Europe, USA Delhi,Chandigarh

Peptic 68 - 72% 18 – 32%Post-op 8 - 21% 1 – 13%Caustic 1 - 4% 33 – 42%Radiation 0 - 1% 3 – 27%EST - 2 – 17%Misc 3 - 9% 5 – 7%-------------------------------------------------------------------------- Patterson 1983,Williamson 197 7, Broor1993,Kochhar 2001

• Focal/straight/symmetric• >12 mm• Easy to dilate• rings, webs,peptic

• Long, >2 cms, tortuous• Asymmetrical• <12 mm

• Caustic• Radiation• Anastomotic

http://images.google.co.in/imgres?imgurl=http://www.wjgnet.com/images/english/V11/5569-1b.jpg&imgrefurl=http://www.wjgnet.com/1007-9327/11/5568.asp&usg=__pFZmFUwYGGUT4Gh0Nlj3qxjqnZw=&h=200&w=256&sz=26&hl=en&start=8&tbnid=wMr7ykvh3AOt4M:&tbnh=87&tbnw=111&prev=/images%3Fq%3Dcorrosive%2Bstrictures%2Bendoscopy%26gbv%3D2%26hl%3Den%26sa%3DG

Endoscopy 2013; 45: E1–E2

Clin Endosc 2013;46:643-646

• Whale bone – 17th century

• Bougienage – 1821

• Flexible – Maloney, Hurst

Bougie Dilators

Through the scope/ Over the guidewire

-Wire/Non wire guided

Eclipse TTC CRE (Microvasive)

• Both effectively relieved dysphagia.• Stricture recurrence during the I year of follow- up similar • In second year, the risk of recurrence was significantly

lower in balloon group. • Other advantages of balloons

• the need for fewer treatment• sessions to achieve the end-diameter for dilation • less procedural discomfort

Gastrointest Endosc 1995

Dysphagia relief : Diameter > 12mm

Actual diameter : 4-8 mm less

(Bennett . 1985)

Dilating beyond 15 mm : not superior relief

: same recurrence

(Saeed ; Dig Dis Sci 1994)

Intraesophageal pressure: Max for 44 Fr-48 Fr

(Kozarek . Gastroent.1981)

• Webs excellent

• Peptic 60% 1 diln

• Caustic difficult and

resistant

• Radiation risk of perf

• Anastomotic difficult

Poddar et al; GI Endoscopy 2001; 54; 480-4Savary Dilatation : 54 children

Layered Patten LostCorrosive stricture

Layered Patten LostCorrosive stricture

Layered Patten Partially LostPeptic Stricture

Layered Patten Partially LostPeptic Stricture

ParameterWithout

recurrenceWith

recurrence

Layer pattern preserved

8 7

Layer pattern lost 5 20

p value 0.061

Refractory strictures:luminal diameter of 14 mm not achieved

despite five consecutive endoscopic sessions occurring every 2 weeks

Recurrent strictures:luminal patency not maintained for 4

weeks after achieving target diameter of 14 mm diameter

52 patients : 47 available

44(93.6%) successful dilatation

94.4% had recurrence with

55% having 5 recurrences

33% having 10 recurrences

8(18.7%) perforations Broor et al; Gut 1993; 34: 1498-1501

Intralesional steroids

Electrodiathermy incision

Stents

Others

• 1966 - Ketchum ,Griffith -

keloids and scars

Gastrointest Endosc 1999

• N-71• Strictures

• corrosive (29)• peptic (14)• anastomotic (19)• radiation-induced (9)

Gastrointest Endosc 2002

Time to first repeat dilatation

Am J Gastroenterol 2005

• Inhibits collagen synthesis

• Direct application to submucosa at the site of mucosal disruption

Journal of Pediatric Surgery 2008

Metal stents

Plastic stents

Biodegradable stents

• Indications : refractory or recurrent strictures

• Continuous dilatation by indwelling prosthesis

• Akin to frequent dilatation

• Remodelling of lumen after removal of stent

Gastrointest Endosc. 2004 Dec;60(6):894-900

• 9 studies : 162 pts : Anast (50), Peptic (27), Caustic (26)

• Outcome:

• Tissue overgrowth : 18%

• Migration : 47%

• Complications : 6%

• Long term relief : 39%

(Siersema Endoscopy 2009;41:363)

Completely covered even at flanges - Tissue reaction minimized

Special SEMS – Double covering both inside & outside

First use 1993 Cwikiel. 5 patients (Radiology 1993, 187,667)

Till 2009 : 12 studies: 168 patients : 50% achalasia

Uncovered 34: not removed

Covered 134: 18 not removed

Overall : Migration 14%

Tissue hyperplasia 17%

Long term data : 14/30 (47%) benefit

Synthetic biodegradable material polylactide

Self disintegration

Biocompatible - Minimal tissue reaction

Projected biologic life 3-6 mo

Loss of mech strength 4-8 wk

2 wks 4 wks

(Jahangeer Endoscopy 2013 )

13 patients

Dysphagia free @ 3 months : 4 patients

Dysphagia free @ 6 months : 3 patients

Dysphagia free @ 12 months : 2 patients

Follow up 3 years - 3 Surgery

- 3 Free of dysphagia

- 7 dilatation infrequent

(Kochhar ,Reddy,Choudhury OESO 2012)

Characteristic BD stent (n 18) SEPS (n 20) p value

Technically successful sent placement, n(%)

16(85) 19(95) 0.49

Median follow-up, d 166(21-559) 385(77-924) 0.23

Clinical success, n(%) 6(33) 6(30) 0.83

Mean number of reinterventions, per stent placed (SD)

0.8(0.6) 1.3(0.4) 0.03

NOTE: Values in bold indicate statistical significance

Clinical Gastroenterology and Hepatology 2011;9:653-659

Overall efficacy of stents 30-40%

SEMS Tissue hyperplasia

Polyflex Migration

Biodegradable Recurrence

SURGERY

Corrosive 15-18%

Peptic , anastomotic, radiation : rare

(Shah GL Endo 2007, Siersema Endo 2009)

StrictureDilatation : Bougie / Balloon

StrictureDilatation : Bougie / Balloon

No response : 3 sessionsNo response : 3 sessions

Complex strictureComplex stricture

2 more sessions : No response

2 more sessions : No response

Add : Steroid injectionAdd : Steroid injection

No response in 5 sessionsNo response in 5 sessions

Refractory strictureRefractory stricture

Incisional therapy + DilationIncisional therapy + Dilation Temporary SEMSTemporary SEMS SurgerySurgery

8 studies : 199 patients : 84 corrosives

Relief in dysphagia : Polyflex 55%

Nitinol 37%

83% of Nitinol group had corrosive strictures

vs 14% of polyflex

(Thomas et al Endoscopy 2011;43:386)

Conclusion:

Efficacy of SERS - 46.2 %

Migration rate - 26.4 %

Successful removal - 87%

SEPS better primary outcome than Nitinol stents

Heterogeneity of data – Subgroups non comparable

Nitinol group – 83% corrosives, Median length > 7cm

Polyflex group – 14% corrosives, Median length < 5cm

Corrosive strcitures - Extensive fibrotic scar tissue formation, hence more resistant to even sustained dilation by stents

8 studies : 199 patients : 84 corrosives

Relief in dysphagia : Polyflex 55%

Nitinol 37%

83% of Nitinol group had corrosive strictures

vs 14% of polyflex

Overall : Etiology, site, length, time to removal had no effect on outcome

(Thomas et al Endoscopy 2011;43:386)

6 studies (> 10pts ) : 119 patients

Dysphagia improvement : 53%

Migration : 30%

(Thomas Endoscopy 2011;43:386)

2 studies : 80 patients : Korea (67 corrosive)

Sustained benefit : 36.7%

Migration : 21.8%

(Thomas Endoscopy 2011;43:386)

8 studies : 199 patients : 84 corrosives

Relief in dysphagia : Polyflex 55%

Nitinol 37%

83% of Nitinol group had corrosive strictures

vs 14% of polyflex

(Thomas et al Endoscopy 2011;43:386)

2 centers in Europe - 21 patients

Technical success - 100%

Stent migration in 7 wks - 9.5%

Fragmentation - 3 months

Median follow-up - 53 wks

Dysphagia free - 45%

No major complication

Gastrointest Endosc. 2010 Nov;72(5):927-34

2 wks 4 wks

8 studies

Polyflex – 6

Nitinol - 2

Endoscopy 2011; 43: 386 –393

• Dysphgia improvement– Polyflex better – 55% vs 37%

• Migration rate – - Similar- 30% vs 22%

8 corrosivesSuccess – 1, Failure - 7

Characteristic BD stent (n 18) SEPS (n 20) p value

Technically successful sent placement, n(%)

16(85) 19(95) 0.49

Median follow-up, d 166(21-559) 385(77-924) 0.23

Clinical success, n(%) 6(33) 6(30) 0.83

Mean number of reinterventions, per stent placed (SD)

0.8(0.6) 1.3(0.4) 0.03

NOTE: Values in bold indicate statistical significance

Clinical Gastroenterology and Hepatology 2011;9:653-659

Ultraflex, Z-stent, Polyflex, Niti-S stent, Choo stent, and Bonastent

In refractory strictures or recurrent strictures

Not responding to intralesional steroids or needle knife

incision

May consider early

• Successful placement : 38/40 : 94%• Successful removal : 31/33 : 94%• Overall changed outcome : 66%• FU : 53 wk• 12 (40%) dysphagia free• 10 opted for long-term stenting• 4 Repeated dilatation• 3 Surgery • 1 Needle knife

• (Dua et al AJG 2008;103:2988)

No of stents

1 2 3

No 28 13 7

Cl. Success 25% 15% 0

Major compl. 29% 8% 29%

Dysphagia free days

90 55 106

• Incidence 9%

• Perforation 3

• Trach compr 1

• Gran tissue 2

• Bleed 3

• TOF 1

(Eloubeidi GIE 2011;73:673)

• 10 studies : 130 patients

• FU 10 months

• Overall success 52%

• Migration 23%

•

(Repici APT 2010;31:1268)

(Shah GL Endo 2007, Siersema Endo 2009)

Dilatation : Bougie / Balloon

Dilatation : Bougie / Balloon

No response : 3 sessionsNo response : 3 sessions

Complex strictureComplex stricture

2 more sessions : No response

2 more sessions : No response

Steroid injection Steroid injection

No response in 5 sessionsNo response in 5 sessions

Refractory strictureRefractory stricture

Incisional therapy + DilationIncisional therapy + Dilation TemporaryStent TemporaryStent SurgerySurgery

• Granulation tissue 56%

• Reactive hyperplasia 22%

• Fibrosis 22%

(Eloubeidi GIE 2011;73:673)

28 patients

First stent

15 13 second stent

7 improved 8 ? 10 3Restricture

Improved

7 Third stent

All recurred

(Shah GL Endo 2007, Siersema Endo 2009)

StrictureDilatation : Bougie / Balloon

StrictureDilatation : Bougie / Balloon

No response : 3 sessionsNo response : 3 sessions

Complex strictureComplex stricture

2 more sessions : No response

2 more sessions : No response

Add : Steroid injectionAdd : Steroid injection

No response in 5 sessionsNo response in 5 sessions

Refractory strictureRefractory stricture

Incisional therapy + DilationIncisional therapy + Dilation Temporary SEMSTemporary SEMS SurgerySurgery

Gastrointest Endosc. 2004 Dec;60(6):894-900

Am J Gastroenterol 2008

• n-40• SEPS for 4 wk (95%)• Removal (94%)• Follow up- 53wk• 12 (40%) dysphagia

free

Migration 8 (22%)

Severe pain 4 (11%)

Bleeding 3 (8%)

Perf 2 (5.5%)

Inability to remove 2 (5.5%)

(Dua et al AJG 2008;103:2988)

10 studies : 130 patients

FU 10 months

Overall success 52%

Migration 23%

(Repici APT 2010;31:1268)

Incidence 9%

Perforation 3

Trach compr 1

Gran tissue 2

Bleed 3

TOF 1

(Eloubeidi GIE 2011;73:673)

21 patients : 62 stents

Migration : 64%

Prox : 68%

Distal : 70%

Mid : 30%

Tissue hyperplasia : 17%

Overall response : 18%

(Holm GIE 2008;67:20)

Completely covered even at flanges - Tissue reaction minimized

Special SEMS – Double covering both inside & outside

• Polyester• Inner lining of silicone• Upper and lower ends

smoothened with silicone membrane

• REMOVED after 4+weeks

First use 1993 Cwikiel. 5 patients (Radiology 1993,

187,667)

Till 2009 : 12 studies: 168 patients : 50% achalasia

Uncovered 34: not removed

Covered 134: 18 not removed

Overall : Migration 14%

Tissue hyperplasia 17%

Long term data : 14/30 (47%) benefit

Two US centers: 35 pts. : 19 strictures

Alimaax stent : fully covered

Removed : ? In all 64 ± 74D

Migration 37%

Long term outcome : 21%

(Eloubeidi GIE 2011;73:673)

Granulation tissue 56%

Reactive hyperplasia 22%

Fibrosis 22%

(Eloubeidi GIE 2011;73:673)

Post-operative; China

Stent removal 8 weeks

12 mo FU : Response 66%

Recurrence 33%

Migration 1/29 stents

(Lie et al Dhsphagia 2012;27:260)

Ther Adv Gastroenterol (2013) 6(5) 365–370

Strength : 10,20,40 mg/ml

Strength dose used :

8 mg/ml - 1 study

10 mg/ml - 4 studies

20 mg/ml - 1 study

40 mg/ml - 1 study

Effective dose :

8 mg/ml - 1 study

10 mg/ml - 1 study

28 mg/ml - 1 study

40 mg/ml - 3 studies

80 mg/ml - 1 study

• Dead space of bougies -Children -Small stomach -Multiple strictures -Caustic gastric

involvement -Anastomotic -Location-small bowel.

colon

Bougie dilator

• Radial & shearing force• Dilation “felt”• Best suited for simple

strictures

Balloon dilators

• dilating force is radial • Simultaneously over the

entire length• Safer with multiple,

tortuous strictures

Outcome is worse for :

Patients with stomach involvement

Patients requiring more no of dilatations to reach 15mm

Multiple strictures required more dilatations to reach 15mm

Parameters which did not influence outcome

Site of stricture

Acid vs Alkali

Major success – 62.5%, Partial success – 19%Major success – 62.5%, Partial success – 19%