Benign Gastrointestinal Strictures

Educational Objectives

The goal of this program is to improve the management of benign gastrointestinal (GI) strictures. After hearing and assimilating this program, the clinician will be better able to:

1. Compare available methods of dilation for treatment of benign esophageal strictures.
2. Analyze evidence supporting treatment for postsurgical GI strictures.

Summary

Esophageal strictures: often cause symptoms of dysphagia when diameter of esophagus is minimized to ≈13 mm; initial assessment is typically through esophagogastroduodenoscopy (EGD) or barium esophagography; consider starting with EGD for mild, intermittent symptoms; more consistent symptoms or risk factors (eg, prior radiation) may warrant barium esophagography; common causes include chronic reflux, prior radiation or esophageal sclerotherapy, caustic ingestion, ablative therapy for Barrett esophagus or squamous dysplasia, and eosinophilic esophagitis; Schatzki rings (short in height) or peptic strictures (have longer segments of narrowing with smooth, tapered margins) may be present on imaging;

Esophageal dilation: bougie dilation (with or without wire guiding) provides radial and longitudinal shear force, while endoscopic balloon dilation (EBD) provides radial force with less longitudinal force; one study demonstrated similar risks for perforation with wire-guided bougie dilation vs EBD, though significantly higher risk with nonwire-guided bougie dilation; the goal is to achieve an esophageal diameter ≥13 mm to alleviate dysphagia; treat active inflammation before dilation; sessions are typically spaced 1 to 2 wk apart until improvement is seen; the response varies by stricture type; 1 to 3 sessions are often needed for peptic strictures, while postsurgical or caustic strictures need ≤5 sessions (Pereira-Lima et al [1999]); consider steroid injections for recurrent or refractory benign strictures, though efficacy and optimal use are not well-established; other treatments include electrocautery incisional therapy (EIT) and stent placement

Gastroduodenal strictures: patients present with symptoms of gastric outlet obstruction, including early satiety, nausea, vomiting, epigastric pain after eating, and weight loss; causes include peptic ulcer disease (PUD), nonsteroidal anti-inflammatory drugs (NSAID) use, surgery, caustic ingestion, acute or chronic pancreatitis, pancreatic pseudocysts, endoscopic submucosal dissection, radiation, eosinophilic enteritis, Crohn disease, and infections; PUD and NSAID-induced strictures can particularly affect the pyloric channel and duodenum; risk factors include Helicobacter pylori infection, NSAID use, and concomitant use of anticoagulants, antiplatelets, or corticosteroids with NSAIDs; refractory or large ulcers can lead to gastric outlet obstruction or pyloric channel ulcers; EBD — studies vary with regard to efficacy; perforation may occur with balloon sizes ≥15 mm; often the initial treatment of choice, due to low cost, though most patients often need >1 EBD to remain asymptomatic; intralesional steroid injection — triamcinolone blocks collagen crosslinking and prevents scar contracture; patients remain asymptomatic for extended periods, though recurrence is possible; significant injection-site adverse effects have not been reported; small efficacy reports show that steroid injection is helpful with EBD; endoscopic stent placement — lumen-apposing metal stenting (LAMS) involves placement of a fully-covered metal stent (FCMS); effective for refractory pyloric strictures ≤1 cm; Tan et al (2019) reported a technical success rate of ≈92%, clinical success rate >77%, and pooled adverse event rate of ≈11% of LAMS for treatment of pyloric strictures; stent suturing can reduce risk for migration (most common adverse event) but is technically challenging and time-consuming; Hallac et al (2018) demonstrated economic efficacy of LAMS after 3 unsuccessful EBDs for nonsurgical strictures and after 2 EBDs for postsurgical strictures; restenosis is concerning for malignancy

Roux-en-Y gastric bypass (ie, gastrojejunal [GJ]) stricture: occur in 8% to 19% of cases; early strictures may result from technical issues (eg, circular stapled anastomosis, ischemia), while late strictures might result from ulcers or be iatrogenic (from transoral gastric outlet reduction); symptoms manifest with GJ diameter <10 mm

Through-the-scope balloon dilation (TTS-BD): Peifer et al (2007) found that 93% of GJ strictures required 1 to 2 TTS-BDs; shorter time from surgery to stricture formation and smaller balloon dilator size used for initial EBD were associated with need for ≥2 TTS-BDs; dilation to ≥15 mm was not linked to weight regain 1 yr following surgery

Electrocautery incisional therapy: 4 to 6 equidistant incisions are made; followed by dilation; the incisions should be made with a blended current, with incisional depth just short of the fibrotic rim; Hordijk et al (2006) demonstrated efficacy of a single EIT session in 20 patients who were refractory to ≈8 EBDs; EIT is considered safest for strictures ≤1 cm

Lumen-apposing metal stenting: the most common adverse events are migration and adjacent stricture (form near the proximal flange of the LAMS in the small bowel); LAMS are typically left in place for 3 to 6 mo; some practitioners check stent positioning after 3 mo to ensure absence of delamination, with removal or exchange generally occurring at ≈6 mo

Sleeve gastrectomy stricture (SGS): usually occurs weeks to months after surgery; affect ≤4% of patients; poor alignment of the staple line at the greater curvature causes sleeve rotation or scarring, usually at the incisura, though sometimes at the GE junction; EBD — initial treatment; typically involves a pneumatic or achalasia balloon dilator under endoscopic and fluoroscopic guidance; EBD helps visualize relative tissue ischemia at the stricture site and may improve sleeve angulation; Chang et al (2020) revealed an overall success rate of ≈76%, ≈90% success for proximal SGSs, and ≈70% success for mid-distal SGSs (at the level of the incisura); a meta-regression did not demonstrate an association between the number of dilations needed, type of balloon, initial or maximum balloon dilation size, and EBD success rate; fully-covered, self-expanding metal stent (FCSEMS) placement — performed for primary treatment or after unsuccessful EBD; success after unsuccessful EBD is ≈70%

Vertical banded gastroplasty (VBG) stricture: EBD — may offer temporary relief for acute obstructive symptoms, but multiple sessions are often needed and long-term relief is not provided; FCSEMS — can be placed across the stricture to induce tissue necrosis and silastic band exposure; stent is removed after ≈6 wk; LAMS — suitable for strictures ≤1 cm in length; can stay in place for ≤6 mo; fluoroscopy imaging can confirm stent placement and efficacy; the exposed band can be removed after stent removal, potentially improving symptoms and avoiding the need for surgery

Readings

Chang SH, Popov VB, Thompson CC. Endoscopic balloon dilation for treatment of sleeve gastrectomy stenosis: a systematic review and meta-analysis. Gastrointest Endosc. 2020;91(5):989-1002.e4. doi:10.1016/j.gie.2019.11.034; Cundra LB, Marcuard M, Parekh PJ. Use of a lumen-apposing metal stent for management of pouch outlet stenosis after vertical banded gastroplasty. ACG Case Rep J. 2021;8(5):e00580. doi:10.14309/crj.0000000000000580; Hallac A, Srikureja W, Liu E, et al. Economical effect of lumen apposing metal stents for treating benign foregut strictures. World J Gastrointest Endosc. 2018;10(10):294-300. doi:10.4253/wjge.v10.i10.294; Hordijk ML, Siersema PD, Tilanus HW, Kuipers EJ. Electrocautery therapy for refractory anastomotic strictures of the esophagus. Gastrointest Endosc. 2006;63(1):157-163. doi:10.1016/j.gie.2005.06.016; Peifer KJ, Shiels AJ, Azar R, et al. Successful endoscopic management of gastrojejunal anastomotic strictures after Roux-en-Y gastric bypass. Gastrointest Endosc. 2007;66(2):248-252. doi:10.1016/j.gie.2006.10.012; Pereira-Lima JC, Ramires RP, Zamin I Jr, et al. Endoscopic dilation of benign esophageal strictures: report on 1043 procedures. Am J Gastroenterol. 1999;94(6):1497-1501. doi:10.1111/j.1572-0241.1999.01061.x; Tan S, Zhong C, Huang S, et al. Clinical outcomes of lumen-apposing metal stent in the management of benign gastrointestinal strictures: a systematic review and meta-analysis. Scand J Gastroenterol. 2019;54(7):811-821. doi:10.1080/00365521.2019.1638447.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Tavakkioli was recorded at What's New in GI 2024, held April 20, 2024, in Dallas, TX, and presented by University of Texas Southwestern Medical Center. For information about upcoming CME activities from this presenter, please visit https://cme.utsouthwestern.edu. Audio Digest thanks the speakers and presenters for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0.75 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0.75 CE contact hours.

Lecture ID:

GE381901

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.