So the talk is entitled, Treating Esophageal Strictures, Tips and Tricks of the Trade. Okay. So those are my disclosures. And again, so 50-year-old male, history of intermittent heartburn and regurgitation, resolving with over-the-counter antacids, presents with intermittent solid food dysphagia. He reports no change in appetite, weight loss, or GI bleeding. And this is what you see on his endoscopy. So for all the endoscopists out in the audience today, I think it's pretty clear this is a Schatzky's ring. And how do we manage Schatzky's ring? So the clue in the history is this history of intermittent solid food dysphagia. I think that's a good clue. And typically we know that treatment either with balloon dilation or with Bougie dilation is effective and safe. Unfortunately, the recurrence rates of Schatzky's ring, even after successful dilation is pretty high. So these are studies that have been published in the literature, 32% in one year, and almost 90% at five years. So almost universal recurrence. And some studies have actually looked at modalities to reduce recurrence. And one of the important studies in the literature showed that if you were to treat Schatzky's rings after dilation with proton pump inhibitors, you can actually reduce the rate of recurrence from 47% at 20 months to 7% at 37 months. So raising the question as to really, is this a sequela from unrecognized or untreated GERD? Of course, anytime you look for any cause of dysphagia, I would encourage you to always biopsy for EOE and obviously treat if present. Let's move on to case two. So this is a 50-year-old male with frequent heartburn and regurgitation for 10 years, uses only over-the-counter meds for control. Now with new onset of dysphagia, but with no weight loss, he's modifying his diet. And this is what endoscopy is showing. So again, going back to our first lecture where we talked about the Los Angeles classification of esophagitis, this is obviously more than 10 millimeters. It is straddling multiple gastric folds and it's definitely over 75% of the circumference. So this would be LA grade D esophagitis. So this is a peptic stricture. We don't see a lot of these anymore because of the widespread availability of over-the-counter H2 blockers as well as proton pump inhibitors, but we still periodically see some of these. And my approach to the management is to combine safe dilation, which provides some immediate relief of dysphagia with aggressive control of acid reflux with PPI. So in someone like this gentleman, I would suggest we would start with full dose, twice a day proton pump inhibitor therapy. We know that for erosive esophagitis, as Dr. Thotta just mentioned in her talk, the evidence of healing is stronger for proton pump inhibitors compared to H2 blockers. You obviously would assess response by following symptoms, in this case with the symptoms of reflux as well as with dysphagia. And as we alluded to before, the current recommendation, particularly in those with severe esophagitis, whether it be LA grade C or D, is to repeat an endoscopy in three months with two objectives. One is to confirm healing, and second is to look for any underlying barrets which could have been hidden by the extensive inflammation. And the recommendation we make in patients who have erosive esophagitis, particularly those with complicated GERD, would be to continue a PPI indefinitely. Now, what happens if you find that these peptic strictures are resistant to full dose PPI therapy? So in this instance, a steroid injection endoscopically was found to be helpful in a randomized control trial that was published out of the Mayo Clinic. Higher dose PPIs plus H2 blockers and of course, if your maximum medical therapy and the stricture is not improving or recurring, then one may have to consider surgical fundamentation. Let's move on to case three. So this is a 30 year old male who has intermittent solid food dysphagia for 15 years and presents to the clinic. He does have seasonal allergies. He did have a food impaction last week and in the emergency room, this resolved with the administration of glucagon. And this is what you see on endoscopy. So again, this should be no surprise, very typical findings of eosinophilic esophagitis, rings, furrows. Sometimes you might just see isolated esophagitis and we also talked about the need, even in patients who may have quote unquote, a normal endoscopy to biopsy the mid and distal esophagus looking for eosinophilic esophagitis. And here the biopsies did show eosinophilic esophagitis. The clues are the male gender, the younger age of the patient and then the history of dysphagia. So the treatment for eosinophilic esophagitis can really be summarized with the three Ds. The first is drugs. So proton pump inhibitors, as well as swallow topical steroids, both fluticasone, which is inhaled or oral budesonide has been shown to be very effective in randomized controlled trials. Diet therapy, stepwise four, or more recently even two food elimination diets might help. And then of course, something I'm going to talk about more in this talk is dilation. So when eosinophilic esophagitis was first described, many of these reports made their way into the literature that when you dilated patients with eosinophilic esophagitis with strictures, you have to be very careful about mucosal friability. You could get deep mucosal tears, even with smaller balloons and indeed pictures like these really scared a lot of endoscopists in terms of being careful with dilation, which in of itself is not a bad thing, but in some ways it made the overall approach to dilation and eosinophilic esophagitis somewhat challenging. Indeed, there were reports, these are early reports in GI endoscopy wherein 87% of patients being dilated, albeit this was a small group, had deep mucosal tears and there was extensive disruption of the esophageal wall in 80% of patients dilated as well. Things have changed since then and I think we have learned a lot in the intervening decades. And these are two meta-analyses that were published sort of close to each other, one in GI endoscopy in 2017 and one in APT, wherein the investigators looked at over 2000 dilations and came up with a very low perforation rate, less than half a percent. And I think this goes to show that dilation and eosinophilic esophagitis is one, safe if it is done in a thoughtful manner and second, it's an important part of the armamentarium that we have to use in these patients with eosinophilic esophagitis, particularly for symptom relief. So what are some principles or pearls that I think we should be thinking of in the endoscopic dilation of patients with EOE-related stricture? So first of all, I think you need to have a slow and steady approach, not too aggressive. I like to, if I'm using a balloon, which I tend to do more often in these patients, and I like this because I can do the dilation under vision, I like to look, deflate the balloon after each level of dilation to see the extent of damage that we are doing and the degree of dilation, and then I can stop. I would suggest that if you do a savory dilation, and I know many do this in the community, you should probably be looking after each or at least after every two levels of increase. I would stop after any significant mucosal disruption just because of the friable nature of the mucosa in these patients. It is also important to educate patients that chest pain is relatively common after dilation in eosinophilic esophagitis, and if you see a moderate amount of disruption after dilation, I would probably watch the patient carefully in the recovery room before being discharged and follow the principle of serial dilation, not being too aggressive in one session, and go through a relatively slow increase in dilator size. And the other important point I would make is to pair dilation with intensive anti-inflammatory medications or dietary therapy to achieve histologic remission. Only dilation alone in the absence of medical therapy to induce histologic remission is unlikely to be successful. So both of these have to be done in parallel. Let's go to case four. So this is a 65-year-old male. He has a history of CABG, severe COPD, underwent an endoscopy for persistent reflux. Long segment Barrett's C6M7. Distal nodularity was noticed, and histology showed high-grade dysplasia. So I'm just gonna show you a brief video of what we did. This was on white light endoscopy. And again, you can actually see the significant nodularity here. This is a Paris 2A lesion with maybe some superficial ulceration. And I will show you the narrowband imaging here as well in a minute. And essentially, we performed wide endoscopic mucosal resection. And you can see, this is the picture. Almost 50 or 60% of the esophageal circumference has been resected with band EMR in the station, removing the area of nodularity. So we did nine band EMRs to remove the entire area of nodularity, and ended up removing 50% of the esophageal circumference. So the first thing one needs to think of is what are some prophylactic measures to prevent stricture formation in this instance? So again, this is a different patient, where, as you can see, almost 360-degree EMR had to be performed to really get a good assessment of the histology. So in this instance, one measure that has been supported in the literature is actually to perform prophylactic steroid injection endoscopically. And I like to do this in a four quadrant fashion at the edges of the endoscopic resection site. And of course, another modality that has been shown to be effective in the literature is to place a fully-coated, self-expanding metal stent right after you finish the endoscopic resection. This is an example of a ESV we performed, and then we placed a fully-coated, self-expanded metal stent. And here, the proximal end of the stent is actually being sutured to hold it in place. So these are two modalities which can help you with reducing the odds of a stricture after extensive endoscopic resection. Now, the Japanese have also shown in randomized studies that oral prednisone can also be helpful in reducing the incidence of stricture. So not only does it reduce the incidence of the stricture, but even if a stricture were to happen, the severity of the stricture in terms of its luminal diameter and its response to therapy to dilation is also reduced. So this patient was left with a C3M6 segment. He still had persistent dysplasia and the residual flat Barrett's mucosa, and we ended up performing circumferential radiofrequency ablation. And again, these are just some pictures that I have for you. This was the residual Barrett's. This is a balloon being deflated, and this is what the mucosa looks like after we performed circumferential radiofrequency ablation. So three weeks later, the patient develops progressive solid food dysphagia. He has no dysphagia or dynophagia, and he is having recurrent food impactions. And this was the endoscopy of the patient. And again, you can see this stricture, which is precluding the passage of the endoscope with significant amount of scarring. So I would estimate the luminal diameter of this stricture to be perhaps between eight and nine millimeters. So again, Barrett's endotherapy is another common cause of stricturing and after radiofrequency ablation. The literature has reported rates for anywhere from five to 14%. And the risk factors of stricturing after Barrett's endotherapy are pre-RFA endoscopic resection, a preexisting stricture that had to be dilated to allow the endotherapy. If you have longer segments of Barrett's, which means you have to do multiple treatments, and then the modality of treatment might also play a role. PDT, which is no longer being done today widely, had a very high stricture rate of almost 33%, followed by radiofrequency ablation. And cryotherapy has been shown in many studies to have a lower risk of stricture formation. NSAIDs as well as smoking have been shown in some studies to increase the risk of stricture formation as well. Now, the good news is that with radiofrequency ablation, at least if you look at the literature, you only need a median of two dilations to resolve the stricture. This may be a little higher or a little lower depending on the severity of the stricture. So my approach to the management of these post-endotherapy strictures is to perform aggressive dilation. And I like to, in this instance, unlike EOE, I like to prefer the use of a savoury over a balloon dilation. And the reason I like this is because unlike a balloon, which provides more radial force, a savoury or any bougie dilation is going to provide you with not only radial force, but also longitudinal shearing, and it can actually help you treat longer lengths of a stricture. So my regimen for these fibrotic inflammatory strictures is fairly aggressive, up to twice a week for a week or two, and then down to once a week for the next couple of weeks, and then once every other week for the next couple of weeks. I continue this till the lumen size is maintained between dilations. And I like to see a luminal diameter anywhere from 13 to 15 to 16 millimeters before I know that I'm making enough progress. Now, steroid injection, as I showed you in a prophylactic setting, might actually help in this instance, particularly in the early on inflammatory phase of treatment as well. So what about the role of stents in benign strictures? So here I would like to make a distinction between benign refractory esophageal strictures, which may be from a variety of conditions, whether this is endotherapy, whether this is reflux, whether this is from any other damage, lye-induced, corrosive-induced versus malignant stricture. So we are talking about benign strictures, and this was a systematic review and meta-analysis that combined the experience of multiple investigators from 18 studies, over 400 patients. And unfortunately, the clinical success rate here was only 40%. And it did not matter whether the stent was either a plastic stent, whether it was a metal stent, or whether it was even the newer biodegradable stents. And with a fairly high migration rate of about 28%, and an adverse event rate of almost 21%. So unfortunately, I think we can conclude that the data on stent efficacy in refractory benign strictures is rather disappointing. Now, if we were to look at malignant strictures, I think this is an instance where perhaps, stents can and do play an important role. And there are two modalities I would like to highlight. So obviously, these would be fully covered or partially covered stents. And it depends on the setting that you are putting the stent in. If this is more for palliation, with metastatic disease, life expectancy is limited, you're doing this for quality of life, I would probably proceed with a partially covered stent, which can remain in place for a long time. On the other hand, if you're looking for a relatively short term, say for instance, to facilitate radiation treatment, then you could use a fully covered stent as well till the treatment begins to affect the tumor and then you can pull the stent out. Have to warn patients about the discomfort that can happen when the stent is placed. And you may have to actually provide even narcotic therapy. The discomfort typically will reduce over a few days and gets better, but there have been instances where this might be still intolerable and the patient might need to come back and the stent to be removed. One has to be very careful about regurgitation, particularly when this is placed across the G-junction. And I would make sure that the patient is counseled about perhaps being on a proton pump inhibitor and also elevating the head end of the bed and also being very careful about making sure they are not lying in bed after a large meal at bedtime. And you always have to be cognizant of the potential for migration in these patients. There is some evidence to suggest that stents may work better for squamous cell cancers than adenocarcinoma. Now, I have to make you aware of another modality, which is spray cryotherapy or cryoablation that has been used in case series and published in several journals, looking at the effect of liquid nitrogen spray cryotherapy to debulk tumors. And particularly with liquid nitrogen spray cryotherapy, it may have some synergy with ongoing chemotherapy and may allow the patient to not need a stent. This has been shown in retrospective studies, both with efficacy and safety. So these are just some examples of a stent being placed, but one of the things we have to be really careful about is particularly as you place these stents in the proximal esophagus, be very, very careful about the potential for a tracheoesophageal fistula. And you have to be careful to choose the smallest diameter stent, perhaps avoid stents which have wide flanges because these flanges can cause pressure necrosis, particularly in the proximal esophagus and can lead to a tracheoesophageal fistula. Some other causes of complex frictures, lye ingestion, esophageal atresia, particularly in children, head and neck radiation, and then other benign esophageal diseases such as lichen planus, which cause chronic inflammation and can lead to stricturing. So what are some methods to treat complex esophageal frictures? And this is where I would like to highlight some of these complex procedures, particularly the rendezvous procedures wherein you would go in, and this has been shown to be very helpful in post-radiation frictures, wherein you would actually go in through the stomach and there would be two endoscopists and you might actually need to do a temporary peg to go in through the stomach, move retrograde up into the esophagus, and then you have a second endoscopist who would go through the mouth and you would make a connection between the two lumens and make the connection sometimes even with endoscopic ultrasound or with newer procedures like third space endoscopy and then establish a lumen. You can also use techniques like endoscopic stricturoplasty, particularly if you see strictures which have a focal fibrotic ledge-like stricture, and then I'd also like to talk a bit about self-dilation, which can be very helpful in chronic benign fibrotic strictures with a respectable 70% success rate. So again, this is an example of a rendezvous procedure and this is a view of the stomach, wherein we are going in with a narrow diameter endoscope through the stomach, move up retrograde into the esophagus, create a lumen from the top, so you would have an endoscopist from the mouth and you would have an endoscopist who would be going in through the stomach and then with either endoscopic ultrasound guidance or even with a regular endoscope using transillumination, you can create a connection between the two lumens, pull a wire through, advance a nasogastric tube, and then slowly dilate the lumen once it is formed. So obviously this requires significant expertise, it requires fluoroscopy, and should be done in a center where endoscopists have the technology to do this. Endoscopic stricturalplasty is an option for fibrotics, for focal strictures that are fibrotic. This can, of course, be challenging for longer strictures. And in this instance, either a needle knife or an ESD knife can be used to create a disruption of the stricture in multiple angles, and then can be followed by balloon dilation and steroid injection. So this was a case series that was published. So again, you're looking at a ridge here and the endoscopist is using either a needle knife or in this instance, either an IT nano knife, which is really an ESD knife, to create, to cut through the fibrotic ledge and then open up the lumen once you have dilated, you make multiple cuts, four to six cuts, and then you can actually dilate with a balloon and reestablish the lumen. So this has been shown to be very effective in these refractory strictures with this morphology of a fibrotic ledge. Esophageal self-dilation is under-recognized and unfortunately underutilized strategy for these refractory benign esophageal strictures. This was a case series that we published from the Mayo Clinic. This was a single center review in which 52 patients underwent with refractory benign esophageal stricture. So this could be radiation-induced, this could be lye-induced or endotherapy-induced who are treated with self-dilation. And as you can see, after a successful self-dilation procedure, the median pre-self-dilation, the median pre-self-dilation EGDs reduced from 9.5 to zero. And the median intervention-free interval increased to 417 days. So this is a very successful approach if it is utilized. And I would refer you to a very nice review written by one of our colleagues in Mayo, Arizona, talking about the underutilization of self-dilation. And of course, this is due to a variety of things. There is lack of patient and provider awareness. There are lack of structured guidelines, lack of physician training, and of course, a paucity of high quality research data. And again, this is a program that one would have to set up and this would be a multidisciplinary program where you would have nurses, endoscopists, and the ability to teach patients. And this is a nice review article which we can post on the chat, wherein it goes through what are the preparations that you would actually require. In this instance, patients would need a minimum diameter of about 13 to 14 millimeters. They would need a teaching session where the physician would model the technique, and then you would pass a Maloney dilator beyond up to the length at which the stricture is present. And some of the tips that they mentioned would be to have a minimal luminal diameter of 12 millimeters before you start this education. You would use Maloney dilators. You would start with dilation at least once a day or more frequently initially. And this would be a team approach where you would have the physician, you would have the nurse and the patient, and have close follow-up perhaps weekly initially and then monthly thereafter. And this is just a picture of a patient who has mastered this technique and typically works very well for more proximal or mid-esophageal strictures, but I have used this very successfully even for distal esophageal strictures. So in summary, peptic strictures and Schatzky's rings, both balloons or Bougie dilation is effective. PPI treatment appears to be critical to reduce recurrence. In eosinophilic esophagitis, careful dilation is safe and effective with medical treatment. Strictures obviously can be common after wide area endoscopic resection and aggressive dilation here is effective. There are ways of prophylactically reducing the incidence of strictures after endoscopic resection. And then finally for complex strictures which might be refractory, several endoscopic options are available and I would consider referral to a center which has endoscopic expertise or perhaps even a self dilation program with a multidisciplinary group. So I'll stop there. Prasad, we have some questions. I know the question and answer session is not now, but I think we can take a few minutes to answer these questions. One is, what is the best test to estimate the diameter and length of the stricture? Yeah, that's a great point. I think it has to be more than one approach. So I think if you have endoscopically, I use the size of the diagnostic endoscope which is between nine and 10 millimeters. So if it is less than that, then that's an easy job. You know it is less than nine or 10 millimeters if you're not able to pass the endoscope. More than that, it becomes challenging because as we are passing the endoscope, we tend to insufflate. And I think that will underestimate the size of the stricture sometimes. So particularly for some of these refractory strictures, I oftentimes will use a barium study to estimate the size of the stricture. So I go by both. And then of course, when you inflate the balloon, you know that as well. It becomes fairly evident at what size of the balloon are we meeting resistance and when can we not move the balloon back and forth. A second question, due to the multifocal and proximal strictures in asinophilic esophagitis, is savory dilation a better option to target the narrowest stricture for best symptomatic relief? Yeah, I would say yes and no. I think the pros of dilating under vision with eosinophilic esophagitis are the fact that you are able to see how much mucosal disruption you are causing with each level of dilation. However, I do agree that if you have multiple levels and you want to tackle many of them at the same point, then a savory would be beneficial, probably more economical as well. But then I would look after every level of dilation because you, at least from my standpoint, even though we are taught and have experience in feeling the amount of resistance as you are passing the savory dilator, I think in conditions like eosinophilic esophagitis, it is sometimes you see more damage than you actually would see. For fibrotic strictures, yes. I think for longer fibrotic strictures, a savory is definitely more preferable and I think more efficient. So I agree with you, Prasad. For the eosinophilic esophagitis patients, when we do stricture dilations with savories or so, with minimal resistance, we stop because even with minimal resistance too, when you go in and see there is this huge tears, big mucosal tears in there. Absolutely, absolutely. Another question, do you recommend empiric dilation in patients with dysphagia? I think that is sort of my last resort. I like to complete the evaluation with endoscopy, biopsies. I like to get a sense of the barium and have a sense of the esophageal diameter and perhaps also perform esophageal manometry to see, are we missing subtle achalasia? Are we missing a cricopharyngeal bar? And only then, if we are seeing some evidence of luminal restriction, do I offer empiric dilation. Treatment for recurrent Schwarzschild's keystring in spite of PPI therapy, needle knife stricturotomy, ESD knife, what settings do you usually use? Yeah, I would say for needle knife, I use a combination of cut and a little bit of coag. I think you could use an ESD knife as well. If you were to use an ESD knife, I like the option of using an IT Nano because that sort of protects us from going too deep. Another option of using an ESD knife would be to use a scissor knife, could use a clutch cutter or an SB Junior. Again, you want to be careful about the depth of the injury. So I would be cautious as I'm moving through and stop as soon as you're seeing any evidence of muscularis propria. But I think any three of these approaches would be helpful. And of course, as I mentioned, it's most effective in the strictures which have a shelf or are relatively discrete. Do you break a Schwarzschild's keystring with forceps prior to dilation? It depends on what I see with dilation. So if with dilation, I'm getting a good disruption, I don't, I tend to use a biopsy if the patient is coming in the second or the third time. And if I'm not making a dent with the balloon. How often are post-link strictures? How do you treat them and for how long? Yeah, I have to say I don't have a lot of experience with post-links strictures. Our center doesn't do a lot of them. It all depends as to where, and maybe Prashanti, you can give your opinion as well, but it depends on where we start. So we would start with a balloon dilation. Second, I think if it is reflux induced, it might reflect the fact that the reflux is not adequately controlled. I would put the patient on a good PPI regimen. And then the last would be removal of the links. I suspect if there is any evidence of erosion into the lumen, I'm curious to see what you do. So link strictures, I do not have any experience with treating link strictures. In terms of the Nissen fundoplication strictures or so, usually the same, we start with an empiric balloon dilation, start with 18 to 20 CRE balloon. And then depending on how things go, sometimes we attempt to do with a pneumatic balloon dilation too, the same thing we use for Echolacea, like a three centimeter balloon or so. Sometimes they would require a revision of the fundoplication. The next question is, when is flip therapy of strictures recommended? Yeah, I think they are talking about esoflip, not endoflip, yes? I think so, so. I'm gonna turn this to you. I don't have experience using esoflip or endoflip. Endoflip would really just give you an idea of the luminal diameter perhaps. And I don't think it's a very compliant balloon, so I don't necessarily know if it's going to give you any therapeutic effect, but there is this concept of esoflip, if I'm not mistaken, Prashanthi, I don't know if you've used that. Yeah, so truly in terms of the endoflip or the esoflip at this time, they are not making any difference in the clinical practice. I would say they're like investigational modalities at this time. So truly, what difference does it make? The answer is at this point of time, we do not know. Because with a balloon dilation, what happens is you don't get the feel, the nurse gets the feel. Because the nurse is inflating the resistance, the nurse gets the feel. So for you to know what is going on, you deflate and see. In terms of the savory dilation, you get the feel of the things. So I would go basically with the endoflip and the feel of the things. So I would go based on that. At this point of time, I do not see any difference using a FLIP-MIX in a chalacia patients or any of the stricture patients or so. Yeah, I guess, you know, there might be a role for FLIP, and I'm talking about endoflip here, after you have done a pneumatic balloon dilation for patients with stricture. So you could look at the distensibility index and you could see if it has changed from the pre to the post distensibility index. And if it's over two, then you know you probably made a difference in terms of the effectiveness of the balloon dilation. So I could see that, get a baseline and then do an endoflip after your pneumatic bill or it's been described in form as well. So I think that might be one point where you could actually use this.

esophageal strictures

management

treatment options

dilation

proton pump inhibitors

endoscopic options

self-dilation