Endosurgical management of cervical esophageal strictures

Stricture formation after cervical esophageal anastomosis is a significant problem. Often management requires multiple patient endoscopies and dilatations. This results in a considerable cost and inconvenience for the patients. We present our experience with the management of these strictures, using endoscopic surgical techniques and outpatient dilatation. Over the last two years we performed 12 transhiatal esophagectomies for malignant disease. In addition we had 1 patient referred to our practice with a stricture following cervical colonic interposition for lye ingestion twenty years previous. In total, three of the transhiatal esophagectomy patients developed significant stricture formation postoperatively. Of these patients two had received preoperative chemoradiation. The patient who had not had previous therapy had metastatic disease on initial presentation. The other patients had limited disease. Our initial approach to the patients involved endoscopy, documentation of the stricture, and biopsy. Balloon dilation was subsequently employed to create a 10mm opening. A guidewire was then placed endoscopically through the opening. Savary dilators were then passed gently over the guidewire to create a 14-16mm opening. Subsequent follow up visits were scheduled at one week and then increased to every other week. In two of the four patients with significant stricture formation symptoms resolved. The remaining two patients entered a program of self esophageal dilatation. This was performed using blunt dilators. Patients appeared to tolerate this form of therapy well and preferred it to repeat endoscopy. One of the four patients has expired from distant disease. The other patients are tolerating an oral diet and there has been no evidence of malnutrition thus far. In conclusion we have used a combination of endosurgical techniques to manage postoperative stricture formation in cervical anastomoses. Using these methods we have been able to limit hospital visits and minimize the number of endoscopies used to manage this complication. Patients generally tolerate outpatient dilatation well. This should be considered a viable option in the management of these patients.