Stanford University Medical Center Woodside, CA, United States
Andrew Li, MD1, Joo Ha Hwang, MD, PhD2 1Stanford University Medical Center, Woodside, CA; 2Stanford University Medical Center, Palo Alto, CA
Introduction: Peptic strictures from longstanding gastroesophageal reflux disease (GERD) are the most common cause of benign esophageal strictures, with serial dilations being the mainstay of treatment to establish adequate luminal patency. Adjunctive techniques include the use of steroids and stents. Strictures that are refractory to repeated dilation are often associated with severe fibrotic changes. For these refractory strictures, endoscopic strictureplasty is a relatively new strategy that involves the dissection of the fibrotic tissue down to the muscularis propria with an electrosurgical knife.
Case Description/Methods: An 81-year-old man with a history of GERD with long-segment Barrett’s and an esophageal peptic stricture recalcitrant to multiple serial dilations was referred for dysphagia. He had recently undergone four endoscopies with serial dilations of a 4 mm (diameter) x 3 cm (length) mid esophageal stricture. However, the stricture was both refractory and recurrent with rapid restricturing within 2-3 weeks.
We performed a strictureplasty with steroid injection and stent placement for treatment of the recalcitrant stricture (Video). The strictureplasty was completed using endoscopic submucosal dissection technique with dissection of the stricture and fibrotic tissue from the underlying deep layers down to the muscularis propria using a Triangle Tip knife. Two separate dissections were completed on opposite walls, involving a partial diverticulectomy. Following the strictureplasty, the endoscope could easily be advanced beyond the stricture. The submucosa was injected with triamcinolone the area was stented with a covered metal stent, with the proximal end secured with an over the scope clip.
The patient returned three weeks later for a repeat upper endoscopy and stent removal and was no longer experiencing dysphagia. The esophagus was widely patent and without severe stenosis, with expected changes related to the strictureplasty. He continues to do well in follow-up without recurrence of dysphagia.
Discussion: Management of refractory esophageal strictures is a challenging clinical scenario. While the utility of strictureplasty for esophageal anastomotic strictures has been described in small case series, the data in peptic strictures are more limited. Our case demonstrates the potential of this technique for refractory and recurrent peptic esophageal strictures, but prospective studies will be needed to determine its relative efficacy.
Disclosures: Andrew Li indicated no relevant financial relationships. Joo Ha Hwang: Boston Scientific – Consultant. LumenDi – Consultant. Medtronic – Consultant. Micro-Tech – Consultant. Olympus – Consultant.
Andrew Li, MD1, Joo Ha Hwang, MD, PhD2. P1759 - Endoscopic Strictureplasty and Stent Placement for a Recalcitrant Esophageal Peptic Stricture, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.