Hitch your wagon to a star-shaped incision? A closer look at electro-incision for benign gastroesophageal anastomotic strictures

An estimated 16,500 new cases of esophageal cancer will be diagnosed in the United States in 2008,1 and of these, some 30% to 40% will have potentially resectable disease at presentation. Esophageal resection remains a challenging operation, with anastomotic leaks and strictures complicating a significant number of them regardless of the techniques used (transhiatal, transthoracic, or 3-field). Most strictures are thought to result from ischemia of the proximal gastric tube, with a smaller proportion related to fistulae or technical difficulties in the creation of the anastomosis.2 The reported incidence of benign postoperative gastroesophageal anastomotic strictures varies widely, from 5% to 55%.3, 4, 5, 6, 7, 8, 9

Anastomotic strictures generally present symptomatically 2 to 3 months postoperatively.10 Most series report resolution of dysphagia in the majority of patients with anastomotic strictures after 1 to 4 treatment sessions of endoscopic dilation with balloons or bougies.8, 10, 11, 12, 13, 14 However, some reports indicate a higher median number of dilations required (>4),15, 16, 17 and many series recognize a subset of ∼10% of patients who require repeated treatment sessions due to refractory strictures.15, 16 Although bougie or balloon dilations have been used most commonly, other endoscopic treatment modalities have been described, including steroid injection,18 electro-incision (EI),19 and temporary placement of a polyester-silicone self-expanding stent.20 However, these alternative modalities have generally been evaluated in the setting of strictures refractory to dilation rather than as primary therapies.

Of these modalities, EI has seen the most attention of late in regard to clinical evaluation, and with promising results. EI of benign anastomotic strictures in the upper gut is not a new concept; this technique was initially described more than 25 years ago, with excellent outcomes reported.21, 22 In these 2 series, a polypectomy snare or “electric scalpel” was used endoscopically to incise the anastomotic scar in a radial fashion by using blended current, and in some cases the intervening fibrotic tissue was removed with a biopsy forceps. Despite the good outcomes in these initial series, EI was not widely adapted, even in cases of dilation-refractory strictures. In the last decade, interest appears renewed in stricture EI, with a number of case series evaluating it in the management of a variety of stricture types, including gastroesophageal anastomotic strictures.23, 24, 25, 26 Although these series have also shown excellent success and minimal adverse events, they all have been small and retrospective.

However, more quality data have recently emerged regarding the safety and efficacy of this technique. Hordijk et al19 presented the first prospective evaluation of EI in 2006, in a series of 20 patients with symptomatic gastroesophageal anastomotic strictures that were refractory to dilation (mean of 8 prior endoscopies). EI was performed by creating 6 to 12 incisions in the stricture in a radial fashion by using a needle-knife with blended cutting and coagulating current. All 20 patients had complete relief of dysphagia after a single treatment with EI, and no complications were observed. The 12 patients with short (<1 cm) focal stenoses remained dysphagia-free for 12 months without retreatment. Eight patients had longer (1.5-5 cm) strictures; these patients had all experienced some postoperative complication (eg, leak, infection). In these 8, dysphagia recurred after initial success, and 2 to 5 (mean 3) endoscopic retreatment sessions were necessary, with eventual durable success in 6 of 8 patients.

Subsequently, Lee et al27 have published their experience with EI as a primary treatment for symptomatic gastroesophageal and esophagojejunal anastomotic strictures in 24 patients enrolled prospectively and followed-up for 2 years. The authors used a transparent cap on the tip of the endoscope to assist in visualization, and used pure-cut current delivered through specialty cutting accessories designed for endoscopic submucosal dissection (though these instruments are comparable to a needle-knife). Twenty-one of 24 patients experienced relief of dysphagia and endoscopic resolution of the stricture (assessed 1 month later) after a single treatment session. Two of the 3 patients in whom dysphagia recurred had strictures >1 cm in length; of the 3 patients with recurrent dysphagia, 2 responded to a second EI treatment. No adverse events were seen in this series.

It is in this context that Hordijk et al28 present their latest endeavor in this arena in this issue of Gastrointestinal Endoscopy. The authors randomized 62 treatment-naïve patients presenting with dysphagia due to a gastroesophageal anastomotic stricture to endoscopic treatment of the stricture with wire-guided bougienage versus EI. This trial was powered on the assumption that patients randomized to bougienage would require a mean of 3 treatments over 6 months, whereas EI patients would require a mean of 1.5 treatments over 6 months. The 2 treatment arms were similar in baseline characteristics, including age, sex, weight, stricture diameter, dysphagia score, time between surgery and first endotherapy, number with surgical complications, and number who received neo-adjuvant chemoradiation. However, importantly, randomization failed this study in regard to distribution of stricture lengths between the 2 arms. The patients randomized to EI had significantly longer strictures as a group, including a mean length of 1.35 cm, compared with 0.55 cm in the bougienage group (P = .002).

In this trial, bougienage (to 16 mm) performed about as well as expected, with patients requiring 3.3 treatment sessions on average in 6 months of follow-up but experiencing improvement in dysphagia scores and health-related quality of life. However, patients randomized to EI required a similar number of treatment sessions (mean 2.9), and had a similar “rate of success” (somewhat arbitrarily defined as requiring ≤5 endoscopic treatments in 6 months). While some secondary endpoints favored EI (weight gain and procedural satisfaction), this was essentially a neutral study.

Given the seemingly more favorable outcomes in prior prospective series, what can be made of the middling performance of EI as a stricture therapy in this randomized controlled trial? First, the more down-to-earth outcomes with EI may reflect on the limited quality of data until now. Even when data are collected prospectively, case series are more prone to selection bias than are randomized trials. Second, the nature of the strictures being treated is important in interpreting the effectiveness of EI as a therapeutic modality. Clearly, previous data have shown that EI is extremely efficacious for short fibrotic strictures, and less so for longer, more complex strictures.19, 27 This is not surprising—irrespective of etiology or treatment method used, longer, complex strictures are more difficult to treat than short, simple strictures.15, 29, 30 The fact that stricture length was significantly greater in the EI group than the bougienage group certainly may have confounded the treatment effects in this trial, as the authors point out, although no subgroup analysis of outcomes by stricture length is provided.

At present, many questions still surround the use of EI for stricture management. In regards to technique, it is difficult to quantify how deep the individual incisions should be. Although anastomotic strictures can be exceptionally thick focally, they are frequently eccentric, and the healthy esophageal wall is only a few millimeters thick. No real landmarks akin to the duodenal transverse fold are present to guide depth of incision. Some have advocated limiting incisions to ≤4 mm,19 but the depth of incision is chiefly guided by the appearance of the treatment effect on the stricture. The optimal type of electrosurgical current (eg, pure cut, blended, etc) is also unknown. These fibrotic strictures tend to be relatively hypovascular, and pure cut current may theoretically induce less thermal damage and future fibrosis, but also may potentially increase risks for bleeding and perforation. Variations in technique have been reported, such as debulking of stricture tissue in addition to EI with argon plasma coagulation25 or biopsy forceps,21 or stricture EI followed immediately by balloon dilation;23, 26 whether or not these methods harbor benefit over incision alone is unknown.

Fortunately, the cumulative safety experience with EI of anastomotic strictures has been favorable, with only a single perforation reported in >150 cumulative cases, and really no other significant complications observed.19, 20, 21, 22, 23, 24, 25, 26, 27, 28 This perforation occurred in an older series and was managed surgically with good outcome;22 one can imagine now that a small perforation at EI could potentially be managed nonoperatively by placement of a covered self-expanding stent. Although experience with EI is limited, it must be noted that the standard of care (dilation) has a small but finite rate of adverse events in this clinical setting, including a perforation rate of up to 0.5%.8, 12, 17, 31 The radial forces generated with dilating balloons, and both radial and longitudinal shear forces from bougies, are delivered in a relatively uncontrolled fashion. Thus, the notion that a more precise technique such as EI might ultimately be associated with a lower rate of perforation is certainly plausible. Beyond anastomotic strictures of the upper gut, EI has also proved a useful and safe modality for anastomotic colorectal strictures,32 Schatzki rings,33 peptic esophageal strictures,34 and pyloric stenoses.35

So what role should EI have today in the management of benign anastomotic strictures, given the available data? It appears clear that patients with relatively short (≤1 cm) anastomotic strictures requiring more than 2 to 3 dilation sessions should be considered for an alternative treatment modality. EI should be strongly considered in this subgroup of patients, given the excellent outcomes reported, including durable eradication of dysphagia after a single treatment in the majority of patients.19, 22 What alternatives can be considered? Intra-stricture steroid injection in conjunction with dilation is an option; several case series have reported a benefit in terms of a reduction in the frequency of dilations,36, 37 though lasting benefit without need for further dilation after a single treatment session was observed in the majority of patients in one small series.18 Temporary placement of a self-expanding polyester-silicone stent has been utilized, though with relatively poor outcomes.20, 38 Stent migration rates of up to 85%, frequent (up to 87%) recurrence of dysphagia upon stent removal, stent-induced ulcers, and nearly ubiquitous post-placement chest pain make this a less attractive treatment modality.20, 39 Patient instruction for self-bougienage has been reported,40 though clearly many patients may be either unwilling or unable to use this option.

Endoscopists and patients certainly may opt for EI as an alternative to dilation for the primary treatment of anastomotic strictures of the upper gut as well. Although the excellent outcomes reported in prospective nonrandomized studies of primary stricture EI24, 27 were not as robustly replicated in the present randomized trial by Hordijk et al,28 EI was at least as effective as bougienage. Additional trials in this patient population would be useful, because more data would clearly have the potential to alter clinical practice.

The role of EI in longer (>1 cm) anastomotic strictures is less certain. As previously mentioned, all treatment modalities suffer in regard to effectiveness in the setting of longer strictures, which tend to occur more frequently after postoperative complications (eg, leaks, infections). In this challenging subset, EI can be considered as an alternative approach to dilation, because beneficial outcomes have been reported, though frequently with multiple treatment sessions.19, 27 The need to extend incisions a greater distance longitudinally may theoretically increase bleeding risk, though this has not been seen in limited experiences.

The American essayist and philosopher Ralph Waldo Emerson coined the phrase “hitch your wagon to a star,” which asserts that we should always aspire to greatness and never accept mediocrity. As our endoscopic arsenal expands, and as more data critically evaluating different techniques become available, we must remain alert to new or historically underutilized approaches such as EI for anastomotic strictures rather than become content with yesterday's suboptimal outcomes. Hopefully, curious minds will continue to evaluate this method and answer questions that will refine our technique, optimize safety, gain a more robust experience with outcomes, and further explore the use of EI in conjunction with other modalities such as dilation and tissue ablation/excision. With the knowledge gained from these efforts guiding our actions, our patients will be truly well served.