Risk of recurrent or refractory strictures and outcome of endoscopic dilation for radiation-induced esophageal strictures

Abstract

Background Radiation therapy for head, neck, and esophageal cancer can result in esophageal strictures that may be difficult to manage. Radiation-induced esophageal strictures often require repeat dilation to obtain relief of dysphagia. This study aimed to determine the long-term clinical success and rates of recurrent and refractory stenosis in patients with radiation-induced strictures undergoing dilation. Methods Retrospective cohort study of patients with radiation-induced strictures who underwent endoscopic dilation by a single provider from October 2007– October 2012. Outcomes measured included long-term clinical efficacy, interval between sessions, number of dilations, and proportion of radiation strictures that were recurrent or refractory. Risk factors for refractory strictures were assessed. Results 63 patients underwent 303 dilations. All presented with a stricture > 30 days after last radiation session. Clinical success to target diameter was achieved in 52 patients (83%). A mean of 3.3 (+/− 2.6) dilations over a median period of 4 weeks was needed to achieve initial patency. Recurrence occurred in 17 (33%) at a median of 22 weeks. Twenty-seven strictures (43%) were refractory to dilation therapy. Fluoroscopy during dilation (OR, 22.88; 95% CI, 3.19 – 164.07), severe esophageal stenosis (lumen <9 mm) (OR, 10.51; 95% CI, 1.94 – 56.88), and proximal location with prior malignancy extrinsic to the lumen (OR, 6.96; 95% CI, 1.33 – 36.29) were independent predictors of refractory strictures in multivariate analysis. Conclusions 1. Radiation-induced strictures have a delayed onset (>30 days) from time of radiation injury. 2. Endoscopic dilation can achieve medium-term luminal remediation but the strictures have a high long-term recurrence rate of up to 33%. 3. Remediation of radiation strictures following laryngectomy can be achieved but require frequent dilations. 4. Clinical and procedural predictors may identify patients at high risk of refractory strictures. 5. The optimal strategy in highly selected refractory patients is not clear.

Benign Pharyngoesophageal Strictures: Increasingly Encountered and Still a Challenge

“…It supports previous data that also exposed an increasing number of dilations during the first year as a predictive factor for non-responsive PES [7] and severely narrowed strictures as a challenging situation [2,8]. Although other characteristics with recognized association to difficult treatment in this setting of aetiology, as stricture length, complexity, and location [8,9], would add value to this analysis if available in a larger population sample. Interestingly, refractory strictures did not present as a worse condition in this population and the authors suggested that these patients may still benefit from endoscopic therapy.…”

Endoscopic Dilation of Pharyngoesophageal Strictures: There Are More Dimensions than a Diameter

“…A recent meta-analysis [7] reported an estimated overall clinical success rate per patient (with a post-chemotherapy and RT or RT alone stricture) of 72.9% (95% CI 65.7-80.1%), with data suffering from significant heterogeneity as success was defined by resolution or improvement of different dysphagia scales. Previous findings stated that a soft/ normal diet may be achieved in > 70% [12,16,23,28] compared to 60% reported in our cohort. On the other hand, our dysphagia improvement perception rate was 58.3% Fig.…”

“…We designed our definition of overall efficacy as a trilogy where dysphagia improvement assessed as a "patient-reported outcome" needs to be associated with a 6-month period of absence of further dilations and PEG feeding. These criteria made our efficacy definition more demanding and therefore hard to compare with previously described endoscopic dilation efficacy rates [2,12,15,16,18,20,23]. A recent meta-analysis [7] reported an estimated overall clinical success rate per patient (with a post-chemotherapy and RT or RT alone stricture) of 72.9% (95% CI 65.7-80.1%), with data suffering from significant heterogeneity as success was defined by resolution or improvement of different dysphagia scales.…”

“…The first definition concerns the ability of the endoscopist to traverse the stricture with the chosen dilator [11] and subsequent completion of dilation effectively increasing the luminal diameter (usually by 3 mm [12,13] and seldom by ≥5 mm [14]). Occasionally this definition includes a target diameter of 14-15 mm [14][15][16].…”

Risk factors associated with refractoriness to esophageal dilatation for benign dysphagia

“…Less satisfactory results in caustic strictures can be explained by a longlasting local inflammatory process that leads to a transmural process, tissue fibrosis, and irreversible deposition of collagen [22]. Caustic strictures, peptic strictures, and complex strictures were associated with a greater need for subsequent dilatations.…”