal leak at the GEJ,
thereby reduce the risks of stent migration, esophageal injury, or anastomotic leak associ-
however, the granulation tissue growing into ated with a more distal conduit leak. There is
the wire meshes embeds the stent, making no gold standard treatment for a fistula sec-
it difficult and unsafe to remove. The fully ondary to an esophageal stent, but the use of a
covered stents are made of a polyester mesh new stent seems to be a promising treatment as
with an outer covering of a silicone membrane it is a quick procedure, with immediate occlu-
and should be considered on a case-by-case sion of the lesion, low rates of serious compli-
basis. The fully covered self-expanding metal cations and mortality, and can prevent bypass
stents are an attractive alternative since they surgery or esophageal exclusion.
come preloaded into a thinner (7–8 mm) r The rate of anastomotic leak is clearly
delivery system and are much easier to place. higher when the substernal route is used for
r The decision as to how long a stent should be esophageal replacement, due to much worse
placed depends on the time needed for the vascular pedicle disposition in comparison to
perforation to heal versus the risk of tissue the posterior mediastinal route. Most leaks are
embedment if the stent is left for too long. of very low output and are treated conser-
Most experts would agree placing stents from vatively with local wound care while enteral
6 to 8 weeks, although fully covered stents have feeding is continued. Early passage of 30, 36,
been left for much longer periods of time. If and 46 Fr Maloney-tapered esophageal dila-
a perforation is large, replacement of a stent tors within 1 week of drainage must be per-
after 6 weeks with a new stent is advised. formed to maintain a satisfactory lumen and
r Self-expandable metal stents (SEMS) are the prevent the late development of a stenosis.
most commonly used modality to palliate ma- If persistent purulent drainage from the neck
lignant dysphagia. Recent detailed assessment is observed, direct visualization of the gastric
of the stricture and experience in using the conduit through the opened cervical incision
various types of stents are essential at the time and upper endoscopy allow one to evaluate the
of stent placement. It is important to position mucosal viability of the intrathoracic stomach
the stent in such a manner that the covered and the extent of anastomotic disruption. Few
segment of the stent is across the strictures patients with benign strictures at the cervical
and/or fistula so as prevent tumor ingrowth esophagogastric anastomosis require operative
and to seal the fistula, respectively. When stents revision. When this is necessary, a partial up-
are placed across the gastroesophageal junc- per sternal split to facilitate exposure of the
tion (GEJ), the results from studies evaluating esophagus in the thoracic inlet is beneficial. In
the efficacy of the currently available antire- the most severe cases, resection of the fibrotic
flux stents have been mixed. For the proxi- ring and a new anastomosis are necessary.
mal esophagus, precise positioning of the stent Placement of self-expandable or biodegrad-
is essential if the distance between the upper able covered stents is relatively contraindi-
esophageal sphincter (UES) and the stricture cated for postoperative esophageal leaks. Even
is less than 2 cm. Hypopharyngeal strictures if pharyngeal discomfort can be avoided, pa-
or strictures at the UES can be stented with tients undergoing stent placement across a
smaller diameter stents. SEMS are highly ef- cervical esophagogastric anastomosis are at
fective in immediately relieving dysphagia but greater risk for severe symptomatic reflux and
can be associated with significant delayed com- aspiration.
plications. Hence one can place a stent for im- r The sensitivity of barium esophagography for
mediate relief of symptoms and then remove detecting Schatzki rings is highly dependent on
120 Ann. N.Y. Acad. Sci. 1300 (2013) 119–143

C 2013 New York Academy of Sciences.
Hourneaux de Moura et al. Stents for benign and malignant strictures; and benign esophageal stenosis
the technique used to perform this examina- and simultaneously over the entire length of
tion. Prone single-contrast views have a higher the stenosis. They are safer especially in multi-
sensitivity because the distal esophagus is bet- ple and tortuous strictures.
ter distended, and hence rings are better visual- r The possible factors that can predict response
ized, when the patient swallows barium in the in benign esophageal strictures could be etiol-
prone position. Thus, barium esophagography ogy, length of stricture, number of strictures,
is a more sensitive technique than endoscopy initial diameter, and stage of corrosive disease
for detecting Schatzki rings, and occasionally (early versus late). Certain characteristic fea-
may demonstrate rings that are missed on en- tures on computed tomography and EUS also
doscopic examinations. Conversely, rings can have a role in predicting response to success-
be missed if the distal esophagus is overdis- ful dilation. Maximal esophageal wall thick-
tended, producing overlap between the lower ness can be helpful in predicting the response
end of the distal esophagus and upper end of to endoscopic dilation.
the hiatal hernia (HH) that prevents visualiza- r The most common causes of stricture for-
tion of the GEJ in profile. mation include caustic ingestion, radiation
r A refractory or recurrent stricture is defined injury, surgery, photodynamic therapy, and se-
as an anatomic restriction resulting from cica- vere peptic injury. There is evidence that in-
tricial luminal compromise or due to fibrosis tralesional steroid injection prior to dilation
leading to clinical symptoms of dysphagia in reduces the risk of recurrent stricture forma-
the absence of any endoscopic evidence of in- tion in RBESs. In patients who have refractory
flammation. The exact mechanism by which strictures caused by caustic ingestion or radia-
intralesional steroids are useful for treatment tion injury, temporary stent placement may be
of these strictures is not clear. Injection of effective. The main limitation of metal stents
steroids into the stricture has been shown to for benign strictures is the occurrence of tissue
inhibit stricture formation by interfering with in- and overgrowth causing recurrent dyspha-
collagen synthesis, fibrosis, and chronic scar- gia. To avoid the hyperplastic tissue reaction,
ring processes. It has been suggested that an en- self-expanding plastic stents are only mod-
doscopic ultrasound (EUS) mini-probe should erately effective for the treatment of refrac-
be used to guide the injection into the thick- tory benign strictures. Biodegradable stents
est portion of the esophageal stricture for bet- (absorbed within 2–3 months after place-
ter results. The efficacy of steroid injections ment) result in a longer period of dysphagia
in humans has traditionally been assessed by relief.
studying the need for dilations, the time to r Several factors are considered in the surgical
dilations, and the number of additional dila- therapy of benign strictures of the esophagus.
tions. The safety of intralesional steroids has The length and location of the stricture de-
been documented in a number of studies. They termine the choice of surgery. The stomach is
augment the response of dilation in esophageal the most common and convenient organ used
strictures and are recommended for use in re- to construct a neoesophagus. However, in ex-
fractory or recurrent strictures. tensive chemical injuries involving the stom-
r Balloon dilators may offer a number of poten- ach, the colon is preferred. Jejunum is consid-
tial advantages versus rigid technologies when ered for esophageal reconstruction if the stom-
performing dilation, including direct endo- ach is diseased and colon interposition is not
scopic visualization, application of radial force possible.
directly to the stricture site, and improved pa- r For corrosive chronic, intractable esophageal
tient comfort. Bougie dilators exert both radial strictures, it is necessary to perform extensive
and shearing force at the stricture. Dilation is preoperative examination to find hidden ma-
usually left to the endoscopist and this is suit- lignancies. Then, synchronous resection of the
able for simple strictures. In contrast, in bal- esophagus with esophageal reconstruction is
loon dilators the entire dilating force is radial the best therapeutic choice.
Ann. N.Y. Acad. Sci. 1300 (2013) 119–143

1. Endotherapy for esophageal high rate of successful treatment (59.5–100%).2,4,10

perforation/leaks: clip, stent, suture, fibrin, The prerequisite for successful stent placement is an
or combinations? adequate drainage of fluid collections in the medi-
astinum or pleural cavity.6
Eduardo Guimarães Hourneaux de Moura and
There is no difference in efficacy between differ-
Kengo Toma
ent types of stents: partially covered self-expandable
kengotoma@gmail.com
metallic (PC-SEMS), fully covered metallic (FC-
Esophageal perforation and leaks remain complica- SEMS), and plastic (SEPS).5,6 The choice between
tions of high morbidity and mortality,1–7 even with these should be based on the chance of occurrence
technological advances in diagnosis, surgery, and in- of complications such as migration (higher in SEPS
tensive care units.1 Successful management depends and FC-SEMS)2,5–7 or tissue in- or overgrowth (11%
on several principles such as detection, characteri- in PC-SEMS).5–7 The anchorage of the stent flare
zation and remediation of early esophageal wall in- top completely covered with the endoscopic clip is
jury, treatment, and control of the infectious com- viable and significantly reduces its migration.5
plications such as contamination and mediastinal The migration of the stent occurs especially
or peritoneal.1,3,7–9 in patients who do not have obstructive lesions,
The conservative and surgical treatments are the which could aid in keeping the stent in place.
most used, because they have high rates of thera- Tissue in- or overgrowth is a frequent complica-
peutic success.1,2,9 The first consists of suspension tion, more common with PSEMS and long-term
of oral intake, the use of broad-spectrum antibiotics, treatment.6
nutritional alternative route (enteral or parenteral), Where the stent is not feasible, as in very prox-
intensive care, and drainage, and is indicated in cases imal or distal (envolving cardia) small esophageal
where there are no signs of sepsis or obstruction dis- perforation, it is recommended to use clips, with
tal to the lesion.8 or without fibrin glue.2,5 The application of fibrin
The surgical procedure is still considered the glue, cyanoacrylate, and endoscopic clips may be
gold standard for some authors, especially in septic sufficient for minor injuries, but none of these tech-
patients8,10 or with large esophageal lesions.6 It cov- niques is suitable for large defects of the esophageal
ers several techniques, including the primary sur- wall. In these cases, the endoscopic treatment envis-
gical repair with or without booster (fibrin), medi- aged is a stent, as mentioned earlier.
astinal drainage with diversion/exclusion of traffic, Endoscopic suturing is technically a more com-
and making a T-tube esophago-cutaneous fistula, plex procedure to be executed and will be an impor-
all aimed at the repair, removal, or exclusion of the tant limiting factor for the widespread use of this
lesion. technology in the correction of esophageal perfora-
Endoscopic therapy has increasingly become a vi- tions or leaks.9
able alternative for the treatment of esophageal leak An ideal treatment for an esophageal perforation
and perforation, because it is a less invasive alterna- or leak would be one that minimized the negative
tive and has low rates of serious complications.6 It is effects of the treatment on the patient while fulfilling
indicated especially in perforations diagnosed after the traditional goal of therapy: preventing further
their occurrence in patients without surgical con- contamination of the mediastinum by direct clo-
dition who progressed to treatment failure of chest sure of the perforation, eliminating infection in the
tube drainage and antibiotic therapy. mediastinum and pleural spaces, maintaining the
The use of stents has increased in recent years integrity of the gastrointestinal tract, and using en-
because it allows immediate correction of the le- teral nutrition. As shown in Figure 1, many experts
sion, early reintroduction of oral diet (2–4 days) now recommend the use of a stent as a first therapy,
and preservation of intestinal transit, and promotes associated with a drainage procedure, depending on
a shorter hospital stay compared with conventional the timing of the diagnosis.
surgical treatment or conservative treatment.2,3 It is The existence of several treatments for esophageal
used in lesions that compromise less than 70% of perforation or leak is an indication that there is still
the circumference of the esophagus5 and presents a no consensus on an optimal treatment.1
122 Ann. N.Y. Acad. Sci. 1300 (2013) 119–143

Figure 1. Treatment algorithm for esophageal stent placement in patients with esophageal leaks or perforations. CT, computed
tomography; EGD, esophagogastroduodenoscopy; POD, postoperative day.7
2. Esophageal perforation: conservative logically guided drainage of localized collections of

management, endotherapy, or surgery? fluid and pus should be carried out at the same
time.11,15,16
Khean-Lee Goh and Ronald Romero
The location, with regard to the cervical, tho-
klgoh56@gmail.com
racic, or abdominal portions of the esophagus, and
Esophageal perforation carries with it a high mor- the size of the perforation influence our treatment
bidity and mortality if not treated appropriately choice. Cervical perforations are often iatrogenic
and aggressively. Several factors determine the suc- in etiology—they arise during intubation with a
cessful outcome of treatment and these include the gastroscope. These tears are usually small and can
time interval between diagnosis of perforation and be treated conservatively, as the perforation or leak
treatment, the location of the perforation,11–13 the is also contained within the triangle of Killian in the
cause of the perforation, the underlying esophageal neck. Endoscopic therapy with clipping is possible,
disease, and the presence of comorbid illness.13,14 but visualization of the area may be difficult and
Three approaches are available for the treatment of endoscopic stent placement not feasible. Most
esophageal perforation: conservative, endotherapy, cervical perforations have a good outcome with
and surgery (Fig. 2). conservative treatment with intravenous antibiotics
Conservative management of perforations can be and nil per orally.
considered in small perforations and with the fol- Treatment of thoracic perforations depends very
lowing features: diagnosis made early and perfora- much on the size of the perforation. Small perfo-
tion contained within the neck and mediastinum; rations due to sclerotherapy injection, for example,
drainage into the esophageal lumen shown by con- can be treated conservatively. Endotherapy can help
trast imaging; injury which does not occur in neo- avoid surgery in other cases—small tears from en-
plastic tissue (or corrosive injury), in the abdomen, doscopic insertion can be clipped and esophageal
or proximal to an obstruction; absence of systemic fistulae can be injected with fibrin glue. On the
sepsis; and availability of interventional radiological other hand, larger perforations can be treated with
and surgical expertise. In all cases managed conser- stent placement if the dehiscence of the lumen cir-
vatively, nutritional support and the use of broad cumference does not exceed 70%.17 Stent placement
spectrum antibiotics as well as appropriate radio- with FC-SEMS, SEPS, or PC-SEMS has been used
Ann. N.Y. Acad. Sci. 1300 (2013) 119–143

Figure 2. A general treatment algorithm for perforation of the esophagus.
with fairly good success.5 One of the major prob- debridement of surrounding necrotic tissue with
lems with stent placement is the migration of these placement of drains close to the site of perforation is
stents, especially in the absence of a stricture to hold important. Repair of perforation can be reinforced
the stents in place, and deployment of the largest di- with muscle or pleural flaps.12 A laparoscopic or
ameter stents is then recommended.6 Migration is a thoracoscopic approach is increasingly used for such
particular problem with fully covered stents, where repairs.
it has been reported in up to 25% of cases.6 As with In cases of a diseased esophagus such as cor-
conservative management, simultaneous drainage rosive injury–related perforations or cancer of the
of any mediastinal or pleural collection of fluid or esophagus, esophageal replacement surgery should
pus should be carried out and patients put on intra- be contemplated with total esophagectomy and gas-
venous antibiotics. tric pull-up surgery or creation of a neo-esophagus
Perforation of the intra-abdominal portion of with colonic interposition.18
the esophagus often results in peritonitis and sepsis
very quickly, and surgery is usually recommended. 3. Should esophageal stents be used for
Small leaks or perforation, for instance, a small tear treating benign esophageal strictures?
from balloon dilation or from sclerotherapy, can
Kulwinder S. Dua
be treated with stent placement across the cardio-
kdua@mcw.edu
esophageal junction. Larger tears such as in Boer-
haave’s syndrome (spontaneous barotraumatic rup-
ture of the esophagus) will require surgery. Introduction
Surgery is mandatory in any part of the esophagus RBES is defined as an anatomic fibrotic esophageal
when the perforation is large or when patients do restriction (absent inflammation and motility dis-
not improve with conservative or endoscopic treat- order) with inability to achieve a diameter of ≥14
ment. The latter usually happens when diagnosis of mm in five sessions of dilations once every 2 weeks
the perforation is delayed and if the perforation is or inability to maintain a diameter of ≥14 mm for
noncontained, resulting in mediastinal or peritoneal 4 weeks once ≥14 mm diameter is achieved.19 These
contamination and systemic sepsis.14 are complex strictures, usually >2 cm (or multiple
In very ill cases, esophageal exclusion surgery can sites), tight, tortuous, and may be associated
be carried out until the patient’s general condition with leaks or fistulas. They usually develop after
stabilizes. The aim of surgery is to achieve primary corrosive injuries, radiation, surgery, and after
repair of the perforation, but identification of the ablative therapies like photodynamic treatment,
perforation may not be easy. Appropriate toilet and mucosal resection, and mucosal dissection.
124 Ann. N.Y. Acad. Sci. 1300 (2013) 119–143

They are not only difficult to dilate (higher com- with RBES, technical success was 98% and func-
plication rate) but also tend to recur within weeks. tional success was 52%.26 Lower success rates were
Hence, alternate endoscopic approaches like steroid observed for cervical esophagus strictures compared
injection, electrocautery incision, or stent place- to other locations. The stent migrated in 24% of pa-
ment have been tried. The safety and efficacy of tients and reintervention was needed in 21%. Major
using stents to treat RBES will be discussed here. complication occurred in 9% of cases. The Polyflex
stent for RBES should be considered on a case-by-
Stents case basis and preferably on a protocol.
Conceptually speaking, if a dilator (bougie or a bal-
loon) kept across a stricture for a few seconds gives a FC-SEMS. The full covering prevents the stent from
few weeks of relief, then keeping a dilator across the embedding by tissue ingrowth and thereby renders
stricture for several weeks to allow tissue stretch- them removable. They come preloaded on a thin-
ing and remolding while still maintaining lumi- ner delivery system and are easy to place. Most of
nal patency may give longer lasting benefits. Self- them also have a purse-string suture attached to
expandable esophageal stents can maintain luminal their upper end for easy repositioning and removal.
patency while simultaneously stretching the stric- A success rate of around 30% with restricturing rates
ture. However, unlike for malignant strictures, they of 40% have been reported.27,28 FC-SEMS are not as
will need to be removed at some point. yet cleared by the FDA for use in benign conditions.
PC-SEMS. The uncovered segments at the upper Biodegradable esophageal stents. Biodegrad-
and the lower ends of PC-SEMS allow for better an- able esophageal stents are made of polylac-
choring and thereby reduce the risks of stent migra- tide/polydioxanon that gets metabolized by the
tion. However, the granulation tissue growing into body and hence they do have to be removed.
the wire meshes embeds the stent, making it difficult In a recent two-center study on 33 patients
and unsafe to remove. Half the patients in one series with RBES, technical success in placement was
developed major complications in the form of new 100%.30 On scheduled endoscopy at 3 months
strictures, stent migrations, and death from stent from deployment, all stents were fragmented.
eroding into the aorta.20 In a review of 29 patients, At median 53-week follow-up, 46% of patients
Sandha et al. observed new stricture formation in were dysphagia-free. Some of the complications
40%, stent migration in 30%, and new tracheo- observed were chest pain (3), migration (2), and
esophageal fistulas in 6%.21 Hence PC-SEMS are bleeding (1). This stent is currently not approved
not recommended for RBES. for use in the United States.
SEPS. The only fully covered SEPS is the Polyflex R

Suggested role of stents to treat RBES
stent from Boston Scientific Corporation. The stent Currently the only stent approved in the United
is made of a polyester mesh with a covering of a States for benign indications is the self-expanding
silicone membrane. In initial reports, its efficacy in plastic stent, the Polyflex stent. Unfortunately this
treating RBES was as high as 80%.22,23 These re- stent requires manual loading into a delivery system.
sults were not reproduced by others.24–26 Recently, The delivery system has a large diameter (12–16 mm
a prospective study was conducted in 40 subjects based on the diameter of the stent being used) and
who fulfilled the definition of RBES.19 A polyflex hence patients may require preinsertion dilation.
stent was deployed across the RBES and removed The stent is associated with significant migration
after 4–6 weeks. Thirty percent of the patients were rates and many patients complain of chest pain.
dysphagia-free at a median follow-up of 53 weeks. Hence, the FC-SEMS are an attractive alternative
Significant complications (30%) included migra- since they come preloaded into a thinner (7–8 mm)
tion, chest pain, bleeding, and perforation includ- delivery system and are much easier to place. They
ing mortality in a patient who refused stent removal are not yet FDA cleared for use in RBES, but several
and died of severe bleeding probably related to an case series have shown them to be safe and effective.
arterio-esophageal fistula. In a pooled-data analysis PC-SEMS should never be used as they get em-
of 10 studies on Polyflex stents used in 130 patients bedded with tissue ingrowth, rendering then unsafe
Ann. N.Y. Acad. Sci. 1300 (2013) 119–143

for removal. Initial experience with biodegradable of time. A further problem with stent placement is
stents has been encouraging. migration of the stents, which has been reported to
The success rate in treating RBES with stents is occur in up to 25% of cases.5,6 Migration is less of
at best around 40%, with complication rates ap- a problem with partially covered stents because of
proaching 30%. Currently, placing stents in patients tissue ingrowth and embedment.6
with RBES should be considered on a case-by-case Most experts would agree placing stents from 6
basis, preferably on a protocol in centers with exper- to 8 weeks, although fully covered stents have been
tise to place these stents and to manage stent-related left for much longer periods of time. If a perforation
complication. No major prospective randomized is large, replacement of a stent after 6 weeks with a
studies have compared the efficacy of stents ver- new stent is advised.
sus other modalities, and due to small sample sizes,
subgroup analysis on the response in relation to the 5. Palliation of malignant dysphagia: how
etiology of the stricture is not known. to choose an esophageal stent?
Kulwinder S. Dua
4. What determines the optimal stenting kdua@mcw.edu
period in benign esophageal
strictures/leaks? Introduction
Khean-Lee Goh and Ronald Romero SEMS are the most commonly used modality to pal-
klgoh56@gmail.com liate malignant dysphagia. Several varieties of SEMS
are available. Since all strictures are not made alike,
Placement of stents to seal esophageal leaks or per- one type of stent does not fit all.
foration has been well documented.5,29–33 Covering
the breach in the esophagus allows healing over the Stent characteristics
stent with re-epithelialization and eventual com- SEMS are made of Nitinol woven (braided or non-
plete tissue regeneration. In the earlier years, PC- braided) into a tubular configuration. Braided stents
SEMS have been used. These have been replaced foreshorten on expansion and nonbraided stents do
by SEPS and, more recently, FC-SEMS. Stent place- not. SEMS can be partially or fully covered with
ment has best results with a healthy esophageal tis- a plastic membrane. Tissue ingrowth into the un-
sue in iatrogenic perforations, anastomotic leaks, covered regions of the stent embeds the stent and
and even Boerhaave’s syndrome. The size of de- allows for better anchoring but renders them unsafe
hiscence should not exceed 70% of the esophageal for removal. Fully covered stents can be removed.
circumference17,32 and is thought to be best for those The majority of the stents are distal release, namely
who have a 25–50% dehiscence.17 they expand from the distal end on release, while
The decision as to how long a stent should be others are proximal release. Some stents can kink
placed depends on the time needed for the perfora- like a straw when placed across angulated strictures.
tion to heal versus the risk of tissue embedment if Other features include stents with antireflux valves,
the stent is left for too long. The time taken for the stents made of woven plastic, or stents that can be
perforation to heal varies and is dependent on the metabolized (biodegradable stents).
size of the perforation. It is estimated that a mini- Expandable stents marketed in the United
mum period of 4 weeks is probably necessary. But States include (1) Boston Scientific Inc: Ultraflex
most experts would allow a period of 6–8 weeks.5 (partially covered), Wallflex (partially and fully
Tissue ingrowth and overgrowth with stent em- covered), SEPS, Polyflex stent, all of which fore-
bedment is a common problem with partially cov- shorten; (2) Cook Medicals: Evolution (partially
ered stents. Eventual removal of these stents may and fully covered, foreshorten), Z-stent (partially
result in complications such as bleeding, further and fully covered and a Dua antireflux variety,
tearing, and perforation and even formation of a fis- nonforeshortening); (3) Merit Medical Endotek:
tulous tract. This was reported to be higher in stents Alimaxx and EndoMAXX; (fully covered, non-
left for longer than 6 weeks.33 These problems are foreshortening); and (4) Taewong Medicals: Niti-S
not seen with SEPS or the new FC-SEMS, and these (foreshortens, antireflux variety, and through-the-
stents could be theoretically left for a longer period endoscope variety).
126 Ann. N.Y. Acad. Sci. 1300 (2013) 119–143

Malignant strictures can immediately relieve dysphagia and after a few

Malignant strictures vary in length, diameter, lo- weeks (4–6 weeks), when the tumor regresses with
cation, and tortuosity. They can be associated with palliative therapy, the stent can be removed so as to
fistula. Strictures near the UES require precise place- prevent delayed stent-related complications which
ment. Stents across the GEJ predispose to reflux and can be as high as 30–40%.17,34
risks of aspiration.
Stricture configuration. Angulated strictures can
Choosing a stent buckle a stent like a kink in a straw when it is bent
It is mandatory to have a recent detailed assessment (e.g., Z-stent, Alimaxx stent).35 Hence, stents that
of the stricture. Updating this information during can withstand buckling forces and conform to the
endoscopy or contract radiology depending on the shape of the stricture should be considered in angu-
approach used at the time of stent placement is es- lated tortuous strictures (e.g., Wallflex stent, Evolu-
sential. Second, the operator should have the knowl- tion stent, Endomaxx stent).
edge, expertise, and experience on using the various
types of stents available, understand their charac- Location of the stricture. When stents are placed
teristics, and manage stent-related complications. across the GEJ, the stomach and the esophagus be-
come a common cavity, thereby predisposing the
Length. The general principles for choosing a stent patient to reflux and the risks of aspiration (re-
involve selecting a stent that can not only bridge the ported incidence 25–80%).36,37 Results from studies
stricture but also have around 2 cm of the stent po- evaluating the efficacy of the currently available an-
sitioned above and 2 cm below the stricture. Stents tireflux stents have been mixed. Laasch et al. showed
come in various lengths from 7 to 15 cm, and if still significantly lower incidence of reflux using the Dua
longer lengths are required, two or more stents can antireflux Z-stent compared to a standard stent.43
be coaxially deployed into each other. There was an aspiration-related death in the stan-
Diameter. The diameter of the stent selected should dard stent group. On the other hand, Homs et al.
be in keeping with how tight the stricture is. Plac- found that the FerX-Ella antireflux stent failed to
ing a 23-mm-diameter stent into an 8-mm-diameter reduce GE reflux.39
stricture may technically be possible but the func- Proximal esophagus
tional success (namely, patient eating) rates drop as Evaluation for impending airway compression is
the patient may experience severe chest pain. Ag- mandatory. Precise positioning of the stent is essen-
gressive preinsertion dilation is not recommended tial if the distance between the UES and the stricture
as it can also lead to chest pain, perforation, bleed- is less than 2 cm. Hence, proximal-release stents or
ing, and stent migration. Stent come in a wide range non-foreshortening stents can be used. Another ap-
of diameters from 12 to 23 mm. proach is to deploy the stent slightly lower and then
Covering. It is important to position the stent in pull it up.
such a manner that the covered segment of the stent Hypopharyngeal strictures or strictures at the
is across the strictures and/or fistula so as prevent tu- UES
mor ingrowth and seal the fistula respectively. The Patients with cancers in close proximity to the UES
short uncovered segments at the upper and lower can be stented with smaller diameter stents like the
ends of the partially covered stents allow for tissue 12 mm Alimaxx stent, 14–16 mm tracheobronchial
ingrowth that in turn anchors the stent and prevents stents, or even 10 mm biliary stents.
migration. In those with shorter life expectancy (less
than 6–12 weeks), partially covered stents are pre- Extrinsic compression
ferred, as need for removing the stent is not there. Assessment for the need for prior airway stenting
On the other hand, fully covered stents may be con- is essential. Bethge et al. studied 24 patients with
sidered in those with longer life expectancy, espe- extrinsic compression and compared the results
cially if they are receiving additional palliative ther- with 22 patients with intrinsic lesions. Dysphagia
apy like chemoradiation or brachytherapy and the scores improved significantly better in the intrinsic
need for stent removal arises. Fully covered stents group.40
Ann. N.Y. Acad. Sci. 1300 (2013) 119–143

Palliative stenting as bridge therapy in their ability to take oral nutrition and hydration,
SEMS are highly effective in immediately relieving and have the potential to experience localized infec-
dysphagia but can be associated with significant de- tious complications as well as sepsis. The traditional
layed complications.34,41 Hence, one can place a treatment for these patients has been a reoperative
stent for immediate relief of symptoms and then attempt at repair or esophageal diversion with or
remove the stent after 4–6 weeks, by which time without esophagectomy.7
the effect of chemoradiation/brachytherapy would Correction of the new fistula may be performed in
have shrunken the tumor.17 In this scenario, it is various ways, but there is no consensus in the litera-
advisable to place stents that can be removed. Alter- ture and the cases must be individualized and treated
natively, biodegradable stents can be tried. according to the need and possibility of treatment.6
Some authors cite a treatment through the ap-
Summary plication of fibrin glue with or without endoscopic
Several types of SEMS are available. Since all ma- clipping, however, these should be performed only
lignant strictures are not made alike, one type of in small leaks.43,47 The endoscopic placement of a
stent does not fit all. The stricture characteris- clip appears to be safe and technically feasible,46 but
tics should be assessed and the most suitable stent there are not many studies in the literature on this
for that stricture should be selected. The art of method.
choosing the right stent for a particular stricture Another form of endoscopic treatment described
is an interaction between knowing the properties is the use of a new stent.43–45,48 This method is min-
of the stent, characteristics of the stricture, and imally invasive, fast, and has high rates of thera-
personal expertise. The operator should also have peutic success.43–45 It is often used when a leak
the expertise in managing potential stent-related occurs during the removal of a previous stent,45
complications. a complication more common in partially covered
6. How should new fistula secondary to metal stents, due to a greater chance of tissue in- or
an esophageal stent be treated?5,6,42–48 overgrowth.5,6
Endoluminal stent placement provides rapid fis-
Eduardo Guimarães Hourneaux de Moura and tula closure, eliminating soilage of the mediastinum,
Kengo Toma pleura, and peritoneum. Furthermore, it allows pa-
kengotoma@gmail.com tients to begin oral intake within 48 h of stent place-
Endoscopic treatment of perforation or leak with ment and eliminates the need for further operations,
esophageal stents shows good results in accordance such as esophageal diversion or exclusion, in the vast
with the literature (85–100%),5,6,42–44 especially in majority of patients.7
cases of early diagnosis and treatment, as the ia- Stent placement also offers an appealing alter-
trogenic injury.43,45 However, treatment failure can native to reoperative repair, especially esophageal
occur and become a devastating and unwieldy diversion and subsequent reconstruction.
event.45,46 There are also surgical treatments such as diver-
The choice of treatment, surgical and/or endo- sion and esophageal exclusion that have high rates
scopic, depends on factors such as degree of con- of morbidity and mortality, and simple suture of
tamination, lesion size, presence or absence of sep- the lesion with or without another method, such as
sis, obstructive factors, and others. fibrin glue or stenting.45 These methods are aggres-
Stent failure can be attributable to four mechan- sive, however, and are usually recommended when
ical factors: an esophageal leak of the proximal cer- the patient is septic.
vical esophagus, an esophageal leak that traverses There is no gold standard treatment for a fistula
the GEJ, an esophageal injury greater than 6 cm, or secondary to an esophageal stent, but the use of a
an anastomotic leak associated with a more distal new stent seems to be a promising treatment because
conduit leak.46 it is a quick procedure, with immediate occlusion of
Patients who have a new esophageal fistula af- the lesion and low rates of serious complications
ter therapy with a stent will most often experience a and mortality, and can prevent a bypass surgery or
prolonged hospital course, realize a significant delay esophageal exclusion.
128 Ann. N.Y. Acad. Sci. 1300 (2013) 119–143

7. What strategy should you adopt when over the anastomosis, and as the amount decreases
a fistula of a cervical anastomosis occurs? the patient is permitted to resume oral intake, ini-
tially, of clear liquids. Early passage of 30, 36, and
Valter Nilton Felix
46 Fr Maloney-tapered esophageal dilators within 1
v.felix@terra.com.br
week of drainage must be performed to maintain a
Although these fistulas usually have a favorable satisfactory lumen and prevent the late development
course, they can compromise quality of life, in- of a stenosis.
terfere with resumption of feeding, require labo- Such an anastomotic fistula generally diminishes
rious local care, and prolong hospital stay. In ad- greatly in output or heals completely within 10–20
dition, 30–50% of those patients who present with days of external drainage. It is not necessary that
fistula go on to develop stenosis.49 Given this sce- the cervical wound and fistula be healed completely
nario, we decided to perform end-to-end cervical before resumption of an oral diet is permitted. If
esophagogastric anastomosis protected with the top adequate dilation of the anastomosis to a 46 Fr size
of the gastric tube surrounding it, shaped like a tie. has been achieved, the majority of swallowed food
Only 6.6% (1/15) of our cancer cases operated upon will enter the intrathoracic stomach preferentially.
by esophagectomy with handsewn esophagogastric If persistent purulent drainage from the neck is
anastomosis and this kind of anastomotic protec- observed or if the characteristic odor of necrotic
tion developed fistula with egress of saliva from the stomach is present at the beginning of the proce-
cervical incision; this rate lies favorably within the dures, a dilute barium esophagogram should be ob-
5–45% limit described by other authors.50 tained or repeated to determine whether undrained
This result could have been due to certain is- mediastinal extravasation of contrast is present. Up-
chemia in the proximal portion of the gastroplasty, per endoscopy can be performed to evaluate mu-
compromising the sutures of the anastomotic pro- cosal viability of the intrathoracic stomach and to
tection. Anastomotic leak rate is clearly higher when estimate the extent of anastomotic disruption. Di-
the substernal route is used for esophageal replace- rect visualization of the gastric conduit through the
ment owing to the much worse vascular pedicle dis- opened cervical incision can confirm the occurrence
position in comparison to the posterior mediastinal of gastric tip necrosis. Large anastomotic dehiscence
route. These events triggered a fibrotic reaction and and gastric tip necrosis necessitate reoperation, with
scarring, with subsequent stenosis formation in the cervical esophagostomy and cervical exteriorization
anastomosis, treated with endoscopic dilations with of the proximal gastric tube for at least 15 days or
a good result. esophagostomy and return of the gastric tube to the
The diagnosis of fistula is made based on clinical abdominal cavity until a better compensatory vas-
criteria and a radiological study with water-soluble cular supply could guarantee a new cervical anas-
contrast medium. Most of the leaks and fistulas are tomosis, around 30 days later. In more severe cases,
of very low output and are treated conservatively. resection of a necrotic gastric tube is provided and
Leak of cervical esophagogastric anastomoses can be esophagostomy is requested until a coloplasty could
handled in the vast majority of patients with open- be performed.
ing of the cervical wound, followed by local wound Although in most instances clinical findings pro-
care while enteral feeding is continued. The wound vide an accurate reflection of the adequacy of tran-
is then packed lightly with saline-moistened gauze, scervical drainage, a chest computed tomography
which is changed at least three times daily or more (CT) can help to determine whether there is per-
frequently as needed. At each dressing change, the sistent mediastinal collection that might require
patient swallows 50 mL of water, and any cervical more extensive transcervical or even transthoracic
drainage from the wound is aspirated with a bedside drainage.
suction device. Healing of the cervical esophagogas- Subsequent stenosis will be submitted to endo-
tric anastomotic leak is assessed by observing the scopic dilations, generally performed by passage
relative amount of swallowed water that issues from of progressively larger tapered Maloney esophageal
the neck wound at the time of the dressing change. dilators. As a general rule, passage of a 46 Fr or
The majority of drainage while swallowing can be larger size dilator through the anastomosis is a pre-
prevented by gentle pressure on the skin directly requisite for achieving comfortable swallowing.51
Ann. N.Y. Acad. Sci. 1300 (2013) 119–143

Four-quadrant 0.5 mL intralesional injections of tri-

amcinolone can be performed immediately preced-
ing esophageal dilation. Few patients with benign
strictures at the cervical esophagogastric anastomo-
sis have required operative revision. When this is
necessary, a partial upper sternal split to facilitate
exposure of the esophagus in the thoracic inlet is
beneficial. In the most severe cases, resection of the
fibrotic ring and a new anastomosis are necessary.
The placement of self-expandable or biodegrad-
able covered stents, actually applied in cer-
tain esophageal perforations52,53 for postoperative
esophageal leaks, has been felt to be relatively con-
traindicated, particularly due to patient discomfort
following placement of such devices which necessi-
tates positioning the proximal portion of the stent
across the UES into the hypopharynx. If stent po-
sition is more distal, then there is a greater risk for
stent migration. Even if pharyngeal discomfort can
be avoided, patients undergoing stent placement
across a cervical esophagogastric anastomosis are
at greater risk for severe symptomatic reflux and
aspiration.
8. Can barium esophagography detect

rings or strictures missed on endoscopy?
Marc S. Levine
marc.levine@uphs.upenn.edu
Peptic strictures typically appear on barium esoph-
agography as smooth, tapered areas of narrowing Figure 3. Schatzki’s ring. Prone, right anterior oblique view
(ranging 1–3 cm in length) in the distal esophagus from single-contrast esophagogram shows a smooth, symmetric
above a HH.54 However, up to 40% of patients have ring-like constriction (arrows) at the GEJ above a small HH.
short, ring-like peptic strictures that can be mis- This patient presented with episodic dysphagia for solids that
was relieved by endoscopic dilation.
taken for Schatzki rings.55 Other peptic strictures
are more asymmetric and may be associated with
one or more focal outpouchings or sacculations sec-
ondary to outward ballooning of the esophageal wall of these 78 proven strictures, including 45 strictures
between areas of fibrosis. Still other strictures may less than 10 mm in caliber and 29 (88%) strictures
be associated with multiple fixed transverse folds greater than 10 mm in caliber. Thus, barium esoph-
with barium trapped between the folds, producing agography is a sensitive examination for detecting
a characteristic stepladder appearance secondary to peptic strictures, occasionally revealing strictures
concomitant longitudinal shortening of the distal that are missed at endoscopy.
esophagus.56 A Schatzki ring is a symptomatic lower esophageal
In a study by Ott et al.,57 barium esophagography ring associated with episodic dysphagia for solids.
detected 95% of strictures diagnosed at endoscopy. These rings are typically manifested on barium
In another study by Ott et al.,58 90 peptic strictures esophagography by a smooth, symmetric ring-like
were diagnosed on barium esophagography, includ- constriction at the GEJ, almost always above a HH,
ing 78 true-positive strictures and 12 false positives. with a vertical height of only 2–4 mm (Fig. 3).54
In that same study, endoscopy detected 74 (95%) Rings less than 13 mm in caliber almost always cause
130 Ann. N.Y. Acad. Sci. 1300 (2013) 119–143

solid food dysphagia, whereas rings between 13 and distending the distal esophagus and optimizing the
20 mm in diameter may or may not cause dysphagia radiologist’s ability to demonstrate these rings. Con-
(depending on the eating habits of the patient), and versely, rings can be missed if the distal esophagus is
rings greater than 20 mm in diameter rarely cause overdistended, producing overlap between the lower
dysphagia unless the patient is unable to adequately end of the distal esophagus and the upper end of
chew his or her food.54 the HH that prevents visualization of the GEJ in
In a study by Ott et al.,59 the sensitivity of barium profile.60 In such cases, additional views are required
esophagography for detecting Schatzki rings was with less distention (and therefore less overlap) in
highly dependent on the technique used to perform order to improve detection of these rings.
this examination; single-contrast images obtained In conclusion, if endoscopy fails to detect lower
as the patient swallowed low-density barium in the esophageal rings (i.e., Schatzki rings) or strictures in
prone, right anterior oblique position revealed 57 patients with solid food dysphagia, barium esoph-
(95%) of 60 proven rings, whereas double-contrast agography should be performed to rule out rings
images obtained as the patient swallowed high- or strictures missed at endoscopy. In such cases, the
density barium in the upright, left posterior oblique barium study should be performed as a biphasic ex-
position revealed only 18 (46%) of 39 proven rings. amination that includes prone single-contrast views
Prone single-contrast views have a higher sensitivity with a low-density barium suspension to improve
in detecting Schatzki rings because the distal esoph- distention of the distal esophagus and optimize de-
agus is better distended (and, hence, rings better tection of lower esophageal rings and strictures.
visualized) when the patient swallows barium in
9. Intralesional steroids for refractory
the prone position. In contrast, upright double-
esophageal strictures
contrast views have a lower sensitivity because the
distal esophagus often is not adequately distended Rakesh Kochhar and Sreekanth Appasani
when the patient swallows barium in the upright dr kochhar@hotmail.com
position.
In contrast, endoscopy detected only 35 (58%) Introduction
of 60 lower esophageal rings, and its sensitivity was Esophageal strictures can be differentiated into two
directly related to the caliber of the ring; 18 (82%) structural types depending on their characteristics
of 22 rings less than 13 mm in caliber were visual- and on the response to treatment—simple or com-
ized at endoscopy versus 14 (54%) of 26 between 14 plex. Complex strictures are long (>2 cm), tortu-
and 19 mm in caliber and 3 (25%) of 12 between 20 ous, and asymmetrical, and are associated with a
and 25 mm in caliber.59 Endoscopy, therefore was severely compromised luminal diameter (<12 mm).
more likely to miss mid-caliber rings, many of which Common causes of benign complex strictures in-
were detected on barium examinations. Finally, 13 clude caustic ingestion, radiation injury, anasto-
(52%) of 25 rings were missed at endoscopy in pa- motic strictures, and photodynamic therapy. Some
tients with dysphagia.59 Thus, barium esophagog- peptic strictures may also be complex in nature.
raphy is a more sensitive technique than endoscopy Complex strictures are usually more difficult to
for detecting Schatzki rings, and occasionally may treat, and they are associated with higher recur-
demonstrate rings that are missed on endoscopic rence rates. They can also be categorized as refrac-
examinations. The inability to visualize some lower tory strictures. A refractory or recurrent stricture is
esophageal rings at endoscopy may be related to defined as an anatomic restriction resulting from ci-
inadequate distention of the esophagogastric region catricial luminal compromise or from fibrosis lead-
by air insufflation or to the caliber of the endoscopic ing to clinical symptoms of dysphagia in the ab-
instrument used for this examination, as the sensi- sence of any endoscopic evidence of inflammation.
tivity of endoscopy is lower with instruments less This may occur either as a result of an inability to
than 10 mm in caliber.59 successfully resolve the anatomic problem up to a
It is also important to be aware of the limitations diameter of 14 mm over five sessions at 2-week in-
of barium esophagography in detecting Schatzki tervals (refractory stricture) or from to an inability
rings. As already described, prone single-contrast to maintain a satisfactory luminal diameter for 4
views of the esophagus are critical for adequately weeks once the target diameter of 14 mm has been
Ann. N.Y. Acad. Sci. 1300 (2013) 119–143

achieved (recurrent stricture).19 Treatment options However, some providers combine steroid injec-
for refractory strictures include intralesional steroid tions with every session of dilation. In all of the stud-
injection combined with dilation, endoscopic inci- ies, steroid injections were combined with bougien-
sional therapy with or without dilation, and place- age or balloon dilation and all of the patients re-
ment of self-expanding metallic or plastic stents or ceived PPIs.
biodegradable stents, self-bougienage, and surgery.
Assessment of efficacy
Mechanism of action
The efficacy of steroid injections in humans has tra-
The exact mechanism by which intralesional
ditionally been assessed by studying the need for
steroids are useful is not clear. Injection of steroids
dilations, the time to dilations, and the number
into the stricture has been shown to inhibit stricture
of additional dilations. A periodic dilation index
formation by interfering with collagen synthesis, fi-
(PDI), calculated as the number of dilations re-
brosis, and chronic scarring processes.61 Triamci-
quired/duration of time in months, has frequently
nolone inhibits the transcription of matrix protein
been used to demonstrate efficacy.65
genes, including fibronectin and procollagen. It also
Three randomized trials have confirmed the util-
reduces the synthesis of ␣2 -macroglobulin, an in-
ity of this form of therapy. Altintas et al. randomly
hibitor of collagenase activity.62 It has also been
assigned 21 patients with esophageal strictures who
thought to prevent the cross-linking of collagen that
were undergoing bougie dilation either to an in-
results in scar contracture. Corticosteroids also de-
tralesional steroid injection group or to a control
crease the fibrotic healing that appears to occur after
group.66 The PDI declined from 0.71 to 0.28 in the
dilation.
study group, which also had a longer symptom-free
Technique interval than the control group. Ramage et al., in
Intralesional injection of corticosteroids has been a study including 30 patients with peptic strictures
practiced in refractory esophageal strictures of vari- who required repeated dilations, randomly assigned
ous etiologies for the last 40 years, but it is only in the the patients to an intralesional triamcinolone group
last decade that it has become a standard treatment (40 mg/mL; 0.5 mL in each quadrant) and a sham
option. The most common steroid used has been injection group.67 During a follow-up period of 1
triamcinolone acetate or acetonide, though some year, two patients (13%) in the study group and nine
have used betamethsone and dexamethasone.63 patients (60%) in the control group required repeat
Injection is given using a 23-gauge, 5-mm scle- dilation. In another randomized study, published
rotherapy needle at the origin of the stricture in four only as an abstract, Rupp et al. randomly assigned
quadrants. Most people give the injection before di- 43 patients with peptic strictures to an intralesional
lation. The concentration of triamcinolone used has steroid group and a control group.68 The PDI was
varied from 10 to 40 mg/mL and it is injected in 0.07 in the steroid group in comparison with 0.253
aliquots of 0.25–0.50 mL per site of injection, re- in the control group over 10–13 months after steroid
sulting in a total dose of up to 80 mg per session.63 therapy.
The injection can also be given into the shaft of This form of therapy has been used for esophageal
the stricture, and in patients with proximal cervi- strictures due to varied etiologies, peptic, caustic,
cal esophageal stricture the injection is best made anastomotic, and radiation induced.
after dilation. Although injections can be made sat-
isfactorily under endoscopic guidance, failures have Safety
been noted. Improper localization of the injection The safety of intralesional steroids has been docu-
has been cited as a probable cause. Bhutani et al. have mented in a number of studies in pediatric patients,
therefore suggested that an EUS miniprobe should including infants. There is a theoretical risk that in-
be used to guide the injection into the thickest por- tramural infection might be induced with this form
tion of the esophageal stricture for better results.64 of therapy. There is a potential for esophageal per-
Kochhar and Makharia repeated intralesional foration and mediastinitis or pleural effusion. The
steroid injections in each session of dilation, with only reported esophageal perforation occurred in a
a limit of four injections65 while Ramage et al.66 and series of patients in whom a rigid endoscope was
Altintas et al.67 gave steroid injections only once. used.62
132 Ann. N.Y. Acad. Sci. 1300 (2013) 119–143

Conclusion treatment of achalasia. Maloney’s bougies are simi-

Intralesional steroid injections have been docu- lar but with a tapered end, and both these types are
mented to augment the response of dilation in still available commercially. In the late nineteenth
esophageal strictures. They are recommended for century, Eder–Puestow and Celestin dilators were
use in refractory or recurrent strictures. Triamci- used with fibreoptic endoscopy for stricture dila-
nolone is injected in a dose of 80 mg per session in tion. Because of the flexibility of the Savary–Gilliard
four quadrants in conjunction with each dilation. dilators, they have largely replaced metal olive dila-
Further research is needed to define when to start tors in the recent era.
and how long to continue this form of therapy. Balloon dilators are designed to be used through
the scope (TTS) and are available in wire-guided or
10. Esophageal strictures: balloon nonwireguided (fixed wire) versions. Balloon dila-
versus bougie dilators tors are made of low-compliance, nonlatex mate-
Rakesh Kochhar and Sreekanth Appasani rials that allow uniform and reproducible expan-
dr kochhar@hotmail.com sion to their specified diameter at maximum infla-
tion. The hydraulic pressure of the balloon may be
monitored manometrically to gauge radial expan-
Introduction sion force. Balloon dilators may offer a number of
Esophageal strictures have been treated historically potential advantages versus rigid technologies when
with bougienage, which improved from wax bou- performing dilation, including direct endoscopic vi-
gies to recently introduced tapered polyvinyl dilators sualization, application of radial force directly to the
that are passed over guide wires. The word bougie stricture site, and improved patient comfort.
is derived from the Arab town, Boujiyah, in Alge-
ria, a medieval center for the wax candle trade. The Balloons versus bougies
sixteenth century marked the first use of a wax tape Bougie dilators exert both radial and shearing force
by Fabricius ab Acquapendente to push a foreign at the stricture. Dilation is usually left to the
body into the stomach.69 Whalebone probang with endoscopist and best suits for simple strictures.
a sponge on the end was first used by Willis (1621– In contrast, in balloon dilation the entire dilating
1675) to describe dilation for achalasia. Sir Arthur force is radial and simultaneous over the entire
Hurstin in 1915 first described mercury-filled bou- length of the stenosis. Baloon dilators are safer es-
gies made of rubber with a blunt rounded end for the pecially in multiple and tortuous strictures.
Figure 4. Comparison of dead space between bougie and balloon dilators.
Ann. N.Y. Acad. Sci. 1300 (2013) 119–143

Table 1. Comparison of studies (balloon vs. bougies)
Study Outcome Recurrence Comments
Shemesh et al.75 Both similar More with balloons –

Scolapio et al.77 Both similar Both similar Majority are peptic/Schatzki
Cox et al.72 Bougie better More with balloons Majority peptic (72%)
Cox et al.73 Bougie better—initially More with balloons Majority peptic
At 1 year—both similar
Saeed et al.76 Both similar More with bougie Only peptic
Yamamoto et al.74 Both similar Both similar –
Dead space is the extra length of dilator that passes In contrast to the above results, Saeed et al.,
beyond the mouth of the stricture and is not useful in a prospective study comparing balloons versus
in dilation. The dead space in Savary bougie dila- bougies in 34 patients, showed that both devices
tors is usually 18 cm, whereas it is 8 cm in balloon effectively relieved dysphagia.74 Stricture recurrence
dilators (Fig. 4). The greater the dead space, the was similar in both groups in the first year, but
greater the chance of passage of the dilator beyond the risk of recurrence was significantly lower with
the stricture, which sometimes is harmful. Balloons balloons in the second year. Other advantages of
obviously score better than bougies in this aspect, es- balloons observed were the need for fewer treatment
pecially in multiple stricture and tortuous strictures. sessions to achieve the defined end-diameter for
In patients with small stomach and in children, bal- dilation and less procedural discomfort.
loon dilators are preferred. Scolapio et al. stratified 251 subjects with benign
esophageal strictures according to the type of stric-
Literature comparing balloons versus bougies ture (peptic versus Schatzki ring) and severity of
In a randomized controlled study by Cox et al., stricture (mild versus moderate/severe) and then
71 patients with benign esophageal strictures were randomized to either Savary (n = 88), microvasive
studied and 65 patients were finally analyzed.70 At balloon (n = 81), or Bard balloon (n = 82) dilators.75
the end of 5 months, the balloon group had signifi- There were no significant differences between the
cantly more dysphagia and more degree of narrow- rigid dilators and the two balloons with regard to
ing of the caliber of strictures. The same authors, immediate relief of dysphagia or the need for repeat
in another paper on 90 adults, reported that bougie dition at 1 year. Patients with moderate/severe stric-
group initially had a better symptomatic response tures required repeat dilation at 1 year twice as often
at 5 months, although this difference had disap- as those with mild strictures.
peared at 1 year.71 Eighteen patients in the balloon We have analyzed a total of 106 patients of var-
group required redilation compared to six in the ied etiology who were randomized to receive ei-
bougie group. The bougie group had a significantly ther balloon or bougie dilation (unpublished data).
greater increase in their stricture diameter, and this Out of 79 patients who could achieve the target
was still present at 1 year after dilation. Finally they of 15 mm dilation, 38 patients underwent balloon
concluded that bougie dilation is to be preferred to dilation while 41 patients underwent bougie dila-
balloon dilation in adults except in special circum- tion. Complete improvement was noted in 76% of
stances. the patients while 24% still required dilations on a
Yamamoto studied both randomized patients and follow-up. When the two dilators were compared,
nonrandomized patients for balloon dilation versus the number of dilations required to reach 15 mm
bougie dilation and observed no statistically sig- were similar to both the groups, but on follow-up
nificant difference in the immediate and long-term the mean dilation frequency (dilations/month) was
outcome.72 Shemesh et al. evaluated 60 patients with significantly higher in the balloon group than in the
benign esophageal strictures.73 They concluded that bougie group.
both methods were highly effective and well toler- Table 1 analyzes the available data on balloon
ated, yet Savary–Gilliard dilators were slightly more versus bougie dilators. While most of them suggest
effective and simpler to use than balloons. bougie dilation to have better outcome, these are
134 Ann. N.Y. Acad. Sci. 1300 (2013) 119–143

derived from data using previous balloons and bou- pared to the peptic group. Overall response rate was
gies. The present era balloons and bougies need to better in the peptic group than the corrosive group,
be compared prospectively in large studies for more of whom the acid group had slightly better response
pertinent results. than the alkali group (66% vs. 50%).
In a long-term study by the same authors over
11. Esophageal strictures: predictors of a period of 6 years in 123 patients, of whom 52
response to dilation (42.3%) had corrosive and 39 (31.7%) had peptic
Rakesh Kochhar and Sreekanth Appasani strictures, initial dilation was adequate in 93.6% of
dr kochhar@hotmail.com corrosive patients and 100% of the peptic group
(P > 0.005).24 Long-term success after adequate
Introduction initial dilation was studied in 36 patients with cor-
Dilation is the treatment of choice for most pa- rosive and 33 patients with peptic strictures. The
tients with benign esophageal strictures; however numbers of patients who had at least one recur-
there is little information on reliable predictors of rence (94.4% vs. 54.5%, P < 0.002), five recurrences
successful dilation. Strictures that are long, tortu- (55.5% vs. 18.2%, P < 0.0002), and 10 recurrences
ous, and asymmetrical are considered to be difficult (33% vs. 9%, P < 0.01) were significantly higher in
strictures. The luminal diameter in these strictures is the corrosive group than in the peptic group. Only
usually <12 mm. Strictures due to caustic ingestion, nine esophageal perforations occurred (incidence
postradiation strictures, and anastomotic strictures 0.66%), and eight of these were in the corrosive
are usually difficult to dilate. stricture group.
Possible predictors of response Length and number of strictures. The length of

The possible factors that can predict response in be- stricture plays a significant role in predicting re-
nign esophageal strictures could be etiology, length sponse to dilation. Poddar et al., in a study of 107
of stricture, number of strictures, initial diameter, children with benign esophageal strictures (54 had
and stage of corrosive disease (early versus late). Cer- corrosive strictures), observed that even though di-
tain characteristic features on CT and EUS also have lation was successful in patients with long (>5 cm)
a role in predicting response to successful dilation. and/or multiple strictures, they required a higher
Kim et al. studied 117 patients with corrosive number of sessions (3.6 ± 2.6 vs.1.7 ± 1.1) to achieve
esophageal strictures dilated with balloons, of whom adequate dilation (P < 0.05) and also a higher num-
30 (26%) patients had no recurrence after initial ber of subsequent sessions for recurrence (10.6 ± 8.0
balloon dilation and 23 (20%) patients experienced vs. 3.9 ± 3.2) when compared to short strictures.79
no recurrence after one or two additional balloon Similarly, in a retrospective analysis of 18 children
dilation procedures.77 Overall recurrence rate was with corrosive strictures treated with balloon dila-
72%. On univariate analysis, factors associated with tion by Temiz et al., five patients had short strictures
recurrence were long strictures (P = 0.037), early and eight patients had long and multiple strictures.
chronic stage (P = 0.003), and resistance to reach They observed a better outcome in patients with
10 mm (P = 0.034). On multivariate analysis, early short strictures when compared to long and multi-
chronic stage was associated with recurrence (P = ple strictures.80 Panieri et al., in a study of 39 patients
0.003). of corrosive strictures, observed that patients with
long strictures (>5 cm) had more often unsuccess-
Etiology. The role of etiology of stricture in pre- ful dilation and requirement of surgery when com-
dicting response to dilation was evaluated by Broor pared to patients with multiple (more than two)
et al., who analyzed patients with benign esophageal strictures.81
strictures (11 patients = corrosive acid; 4 patients =
alkali ingestion; 11 patients = peptic stricture).78 Luminal diameter. Gun et al. evaluated the effect
The mean number of dilation sessions required of initial luminal diameter in predicting response to
(acid group = 14; alkali group = 8; peptic group dilations in corrosive strictures. They prospectively
= 7), and recurrence rate (66% vs. 27%) were sig- evaluated 91 patients of corrosive strictures who un-
nificantly higher in the corrosive group when com- derwent dilation and found that one of five patients
Ann. N.Y. Acad. Sci. 1300 (2013) 119–143

with initial luminal diameter of <3 mm, six of 16 12. Do refractory strictures from different
patients with a luminal diameter of 4–6 mm, and 21 etiologies (radiation, corrosive,
of 22 patients with a luminal diameter of 7–10 mm post-PDT/ESD, anastomotic) respond
had successful dilation.82 differently to endotherapy?
Eduardo Guimarães Hourneaux de Moura and
Early versus delayed intervention. In a study by Carla Cristina Gusmon
Contini et al., 78 children with esophageal strictures carlagusmon@yahoo.com.br
following alkaline caustic ingestion were divided
The mainstay of treatment for benign esophageal
into two groups (early <6 weeks, n = 31; late >6
strictures is dilation. Strictures that are long (>2
weeks, n = 25) depending on time of presentation
cm), tortuous, or associated with a diameter that
to hospital. The number of dilations required (6.4
precludes passage of an endoscope are defined as
vs. 4.5), perforation rates (16% vs. 3.2%), and
complex.85
stricture rates (72% vs. 30%) were significantly
The inability to successfully remediate the
higher in the late group when compared to the early
anatomic problem to a diameter of 14 mm during
group.83
five sessions at 2-week intervals defines the refrac-
tory stricture.86 The most common causes of stric-
Esophageal wall thickness. Lahoti et al. evaluated ture formation include caustic ingestion, radiation
the esophageal wall thickness measured by contrast- injury, surgery, photodynamic therapy (PDT), en-
enhanced CT of the chest and correlated it with the doscopic submucosal dissection (ESD), and severe
number of sessions required for adequate dilation peptic injury. The success rate of dilation therapy
in 21 patients with corrosive esophageal strictures. ranges from 70% to 90%, with up to 40% of pa-
On multivariate analysis, maximal esophageal wall tients requiring more than three dilation sessions to
thickness (size of the thickest wall; P < 0.01), but not achieve adequate result.86,87
average esophageal wall thickness (mean thickness Novel treatment modalities for refractory stric-
of all four walls) or stricture length, was indepen- tures include steroid injection, incisional therapy,
dently associated with the number of sessions re- and temporary stent placement.
quired for adequate dilation. Patients with maximal There is evidence that intralesional steroid injec-
esophageal wall thickness (>9 mm) required a sig- tion prior to dilation reduces the risk of recurrent
nificantly higher number of sessions than those with stricture formation in RBESs.69,86,87 Ramage et al.69
wall thickness <9 mm (7.57 ± 1.80 vs.1.42 ± 0.27, found that this combined treatment, together with
P < 0.05), indicating that maximal esophageal wall gastric acid–suppression therapy, reduced the need
thickness can be helpful in predicting the response for repeat dilations and the average time to repeat
to endoscopic dilation.84 dilation. An alternative approach for short anasto-
motic strictures (<10 mm) is the use of incisional
therapy, as demonstrated by Hordijk et al.88 Anas-
Loss of layered pattern in esophagus. We evaluated
tomotic strictures are usually secondary to tissue
the role of EUS in predicting the response to dilation.
ischemia, leakage, or radiation therapy, and are re-
Of 40 patients, loss of layered pattern was seen in 25
fractory in 2–30% of cases. In patients with a firm
and preserved layered pattern in 15 patients. Patients
fibrotic stricture, such as can be found at an anasto-
with loss of layered pattern had higher recurrence
motic site, incisional therapy could be a safe alterna-
rate compared to preserved layered pattern (80% vs.
tive treatment modality in refractory situations.33
46.6%, P = 0.06).
In patients who have refractory strictures caused
by caustic ingestion or radiation injury, temporary
Conclusion stent placement may be effective. By contrast, inci-
From the limited available literature, esophageal sional therapy can be considered for patients with
wall thickness on CT scan is probably the best pre- anastomotic strictures and Schatzki’s rings.85 The
dictor of response to dilation. Other factors that can most common indications for stent placement in-
predict response are length of stricture and initial clude achalasia and strictures: caustic, postradia-
diameter of the stricture. tion, anastomotic, and peptic. Stent types that have
136 Ann. N.Y. Acad. Sci. 1300 (2013) 119–143

been used for benign esophageal strictures include able option to treat these lesions, because of their
PC-SEMS and FC-SEMS, SEPS, and recently also ability to exert a prolonged and persistent radial
biodegradable stents. force. Due to extensive fibrotic scar tissue formation,
The management of patients who have refrac- these strictures are more resistant to even sustained
tory hypopharyngeal strictures after chemoradi- dilation by stents, and the recurrence rates after di-
ation and/or surgery can be unsatisfactory, as lation are high, especially in the chronic stage of the
normal-diameter stents placed in this location can disease.89
cause a foreign-body sensation, severe pain, fistula When considering that these patients were
formation, or perforation. Because of this, a cervi- already shown to be refractory or dependent on
cal Niti-S stent was developed (body diameter of endoscopic dilations, and thus represent the most
10, 12, or 14 mm, with or without a flare that is severe subgroup of patients with a symptomatic
2 mm wider than the body diameter and is covered benign stricture, this success rate can be considered
or uncovered).85 as clinically meaningful. Alternative treatments in
Hypopharyngeal strictures have a high recur- these patients include in most cases surgery, which
rence rate, and prolonged stent placement with is associated with high morbidity and mortality
periodic stent exchanges at intervals of 6 weeks rates, or periodical repeated endoscopic dilations,
to 3 months is therefore indicated.85 Given the which also substantially affect quality of life of these
high complication rate of cervical stent placement patients.26
for benign strictures, more conventional meth- It is important to treat benign esophageal stric-
ods such as dilation therapy, or in the case of tures in a stepwise manner (Fig. 5), starting with the
anastomotic strictures, incisional therapy, may be least invasive approach. A final step in the algorithm
better alternatives.87 The use of partially uncov- includes surgery; however, it is recognized that even
ered SEMS was associated with complications, and after a surgical solution, the risk of recurrent stric-
the most common was the ingrowth of granula- ture formation remains.
tion tissue through the stent.85 This tissue reaction
causes the uncovered stent parts to embed in the
esophageal wall, which precludes easy removal. An
obvious advantage of this anchoring is that migra-
tion of uncovered or partially covered SEMS is un-
common, although it is more frequent with FC-
SEMS (Polyflex stent), occurring in almost half
R
of patients.86 The most frequent complications of

stent placement included pain, followed by reflux
(esophagitis), and, rarely, perforation.86 Postradi-
ation strictures are more successfully treated than
peptic, anastomotic, or achalasia strictures.86 The
main limitation of metal stents for benign stric-
tures is the occurrence of tissue in- and overgrowth,
causing recurrent dysphagia in more than 15% of
patients.34,35
To avoid the hyperplastic tissue reaction, SEPS
have recently been introduced. Repici et al.26 con-
cluded that plastic stents are only moderately effec-
tive for the treatment of refractory benign strictures.
Biodegradable stents (absorbed within 2–3 months
after placement) result in a longer period of dyspha-
gia relief.87
Figure 5. The importance of treating benign esophageal stric-
The use of covered removable stents (plastic or tures in a stepwise manner, starting with the least invasive ap-
metal) is therefore considered an alternative and vi- proach.
Ann. N.Y. Acad. Sci. 1300 (2013) 119–143

13. Surgical therapy of benign ach pull-up can be done for short strictures in the
esophageal strictures distal esophagus. Strictures at the middle and dis-
tal esophagus are corrected by esophagoplasty with
Khean-Lee Goh and Ronald Romero
colon interposition.18
klgoh56@gmail.com
Surgical access is also a consideration. In the tran-
Benign esophageal strictures can be classified into shiatal approach, the esophagus is accessed by blunt
simple and complex strictures. Lew and Kochman dissection from an abdominal incision. If the tran-
have defined simple strictures as those allowing pas- shiatal approach is not possible, an abdominotho-
sage of a normal endoscope, short, focal, and not racic incision is made to resect and reconstruct the
angulated.90 Complex strictures are defined as those esophagus.18 The stomach is the most common and
that are angulated, long (>2 cm), irregular, or hav- convenient visceral organ used to construct a neoe-
ing a severe narrowing of the lumen.90 Complex sophagus. However, in extensive chemical injuries
strictures are often caused by radiation therapy, involving the stomach, the colon is preferred.18
corrosives ingestion, and photodynamic therapy. Jejunum is considered for esophageal reconstruc-
Anastomotic strictures are often considered com- tion if the stomach is diseased and colon interposi-
plex strictures as well. tion is not possible. However, long-term problems
Simple strictures are optimally treated by bougie with colonic dilation and loss of peristalsis may pose
or balloon dilation, as they are focal and straight problems.
and allow the passage of an endoscope.85,90 An There are several routes for placing the neoe-
average of 1–3 dilation sessions are needed to sophagus. The posterior mediastinal route using the
treat simple esophageal strictures.91 Complex stric- original esophageal bed is the shortest route with
tures are often impassable to a normal-diameter the least angulations at the anastomosis. However,
endoscope.90 These strictures can be recurrent or in corrosive strictures this area is often inflamed,
refractory to dilation. Refractory strictures do not scarred, and fibrotic, and becomes therefore not
attain a luminal diameter of 14 mm after five sessions feasible. The easiest routes surgically are the sub-
at 2-week intervals.87 Recurrent strictures do not cutaneous or substernal route. Both these routes are
maintain a satisfactory luminal diameter for 4 weeks however the longest routes and a long graft is there-
after achieving a diameter of 14 mm.87 fore necessary.18
The mainstay of treatment of benign esophageal
strictures is endoscopic therapy. Dilation with 14. Should stenoses following severe
bougies and balloons can be considered basic esophageal burns be treated by
endotherapy for benign strictures. For anastomotic esophageal resection or esophageal
strictures, these can be augmented with predilation bypass?
injection with steroids.65,66 Endoscopic incision
Valter Nilton Felix
with a needle knife has also been used to decrease the
v.felix@terra.com.br
fibrosis and increase the success of dilation.88 Newer
endoscopic therapies include placement of covered Patients of corrosive injury of the esophagus are
or biodegradable stents.92 However, difficult referred to a surgeon in the chronic stage, having
complex strictures still require surgery. These stric- persistent dysphagia because of esophageal stenoses.
tures usually accompany damage from corrosive These patients need esophageal substitution for nor-
ingestion, photodynamic therapy, or anastomotic mal alimentation. However, the esophageal resec-
strictures. tion in these patients is debatable.
Several factors are considered in the surgical ther- It has been suggested that the esophageal can-
apy of benign strictures of the esophagus. The length cer developing from the stricture site is related
and location of the stricture determine the choice of to chronic irritation. Advocates of simple bypass
surgery. Strictures of the entire length of the esoph- point out that since the diseased esophagus might
agus will require resection and reconstruction of a be chronically exposed to the irritation, bouginage,
neoesophagus. Viscus structures that can be used and re-stenosis to develop cancer, the risk disap-
to replace the esophagus are the stomach, colon, pears when the esophagus is excluded from the ali-
and jejunum. Partial esophagectomy with a stom- mentary transit and esophagectomy can be avoided.
138 Ann. N.Y. Acad. Sci. 1300 (2013) 119–143

However, even with efforts of seeking for hidden ma- proach such as less pain and less respiratory com-
lignancy, there is still high chance of missing cancer plications.
if esophagectomy is not performed.93 There was no mortality in the series and
Moreover, GER into the bypassed strictured procedure-related morbidity was low. Damage to
esophagus may be a potential source of gastrointesti- the membranous wall of the trachea and to the
nal bleeding and cancer from subsequent esophagi- laryngeal nerves, a significant increased operative
tis. In patients with corrosive injury who are young time, and postoperative bleeding did not occur.
and otherwise expected to have normal life span, a Careful attention to the details of surgery avoided
lifelong surveillance would be required if such an these complications. The dissection in the medi-
esophagus is retained. In addition to this, malig- astinum began posteriorly and then proceeded later-
nancy has been reported to be in advanced stage ally and anteriorly. The risk of injury to the thoracic
at the time of detection and beyond the realm of duct and azygos vein is greater if the surgeon leaves
cure.94 Retained and excluded esophagus has also the company of the esophagus. The periesophageal
been reported to develop mucocele in up to 50% adhesions are usually present all along the length
of patients after 5 years. The mucocele may become of the esophagus in corrosive injury. Hence the
infected and rupture at the suture line or lead on progress in blunt esophageal dissection must be
to features of lung compression that may require slower, and greater care is necessary at the upper
thoracotomy and esophagectomy.95 third of the esophagus, especially anteriorly where
Cicatricial carcinoma has symptoms of luminal the esophagus abuts the tracheal membrane. The
obstruction that are more apt to occur before the periesophageal lysis of the adhesions at this area
extrinsic spread of the neoplasm. This newly aggra- must be performed using gentle force. The greater
vated dysphagia can bring the patient to the hospital part of this dissection can be accomplished under vi-
before the cancer advances. However, it is often dif- sion through cervical incision. If in this area, the sur-
ficult to establish a diagnosis of carcinoma in these geon makes no substantial progress, a thoracoscopy
patients because symptoms due to carcinoma may is recommended to perform sharp dissection under
be erroneously attributed to the original disease, and vision as done in those two mentioned cases. Use of
also because the malignant process begins in a loca- excessive blunt force can lead to tracheal membrane
tion that is often inaccessible to standard esophago- tear. The most common injury of the recurrent la-
scopic examination and biopsy. There are missed ryngeal nerve is neuropraxia that is caused by trac-
cancers even after the careful endoscopic examination on the nerve during medial retraction. Avoiding
tion, mainly if they are small enough or are located use of retractors for medial retraction and instead
at the distal portion of the stenosis where the en- using gentle retraction with the finger can help pre-
doscopy is inaccessible. The risk of cancer develop- vent traction injury to the nerve. The esophageal
ment would be high if the patient has suffered from substitution was done by gastric conduits. In cases
lye corrosive esophagitis more than 25–30 years. where the stomach was not found suitable, trans-
It is necessary in the current approach for corro- verse and left colonic conduits can be used. Mere
sive esophageal stricture to perform extensive pre- presence of antral nonobstructive stricture was not
operative examination to find hidden malignan- considered an indication for colonic transplant if the
cies. If the malignancy is detected preoperatively, size of the stomach was normal. It has been observed
esophagectomy through the right lateral thoraco- that colonic conduits did not offer any inherent ad-
tomy or thoracoscopy is followed by an appro- vantage to outweigh the operative time, complexity,
priate reconstruction. If there is no evidence of and technical demands of their preparation.
malignancy, resection of the diseased esophagus is The esophageal substitute was placed in the poste-
recommended to avoid any chance of hidden malig- rior mediastinum after esophagectomy. The shortest
nancy and to prevent future development of cancer. route and the orthotopic position of the substitute
It is still uncertain which approach of esophagec- reduce the anastomotic leak rates and facilitate deg-
tomy would be better for this particular group of lutition. Aspiration during swallowing has been the
patients. It has been accepted that the transhiatal major cause of concern in these patients postoper-
method has its advantages to the transthoracic ap- atively. Loss of sensation in the hypopharynx and
Ann. N.Y. Acad. Sci. 1300 (2013) 119–143

supraglottic larynx, concomitant injury to glottic 10. Fischer, A., H.J. Schrag, M. Goos, et al. 2007. Nonoperative
mechanism, and dyscoordinate swallowing follow- treatment of four esophageal perforations with hemostatic
clips. Dis. Esophagus 20: 444–448.
ing long periods of absolute dysphagia are the fac-
11. Hasan, S., A.N. Jilaihawi & D. Prakash. 2005. Conserva-
tors reported to affect oral alimentation. The site of tive management of iatrogenic oesophageal perforations—a
anastomosis, pharynx or hypopharynx, and cervical viable option. Eur. J. Cardiothorac. Surg. 28: 7–10.
esophagus, had been found to alter the incidence of 12. Chirica, M., A. Champault, X. Dray, et al. 2010. Esophageal
aspiration, less frequent the lower the anastomosis is perforations. J. Visc. Surg. 147: e117–e128.
13. Bhatia, P., D. Fortin, R.I. Inculet & R.A. Malthaner. 2011.
made. Paste food is preferable to prevent aspiration
Current concepts in the management of esophageal per-
following the beginning of reuse of the oral route.96 forations: a twenty-seven year Canadian experience. Ann.
Considering that there was no significant increase Thorac. Surg. 92: 209–215.
of morbidity, regardless of performing esophagec- 14. Abbas, G., M.J. Schuchert, B.L. Pettiford, et al. 2009.
tomy, the synchronous resection of the esophagus Contemporaneous management of esophageal perforation.
Surgery 146: 749–755; discussion 755–756.
with the esophageal reconstruction for patients with
15. Altorjay, A., J. Kiss, A. Voros & A. Bohak. 1997. Nonoperative
chronic intractable caustic esophageal stricture is management of esophageal perforations. Is it justified? Ann.
the best choice. Surg. 225: 415–421.
16. Repici, A.R.G. 2010. Stent for nonmalignant leaks, perfora-
Conflicts of interest tions, and ruptures. Tech. Gastrointest. Endosc. 13: 237–245.
17. Siersema, P.D. 2005. Treatment of esophageal perforations
The authors declare no conflicts of interest. and anastomotic leaks: the endoscopist is stepping into the
arena. Gastrointest. Endosc. 61: 897–900.
References 18. Hiebert, C.A. & C.E. Bredenberg. 2002. “Selection and place-
ment of conduits.” In Esophageal Surgery. 2nd ed. F. Griffith
1. Erdogan, A., G. Gurses, H. Keskin & A. Demircan. 2007. Pearson, J.D. Cooper, J. Deslauriers, R. Ginsberg, C. Hiebert,
The sealing effect of a fibrin tissue patch on the esophageal G.A. Patterson & H.C. Urschel, Eds. pp. 794–801. Philadel-
perforation area in primary repair. World. J. Surg. 31: 2199– phia: Churchill Livingstone.
2203. 19. Kochman, M.L., S.A. McClave & H.W. Boyce. 2005. The re-
2. Freeman, R.K., A. Vyverberg & A.J. Ascioti. 2011. Esophageal fractory and the recurrent esophageal stricture: a definition.
stent placement for the treatment of acute intrathoracic Gastrointest. Endosc. 62: 474–475.
anastomotic leak after esophagectomy. Ann. Thorac. Surg. 20. Wadhwa, R.P., R.A. Kozarek, R.E. France, et al. 2003. Use of
92: 204–208; discussion 208. self-expandable metallic stents in benign GI diseases. Gas-
3. Babor, R., M. Talbot & A. Tyndal. 2009. Treatment of up- trointest. Endosc. 58: 207–212.
per gastrointestinal leaks with a removable, covered, self- 21. Sandha, G.S. & N.E. Marcon. 1999. Expandable metal stents
expanding metallic stent. Surg. Laparosc. Endosc. Percutan. for benign esophageal obstruction. Gastrointest. Endosc.
Tech. 19: e1–e4. Clin. N. Am. 9: 437–446.
4. Swinnen, J., P. Eisendrath, J. Rigaux, et al. 2011. Self- 22. Repici, A., M. Conio, C. De Angelis, et al. 2004. Tempo-
expandable metal stents for the treatment of benign upper rary placement of an expandable polyester silicone-covered
GI leaks and perforations. Gastrointest. Endosc. 73: 890–899. stent for treatment of refractory benign esophageal stric-
5. van Boeckel, P.G., K.S. Dua, B.L. Weusten, et al. 2012. Fully tures. Gastrointest. Endosc. 60: 513–519.
covered self-expandable metal stents (SEMS), partially cov- 23. Evrard, S., O. Le Moine, G. Lazaraki, et al. 2004. Self-
ered SEMS and self-expandable plastic stents for the treat- expanding plastic stents for benign esophageal lesions. Gas-
ment of benign esophageal ruptures and anastomotic leaks. trointest. Endosc. 60: 894–900.
BMC Gastroenterol. 12: 19. 24. Holm, A.N., J.L. Levy, C.J. Gostout, et al. 2008. Self-
6. van Boeckel, P.G., A. Sijbring, F.P. Vleggaar & P.D. Siersema. expanding plastic stents in treatment of benign esophageal
2011. Systematic review: temporary stent placement for be- conditions. Gastrointest. Endosc. 67: 20–25.
nign rupture or anastomotic leak of the oesophagus. Ali- 25. Dua, K.S., F.P. Vleggaar, R. Santharam, et al. 2008. Remov-
ment Pharmacol. Ther. 33: 1292–1301. doi: 10.1111/j.1365– able self-expanding plastic esophageal stent as a continu-
2036.2011.04663.x. [Review] ous, non-permanent dilator in treating refractory benign
7. D’Cunha, J., N.M. Rueth, S.S. Groth, et al. 2011. Esophageal esophageal strictures: a prospective two-center study. Am. J.
stents for anastomotic leaks and perforations. J. Thorac. Car- Gastroenterol. 103: 2988–2994.
diovasc. Surg. 142: 39–46.e1. 26. Repici, A., C. Hassan, P. Sharma, et al. 2010. Systematic
8. Vallböhmer, D., A.H. Hölscher, M. Hölscher, et al. 2010. Op- review: the role of self-expanding plastic stents for benign
tions in the management of esophageal perforation: analysis oesophageal strictures. Aliment Pharmacol. Ther. 31: 1268–
over a 12-year period. Dis. Esophagus 23: 185–190. 1275.
9. Raju, G.S., C. Thompson & J.B. Zwischenberger. 2005. 27. Eloubeidi, M.A. & T.L. Lopes. Novel removable internally
Emerging endoscopic options in the management of fully covered self-expanding metal esophageal stent: feasi-
esophageal leaks (videos). Gastrointest. Endosc. 62: 278–286 bility, technique of removal and tissue response in humans.
[Review]. Am. J. Gastroenterol. 104: 1374–1381.
140 Ann. N.Y. Acad. Sci. 1300 (2013) 119–143

28. Song, H.Y., H.Y. Jung, S.I. Park, et al. 2000. Covered re- a self-expandable metallic stent. Surg. Endosc. 23: 2258–2262.
trievable expandable nitinol stents in patients with benign doi: 10.1007/s00464-008-0302-5.
esophageal strictures: initial experience. Radiology 217: 551– 45. Blackmon, S.H., R Santora, P. Schwarz, et al. 2010.
557. Utility of removable esophageal covered self-expanding
29. Repici, A., F.P. Vleggaar, C. Hassan, et al. 2010. Ef- metal stents for leak and fistula management. Ann.
ficacy and safety of biodegradable stents for refrac- Thorac. Surg. 89: 931–936; discussion 936–7. doi:
tory benign esophageal strictures: the BEST (Biodegrad- 10.1016/j.athoracsur.2009.10.061.
able esophageal stent) study. Gastrointest. Endosc. 72: 46. Freeman, R.K., A.J. Ascioti, T. Giannini & R.J. Mahidhara.
927–934. 2012. Analysis of unsuccessful esophageal stent placements
30. Siersema, P.D., M.Y. Homs, J. Haringsma, et al. 2003. Use of for esophageal perforation, fistula, or anastomotic leak. Ann.
large-diameter metallic stents to seal traumatic nonmalig- Thorac. Surg. 94:959–964.
nant perforations of the esophagus. Gastrointest. Endosc. 58: 47. Pohl, J., M. Borgulya, D. Lorenz & C. Ell. 2010. Endo-
356–361. scopic closure of postoperative esophageal leaks with a novel
31. Gelbmann, C.M., N.L. Ratiu, H.C. Rath, et al. 2004. Use of over-the-scope clip system. Endoscopy 42: 757–759. doi:
self-expandable plastic stents for the treatment of esophageal 10.1055/s-0030-1255634.
perforations and symptomatic anastomotic leaks. Endoscopy 48. Freeman, R.K., A.J. Ascioti & T.C. Wozniak. 2007. Post-
36: 695–699. operative esophageal leak management with the Polyflex
32. Schubert, D., H. Scheidbach, R. Kuhn, et al. 2005. Endo- esophageal stent. J. Thorac. Cardiovasc. Surg. 133: 333–338.
scopic treatment of thoracic esophageal anastomotic leaks doi: 10.1016/j.jtcvs.2006.10.008.
by using silicone-covered, self-expanding polyester stents. 49. Szücs, G., I. Tóth, K. Gyáni & J.I. Kiss. 2003. Telescopic
Gastrointest. Endosc. 61: 891–896. esophageal anastomosis: operative technique, clinical expe-
33. van Heel, N.C., J. Haringsma, M.C. Spaander, et al. 2010. riences. Dis. Esophagus 16: 315–322.
Short-term esophageal stenting in the management of be- 50. Orringer, M.B., B. Marshall & M.D. Iannettoni. 2000. Elim-
nign perforations. Am. J. Gastroenterol. 105: 1515–1520. inating the cervical esophagogastric anastomotic leak with a
34. Dua, K.S. 2007. Stents for palliating malignant dysphagia side-to-side stapled anastomosis. J. Thorac. Cardiovasc. Surg.
and fistula: is the paradigm shifting? Gastrointest. Endosc. 119: 277–288.
65: 77–81. 51. Davis, S.J., L. Zhao, A.C. Chang & M.B. Orringer. 2011.
35. Ross, W.A., F. Alkassab, P.M. Lynch, et al. 2007. Evolving role Refractory cervical esophagogastric anastomotic strictures:
of self-expanding metal stents in the treatment of malignant management and outcomes. J. Thorac. Cardiovasc. Surg. 141:
dysphagia and fistulas. Gastrointest. Endosc. 65: 70–76. 444–448.
36. Chan, A.C., F.G. Shin, Y.H. Lam, et al. 1999. A comparison 52. Černá, M., M. Köcher, V. Válek, et al. 2011. Covered
study on physical properties of self-expandable esophageal biodegradable stent: new therapeutic option for the man-
metal stents. Gastrointest. Endosc. 49: 462–465. agement of esophageal perforation or anastomotic leak. Car-
37. Dua, K.S. 2001. Antireflux stents in tumors of the cardia. diovasc. Intervent. Radiol. 34: 1267–1271.
Am. J. Med. 111(Suppl. 8A): 190S–196S. 53. Felix, B., M.D. Langer, E. Wenzl, et al. 2005. Management
38. Dua, K.S., R. Kozarek, J. Kim, et al. 2001. Self-expanding of postoperative esophageal leaks with the polyflex self-
metal esophageal stent with anti-reflux mechanism. Gas- expanding covered plastic stent. Ann. Thorac. Surg. 79: 398–
trointest. Endosc. 53: 603–613. 404.
39. Laasch, H.U., A. Marriott, L. Wilbraham, et al. 2002. Ef- 54. Levine, M.S. 2008. “Reflux esophagitis.” In Textbook of Gas-
fectiveness of open versus antireflux stents for palliation of trointestinal Radiology. 3rd ed. R.M. Gore & M.S. Levine,
distal esophageal carcinoma and prevention of symptomatic Eds.: 337–335. Philadelphia: Elsevier.
gastroesophageal reflux. Radiology 225: 359–365. 55. Gupta, S., M.S. Levine, S.E. Rubesin, et al. 2003. Usefulness
40. Homs, M.Y., P.J. Wahab, E.J. Kuipers, et al. 2004. Esophageal of barium studies for differentiating benign and malignant
stents with antireflux valve for tumors of the distal esophagus strictures of the esophagus. AJR Am. J. Roentgenol. 180: 737–
and gastric cardia: a randomized trial. Gastrointest. Endosc. 744.
60: 695–702. 56. Levine, M.S. & H.M. Goldstein. 1984. Fixed transverse folds
41. Bethge, N., A. Sommer & N. Vakil. 1998. Palliation of malig- in the esophagus: a sign of reflux esophagitis. AJR Am. J.
nant esophageal obstruction due to intrinsic and extrinsic Roentgenol. 143: 275–278.
lesions with expandable metal stents. Am. J. Gastroenterol. 57. Ott, D.J., D.W. Gelfand, T.G. Lane, et al. 1982. Radiologic
93: 1829–1832. detection and spectrum of appearances of esophageal stric-
42. Homs, M.Y., E.W. Steyerberg, W.M. Eijkenboom, et al. 2004. tures. J. Clin. Gastroenterol. 4: 11–15.
Single-dose brachytherapy versus metal stent placement for 58. Ott, D.J., Y.M. Chen, W.C. Wu, et al. 1985. Endoscopic sen-
the palliation of dysphagia from oesophageal cancer: multi- sitivity in the detection of esophageal strictures. J. Clin. Gas-
centre randomised trial. Lancet 364: 1497–1504. troenterol. 7: 121–125.
43. Dai, Y.Y., S. Gretschel, O. Dudeck, et al. 2009. Treatment of 59. Ott, D.J., Y.M. Chen, W.C. Wu, et al. 1986. Radiographic and
oesophageal anastomotic leaks by temporary stenting with endoscopic sensitivity in detecting lower esophageal mucosal
self-expanding plastic stents. Br. J. Surg. 96: 887–891. doi: ring. AJR Am. J. Roentgenol. 147: 261–265.
10.1002/bjs.6648. 60. Hsu, W.C., M.S. Levine & S.E. Rubesin. 2003. Overlap phe-
44. Leers, J.M., C. Vivaldi, H. Schäfer, et al. 2009. Endoscopic nomenon: a potential pitfall in the radiographic detection of
therapy for esophageal perforation or anastomotic leak with lower esophageal rings. AJR Am. J. Roentgenol. 180: 745–747.
Ann. N.Y. Acad. Sci. 1300 (2013) 119–143

61. Ketchum, L.D., J. Smith, D.W. Robinson & F.W. Master. 77. Kim, J.H., H.Y. Song, H.C. Kim, et al. 2008. Corro-
1966. The treatment of hypertrophic scar, keloid and scar sive esophageal strictures: long-term effectiveness of bal-
contracture by triamonolone acetonide. Plast. Reconstr. Surg. loon dilation in 117 patients. J. Vasc. Interv. Radiol. 19:
38: 209–218. 736–741.
62. Mendelson, H.J. & W.H. Maloney. 1970. The treatment of 78. Broor, S.L., A. Kumar, S.T. Chari, et al. 1989. Corrosive oe-
benign strictures of the esophagus with cortisone injection. sophageal strictures following acid ingestion: clinical profile
Ann. Otol. Rhinol. Laryngol. 79: 900–904. and results of endoscopic dilation. J. Gastroenterol. Hepatol.
63. Kochhar, R. & K.S. Poornachandra. 2010. Intralesional 4: 55–61.
steroid injection therapy in the management of resistant 79. Poddar, U. & B.R. Thapa. 2001. Benign esophageal strictures
gastrointestinal strictures. World J. Gastrointest. Endosc. 2: in infants and children: results of Savary-Gilliard bougie
61–68. dilation in 107 Indian children. Gastrointest. Endosc. 54: 480–
64. Bhutani, M.S., N. Usman, V. Shenoy, et al. 1997. Endo- 484.
scopic ultrasound miniprobe-guided steroid injection for 80. Temiz, A., S.S. Ezer, P. Oguzkurt, et al. 2010. Long-term
treatment of refractory esophageal strictures. Endoscopy 29: management of corrosive esophageal stricture with balloon
757–759. dilation in children. Surg. Endosc. 24: 2287–2292.
65. Kochhar, R. & G.K. Makharia. 2002. Usefulness of intrale- 81. Panieri, E., H. Rode, A.J.W. Millar, et al. 1998. Oe-
sional triamcinolone in treatment of benign esophageal sophageal replacement in the management of corrosive
strictures. Gastrointest. Endosc. 56: 829–834. strictures: when is surgery indicated? Pediatr. Surg. Int. 13:
66. Altintas, E., S. Kacar, B. Tunc, et al. 2004. Intralesional steroid 336–340.
injection in benign esophageal strictures resistant to bougie 82. Gün, F., L. Abbasog*lu, A. Çelik, et al. 2007. Early and late
dilation. J. Gastroenterol. Hepatol. 19: 1388–1391. term management in caustic ingestion in children: a 16-year
67. Ramage, J.I., Jr., A. Rumalla, T.H. Baron, et al. 2005. A experience. Acta Chir. Bel. 107: 49–52.
prospective, randomized, double-blind, placebo-controlled 83. Contini, S., M. Garatti, A. Swarray-Deen, et al. 2009. Corro-
trial of endoscopic steroid injection therapy for recalcitrant sive oesophageal strictures in children: outcomes after timely
esophageal peptic strictures. Am. J. Gastroenterol. 100: 2419– or delayed dilation. Dig. Liver Dis. 41: 263–268.
2425. 84. Lahoti, D., S.L. Broor, P.P. Basu, et al. 1995. Corrosive
68. Rupp, T., D. Earle, S. Ikenberry, et al. 1995. Randomized esophageal strictures: predictors of response to endoscopic
trial of Savary dilation with/without intralesional steroids dilation. Gastrointest. Endosc. 41: 196–200.
for benign gastroesophageal reflux strictures. Gastrointest. 85. Siersema, P.D. 2008. Treatment options for esophageal
Endosc. 41: 357. strictures. Nat. Clin. Pract. Gastroenterol. Hepatol. 5:
69. Earlham, R. & J.R. Cunha-Melo. 1981. Benign oesophageal 142–52.
strictures: historical and technical aspects of dilation. Br. J. 86. Siersema, P.D. & L.R. de Wijkerslooth. 2009. Dilation of
Surg. 68: 829–836. refractory benign esophageal strictures. Gastrointest. Endosc.
70. Cox, J.G.C., R.K. Winter, S.C. Maslin, et al. 1988. Balloon 70: 1000–1012.
or bougie for dilation of benign oesophageal stricture? An 87. De Wijkerslooth, L.R.H., F.P. Vleggaar & P.D. Siersema. 2011.
interim report of a randomised controlled trial. Gut 29: Endoscopic management of difficult or recurrent esophageal
1741–1747. strictures. Am. J. Gastroenterol. 106: 2080–2091.
71. Cox, J.G.C., R.K. Winter, S.C. Maslin, et al. 1994. Balloon or 88. Hordijk, M.L., P.D. Siersema, H.W. Tilanus, et al. 2006. Elec-
bougie for dilation of benign esophageal stricture? Dig. Dis. trocautery therapy for refractory anastomotic strictures of
Sci. 39: 776–781. the esophagus. Gastrointest. Endosc. 63: 157–163.
72. Yamamoto, H., R.W. Hughes, Jr., et al. 1992. Treatment 89. Thomas, T., K.R. Abrams, V. Subramanian, et al. 2011.
of benign esophageal strictures by Eder-puestow or balloon Esophageal stents for benign refractory strictures: a meta-
dilators: a comparison between randomized and prospective analysis. Endoscopy 43: 386–393.
nonrandomized trials. Mayo Clin. Proc. 67: 228–236. 90. Lew, R.J. & M.L. Kochman. 2002. A review of endoscopic
73. Shemesh, E. & A. Czerniak. 1990. Comparison between methods of esophageal dilation. J. Clin. Gastroenterol. 35:
Savary-Gilliard and balloon dilation of benign esophageal 117–126.
strictures. World J. Surg. 14: 518—522. 91. Pereira-Lima, J.C., R.P. Ramires, I. Zamin, Jr., et al. 1999.
74. Zahid, A., M.D. Saeed, B. Carolyn, et al. 1995. Prospective Endoscopic dilation of benign esophageal strictures: re-
randomized comparison of polyvinyl bougies and through- port on 1043 procedures. Am. J. Gastroenterol. 94: 1497–
the-scope balloons for dilation of peptic strictures of the 1501.
esophagus. Gastrointest. Endosc. 41: 189–195. 92. Hirdes, M.M., P.D. Siersema, P.G. van Boeckel & F.P. Vleg-
75. Scolapio, J.S., T.M. Pasha, C.J. Gostout, et al. 1999. A ran- gaar. 2012. Single and sequential biodegradable stent place-
domized prospective study comparing rigid to balloon dila- ment for refractory benign esophageal strictures: a prospec-
tors for benign esophageal strictures and rings. Gastrointest. tive follow-up study. Endoscopy 44: 649–654.
Endosc. 50: 13–17. 93. Chirica, M., N. Veyrie, N. Munoz-Bongrand, et al. 2010. Late
76. Broor, S.L., G.S. Raju, P.P. Bose, et al. 1993. Long term results morbidity after colon interposition for corrosive esophageal
of endoscopic dilation for corrosive oesophageal strictures. injury: risk factors, management, and outcome. A 20-years
Gut 34: 1498–1501. experience. Ann. Surg. 252: 271–280.
142 Ann. N.Y. Acad. Sci. 1300 (2013) 119–143

94. Jung, H.Y., H.J. Kim, S.B. Kim, et al. 1999. Esophageal cancer gus after ingestion of the caustics. Ann. Chir. 43: 724–
in an esophagus remaining after colonic interposition for lye 730.
stricture. Endoscopy 31: S1. 96. Keh, S.M., N. Onyekwelu, K. McManus & J. McGuigan. 2006.
95. Chambon, J.P., Y. Robert & J. Remy. 1989. Esophageal Corrosive injury to upper gastrointenstinal tract: still a major
mucoceles complicating double exclusion of the esopha- surgical dilemma. World J. Gastroenterol. 12: 5223–5228.
Ann. N.Y. Acad. Sci. 1300 (2013) 119–143


Stent thực quản

Uploaded by

Copyright:

Available Formats

Stent thực quản

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Stent thực quản

Uploaded by

Copyright:

Available Formats

Ann. N.Y. Acad. Sci.

Stents for benign and malignant esophageal strictures

Address for correspondence: annals@nyas.org

Keywords: stent; anastomic leak; stricture formation; neoesophagus; esophageal perforation

Concise summaries r For cervical perforations, endoscopic therapy

120 Ann. N.Y. Acad. Sci. 1300 (2013) 119–143

Ann. N.Y. Acad. Sci. 1300 (2013) 119–143

1. Endotherapy for esophageal high rate of successful treatment (59.5–100%).2,4,10

122 Ann. N.Y. Acad. Sci. 1300 (2013) 119–143

2. Esophageal perforation: conservative logically guided drainage of localized collections of

Ann. N.Y. Acad. Sci. 1300 (2013) 119–143

Figure 2. A general treatment algorithm for perforation of the esophagus.

124 Ann. N.Y. Acad. Sci. 1300 (2013) 119–143

SEPS. The only fully covered SEPS is the Polyflex R

Ann. N.Y. Acad. Sci. 1300 (2013) 119–143

126 Ann. N.Y. Acad. Sci. 1300 (2013) 119–143

Malignant strictures can immediately relieve dysphagia and after a few

Ann. N.Y. Acad. Sci. 1300 (2013) 119–143

128 Ann. N.Y. Acad. Sci. 1300 (2013) 119–143

Ann. N.Y. Acad. Sci. 1300 (2013) 119–143

Four-quadrant 0.5 mL intralesional injections of tri-

8. Can barium esophagography detect

130 Ann. N.Y. Acad. Sci. 1300 (2013) 119–143

Ann. N.Y. Acad. Sci. 1300 (2013) 119–143

132 Ann. N.Y. Acad. Sci. 1300 (2013) 119–143

Conclusion treatment of achalasia. Maloney’s bougies are simi-

Figure 4. Comparison of dead space between bougie and balloon dilators.

Ann. N.Y. Acad. Sci. 1300 (2013) 119–143

Table 1. Comparison of studies (balloon vs. bougies)

Study Outcome Recurrence Comments

Shemesh et al.75 Both similar More with balloons –

134 Ann. N.Y. Acad. Sci. 1300 (2013) 119–143

Possible predictors of response Length and number of strictures. The length of

Ann. N.Y. Acad. Sci. 1300 (2013) 119–143

136 Ann. N.Y. Acad. Sci. 1300 (2013) 119–143

of patients.86 The most frequent complications of

Ann. N.Y. Acad. Sci. 1300 (2013) 119–143

138 Ann. N.Y. Acad. Sci. 1300 (2013) 119–143

Ann. N.Y. Acad. Sci. 1300 (2013) 119–143

140 Ann. N.Y. Acad. Sci. 1300 (2013) 119–143

Ann. N.Y. Acad. Sci. 1300 (2013) 119–143

142 Ann. N.Y. Acad. Sci. 1300 (2013) 119–143

Ann. N.Y. Acad. Sci. 1300 (2013) 119–143

You might also like