As you can see, this topic is quite a big one, and not only is it a daunting task to discuss all these topics in one lecture, but these are quite clinically challenging entities, and they can be difficult to treat, especially because there are no dedicated and definitive management guidelines. So for the purpose of my talk today, I'm going to just try to provide you with an outline of how I like to approach these lesions and what are the various endoscopic options that are available. We'll start with esophageal strictures. I think it's really helpful to divide your strictures into two major categories. First, you have the simple category, which is what you'll probably encounter most commonly. Those strictures are short, straight, and I say they're not too tight, meaning that a standard diagnostic endoscope, which is about 9 to 10 millimeters in diameter, can pass through the stricture. This simple category includes peptic strictures, Schottky's rings, strictures that are pill-induced or related to ablation therapy. In contrast, you have complex strictures. As the name implies, these are more involved. They're longer, typically more than 2 centimeters in length, angulated, multifocal, and severe in terms of tightness. The scope cannot get through them. We see these with aggressive endoscopic resections, caustic ingestions, radiation therapy, EOE, and after esophagectomy, we can see anastomotic strictures. Now these can sometimes turn into refractory strictures. In fact, 10 to 15 percent of all esophageal strictures will become refractory. And I think it's important to think about what that means. Mike Coachman published in 2005 a pretty useful definition where he defined a refractory esophageal stricture as a situation where you have luminal compromise or fibrosis that causes dysphagia in the absence of inflammation because PPI therapy, in theory, could perhaps reduce inflammation. The inability to get to 14 millimeters over 5 sessions at 1 to 2-week intervals or the inability to maintain 14 millimeters for 4 weeks once you've dilated to that diameter. And the key here is that 14-millimeter number. That diameter allows the patient to swallow solids and not complain of dysphagia. So keep this in mind when you're thinking about your dilation therapy. In terms of endoscopic treatment, again, dilation is going to be the mainstay of therapy. The good news is that most simple strictures can be palliated in just a few sessions, typically less than 3. But once you start talking about complex or refractory strictures, you know going in that this is going to take a higher number of sessions. All of you know that there's two major types of dilators available. There are the bougie dilators and the balloon dilators. I tend to like the wire-guided versions of both. Now, is one type of dilator better than the other? And the answer is not that it's been shown in the literature. There's no safety or efficacy advantage between either type. In fact, stricture dilation in general has less than a 1% chance of perforation. Balloon dilators are great, especially if you have a short single stricture. They're easy to use. And for me, I like to see the dilation under direct vision. But there are a few instances where I prefer bougie dilators, and that's when you have a very high proximal esophageal stricture, a stricture that's multifocal, or a long stricture where you want to dilate the entire length of the esophageal lumen. When I'm thinking about performing a dilation, in the back of my mind, I always keep that 14-millimeter number in my head. So if I want to achieve 14 millimeters long-term, you have to overshoot a little bit during your dilation, and I try to aim for 16 to 18 millimeters, but that's not always possible in one session, and it may take a few. So you think about a couple things. What size dilator do I start with? And that is an estimate that I base on the relationship of my stricture diameter to the size of my scope and if my scope can pass through the stricture. Again, if it's a standard scope, a diagnostic scope, that'll be 9 to 10 millimeters. If I can't get through the stricture, I'll downsize to an ultra-thin scope, which has a diameter of 5 to 6 millimeters, and gauge my dilation size from there. And I like to use guide wires if I cannot get through a stricture. How do you know when to stop dilating during a procedure? I'm always looking for mucosal disruption. If I use a Bougie dilator and I feel significant mucosal resistance, I prefer to pass the scope again and look at the mucosa for that tearing. If I do a balloon dilation, I can do it under direct visualization. And this is just an example of an anastomotic stricture that I was dilating. I went up to 18 millimeters, and now you can see I clearly caused some mucosal tearing. I always inspect my dilation site. There was no perforation here. So now I know this is the time to stop. Now my repeat session interval is going to depend on the etiology of the stricture. If I have a tough stricture like this that's refractory, I am going to follow those original guidelines that I mentioned. I'm going to bring that patient back every week for up to five sessions. Because again, the tendency is for the stricture to close down again. So you want to kind of hit it very hard up front. If I have a Schottky's ring, then that patient, once I dilate them, I just tell them, you know, call me if your symptoms recur. Steroids are a great adjunct therapy. They're cheap. They're very easy to inject. And there is some data that suggests that it can be helpful. So my answer is always, if you want to inject steroids, why not go ahead and do it? I would avoid its use with radiation-induced strictures because there are case reports of fistula formation. Incisional therapy is another endoscopic option that has shown some benefit in very limited case series. I will say in our center, our experience has been mixed in terms of getting long-term stricture resolution. But it is another option to try. And that leads me to our last treatment option, esophageal stents. There are different types of esophageal stents available. In the U.S., the type of stent that we use most commonly are the self-expandable metal stents or SEMS, although these are not FDA-approved for benign esophageal disease or removal. In terms of the types of metal stents that you can place, we tend to use fully covered metal stents. Because of the coating, they're very easy to remove later on, which is what you want in a benign condition. But the downside is that that coating also makes them very easy to migrate. And some studies suggest up to 50 percent migration rates. So in order to decrease the migration rate, some people like to place partially covered stents because you have tissue ingrowth into the uncovered portions of the stents on the ends. But then the problem there is that you might embed the stent, and then you can't remove it later on. Both types of coated stents, especially with long-term placement, can cause fistula development. You can get tracheal esophageal fistulas and aorta esophageal fistulas. Most of the esophageal stents are deployed over a guide wire, but one can be deployed under direct vision with a therapeutic channel endoscope. If you look at the outcomes for stent use in refractory esophageal strictures, the overall success rates are not great. You can probably achieve up to a 50 percent resolution long-term. Adverse events include, again, the fistulas, and having prior radiation is a risk factor for development with stent placement. The use of partially covered stents has been shown to be a risk factor for adverse events overall. This is just a video showing how I like to place esophageal stents. You pass a guide wire down, exchange off your endoscope, and then I start deploying the distal end of the stent under fluoroscopic guidance. I pass a scope next to the stent catheter so I can watch the proximal end deploy under direct vision. And then I do always place two sutures at the proximal end of the stent to decrease migration rates. And again, there have been a couple retrospective series that have shown that suturing does have some benefit. So I tend to follow the European Society stenting guidelines for stent therapy in refractory strictures. I use fully covered stents. I leave them for about three months, and then my preference is to suture them. Moving on to esophageal fistulas and leaks, I think it's important to define what these issues are up front and also to contrast them with perforations. Now perforations are acute, full thickness defects in the GI tract wall. Typically the surrounding mucosa around the defect is normal. You can see these as an adverse event from endoscopy or spontaneous rupture with Borhoff syndrome. This is in contrast to a fistula, which occurs over time. It's a chronic condition. You see it with tracheoesophageal fistulas from malignancy or from radiation. But typically the mucosa here is going to be very fibrosed or ulcerated. Now leaks are a postoperative event where you have a defect in your surgical anastomosis. We see these after esophagectomies or in the proximal esophagus and also near the G-junction after bariatric sleeve surgeries. Now here the integrity of the esophageal mucosa is going to be dependent on how quickly you make the diagnosis and initiate treatment. But the overall teaching point is that success of your closure attempt is going to be dependent upon early recognition and the condition of the esophageal mucosa. The healthier it is, the better your outcome. Now primary closure is with clips, whether they're through the scope or over the scope and suturing are best used for acute perforations, again, sealing that normal mucosa. They're not as helpful in fistulas and leaks where the surrounding mucosa may be abnormal. Now this was a perforation in the proximal esophagus, about 5-6 millimeters that was caused by, I'll say, my fellow passing an EUS scope. Now in the proximal esophagus, you might be a little bit tight for space. So this was a small defect, very high up. The decision was made to close it with through-the-scope clips. And you can see it's fairly easy to bring that tissue together. And with two clips, the perforation sealed. We got an esophagram afterwards and the patient did great without any further intervention. So again, with these leaks and fistulas, once your mucosa is fibrosed or ulcerated, the main goal of therapy is to divert GI secretions. You can try to prep the mucosa up front before you place stents. Sometimes we'll do APC. You can remove any foreign bodies like sutures or clips around the anastomosis. Then we place our metal stents. I mentioned already that I like to place sutures. If there's any issue of respiratory compromise, then you also want to consider placing a stent in the airway. And in some cases, as in this one where I had a patient with an esophagoplural fistula where you have an adjacent collection that you also want to drain, we sometimes use double pigtail plastic stents. Stent data in perforations, leaks, and fistulas, on first glance, looks pretty good. You can get to almost 80% success rates with stenting. But that includes 100% success rate with perforations. So if you separate out fistulas and leaks, your success rates go down to around 50%, which is what we saw with refractory strictures as well. And it highlights the difficulty in treating these patients. There's no difference between stent types that's been shown. And again, higher rates of success with shorter times to diagnosis and smaller defect diameters. In our search for more techniques and devices that can help us treat these difficult conditions, there have been case reports using other off-label devices like Fibrin Glue, EVAC therapy where you place a sponge into a wound cavity and attach it to a suction device, cardiac septal occluders for small diameter TE fistulas. All of these have been described in a few case reports. And so I'll end with my practice pearls. I think the most important thing is to know and recognize what type of lesion you're dealing with up front because that's going to determine how successful the outcome will be and how much effort you have to put into treating that condition. If you have a simple stricture or an acute perforation, you are going to see higher success rates with less number of procedures. But once you start dealing with refractory strictures, fistulas, and leaks, you know that you're going to need to perform multimodality therapy using some of the techniques that I already described. You're oftentimes going to have to involve your surgeons and your interventional radiologists to provide a multidisciplinary approach. But I think most importantly, you and your patient are going to have to have a lot of patience because you may be performing a number of procedures over many months. But hopefully, you might be able to achieve some success with a concerted effort and an individualized approach to each situation. Thank you.

esophageal strictures

dilation therapy

refractory strictures

esophageal fistulas

early recognition