Primary incision of esophageal strictures: the technical details?

Ozaslan, Ersan

doi:10.1016/j.gie.2009.08.019

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Volume 71, Issue 4 , Page 883, April 2010

Primary incision of esophageal strictures: the technical details?

Department of Gastroenterology, Ankara Numune Education and Research Hospital, Ankara, Turkey

To the Editor:

I read with great interest the study by Lee et al¹ that described 24 patients with benign anastomotic esophageal stricture after esophagojejunostomy who were successfully treated with endoscopic incisions by using Iso-Tome or IT-knife. The length of the stricture was less than 1 cm for 21 (87.5%) of 24 patients; stricture recurrence developed in only 3 patients (12.5%), in 2 of 3 patients with a long-segment stricture (>1 cm) and in 1 of 21 patients with a short-segment stricture (<1 cm). Stricture recurrence after incisional therapy was statistically more prevalent in long-segment than short-segment strictures.

I have 3 questions: First, is there any advantage of the Iso-Tome or IT-knife over the classic needle-knife in a case of simple or complex stricture? For example, Hordijk et al² treated 20 patients with a refractory anastomotic stricture by using electrocautery by conventional needle-knife. A single electrocautery treatment resulted in complete relief of dysphagia in all 20 patients without complications, similar to the series of Lee et al, and after 1 year, all 12 patients with an anastomotic stricture of less than 1 cm had remained dysphagia free. In the remaining 8 patients with long-segment stenosis, a mean of 3 treatments (range 2-5 treatments) was necessary before patients were dysphagia free.

Second, how did they perform a complete incision in long-segment stenosis, careful observation during blind dissection, and passage of a small-diameter endoscope or a balloon dilation after incision? If complete incision cannot be performed, this may be the underlying mechanism of an increased stricture recurrence rate compared with simple strictures.

Third, could one use this technique in strictures occurring on other than postoperative cases, ie, radiation or corrosive injury?

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References

Lee TH, Lee SH, Park JY, et al. Primary incisional therapy with a modified method for patients with benign anastomotic esophageal stricture. Gastrointest Endosc. 2009;69:1029–1033

Hordijk ML, Siersema PD, Tilanus HW, et al. Electrocautery therapy for refractory anastomotic strictures of the esophagus. Gastrointest Endosc. 2006;63:157–163