Esophageal strictures are segments of significant narrowing that develop in the esophagus. They cause symptoms such as difficulty swallowing, pain with swallowing, regurgitation of food and liquid, and a sensation of something being stuck in the chest for brief or prolonged periods. They can be life threatening if they lead to malnourishment or dehydration or if they result in back-up of food and liquids into throat and lungs. Food that gets stuck in the esophagus for a long period of time can also wear a hole in the esophagus that results in potentially deadly infection.
Esophageal strictures may develop from either benign or malignant causes. The proper treatment of a stricture depends on its cause and its severity.
Malignant strictures arise from growth of tumors (typically adenocarcinoma or squamous cell carcinoma) within the esophagus. They also occur when growing cancers start to squeeze the esophagus from the outside. Treatment of malignant esophageal strictures is aimed at shrinking or removing the culpable tumor with surgery, endoscopic therapy, chemotherapy, and/or radiation therapy. The correct method(s) of treatment depends on the type of tumor, the stage of the cancer at diagnosis, and overall treatment goals (cure versus palliation).
The options for endoscopic therapy of a malignant esophageal stricture include endoscopic resection, endoscopic ablation, endoscopic dilation, and or endoscopic stent placement.
For endoscopic resection, in the right scenarios, an esophageal cancer may be completely removed endoscopically without the need for surgery with techniques that include endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD)
Endoscopic ablation entails the use of electric current for tumor heating and destruction, or liquid nitrogen for tumor freezing and destruction. With these methods, the tumor is shrunk and the narrowing and blockage of the esophagus that the tumor caused is relieved.
Dilation of a malignant esophageal stricture may also occasionally be performed (usually to facilitate other types of therapy), but alone this is not an effective method at providing durable relief and carries an increased risk of perforation.
Finally, endoscopic stenting involves placement of one or more temporary or permanent self-expanding metal tubes in order to establish a new channel of flow across the region of the stricture.
Benign (non-cancerous) esophageal strictures develop from a variety of causes – inflammation from acid reflux, prior radiation therapy, inflammatory disorders such as eosinophilic esophagitis, long-term use of a nasogastric feeding tube, scarring from prior endoscopic therapy or injury, scarring at points of prior surgery, or damage from swallowing harmful substances (batteries, lye, bleach, and other corrosive substances).
Endoscopic treatment is the first choice of therapy for a benign esophageal stricture. The initial treatment of a benign esophageal stricture is endoscopic dilation, in which an inflatable balloon or graduated catheters are used to progressively stretch open the stricture.
With this technique, successful therapy may often require multiple endoscopic sessions for serial and maintenance dilation.
When dilation produces initial but temporary results and the stricture recurs, the application of steroids, cryotherapy (freezing therapy), or a medication called mitomycin C may be useful in achieving long-term stricture resolution.
Alternatively, if a stricture is refractory to prior dilation or if it is very severe to start with, use of a temporary stent may be used to achieve long-term resolution. Since the stent has to have a slippery coating in order to be removed in the future, we perform endoscopic suturing to fix the stent in place until it is meant to be removed.
Finally, if we encounter a refractory esophageal stricture, we may perform a procedure called endoscopic stricturoplasty. In this technique, we use a cautery knife (a knife with electric current) to carefully make multiple cuts through the esophageal stricture while leaving the outer wall of the esophagus intact.
At Interventional Endoscopy Services, we have extensive experience using advanced techniques for the therapy of benign and esophageal malignant strictures. We frequently treat patients who have had persistent symptoms despite prior standard endoscopic techniques performed by a patient’s primary gastroenterologist.
While surgery may sometimes be necessary for esophageal stricture management, we aim to avoid surgical intervention whenever it is appropriate.