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Resolution of a Refractory Anastomotic Stricture With a Novel Biodegradable Esophageal Stent
Electronic Image of the Month Resolution of a Refractory Anastomotic Stricture With a Novel Biodegradable Esophageal Stent DIEGO SÁNCHEZ MUÑOZ, CARLOS ORTIZ–MOYANO, and BLAS GÓMEZ–RODRÍGUEZ Endoscopy Unit, Digestive Diseases Department, Hospital Quiron Sagrado Corazón, Sevilla, Spain
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ndoscopic therapy for esophageal strictures may be complex, relying on multiple sessions in most cases, using dilatation, corticosteroid injections, or stent placement. Moreover, anastomotic strictures have a poor prognosis.1 Recently, biodegradable stents were shown to be a good option to resolve benign, refractory esophageal strictures.2
Case Report A 47-year-old man was admitted to our unit, suffering from a postsurgical esophageal-cutaneous fistula after subtotal esophagectomy plus cervical gastroplasty resulting from esophageal adenocarcinoma. Initially, it was resolved by a temporally placed, covered, self-expandable metal stent (8-cm long, 18-mm diameter, Hanarostent; M.I. Tech, Co, Ltd, Republic of Korea), which was extracted 24 days after its placement as a result of proximal migration. Fistula resolution was confirmed. Thirty days later, a tracheoesophageal fistula was diagnosed and was resolved with the placement of a new stent similar to the former one, keeping it in place for 2 months. Nevertheless, although high doses of proton pump inhibitors were given, the patient developed mixed anastomotic and peptic stricture refractory to repeated balloon dilatations and corticosteroid injections (Figure A). We chose to place a polidioxanone, 8-cm long, 25-mm diameter, biodegradable stent (SX-ELLA biodegradable stent BD, ELLA-CS, s.r.o, Hradec Králové, Czech Republic), recovering from dysphagia (Figure B). An upper-gastrointestinal endoscopy was performed 4 weeks after stent placement, showing initial degradation of the stent with a good esophageal diameter (Figure C). After 5 months, it was completely reabsorbed, and the patient maintained adequate oral intake (Figure D). Only one session of soft-balloon dilation was necessary while the biodegradable stent was in place. Several biopsy specimens taken throughout the therapeutic process did not show malignancy. The patient died of metastatic disease, without relapse of dysphagia 20 months after biodegradable stent placement.
Discussion Therapy for postsurgical esophageal strictures can be discouraging. The introduction of temporally placed, covered,
esophageal stents changed the natural history of benign esophageal strictures and leakages.3 Nevertheless, the complication rate was not negligible, occurring in 36% patients, with a 19% rate of recurrent dysphagia as a result of migration or re-stenosis.4 Biodegradable stents are an initial attempt to improve esophageal permeability for a longer time, adding the advantage of avoiding the potential complications of stent extraction. These stents also have the ability to maintain radial dilation force throughout the entire reabsorption period. A potential problem may be the acidic exposure to the proximal part of the esophagus while the stent is in place. Nevertheless, there are a lack of data regarding the potential for gastroesophageal reflux as a complication of the biodegradable stent.5 In conclusion, biodegradable stents may be a good option in patients with refractory, benign esophageal strictures when other treatments have failed.
References 1. Siersema PD. Treatment options for esophageal strictures. Nat Clin Pract Gastroenterol Hepatol 2008;5:142–152. 2. Saito Y, Tanaka T, Andoh A, et al. Usefulness of biodegradable stents constructed of poly-l-lactic acid monofilaments in patients with benign esophageal stenosis. World J Gastroenterol 2007;13:3977–3980. 3. Barthel JS, Kelley ST, Klapman JB. Management of persistent gastroesophageal anastomotic strictures with removable self-expandable polyester silicon-covered (Polyflex) stents: an alternative to serial dilation. Gastrointest Endosc 2008;67:546 –552. 4. Battersby NJ, Bonney GK, Subar D, et al. Outcomes following oesophageal stent insertion for palliation of malignant strictures: a large single centre series. J Surg Oncol 2012;105:60 – 65. 5. van Hooft JE, van Berge Henegouwen MI, Rauws EA, et al. Endoscopic treatment of benign anastomotic esophagogastric strictures with a biodegradable stent. Gastrointest Endosc 2011;73:1043–1047.
Conflicts of interest The authors disclose no conflicts. © 2013 by the AGA Institute 1542-3565/$36.00 http://dx.doi.org/10.1016/j.cgh.2012.11.023 CLINICAL GASTROENTEROLOGY AND HEPATOLOGY 2013;11:e63
E
ndoscopic therapy for esophageal strictures may be complex, relying on multiple sessions in most cases, using dilatation, corticosteroid injections, or stent placement. Moreover, anastomotic strictures have a poor prognosis.1 Recently, biodegradable stents were shown to be a good option to resolve benign, refractory esophageal strictures.2
Case Report A 47-year-old man was admitted to our unit, suffering from a postsurgical esophageal-cutaneous fistula after subtotal esophagectomy plus cervical gastroplasty resulting from esophageal adenocarcinoma. Initially, it was resolved by a temporally placed, covered, self-expandable metal stent (8-cm long, 18-mm diameter, Hanarostent; M.I. Tech, Co, Ltd, Republic of Korea), which was extracted 24 days after its placement as a result of proximal migration. Fistula resolution was confirmed. Thirty days later, a tracheoesophageal fistula was diagnosed and was resolved with the placement of a new stent similar to the former one, keeping it in place for 2 months. Nevertheless, although high doses of proton pump inhibitors were given, the patient developed mixed anastomotic and peptic stricture refractory to repeated balloon dilatations and corticosteroid injections (Figure A). We chose to place a polidioxanone, 8-cm long, 25-mm diameter, biodegradable stent (SX-ELLA biodegradable stent BD, ELLA-CS, s.r.o, Hradec Králové, Czech Republic), recovering from dysphagia (Figure B). An upper-gastrointestinal endoscopy was performed 4 weeks after stent placement, showing initial degradation of the stent with a good esophageal diameter (Figure C). After 5 months, it was completely reabsorbed, and the patient maintained adequate oral intake (Figure D). Only one session of soft-balloon dilation was necessary while the biodegradable stent was in place. Several biopsy specimens taken throughout the therapeutic process did not show malignancy. The patient died of metastatic disease, without relapse of dysphagia 20 months after biodegradable stent placement.
Discussion Therapy for postsurgical esophageal strictures can be discouraging. The introduction of temporally placed, covered,
esophageal stents changed the natural history of benign esophageal strictures and leakages.3 Nevertheless, the complication rate was not negligible, occurring in 36% patients, with a 19% rate of recurrent dysphagia as a result of migration or re-stenosis.4 Biodegradable stents are an initial attempt to improve esophageal permeability for a longer time, adding the advantage of avoiding the potential complications of stent extraction. These stents also have the ability to maintain radial dilation force throughout the entire reabsorption period. A potential problem may be the acidic exposure to the proximal part of the esophagus while the stent is in place. Nevertheless, there are a lack of data regarding the potential for gastroesophageal reflux as a complication of the biodegradable stent.5 In conclusion, biodegradable stents may be a good option in patients with refractory, benign esophageal strictures when other treatments have failed.
References 1. Siersema PD. Treatment options for esophageal strictures. Nat Clin Pract Gastroenterol Hepatol 2008;5:142–152. 2. Saito Y, Tanaka T, Andoh A, et al. Usefulness of biodegradable stents constructed of poly-l-lactic acid monofilaments in patients with benign esophageal stenosis. World J Gastroenterol 2007;13:3977–3980. 3. Barthel JS, Kelley ST, Klapman JB. Management of persistent gastroesophageal anastomotic strictures with removable self-expandable polyester silicon-covered (Polyflex) stents: an alternative to serial dilation. Gastrointest Endosc 2008;67:546 –552. 4. Battersby NJ, Bonney GK, Subar D, et al. Outcomes following oesophageal stent insertion for palliation of malignant strictures: a large single centre series. J Surg Oncol 2012;105:60 – 65. 5. van Hooft JE, van Berge Henegouwen MI, Rauws EA, et al. Endoscopic treatment of benign anastomotic esophagogastric strictures with a biodegradable stent. Gastrointest Endosc 2011;73:1043–1047.
Conflicts of interest The authors disclose no conflicts. © 2013 by the AGA Institute 1542-3565/$36.00 http://dx.doi.org/10.1016/j.cgh.2012.11.023 CLINICAL GASTROENTEROLOGY AND HEPATOLOGY 2013;11:e63