44: Techniques for Dilation of Benign Esophageal Stricture

Introduction

Benign strictures of the esophagus usually result from scarring and subsequent tissue contraction secondary to esophageal wall injury. This pathology is caused in most cases by long-standing gastroesophageal reflux disease (GERD), often in association with one of the esophageal motility disorders (e.g., achalasia, diffuse esophageal spasm, or aperistalsis).^1,2 Endoscopic dilation of benign esophageal strictures that are refractory to medical management is a less morbid alternative to surgery. Approximately 20% to 30% of cases are unrelated to GERD, and their treatment usually is more challenging. Examples include strictures arising from complications of surgical anastomosis,³ injuries caused by caustic ingestions, early and late consequences of external-beam radiation, esophageal sclerotherapy, laser or photodynamic therapy, medication- or pill-induced esophagitis that is associated with numerous medications (e.g., alendronate, ferrous sulfate, nonsteroidal anti-inflammatory drugs, phenytoin, potassium chloride, quinicline, tetracycline, and ascorbic acid) but most often aspirin, and rare dermatologic diseases, including epidermolysis bullosa dystrophica, among others.

Benign strictures also may result from external compression of the esophagus caused by mediastinal fibrosis induced by tuberculosis, fungal infection, radiation therapy, or idiopathic fibrosing mediastinitis. These conditions may give rise to long, narrow strictures that are difficult to dilate and in which dilation may be associated with a higher rate of complications.

Clinical Presentation

Dysphagia is the most common presenting symptom of benign esophageal stricture. The degree of dysphagia is proportional to the scope (e.g., length) of the stricture and the luminal diameter of the esophagus (<13-mm diameter is associated with dysphagia to solids, >18-mm luminal diameter for normal swallowing). As the stenosis worsens over time, the dysphagia progresses from solid to semisolid to liquid foods. The etiology of the esophageal stricture usually can be identified using radiographic modalities and is confirmed by endoscopic visualization and tissue biopsy. Manometry is the defining diagnostic procedure when esophageal dysmotility is suspected as the primary inciting process. CT scan and endoscopic ultrasound are valuable diagnostic aids that can distinguish benign from malignant strictures. Fortunately, most benign esophageal strictures are amenable to single or combined pharmacologic, endoscopic, or surgical intervention.

Management

The goal of therapy for benign esophageal stricture is twofold: to relieve the patient's dysphagia and to prevent recurrence of the stricture.⁴ Conservative and surgical approaches to management are recommended depending on the etiology of the inciting injury. Surgical and medical issues related to esophageal dilation in patients with primary esophageal motility disorders are discussed in Part 4 (see Chapter 33). Medical and surgical issues related to GERD are the topic of this part and are summarized in the Overview (see Chapter 37). This chapter focuses on surgical instrumentation and techniques for the less common or complex benign esophageal stricture.

Diagnosis

Dysphagia is the cardinal symptom of esophageal stricture. In most cases, when a stricture is suspected, the patient is evaluated radiographically with a barium swallow. The goals of this ...