This document discusses the management of cervical esophageal anastomotic strictures. The most common cause is gastroesophageal reflux disease. Evaluation includes ruling out other potential causes through history, barium swallow, and endoscopy prior to dilatation. Dilatation can be done using bougie or balloon dilators in 1-3 sessions. Refractory strictures may require intralesional steroid injection, temporary stenting, or surgery such as patch stricturoplasty using local or free flaps to repair the stricture. The radial forearm free flap is an option that avoids the morbidity of laparotomy and provides a thin, well-vascularized tissue for repair.

1. Management of cervical
esophageal anastomotic stricture
Zeeshan

2. Introduction
• Most common etiology:
GERD (75%)
• Other causes:
- Caustic ingestion
- External beam radiotherapy
- Surgical anastomoses
- Rare dermatological diseases eg.
Epidermolysis bullosa

3. Rare causes
- Extrinsic compression of esophagus
• Tuberculosis
• Idiopathic fibrosing mediastinitis
• Eosinophilic esophagitis
- Dilatation associated with mucosal tearing and
perforation

4. Goal of therapy
• Relief of dysphagia
• Prevention of stricture recurrence

5. Evaluation prior to dilatation
• H/O
Dysphagia
D/D
• GERD
• Motility disturbance
• Infection
• Malignancy
• Esophageal webs/rings

6. PRIOR TO ENDOSCOPIC
DILATATION ALWAYS RULE OUT
OTHER CAUSES

7. Investigations
• Barium swallow

10. AFTER CONFIRMATION
PROCEED TO ENDOSCOPIC
DILATATION

11. Contraindication for dilatation
• In acute or incompletely healed esophageal
perforation
• In potentially malignant stricture
• Patients with pulmonary /cardiac risk factor
• EXTREME CARE in cervical deformity/ thoracic
aneurysm/ recent surgery
• Eosinophilic esophagitis

12. Types of esophageal dilators
Mechanical dilators
• Bougie dilators
Balloon dilators

13. Mechanical dilators
• Divided into 2 types:
1. Those that pass freely
2. Those that are inserted over guidewire

14. Maloney dilators
•
• In USED to be
• filled with Hg.
• Tungsten used

15. Savary-Gillard dilators

16. Balloon dilators
• 2 types
1. Through the scope dilators (TTS)
2. Over the guidewire dilators (OTW)

18. Therapeutic approach
• Simple strictures:
- Related to prolonged reflux
- Short segment
- Scope can be passed easily
- Maloney dilators can be safely used

19. • Complex strictures:
- Long narrow and tortuous
- Scope cannot be passed easily
- Stricture associated with hiatal
hernia/esophageal diverticula

20. Technique

21. Number of dilatations per session
• Bougie dilators
- No more than 3 dilatations per session
- Lumen french should not be increase by > 6Fr
• Ballon dilators
- No more than 3 incremental inflations
- Very tight or long strictures- 2 dilatations per
sitting

22. Frequecy of dilatation
• Depends upon
1. Success of initial dilatation
2. Response of patient to initial dilatation

23. • Pt undergoing dilatation fr 1st time – required
multiple sittings once every 5-6 days
• Last dilator used in previous session to be
passed 1st.

24. End point of dilatation
• Dilatation to 18mm (56 Fr) – Solid diet
• Dilatation to 13mm (39Fr) – Dysphagia to
solids
• Dilatation to 15mm (45Fr) – Soft solids

25. Refractory strictures
• Patients FAILING to respond to esophageal
dilatations
• Poor candidates for surgical repair

26. Other methods
1. Intralesional injection of steroids
2. Non-metal stents
3. Metal stents
4. Other methods

27. Intralesional injection of steroids
• Injection of triamcinolone MAY reduce
stricture recurrence
• MOA
Corticosteroids MAY impede collagen
deposition and enhance its breakdown locally
to prevent scar formation

28. Non-metal expandable stents
• Temporary placement of non-metal
expandable stents- effective in management
of benign strictures
• Stent: Silicon coated self expanding plastic
stent

30. • To be left in place for 6 weeks to allow
remodelling of scar tissue
• Longer time required for anastomotic
strictures
• Problem: Stent migration

31. 11 Patients with anastomotic stricture following
esophagogastrectomy.
• Stent placed for ALL patients
• ALL patients had satisfactory relief of
dysphagia
• Recurrence of symptoms after stent removal –
23% patients
• Mean time for repeat dilatation/stent
reinsertion- 37 days
• Clinical outcomes after self-expanding plastic stent placement for
refractory benign esophageal strictures.
• Oh YS, Kochman ML, Ahmad NA, Ginsberg GG

32. • Largest study conducted
40 patients with refractory benign esophageal strictures
treated with Polyflex stent x 4 weeks
• Median dysphagia score improved
• Follow-up after 1 year – 40% dysphagia FREE
• Complications included:
- Stent migration
- Severe chest pain
- Bleeding
- Perforation
- GERD
- Stent impaction
- Fistula formation

33. Others
• Injection of Mitomycin
• Endoscopic electrosurgical incision of peptic
ulcer

34. Surgery

35. Post- esophagogastrectomy strictures
• Following esophagogastrectomy – Benign
esophageal stricture 40%
• Association:
- Anastomotic leak
- Inadequate/ marginally adequate blood flow
to most cranial part of gastric tube

36. • Strictures usually respond to endoscopic
dilatation
• If NOT responding:
- Resection
- Transection
- Patch repair of stricture

37. TO RE-ESTABLISH GI CONTINUITY

38. Options available
• Colon interposition
• Mobilisation and advancement of stomach
and reanastomoses
• Free jejunal graft
• Patch stricturoplasty

39. Patch stricturoplasty
1. Staged flap
2. Myocutaneous flap
3. Free flap

40. Staged flaps
• Wookey’s cervical skin flap
• Bakamjiam’s deltopectoral flap

41. Myocutaneous flaps
• Pectoralis major myocutaneous flap
• Latissimus dorsi myocutaneous flap
• Platysma myocutaneous flap

42. Platysma myocutaneous flap
• Arterial supply: Submental,
• Facial A., Sup. Thyroid A.
• Occipital A., Tr. Cervical A.
• Venous drainage: IJV,
• Submental V.

43. Platysma myocutaneous flap

44. • Failure rate – 40%
• Leak rate - 10.7 %
• Restenosis rate – 7.1%
• Platysma Myocutaneous Flap for Patch Stricturoplasty in Relieving Short
and Benign Cervical Esophageal Strictur Yi-Dan Lin, MD, Yao-Guang
Jiang, MD, , Ru-Wen Wang, MD, Tai-Qian Gong, MD, Jing-Hai Zhou,MD

45. Advantages
• Less bulky compared to PMMC/ LD flap
• Local flap – morbidity of laparotomy avoided
• Leak rate and restenosis rates lower
• Early enteral nutrition can be intiated through
NG tube

46. Disadvantages
• Cannot motivate peristalsis

47. Free flaps
• Radial fore-arm free flap

48. Radial fore-arm free flap
• Fasciocutaneous flap
• Based on Radial A. and its vena commitantes

49. Advantages over jejunal free flap
1. Does NOT require laparotomy to harvest
2. Pedicle is LONG – giving surgeons the use of
several feeding vessels
3. NOT bulky
4. Mucosa DOESNOT secrete mucus

50. Study
• 5 men and 1 woman
• Age between 24- 60 years
• Between 1993 – 1996
• All patients had esophageal replacement for non-
malignant disease
• All had failed multiple esophageal dilatation
• 1 patient 6 weeks post esophagogastrectomy had
a persistent leak with necrosis of 60% of proximal
stomach – NOT septic

51. Procedure
• RFFF was harvested from non-dominant arm
unless Allen’s test was positive
• Stricture was transected in longitudinal direction
of esophagus and stomach and patch applied
• Size of graft 5x8cm to 5x12cm
• Length of graft 8 – 12cm

52. RFFF

53. • Treatment was accomplished through NECK
incision in 5 patients
• Thoracotomy and neck incision in 1 patient
• In patients with VC palsy on the side of the
previous incision (2 of 6) – SAME side used
• Patients with no VC palsy – Opposite side used

54. • Graft sewed using single layer interrupted
technique
• Revascularised using microvascular technique
• Artery – anastomosed to Facial A./Inf. Thyroid
A./ Transverse cervical A.
• Vein – anastomosed to IJV

55. • Follow-up
3/12 interval for 1 year
Yearly intervals after that

56. Results
• 1 patient developed LEAK from graft stomach
anastomotic site ---POD 8
• Exsanguinated from venous anastomoses of
patch graft ---- POD 12
• Postmortem – GRAFT was viable.
• ONLY patient to be treated in ACUTE phase of
illness

57. • Other 5 patients – normal diet within 4 -6
weeks of surgery
• NO anastomotic leaks
• 1 patient developed narrowing of distal
anastomoses of tubularised graft—Dilatation
• ALL patients could eat solid food– 7 years
follow up

58. • When one is confronted with the rare problem of
a stricture or persistent fistulae from the cervical
esophagogastrectomy anastomosis, we would
recommend the use of the radial forearm flap to
patch this anastomosis.
• Use of the radial forearm free tissue flap to treat persistent
stricture after esophagogastrectomy
• Clifford W Deveney, M.D.a, , Scott Soot, M.D.a, Blair Jobe, M.D.a, James I
Cohen, M.D.a, Peter Anderson, M.D.a, Mark K Wax, M.D.a, Michael
Wheatley, M.D.a, Brett C Sheppard, M.D.a