Management of cervical esophageal anastomotic stricture

Zeeshan

Introduction

• Most common etiology: GERD (75%)• Other causes:- Caustic ingestion- External beam radiotherapy- Surgical anastomoses- Rare dermatological diseases eg.

Epidermolysis bullosa

Rare causes

- Extrinsic compression of esophagus• Tuberculosis• Idiopathic fibrosing mediastinitis

• Eosinophilic esophagitis- Dilatation associated with mucosal tearing and

perforation

Goal of therapy

• Relief of dysphagia

• Prevention of stricture recurrence

Evaluation prior to dilatation

• H/O Dysphagia

D/D• GERD• Motility disturbance• Infection• Malignancy• Esophageal webs/rings

PRIOR TO ENDOSCOPIC DILATATION ALWAYS RULE OUT

OTHER CAUSES

Investigations

• Barium swallow

AFTER CONFIRMATION PROCEED TO ENDOSCOPIC

DILATATION

Contraindication for dilatation

• In acute or incompletely healed esophageal perforation

• In potentially malignant stricture• Patients with pulmonary /cardiac risk factor• EXTREME CARE in cervical deformity/ thoracic

aneurysm/ recent surgery• Eosinophilic esophagitis

Types of esophageal dilators

Mechanical dilators

• Bougie dilators

Balloon dilators

Mechanical dilators

• Divided into 2 types:1. Those that pass freely2. Those that are inserted over guidewire

Maloney dilators

• • In USED to be • filled with Hg.• Tungsten used

Savary-Gillard dilators

Balloon dilators

• 2 types

1. Through the scope dilators (TTS)

2. Over the guidewire dilators (OTW)

Therapeutic approach

• Simple strictures:- Related to prolonged reflux- Short segment- Scope can be passed easily- Maloney dilators can be safely used

• Complex strictures:- Long narrow and tortuous- Scope cannot be passed easily- Stricture associated with hiatal

hernia/esophageal diverticula

Technique

Number of dilatations per session

• Bougie dilators- No more than 3 dilatations per session- Lumen french should not be increase by > 6Fr

• Ballon dilators- No more than 3 incremental inflations- Very tight or long strictures- 2 dilatations per

sitting

Frequecy of dilatation

• Depends upon1. Success of initial dilatation

2. Response of patient to initial dilatation

• Pt undergoing dilatation fr 1st time – required multiple sittings once every 5-6 days

• Last dilator used in previous session to be passed 1st.

End point of dilatation

• Dilatation to 18mm (56 Fr) – Solid diet

• Dilatation to 13mm (39Fr) – Dysphagia to solids

• Dilatation to 15mm (45Fr) – Soft solids

Refractory strictures

• Patients FAILING to respond to esophageal dilatations

• Poor candidates for surgical repair

Other methods

1. Intralesional injection of steroids

2. Non-metal stents

3. Metal stents

4. Other methods

Intralesional injection of steroids

• Injection of triamcinolone MAY reduce stricture recurrence

• MOA Corticosteroids MAY impede collagen

deposition and enhance its breakdown locally to prevent scar formation

Non-metal expandable stents

• Temporary placement of non-metal expandable stents- effective in management of benign strictures

• Stent: Silicon coated self expanding plastic stent

• To be left in place for 6 weeks to allow remodelling of scar tissue

• Longer time required for anastomotic strictures

• Problem: Stent migration

11 Patients with anastomotic stricture following esophagogastrectomy.

• Stent placed for ALL patients• ALL patients had satisfactory relief of dysphagia• Recurrence of symptoms after stent removal –

23% patients• Mean time for repeat dilatation/stent

reinsertion- 37 days• Clinical outcomes after self-expanding plastic stent placement for

refractory benign esophageal strictures.• Oh YS, Kochman ML, Ahmad NA, Ginsberg GG

• Largest study conducted40 patients with refractory benign esophageal strictures

treated with Polyflex stent x 4 weeks

• Median dysphagia score improved• Follow-up after 1 year – 40% dysphagia FREE• Complications included:- Stent migration- Severe chest pain- Bleeding- Perforation- GERD- Stent impaction- Fistula formation

Others

• Injection of Mitomycin

• Endoscopic electrosurgical incision of peptic ulcer

Surgery

Post- esophagogastrectomy strictures

• Following esophagogastrectomy – Benign esophageal stricture 40%

• Association:- Anastomotic leak- Inadequate/ marginally adequate blood flow

to most cranial part of gastric tube

• Strictures usually respond to endoscopic dilatation

• If NOT responding:- Resection - Transection- Patch repair of stricture

TO RE-ESTABLISH GI CONTINUITY

Options available

• Colon interposition• Mobilisation and advancement of stomach

and reanastomoses• Free jejunal graft• Patch stricturoplasty

Patch stricturoplasty

1. Staged flap

2. Myocutaneous flap

3. Free flap

Staged flaps

• Wookey’s cervical skin flap

• Bakamjiam’s deltopectoral flap

Myocutaneous flaps

• Pectoralis major myocutaneous flap

• Latissimus dorsi myocutaneous flap

• Platysma myocutaneous flap

Platysma myocutaneous flap

• Arterial supply: Submental,

• Facial A., Sup. Thyroid A.• Occipital A., Tr. Cervical A.

• Venous drainage: IJV, • Submental V.

Platysma myocutaneous flap

• Failure rate – 40%

• Leak rate - 10.7 %

• Restenosis rate – 7.1%

• Platysma Myocutaneous Flap for Patch Stricturoplasty in Relieving Short and Benign Cervical Esophageal Strictur Yi-Dan Lin, MD, Yao-Guang Jiang, MD, , Ru-Wen Wang, MD, Tai-Qian Gong, MD, Jing-Hai Zhou,MD

Advantages

• Less bulky compared to PMMC/ LD flap

• Local flap – morbidity of laparotomy avoided

• Leak rate and restenosis rates lower

• Early enteral nutrition can be intiated through NG tube

Disadvantages

• Cannot motivate peristalsis

Free flaps

• Radial fore-arm free flap

Radial fore-arm free flap

• Fasciocutaneous flap

• Based on Radial A. and its vena commitantes

Advantages over jejunal free flap

1. Does NOT require laparotomy to harvest

2. Pedicle is LONG – giving surgeons the use of several feeding vessels

3. NOT bulky

4. Mucosa DOESNOT secrete mucus

Study

• 5 men and 1 woman• Age between 24- 60 years• Between 1993 – 1996

• All patients had esophageal replacement for non-malignant disease

• All had failed multiple esophageal dilatation• 1 patient 6 weeks post esophagogastrectomy had a

persistent leak with necrosis of 60% of proximal stomach – NOT septic

Procedure

• RFFF was harvested from non-dominant arm unless Allen’s test was positive

• Stricture was transected in longitudinal direction of esophagus and stomach and patch applied

• Size of graft 5x8cm to 5x12cm• Length of graft 8 – 12cm

RFFF

• Treatment was accomplished through NECK incision in 5 patients

• Thoracotomy and neck incision in 1 patient

• In patients with VC palsy on the side of the previous incision (2 of 6) – SAME side used

• Patients with no VC palsy – Opposite side used

• Graft sewed using single layer interrupted technique

• Revascularised using microvascular technique

• Artery – anastomosed to Facial A./Inf. Thyroid A./ Transverse cervical A.

• Vein – anastomosed to IJV

• Follow-up

3/12 interval for 1 year

Yearly intervals after that

Results

• 1 patient developed LEAK from graft stomach anastomotic site ---POD 8

• Exsanguinated from venous anastomoses of patch graft ---- POD 12

• Postmortem – GRAFT was viable.

• ONLY patient to be treated in ACUTE phase of illness

• Other 5 patients – normal diet within 4 -6 weeks of surgery

• NO anastomotic leaks• 1 patient developed narrowing of distal

anastomoses of tubularised graft—Dilatation

• ALL patients could eat solid food– 7 years follow up

• When one is confronted with the rare problem of a stricture or persistent fistulae from the cervical esophagogastrectomy anastomosis, we would recommend the use of the radial forearm flap to patch this anastomosis.

• Use of the radial forearm free tissue flap to treat persistent stricture after esophagogastrectomy

• Clifford W Deveney, M.D.a, , Scott Soot, M.D.a, Blair Jobe, M.D.a, James I Cohen, M.D.a, Peter Anderson, M.D.a, Mark K Wax, M.D.a, Michael Wheatley, M.D.a, Brett C Sheppard, M.D.a