Treatment Options for Esophageal Strictures

Summary and Introduction

Summary

Esophageal strictures are a problem commonly encountered in gastroenterological practice and can be caused by malignant or benign lesions. Dysphagia is the symptom experienced by all patients, regardless of whether their strictures are caused by malignant or benign lesions. The methods most frequently used for palliation of malignant esophageal strictures are stent placement (particularly in patients with an expected survival of 3 months or less) and brachytherapy (in patients with a life expectancy of more than 3 months). Brachytherapy has been shown to be beneficial in patients with an expected survival of longer than 3 months with regard to (prolonged) dysphagia improvement, complications and quality of life. The mainstay of benign esophageal stricture treatment is dilation. Although dilation usually results in symptomatic relief, recurrent strictures do occur. In order to predict which types of strictures are most likely to recur, it is important to differentiate between esophageal strictures that are simple (i.e. focal, straight strictures with a diameter that allows endoscope passage) and those that are more complex (i.e. long (>2 cm), tortuous strictures with a narrow diameter). These complex strictures are considered refractory when they cannot be dilated to an adequate diameter. Novel treatment modalities for refractory strictures include temporary stent placement and incisional therapy.

Introduction

Esophageal strictures are a problem frequently encountered by gastroenterologists, and they can be subdivided into those with a malignant origin and those with a benign origin. Malignant esophageal strictures are mainly caused by primary esophageal cancer, but can also be caused by extraesophageal malignancies that compress the esophagus. More than 50% of patients with esophageal cancer have incurable disease at presentation because of metastases, locally advanced disease or their poor medical condition. Most of these patients require palliative treatment to relieve dysphagia.^[1] The most common causes of benign esophageal strictures include peptic injury, Schatzki's ring, esophageal web, radiation injury, caustic injury and anastomotic strictures. In particular, strictures caused by radiation or caustic injury and anastomotic strictures are the most resistant to endoscopic dilation, which is the customary treatment modality.^[2]

Upper endoscopy is the diagnostic procedure of choice for the detection of an esophageal stricture and its underlying cause. Nevertheless, it is mandatory that biopsy samples are taken to confirm whether the stricture is benign or malignant in nature, particularly if the suspicion of malignancy is high. Most treatment options available for the relief or treatment of dysphagia can be performed endoscopically.

This article reviews the modalities available for the treatment of dysphagia in patients with malignant or benign esophageal strictures. Stateof- the-art techniques, such as stent placement for malignant strictures and dilation therapy for benign strictures, are discussed, as are new developments, such as intraluminal radiation therapy (brachytherapy) for malignant strictures. New indications, such as temporary stent placement and incisional therapy for refractory benign strictures, are also considered.