Sreeni Jonnalagadda, MD., FASGE Professor of Medicine, UMKC Director of Interventional Endoscopy Saint Luke s Hospital, Kansas City Peptic stricture Shtki Schatzki s ring Esophageal cancer Radiation therapy Esophageal surgery Eosinophilic esophagitis Caustic injury Iatrogenic PDT, EMR, sclerotherapy 1
Location Proximal strictures tur close to UES Length of stricture Cause of stricture Extent of transmural involvement Associated fistula Failure of traditional therapies Perforation 0.1% to 0.4 % Higher in more complex strictures tur Higher in radiation strictures Endoscopist experience (500 procedures) Br J Surg 1995;82:530-3. 2
Gastrointestinal Endoscopy 2009; 70:1000-1012 3
First reported in 1966 in the therapy of cutaneous scars cutaneous scars Intralesional steroids soften scars and keloids Technique triamcinolone acetate 40 mg/ml Dilute 1:1 with saline Inject with sclerotherapy needle in aliquots of 0.5 ml in 4 quadrants World J Gastrointest Endosc. 2010 February 16; 2(2): 61 68 4
Prospective randomized, double-blind study comparing steroid with sham injection in peptic strictures Patients maintained on PPI Phone followup at 1, 3, 6, 9 and 12 months 15 patients randomized to each group Strictures were dilated to 15-18 mm Am J Gastroenterol 2005;100:2419-2425 2/15 patients in steroid group and 9/15 in sham group required repeat dilation (p = 0.0209) Shorter time to repeat dilation in the sham group (p = 0.01) In patients with recalcitrant peptic strictures, steroid injection combined with acid suppression significantly ifi diminishes i i need dfor repeat dilation and average time to repeat dilation compared to sham injection and acid suppression. Am J Gastroenterol 2005;100:2419-2425 5
Schatzki s rings and esophagogastric anastomosis strictures following failure of standard therapy Electrocautery using a a needle knife Incise the stricture in 4 quadrants 6
Randomized trial of 62 patients with dysphagia secondary to anastomotic stricture after esophageal resection Savary dilation versus incisional therapy No difference in clinical success rates between the two groups at 6 months Conclusion: incisional i i therapy can be considered in refractory Schatzki s ring and anastomotic stricture but more studies are required. Gastrointest Endosc;70:849-55 7
SEPS FcSEMS 8
Intraprocedural: Complications of conscious sedation. Aspiration. Malposition. Esophageal perforation. Postprocedural: Chest pain. Bleeding. Tracheal compression and respiratory arrest. Delayed: Stent migration. Tracheoesophageal fistula. GERD, Recurrent dysphagia. Tumor ingrowth or overgrowth. Bleeding. Perforation and stent occlusion Self expanding plastic stents Approved for use in benign refractory r strictures tur Fully covered self expanding metal stents Off label use No assembly required Ease of deployment Ease of removal Use of partially covered and uncovered stents is not recommended 9
10 studies, 130 patients with refractory or recurrent benign esophageal strictures treated with SEPS Median follow-up 13 months (range 6-23 months) Technical success 128/130 Clinical i l success in 68/128 (52%) Aliment Pharmacol Ther 2010;31:1268-1275 10
Success was lower in upper esophagus Early stent tmigration in 19 (23 %) Post endoscopic reintervention in 25 (21 %) Fatal bleed (1), tissue overgrowth (2), perforation (3) Relatively high migration rate and need for reintervention! Aliment Pharmacol Ther 2010;31:1268-1275 11
31 patients: 15 leaks, 9 refractory strictures, 4 anastomotic strictures, 3 radiation induced strictures 30 Wallflex stents 12 Bonastent and 1 Evolution Migration was seen 3/19 (15.8 %) stricture patients, and overall migration in 25.6 %. All strictures resolved in this retrospective series. Gastrointest Endosc 2011;74:207-211 12
214 patients with benign esophageal disease Refractory r strictures tur 492% 49.2 Fistulae 49.8 % 52 % FCSEMS; 28.6 % PCSEMS; 19.5 % SEPS 329 stent extractions 35 (10.6 %) procedure related adverse events 7 major events: PCSEMS: embedded, esophageal avulsion, stent fracture, perforation (3), SEPS: fistula Gastrointest Endosc 2013;77:18-28 13
Endoscopic clips Endoluminal lsuturing 14
15
18 patients underwent 21 endoscopic suturing procedures to anchor SEMS 19 previously placed metal stents: 14 (74%) migrated at median of 19 days. 1-5 interrupted 2-0 polypropylene sutures Technical success rate 100 % Despite suture fixation, stent migration occurred in 7/21 (33%) No association between number of sutures and migration rate Fujii et al. Gastrointest Endosc 2013 16
For complex strictures in patients with existing PEG tube consider retrograde access to allow passage of a wire across the stricture followed by antegrade dilation. 17
Consider size of stent being placed Are you crossing the LES? Reflux precautions Uncovered, covered, partially covered Antireflux valve 18
Best to use a proximal release system Deploy under direct endoscopic and fluoroscopic guidance Airway compression Options remove stent place smaller caliber stent consult interventional pulmonologist for simultaneous endotracheal/bronchial stent 19
Retrospective analysis of 23 patients undergoing circumferential ESD for esophageal cancer in Japan Balloon dilation alone (13) or dilation plus 30 mg oral prednisoloe daily (10) Steroid + EBD required fewer sessions ans shorter management period :13.8 versus 33.5 P<0.001 001 Early steroid therapy may impact collangen deposition and fibrosis which occur 3-7 days after injury. Gastrointest Endosc 2013;78:250-7 Two animal studies evaluating ability to prevent esophageal stricture following circumferential EMR and ESD Fabricated autologous epidermal cell sheets isolated from oral mucosa and seeded on cell culture inserts Extracellular matrix scaffold from porcine urinary bladders Prevented esophageal stricture formation in the short term Gastrointest Endosc 2009;69:289-96 Gastroinetst Endosc 2012;76:873-880 20
21