Difficult Esophageal Strictures. Disclosures

Transcription

1 Difficult Esophageal Strictures John A. (Jerry) Evans, MD Ochsner Medical Center New Orleans, LA Disclosures Prior Consultant: Cook Medical Pentax America 1

2 Format Review of Dilation Options Definition of the Difficult Stricture refractory vs recurrent complicated stricture Review Adjunct Techniques Steroid injection Incision SEMs 3 Key aspect Succesful resolution of esophageal stricture will be aided by healing (after dilation) in a mileu of minimal oxidative stress and maximal ph. i.e.,stop smoking, stop NSAIDs, use PPI s PPI s are better than H2 blocker Smith et al Gastro 1994 NSAIDs are related to a increased risk of esophageal stricture El-Seraq AmJ of Gastro

3 Stricture characteristics and treatment planning Anatomy: SIMPLE COMPLEX Length Short (<2cm) Long (>2cm) Angulation Straight Tortuous Diameter Large, >12mm Small, <12mm Causes Webs, rings, peptic Caustic, XRT, post-op Response to standard dilation Good Difficult, high recurrence ASGE Standards of Practice Guideline GIE 2014 Does fluoroscopy make dilation safer or more effective? Study Hernandez et al. GIE 2000 Outcome Review of Maloney, Savary, balloon (n=348) 4 perfs in 102 Maloney dilations (3.9%) Attributed to blind passage into complex stricture McClave et al. GIE 1996 McClave et al. GIE 1990 Rand. trial- fluoro vs. blind Maloney (n=100) Passage of 12.5mm barium pill (62% vs. 42%, p=0.045) Symptom improvement (93% vs. 69%, p=0.006) Rand. trial- fluoro vs. blind Maloney (n=162) Higher success rate (96% vs. 80%, p<0.05) Lower adverse events (5.4% vs. 11.3%, p=ns) Higher recognition of AE (100% vs. 20%, p<0.05) 3

4 Standard treatment: esophageal dilation Dilator Type Material Wireguided Fixeddiameter, taper-tip, push-type (Bougie) Maloney and Hurst (Medovations, Milwaukee, WI, Teleflex Medical, RTP, NC) Savary-Gilliard (Wilson- Cook, Winston-Salem, NC) American Dilation System (ConMed, Utica, NY) Flexible rubber, tungsten or mercury weighted in older Tapered, PVC, radio-opaque marking Tapered, PVC, radio-opaque throughout Balloons Many manufacturers Non-latex, many sizes / lengths No Yes Yes +/- (TTS and over-wire) Reuse Yes Yes Yes No ASGE Tech: Tools for endoscopic stricture dilation 2013 Esophageal dilation: rigid or balloon? Largest randomized trial comparing dilation type stratified for stricture etiology (peptic vs. Schatzki) and severity (n=88) Savary (n=163) Balloon 1-year incidence of repeat dilation 9% 12% (NS) Major procedural complications None None Patients dilated from 15-17mm, clinically followed, and re-dilated for worsening dysphagia. Scolapio et al. (Mayo Clinic). Gastrointest Endosc

5 Dilation: Rule of 3 s Initial dilator based on estimate of stricture diameter After 1st resistance no more than 3 additional 1mm incremental dilators during a single session rule may not strictly apply to balloons Goal: achieve patent diameter > 14mm ASGE Standards of Practice Guideline GIE 2014 Non adherence does not increase adverse events Grooteman et al GIE 2017 Bougie Originally a term for a wax candle made in Bugia, Algeria a town with a long standing wax trade in the 1700 s. Previous Bougies were made of waxed silk or cotton rolled cylindrically. The term used because the dilators were of similar shape to a candle 10 5

6 Defining the Difficult Stricture Refractory vs recurrent stricture:...the inability to successfully remediate the anatomic problem to a diameter of 14mm over 5 sessions at 2 week interval (refractory) or as a result of an inability to maintain a satisfactory luminal diameter for 4 weeks once the target of 14mm has been achieved (recurrent) Kochman GIE (3) Adjunctive treatments for difficult strictures Steroid injection Incisional therapy Removable esophageal stents (SEMS) 6

7 Steroid injection: reported techniques mg triamcinolone typically come in 40mg/ml can be diluted to increase the volume flush needle with sterile saline 4 quadrant injection: Into, above, and/or below Pre vs. post dilation: Larger series performed Pre-dilation Corticosteroid injection Triamcinolone injection- concept arose from dermatologic applications Inhibition of inflammatory response Decreased production of fibrous tissue and collagen deposition Case series and comparative trials suggest: Longer dilation-free intervals Decreased number dilations Lee GIE 1995, Kochar GIE 2002, Altintas J Gas Hep 2004 Mayo clinic trial Ramage AJG pts, hx of > 1 dilation for peptic stx, rand. double-blind trial (min 1-yr f/u) 15 steroid + dilation 15 sham + dilation Findings: Repeat dilation- 13% vs 60% Time to repeat dil- longer in steroid group 7

8 Electrosurgical incisional treatment of refractory anastomotic stricture Incisional treatment of difficult esophageal strictures Study N Treatment Success Burdick (Wisc.) GIE 1993 Schubert (Germ) Surg Endosc 2003 Hordijk (Neth) GIE Electrosurgical incision 15 Electrosurgical incision + APC 62 Electrosurgical incision 100%, 1 recurrence 92% Randomized, Inc vs BD, equivocal Kochman (Penn) GIE Mechanical incision (endo scissors) yes Gonzalez (Boston Dis Esoph Mechanical disruption (forceps) yes 16 8

9 Incisional Treatment of Refractory Anastomotic Stricture 17 Removable self-expandable stents for refractory esophageal strictures (1)Temporary esophageal stenting: similar concept to interval plastic stents following biliary stricture dilation (2)Temporary indwelling stent allows stricture remodeling around larger, post-dilation diameter Self-expandable plastic stent (SEPS) for refractory anastomotic stricture 9

10 History of Stent In the 19 th century dental impressions were made with bee s wax and plaster of Paris Edwin Truman in 1847 added gutta percha (rubber) but it still performed poorly 1856 a dentist added stearine (animal fat) and talc to the gutta percha and the stability and plasticity of dental moulding improved significantly Charles Stent, DDs 10

11 Stents In WWI a Dutch surgeon working in Austria used Stent s compound as an aid for orbital, otic and other facial reconstruction efforts. Stent appeared to then become a term for stretching and fixing a structure to a frame. Song (Korea) Radiol 2000 Temporary stenting for benign refractory strictures Study Patients Stent 25 Investigator- made, fully-covered SEMS Evrard (Belgium) GIE SEPS Radecke (Germany) GIE SEPS Repici (Italy) GIE 2004 Holm (Mayo) GIE SEPS 25 (61 stents-5-yr) SEPS 11

12 Outcomes of temporary stenting Study Outcome Complications Song % success - mean f/u 13mo Stents removed mean 3-wk (plan was for 8-wk) Migration- 12% Pain (stent removal)- 20% Tissue hyperplasia- 48% TE fistula- 4% Evrard 2004 Radecke 2005 Repici % success- median f/u 23mo Stent removed 6wk-12mo 5/6 (83%) success: f/u and stent removal unclear as study included other indications (benign and malignant) for stent placement Prospective series: 80% long-term success (mean f/u 23 mo) Stent removal 6-wk Migration- 50% Migration- 21% Hyperplasia- 13% Fistula- 5% Migration- 7% (1 patient) Pain - 33% Mild-mod hyperplasia- 27% Holm % of patients with long-term success Migration- 62% Pain- 26% Hyperplasia- 17% SEMS 2016 retrospective study 70 patients with benign conditions Suzuki J Clin Gastro % Success rate for strictures 40% migration rate 24 12

13 Enthusiasm is waning 2016 review and meta-analysis of 18 studies (444 patients) Fuccio Endoscopy 2016 All benign strictures Using SEMs, SEPs, biodegradable Pooled success 40%, adverse event 20%, no stent was better 25 Does anchoring help? Means Study Results Clips OTS clip Suture Vanbiervliet (Surg End 2012) Mdumbi (Endoscopy 2014) Sharaiha (J Cl of Gastro patients- all 3 migrations (13%) 12 patients-benign 2 migrations (17%) 37 patients-benign 17 sutured (11%) 20 not (55%) 26 13

14 Apollo suturing 27 Thank you 28 14