Endoscopic incisional therapy for benign esophageal strictures: Technique and results

Abstract

Benign esophageal strictures refractory to the conventional balloon or bougie dilatation may be subjected to various adjunctive modes of therapy, one of them being endoscopic incisional therapy (EIT). A proper delineation of the stricture anatomy is a prerequisite. A host of electrocautery and mechanical devices may be used, the most common being the use of needle knife, either standard or insulated tip. The technique entails radial incision and cutting off of the stenotic rim. Adjunctive therapies, to prevent re-stenosis, such as balloon dilatation, oral or intralesional steroids or argon plasma coagulation can be used. The common strictures where EIT has been successfully used are Schatzki's rings (SR) and anastomotic strictures (AS). Short segment strictures (< 1 cm) have been found to have the best outcome. When compared with routine balloon dilatation, EIT has equivalent results in treatment naïve cases but better long term outcome in refractory cases. Anecdotal reports of its use in other types of strictures have been noted. Post procedure complications of EIT are mild and comparable to dilatation therapy. As of the current evidence, incisional therapy can be used for management of refractory AS and SR with relatively short stenosis (< 1 cm) with good safety profile and acceptable long term patency.

Keywords: Anastomotic strictures; Endoscopic incisional therapy; Esophageal strictures; Needle knife; Radial incision and cutting.

Figure 1

Accessories for incisional therapy. A: Triple lumen needle knife; B: Hook knife; C: Needle knife (KD 10Q); D: Insulated tip knife; E: Endoscopic surgical scissors (Image courtesy of Olympus); F: Heiss-Device flexible endoscopic scissors (image courtesy of Telemed systems).

Figure 2

The technique of endoscopic incisional therapy procedure. A-D: Schematic front view of stricture site; B: Arrows depict the radial direction of incision; C: Curved arrows depict the slicing off of the intervening areas; D: Final outcome at the end of procedure; E: Lateral view of stricture site depicting the transverse working domain of the needle knife (arrows); 1: Use of needle knife for incision; 2: After radial incision; 3: At the end of EIT and balloon dilatation. EIT: Endoscopic incisional therapy.

Figure 3

Algorithm for the management of benign esophageal strictures.