Endoscopic Treatment of Anastomotic Esophageal Stricture. A Randomised Study Comparing Initial Dilation by Electrocautery with Savary Bougies with Electrocautery.

Summary:

Anastomotic strictures are common after esophageal resection. These strictures often need multiple dilation procedures with Savary bougies, and some even fail despite many dilations. Based on the literature and our pilot study of electrocautery therapy of refractory benign esophageal stenosis (Hordijk Marjan L. , Siersema Peter D., Tilanus Hugo W. , Kuipers Ernst J. Electrocautery therapy for refractory anastomotic strictures of the esophagus. Gastrointest Endosc 2006;63:157-63. ), electrocautery treatment is safe, and may provide an excellent alternative for primary treatment of esophageal strictures. A prospective randomized controlled is needed to compare dilation therapy with Savary bouginage with electrocautery therapy for the primary treatment of these strictures.

Anastomotic strictures are common after esophageal resection. These strictures often need multiple dilation procedures with Savary bougies, and some even fail despite many dilations. Based on the literature and our pilot study of electrocautery therapy of refractory benign esophageal stenosis (Hordijk Marjan L. , Siersema Peter D., Tilanus Hugo W. , Kuipers Ernst J. Electrocautery therapy for refractory anastomotic strictures of the esophagus. Gastrointest Endosc 2006;63:157-63. ), electrocautery treatment is safe, and may provide an excellent alternative for primary treatment of esophageal strictures.
A prospective randomized controlled is needed to compare dilation therapy with Savary bouginage with electrocautery therapy for the primary treatment of these strictures.

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- Upper gastrointestinal endoscopy will be performed. The postoperative stenosis will be inspected and the diameter of the stenosis will be estimated by using the diameter of the endoscope (9.5 mm). These stenoses are usually located at 17 to 20 cm from the incisors.

- For endoscopic bougie dilation of the stricture, a guide wire will be placed in the stomach, followed by removal of the endoscope and passage of Savary Gilliard bougies (Wilson Cook) of increasing diameter over the guidewire according to standard procedures to a diameter of minimal of 16 mm and maximal 19 mm.

- For endoscopic dilation of the strictures with electrocautery, the tip of the endoscope is positioned just proximal from the stenosis, and a needle knife catheter (Wilson Cook, Boston Scientific) is introduced through the working channel. Radial incisions are made in the stenotic ring with the needle knife catheter under direct visualization. The required length of the cut is gauged according to the length of the stricture assumed by the endoscopist in the light of the membranous nature and the caliber of the stricture. The depth of the incision (estimated using the length of the needle knife as a comparator) is not deeper than 4 mm. The length of the incision is dosed to completely remove the rim of the stenosis.

- In case of recurrent stenosis, dilation therapy will be repeated with the same modality as was used at baseline. Recurrent stenosis is defined as no passage or only passage with pressure of the endoscope (diameter 9.5 mm.).