A 67 yo male presented with dysphagia, 2 months after a distal esophagectomy for esophageal cancer. As shown here, the patient has a tight anastamotic stricture. Multiple staples can be seen adjacent to the stricture. A few of the staples were removed to allow for access to the esophageal lumen. A TTS dilation balloon catheter is just able to traverse the stricture. Using fluoroscopy, the stricture was dilated sequentially in 1mm increments following the conventional rule of three. The results of the first dilation can be seen here. A total of 4 endoscopic dilations were performed at weekly intervals; triamcinolone was injected on two occasions. During the 5th dilation, perforation at the anastamosis was suspected and during the same endoscopic session, a fully covered SEMS was placed across the anastamosis. An esophagram was obtained immediately afterwards. As can be seen on these images, no extravasation of contrast was noted on esophagram. The patient was given oral antibiotics and followed as an outpatient. The patient's symptoms of dysphagia had completely resolved. The fully covered SEMS was left in place for 5 weeks and removed endoscopically. At the time of stent removal, the waist on the anastamotic stricture was competely. The anastamosis can be seen here, and again on retroflexion. Four weeks after stent removal , the patient complained of recurrent dysphagia and endoscopy revealed stricture recurrence. Repeated endoscopic dilation, steroid injection, and SEMS placement all failed to yield a lasting improvement. Electroincision of the anastamotic stricture with a needle knife was then pursued. Given the immediate recurrence of the stricture and it’s fibrotic nature, we were confident that perforation risk would be low. As a safety measure, the procedure was performed on the fluoroscopy table. A standard biliary needle knife was utilized, our preference is to use a blended current setting. The needle is used to incise the stricture radially beginning from the center of the lumen. No consensus exists about the number of incisions that need to be made. A recent retrospective cohort study comparing electroincision of anastamotic strictures in 54 consecutive patients with endoscopic balloon dilation demonstrated the safety of electroincision and it’s superiority in lasting improvement of dysphagia scores. The incisions were extended to the expected base of the stricture. A surgical staple can be seen here, although limited data exist regarding the removal of retained surgical material in anastamotic strictures, we opted to remove this staple as it may have contributed to the ongoing fibrogenesis in the stricture. While the patient was on the fluoroscopy table, an intraprocedural esophagram was obtained to ensure no perforation, none was seen. Here is the final result of the incision with comparison to the initial appearance of the stricture. The patient reported significant improvement of dysphagia. Repeat endoscopy was performed 4 weeks later. Some return of luminal narrowing was appreciated and repeat electroincision was undertaken with similar settings as previously described, the final result of the second session of electroincision is seen here. Repeat visit 4 weeks after the second session found the patient to be free of dysphagia. The endoscope was able to pass through the anastamosis with ease. The patient has remained symptom free. The initial endoscopic appearance of the stricture is shown here for comparison.
In summary, in selected patients with anastamotic strictures, electroincision of the stricture is not only a safe procedure, but one where durable results can be achieved.
Reference: Muto M, Ezoe Y, Yano T, et al. Usefulness of endoscopic radial incision and cutting method for refractory esophagogastric anastomotic stricture (with video). Gastrointest Endosc. 2012 May;75(5):965-72.
Serag Dredar, MD, Yale University
Harry Aslanian, M.D., Yale University