Esophstrictures chennai

2. Europe, USA Delhi,Chandigarh
Peptic 68 - 72% 18 – 32%
Post-op 8 - 21% 1 – 13%
Caustic 1 - 4% 33 – 42%
Radiation 0 - 1% 3 – 27%
EST - 2 – 17%
Misc 3 - 9% 5 – 7%
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Patterson1983,Williamson 197 7, Broor1993,Kochhar 2001

3. • Focal/straight/symmetric
• >12 mm
• Easy to dilate
• rings, webs,peptic

5. • Long, >2 cms, tortuous
• Asymmetrical
• <12 mm
• Caustic
• Radiation
• Anastomotic

10. Endoscopy 2013; 45: E1–E2

11. Clin Endosc 2013;46:643-646

12. • Whale bone
– 17th
century
• Bougienage
– 1821
• Flexible
– Maloney, Hurst
Bougie Dilators

13. Through the scope/ Over the guidewire
-Wire/Non wire guided
Eclipse TTC CRE (Microvasive)

15. • Both effectively relieved dysphagia.
• Stricture recurrence during the I year of follow- up similar
• In second year, the risk of recurrence was significantly
lower in balloon group.
• Other advantages of balloons
• the need for fewer treatment
• sessions to achieve the end-diameter for dilation
• less procedural discomfort
Gastrointest Endosc 1995

16. Dysphagia relief : Diameter > 12mm
Actual diameter : 4-8 mm less
(Bennett . 1985)
Dilating beyond 15 mm : not superior relief
: same recurrence
(Saeed ; Dig Dis Sci 1994)
Intraesophageal pressure: Max for 44 Fr-48 Fr
(Kozarek . Gastroent.1981)

17. • Webs excellent
• Peptic 60% 1 diln
• Caustic difficult
and resistant
• Radiation risk of
perf
• Anastomotic
difficult

20. Poddar et al; GI Endoscopy 2001; 54; 480-4Savary Dilatation : 54 children

22. Layered Patten Lost
Corrosive stricture
Layered Patten Lost
Corrosive stricture

23. Layered Patten Partially Lost
Peptic Stricture
Layered Patten Partially Lost
Peptic Stricture

24. Parameter
Without
recurrence
With
recurrence
Layer pattern preserved 8 7
Layer pattern lost 5 20
p value 0.061

25. Refractory strictures:luminal diameter of 14 mm not achieved
despite five consecutive endoscopic sessions occurring every 2 weeks
Recurrent strictures:luminal patency not maintained for 4
weeks after achieving target diameter of 14 mm diameter

26. 52 patients : 47 available
44(93.6%) successful dilatation
94.4% had recurrence with
55% having 5 recurrences
33% having 10 recurrences
8(18.7%) perforations
Broor et al; Gut 1993; 34: 1498-1501

27. Intralesional steroids
Electrodiathermy incision
Stents
Others

28. • 1966 - Ketchum ,Griffith -
keloids and scars

29. Gastrointest Endosc 1999

30. • N-71
• Strictures
• corrosive (29)
• peptic (14)
• anastomotic (19)
• radiation-induced (9)
Gastrointest Endosc 2002

31. Time to first repeat dilatation
Am J Gastroenterol 2005

33. • Inhibits collagen
synthesis
• Direct application to
submucosa at the
site of mucosal
disruption
Journal of Pediatric Surgery 2008

46. Metal stents
Plastic stents
Biodegradable stents

47. • Indications : refractory or recurrent strictures
• Continuous dilatation by indwelling prosthesis
• Akin to frequent dilatation
• Remodelling of lumen after removal of stent

48. Gastrointest Endosc. 2004 Dec;60(6):894-900

49. • 9 studies : 162 pts : Anast (50), Peptic (27), Caustic (26)
• Outcome:
• Tissue overgrowth : 18%
• Migration : 47%
• Complications : 6%
• Long term relief : 39%
(Siersema Endoscopy 2009;41:363)

50. Completely covered even at flanges - Tissue reaction minimized
Special SEMS – Double covering both inside & outside

51. First use 1993 Cwikiel. 5 patients (Radiology 1993, 187,667)
Till 2009 : 12 studies: 168 patients : 50% achalasia
Uncovered 34: not removed
Covered 134: 18 not removed
Overall : Migration 14%
Tissue hyperplasia 17%
Long term data : 14/30 (47%) benefit

52. Synthetic biodegradable material polylactide
Self disintegration
Biocompatible - Minimal tissue reaction
Projected biologic life 3-6 mo
Loss of mech strength 4-8 wk

53. 2 wks 4 wks
(Jahangeer Endoscopy 2013 )

54. 13 patients
Dysphagia free @ 3 months : 4 patients
Dysphagia free @ 6 months : 3 patients
Dysphagia free @ 12 months : 2 patients
Follow up 3 years - 3 Surgery
- 3 Free of dysphagia
- 7 dilatation infrequent
(Kochhar ,Reddy,Choudhury OESO 2012)

56. Characteristic BD stent (n 18) SEPS (n 20) p
value
Technically successful sent
placement, n(%)
16(85) 19(95) 0.49
Median follow-up, d 166(21-559) 385(77-924) 0.23
Clinical success, n(%) 6(33) 6(30) 0.83
Mean number of reinterventions,
per stent placed (SD)
0.8(0.6) 1.3(0.4) 0.03
NOTE: Values in bold indicate statistical significance
Clinical Gastroenterology and Hepatology 2011;9:653-659

57. Overall efficacy of stents 30-40%
SEMS Tissue hyperplasia
Polyflex Migration
Biodegradable Recurrence

58. SURGERY
Corrosive 15-18%
Peptic , anastomotic, radiation : rare

59. (ShahGLEndo 2007, SiersemaEndo 2009)
Stricture
Dilatation : Bougie / Balloon
Stricture
Dilatation : Bougie / Balloon
No response : 3 sessionsNo response : 3 sessions
Complex strictureComplex stricture
2 more sessions : No
response
2 more sessions : No
response
Add : Steroid injectionAdd : Steroid injection
No response in 5 sessionsNo response in 5 sessions
Refractory strictureRefractory stricture
Incisional therapy + DilationIncisional therapy + Dilation Temporary SEMSTemporary SEMS SurgerySurgery

63.  8 studies : 199 patients : 84 corrosives
 Relief in dysphagia : Polyflex 55%
 Nitinol 37%
 83% of Nitinol group had corrosive strictures
 vs 14% of polyflex
(Thomas et al Endoscopy 2011;43:386)

64. Conclusion:
Efficacy of SERS - 46.2 %
Migration rate - 26.4 %
Successful removal - 87%
SEPS better primary outcome than Nitinol stents
Heterogeneity of data – Subgroups non comparable
Nitinol group – 83% corrosives, Median length > 7cm
Polyflex group – 14% corrosives, Median length < 5cm
Corrosive strcitures - Extensive fibrotic scar tissue formation,
hence more resistant to even sustained dilation by stents

66.  8 studies : 199 patients : 84 corrosives
 Relief in dysphagia : Polyflex 55%
 Nitinol 37%
 83% of Nitinol group had corrosive strictures
 vs 14% of polyflex
 Overall : Etiology, site, length, time to removal had
no effect on outcome
(Thomas et al Endoscopy 2011;43:386)

67. 6 studies (> 10pts ) : 119 patients
Dysphagia improvement : 53%
Migration : 30%
(Thomas Endoscopy 2011;43:386)

68. 2 studies : 80 patients : Korea (67 corrosive)
Sustained benefit : 36.7%
Migration : 21.8%
(Thomas Endoscopy 2011;43:386)

69.  8 studies : 199 patients : 84 corrosives
 Relief in dysphagia : Polyflex 55%
 Nitinol 37%
 83% of Nitinol group had corrosive strictures
 vs 14% of polyflex
(Thomas et al Endoscopy 2011;43:386)

70. 2 centers in Europe - 21 patients
Technical success - 100%
Stent migration in 7 wks - 9.5%
Fragmentation - 3 months
Median follow-up - 53 wks
Dysphagia free - 45%
No major complication
Gastrointest Endosc. 2010 Nov;72(5):927-34

72. 2 wks 4 wks

73. 8 studies
Polyflex – 6
Nitinol - 2
Endoscopy 2011; 43: 386 –393
• Dysphgia
improvement
– Polyflex better
– 55% vs 37%
• Migration rate –
- Similar
- 30% vs 22%

75. 8 corrosives
Success – 1, Failure -
7

82. Characteristic BD stent (n 18) SEPS (n 20) p
value
Technically successful sent
placement, n(%)
16(85) 19(95) 0.49
Median follow-up, d 166(21-559) 385(77-924) 0.23
Clinical success, n(%) 6(33) 6(30) 0.83
Mean number of reinterventions,
per stent placed (SD)
0.8(0.6) 1.3(0.4) 0.03
NOTE: Values in bold indicate statistical significance
Clinical Gastroenterology and Hepatology 2011;9:653-659

84. Ultraflex, Z-stent, Polyflex, Niti-S stent, Choo stent, and Bonastent

96. In refractory strictures or recurrent strictures
Not responding to intralesional steroids or needle knife
incision
May consider early

97. • Successful placement : 38/40 : 94%
• Successful removal : 31/33 : 94%
• Overall changed outcome : 66%
• FU : 53 wk
• 12 (40%) dysphagia free
• 10 opted for long-term stenting
• 4 Repeated dilatation
• 3 Surgery
• 1 Needle knife
• (Dua et al AJG 2008;103:2988)

99. No of stents
1 2 3
No 28 13 7
Cl. Success 25% 15% 0
Major compl. 29% 8% 29%
Dysphagia free
days
90 55 106

100. • Incidence 9%
• Perforation 3
• Trach compr 1
• Gran tissue 2
• Bleed 3
• TOF 1
(Eloubeidi GIE 2011;73:673)

103. • 10 studies : 130 patients
• FU 10 months
• Overall success 52%
• Migration 23%
•
(Repici APT 2010;31:1268)

105. (ShahGLEndo 2007, SiersemaEndo 2009)
Dilatation : Bougie /
Balloon
Dilatation : Bougie /
Balloon
No response : 3 sessionsNo response : 3 sessions
Complex strictureComplex stricture
2 more sessions : No
response
2 more sessions : No
response
Steroid injectionSteroid injection
No response in 5 sessionsNo response in 5 sessions
Refractory strictureRefractory stricture
Incisional therapy + DilationIncisional therapy + Dilation TemporaryStentTemporaryStent SurgerySurgery

107. • Granulation tissue 56%
• Reactive hyperplasia 22%
• Fibrosis 22%
(Eloubeidi GIE 2011;73:673)

108. 28 patients
First stent
15 13 second stent
7 improved 8 ?
10 3
Restricture Improved
7 Third stent
All recurred

111. (ShahGLEndo 2007, SiersemaEndo 2009)
Stricture
Dilatation : Bougie / Balloon
Stricture
Dilatation : Bougie / Balloon
No response : 3 sessionsNo response : 3 sessions
Complex strictureComplex stricture
2 more sessions : No
response
2 more sessions : No
response
Add : Steroid injectionAdd : Steroid injection
No response in 5 sessionsNo response in 5 sessions
Refractory strictureRefractory stricture
Incisional therapy + DilationIncisional therapy + Dilation Temporary SEMSTemporary SEMS SurgerySurgery

112. Gastrointest Endosc. 2004 Dec;60(6):894-900

113. Am J Gastroenterol 2008
• n-40
• SEPS for 4 wk (95%)
• Removal (94%)
• Follow up- 53wk
• 12 (40%) dysphagia
free

114. Migration 8 (22%)
Severe pain 4 (11%)
Bleeding 3 (8%)
Perf 2 (5.5%)
Inability to remove 2 (5.5%)
(Dua et al AJG 2008;103:2988)

115. 10 studies : 130 patients
FU 10 months
Overall success 52%
Migration 23%
(Repici APT 2010;31:1268)

116. Incidence 9%
Perforation 3
Trach compr 1
Gran tissue 2
Bleed 3
TOF 1
(Eloubeidi GIE 2011;73:673)

118. 21 patients : 62 stents
Migration : 64%
Prox : 68%
Distal : 70%
Mid : 30%
Tissue hyperplasia : 17%
Overall response : 18%
(Holm GIE 2008;67:20)

119. Completely covered even at flanges - Tissue reaction minimized
Special SEMS – Double covering both inside & outside

120. • Polyester
• Inner lining of silicone
• Upper and lower ends
smoothened with silicone
membrane
• REMOVED after 4+weeks

122. First use 1993 Cwikiel. 5 patients (Radiology 1993,
187,667)
Till 2009 : 12 studies: 168 patients : 50% achalasia
Uncovered 34: not removed
Covered 134: 18 not removed
Overall : Migration 14%
Tissue hyperplasia 17%
Long term data : 14/30 (47%) benefit

123. Two US centers: 35 pts. : 19 strictures
Alimaax stent : fully covered
Removed : ? In all 64 ± 74D
Migration 37%
Long term outcome : 21%
(Eloubeidi GIE 2011;73:673)

125. Granulation tissue 56%
Reactive hyperplasia 22%
Fibrosis 22%
(Eloubeidi GIE 2011;73:673)

126. Post-operative; China
Stent removal 8 weeks
12 mo FU : Response 66%
Recurrence 33%
Migration 1/29 stents
(Lie et al Dhsphagia 2012;27:260)

135. Ther Adv Gastroenterol (2013) 6(5) 365–370

136. Strength : 10,20,40 mg/ml
Strength dose used :
8 mg/ml - 1 study
10 mg/ml - 4 studies
20 mg/ml - 1 study
40 mg/ml - 1 study
Effective dose :
8 mg/ml - 1 study
10 mg/ml - 1 study
28 mg/ml - 1 study
40 mg/ml - 3 studies
80 mg/ml - 1 study

139. • Dead space of bougies
-Children
-Small stomach
-Multiple strictures
-Caustic gastric
involvement
-Anastomotic
-Location-small bowel.
colon

140. Bougie dilator
• Radial & shearing force
• Dilation “felt”
• Best suited for simple
strictures
Balloon dilators
• dilating force is radial
• Simultaneously over the
entire length
• Safer with multiple,
tortuous strictures

142. Outcome is worse for :
Patients with stomach involvement
Patients requiring more no of dilatations to reach 15mm
Multiple strictures required more dilatations to reach 15mm
Parameters which did not influence outcome
Site of stricture
Acid vs Alkali

144. Major success – 62.5%, Partial success – 19%Major success – 62.5%, Partial success – 19%