|Ahead of print publication
Surgical treatment of noncaustic benign esophageal stenosis
Ming-Ho Wu, Han-Yun Wu
Department of Surgery, Tainan Municipal Hospital, Show Chwan Medical Care Corporation, Tainan, Taiwan
|Date of Submission||21-Feb-2018|
|Date of Decision||02-Apr-2018|
|Date of Acceptance||28-Jun-2018|
No. 670, Chung Te Road, Tainan City 701
Source of Support: None, Conflict of Interest: None
Background: Noncaustic benign esophageal stenosis is an uncommon esophageal disorder. We report herein our surgical results for this type of esophageal stenosis.
Materials and Methods: A retrospective review of 30 patients presenting with noncaustic benign esophageal stenosis between June 2009 and February 2018 was conducted. Patient demographics, preoperative diagnoses, treatment strategies, surgical procedures, and the postoperative course of treatment were investigated.
Results: No hospital death occurred. Four (13.3%) patients had operative complications, namely, one incident of a duodenal bleeding ulcer, one incident of respiratory failure, and two incidents of wound infections. One patient with primary achalasia required a second myotomy 5 months after initial surgery. All other patients resumed a regular diet after surgery.
Conclusion: Delayed diagnosis and treatment of noncaustic benign esophageal stenosis are common. The surgical approach depends on the location and nature of the esophageal disease. Quality of life of patients can be enhanced through careful surgery.
Keywords: Achalasia, esophageal stenosis, noncaustic
| Introduction|| |
Ingestion of hydrochloric acid was common in Taiwan approximately 30 years ago, typically occurring among adults and causing caustic esophageal strictures., Many thoracic surgeons have treated numerous patients with this type of esophageal disorder. Some other benign esophageal stenoses were also of interest in this study. To understand the therapeutic outcomes, this paper reports our surgical procedures used in the treatment of different categories of noncaustic esophageal stenosis. Clinical data, technical considerations, and short-term results are discussed herein.
| Materials and Methods|| |
We retrospectively reviewed patients with benign esophageal stenosis treated by the first author between June 2009 and February 2018. A total of 30 patients with noncaustic benign esophageal stenosis were enrolled; most had been primarily treated at our hospital. Four patients had recurrent achalasia, three had undergone repeated myotomies, and one had undergone an esophagoplasty with a gastric flap at another hospital.
Regarding patients presenting with dysphagia, after a review of their medical history, the level, severity, and nature of their esophageal stenosis were evaluated using esophagography [Figure 1], panendoscopy, and computed tomography. None of these patients had a history of corrosive agent ingestion or evidence of esophageal benign tumors or malignancy.
|Figure 1: The esophagograms show different level and shape of esophageal stenosis; cricopharyngeal bar (a), peptic esophageal stricture (b), achalasia at distal end of the esophagus (c), and end-stage achalasia (d)|
Click here to view
Selection of the surgical procedure depended on the location and nature of the esophageal disease. In patients with primary cardiac achalasia, thoracoscopic myotomy was performed based on the surgeon's preference. Combinations of distal esophagectomy and esophagogastrostomy with or without fundoplication were used for patients with distal esophageal peptic strictures and recurrent achalasia with severe fibrotic change. The surgical approach was laparotomy or thoracolaparotomy. The esophagogastrostomy was usually performed near the hiatus of the distal esophagus after mobilization. In three patients with end-stage achalasia, a side-to-side esophagogastrostomy using a 60-mm linear stapler (ECHELON FLEX™ GST) was performed, and esophageal reconstruction was performed on one other patient. In patients with long segments of middle and lower esophageal peptic strictures, ileocolonic bypasses were performed through the substernal route. In one patient with a cricopharyngeal bar, a slide pharyngo-esophagoplasty or cricopharyngeal myotomy through an oblique left neck incision was effective. In the case of cricopharyngeal myotomy, most muscles of the cricopharyngeal junction were excised, and the mucosa and recurrent laryngeal nerve were carefully preserved. One patient with a peptic stricture underwent concurrent gastrostomy and cholecystectomy for a comorbidity of gallstones associated with chronic cholecystitis. In patients who underwent distal esophagectomy and esophagogastrostomy, the associated procedure of pyloroplasty was also performed.
Esophagography and endoscopy were routinely conducted 2 weeks and 1 month after surgery, respectively, to evaluate the patency of conduits and the condition of anastomoses. Patients were monitored in the outpatient department after discharge. Data were obtained through clinical visits and questionnaires completed after patients had been discharged from the hospital. The ability to maintain a regular diet without dysphagia or restriction to a semiliquid or liquid diet, body weight, activity level, aspiration level, and the timing and frequency of regurgitation were recorded. Complications that developed immediately after surgery or during the follow-up period were considered cases of operative morbidity.
The study variables were summarized using descriptive statistics. Continuous variables are expressed as mean (standard deviation) and were compared using the Student's t test. Categorical variables are presented as frequency counts and intergroup comparisons were performed using the Chi-squared test. P < 0.05 was considered statistically significant. Statistical analysis was performed using the Statistical Package for Social Sciences software SPSS® version 22 (IBM, Armonk, New York, USA).
The study was conducted in accordance with the Declaration of Helsinki and was approved by the local ethics committee of the institute. Informed written consent was obtained from all patients prior to their enrollment in this study.
| Results|| |
The age, sex, and duration of dysphagia of each of the 30 patients were summarized based on seven categories of esophageal stenosis [Table 1]. No significant differences in these variables were apparent among these seven categories (P = 0.229, 0.725, and 0.424, respectively). Surgical procedures varied according to the nature of esophageal stenosis [Table 2]. Operation time was longer for esophageal reconstruction than for other surgical procedures, but not to a statistically significant extent (P = 0.29). Hospital stay was significantly longer among patients who had undergone esophagectomy and esophageal reconstruction than among those who had undergone other procedures, and shorter in patients who had undergone myotomy or esophagogastrostomy with a stapler (P = 0.03). Recurrence of dysphagia (3.3%) was observed in an 80-year-old patient who had undergone thoracoscopic myotomy for primary achalasia. This patient required a second myotomy 5 months after initial surgery. All patients resumed a regular diet after completion of surgery over a mean follow-up period of 30 months (ranging from 3 months to 9 years). No hospital death, anastomotic leakage, or stenosis occurred. Four patients had operative complications, namely, one incident of duodenal ulcer bleeding controlled by endoscopic coagulation, two incidents of wound infections treated conservatively, and one incident of respiratory failure that required ventilator support for 2 months. In the postoperative follow-up period, three (10%) patients experienced symptoms of mild acid regurgitation and four (13.3%) patients had occasional dysphagia.
| Discussion|| |
In 1992, we reported results of esophageal reconstruction in 75 patients with caustic sequelae. The patients were aged 27 years on average. The anastomotic leakage rate was 6.7%. In 2001, we reported our experiences of treating 152 patients with caustic sequelae. In that series, most patients with multiple or diffuse caustic strictures typically underwent the anastomosis of an esophageal substitute to the cervical esophagus (67.1%, 102/152) or hypopharynx (32.9%, 50/152). The most commonly used esophageal substitute for esophageal reconstruction surgery was ileocolonic bypass through the substernal route. All these surgical procedures and postoperative care regimens are challenging. Compared with treatment of the aforementioned disorders, treatment of noncaustic esophageal stenosis is uncomplicated; however, noncaustic benign esophageal stenoses typically occur in older adults. In a literature review of management of benign esophageal stricture, the treatments include esophageal stent, gastrostomy, jejunostomy and reconstructive surgery. In the present series, all patients were referred for surgical treatment from our colleges or other hospitals. To evaluate our surgical results, the 30 patients were classified into seven categories. Category 1 was primary cardiac achalasia, all cases of which were evaluated using esophagography rather than esophageal manometry, for which our hospital lacks the necessary facility. We chose the thoracoscopic approach to perform Heller myotomy based on surgeon preference. The myotomy was extended 5 mm into the gastric wall and did not include an antireflux procedure. Following the Society of American Gastrointestinal and Endoscopic Surgeons guidelines for the surgical treatment of esophageal achalasia, we shifted thoracoscopic myotomy to laparoscopic myotomy with partial fundoplication. A meta-analysis pointed out that the peroral endoscopic myotomy is a relatively novel minimally invasive technique used to treat achalasia. The technique needs to be well trained. Category 2 was recurrent achalasia. Esophagectomy was considered in appropriately selected patients for whom myotomy had failed. In these cases, the distal esophagus presented with severe fibrosis. To solve the problem of fibrotic change in the esophagogastric junction, we preferred the surgical procedure of distal esophagectomy with esophagogastrostomy, fundoplication, and pyloroplasty. Category 3 was end-stage achalasia. Some alternative procedures were suggested to treat this disorder such as an esophagectomy and laparoscopic esophagogastrostomy with a stapler., We used laparotomy to perform side-to-side esophagogastrostomy by using a 60-mm linear stapler; this simple surgical procedure can provide satisfactory patency of the esophagogastric junction [Figure 2]. Category 4 was peptic stricture caused by gastroesophageal reflux. The stricture could involve a long segment of the esophagus. In patients with complicated gastroesophageal reflux disease, surgery is significantly more effective than medical therapy. The variety of interventions for refractory strictures includes injection of intralesional corticosteroids, temporary placement of self-expanding plastic stents, and surgery., In these patients, a variety of associated procedures were required to prevent recurrence of peptic disease. Category 5 was a cricopharyngeal bar with a prominent, persistent, posterior indentation at the level of the lower third of the cricoid cartilage, which is a primary cause of oropharyngeal dysphagia, particularly in elderly individuals. The lateral projection of esophagography provides a good visualization. Stenosis can be treated successfully with cricopharyngeal myotomy or slide pharyngo-esophagoplasty to achieve long-term relief. In a previous study, we reported on the surgical technique of slide pharyngo-esophagoplasty. Category 6 was extensive esophageal fibrosis—a rare disease [Figure 3]. This patient was diagnosed as autoimmune disease. Category 7 was esophageal compression by the tortuous aorta denominated as dysphagia aortica. Some patients with dysphagia aortica were delayed in receiving a diagnosis, and some even had fatal outcomes., Surgical intervention consists of an aortic stent for aortic aneurism, aortic resection and graft, or esophageal transposition. In 1971, Lambert described the surgical correction procedure for esophageal obstruction caused by tortuosity of the aorta. To achieve an optimal result for our patient, we performed three-dimensional imaging using contrast-enhanced computed tomography to ensure that the most suitable surgical procedures were selected. In the series, the associated pyloroplasty was performed using the linear stapler technique. No patients underwent perioperative jejunostomy. From the surgical perspective, myotomy for cricopharyngeal bar and primary cardiac achalasia usually require relatively short operating times. By contrast, the surgical procedures for treating recurrent achalasia and peptic esophageal stricture are complicated and require relatively long operating times. After surgery, a few patients still experienced occasional subjective dysphagia, despite having normal endoscopy findings. This phenomenon could be related to a disorder of esophageal motility.
|Figure 2: A patient with end-stage achalasia (a) was treated by side-to-side esophagogastrostomy using a stapler through gastrostomy (b and c). The postoperative esophagogram showed good patency (d)|
Click here to view
|Figure 3: The preoperative esophagogram (a) and computed tomography scan (b), Operative specimen (c), and postoperative esophagogram (d) were belonging to a patient with extensive esophageal fibrosis|
Click here to view
| Conclusion|| |
Although delayed diagnosis and treatment of noncaustic benign esophageal stenosis are common, careful surgery can enhance the quality of life of patients. Selecting the appropriate surgical approach depends on the location and nature of the esophageal disease.
The present study was limited by its retrospective nature and small number of patients.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Wu MH, Lai WW. Esophageal reconstruction for esophageal strictures or resection after corrosive injury. Ann Thorac Surg 1992;53:798-802.
Wu MH, Tseng YT, Lin MY, Lai WW. Esophageal reconstruction for hypopharyngoesophageal strictures after corrosive injury. Eur J Cardiothorac Surg 2001;19:400-5.
Frazzoni L, La Marca M, Montale A, Fuccio L. Management of benign esophageal strictures: A literature review. Recenti Prog Med 2018;109:46-9.
Stefanidis D, Richardson W, Farrell TM, Kohn GP, Augenstein V, Fanelli RD. SAGES guidelines for the surgical treatment of esophageal achalasia. Surg Endosc 2012;26:296-311.
Akintoye E, Kumar N, Obaitan I, Alayo QA, Thompson CC. Peroral endoscopic myotomy: A meta-analysis. Endoscopy 2016;48:1059-68.
Molena D, Yang SC. Surgical management of end-stage achalasia. Semin Thorac Cardiovasc Surg 2012;24:19-26.
Ablassmaier B, Jacobi CA, Stoesslein R, Opitz I, Müller JM. Laparoscopic esophagogastrostomy: An alternative minimally invasive treatment for achalasia stage III. Surg Endosc 2002;16:216.
Yamasaki Y, Ozawa S, Oguma J, Kazuno A, Ninomiya Y. Long peptic strictures of the esophagus due to reflux esophagitis: A case report. Surg Case Rep 2016;2:64.
Spechler SJ. Comparison of medical and surgical therapy for complicated gastroesophageal reflux disease in veterans. The department of veterans affairs gastroesophageal reflux disease study group. N Engl J Med 1992;326:786-92.
Mercer CD, Hill LD. Surgical management of peptic esophageal stricture. Twenty-year experience. J Thorac Cardiovasc Surg 1986;91:371-8.
Ferguson DD. Evaluation and management of benign esophageal strictures. Dis Esophagus 2005;18:359-64.
Williams RB, Grehan MJ, Hersch M, Andre J, Cook IJ. Biomechanics, diagnosis, and treatment outcome in inflammatory myopathy presenting as oropharyngeal dysphagia. Gut 2003;52:471-8.
Suda K, Takeuchi H, Seki H, Yoshizu A, Yasui N, Matsumoto H, et al.
Cricopharyngeal myotomy for primary cricopharyngeal dysfunction caused by a structural abnormality localized in the cricopharyngeus muscle: Report of a case. Surg Today 2011;41:1238-42.
Wu MH, Wu HY. Sequential correction of caustic stricture of trachea and esophageal orifice. Clin Case Rep Rev 2016;2:484-5.
Rajpoot M. Dysphagia aortica: Systematic review of a fatal disease JMPR 2016;3:10-1.
Liao CY, Huang SC, Wang YC, Chin HK, Tsai CC, Ben RJ, et al.
Dysphagia aortica: A fatal delay in diagnosis. Am J Emerg Med 2015;33:1117.e3-5.
Lambert A. Surgical correction of esophageal obstruction due to tortuosity of the aorta. Case report describing relief by means of a new operative procedure. J Thorac Cardiovasc Surg 1971;62:973-8.
Wu MH, Wu HY. Surgical relief of esophageal compression by thoracic aorta Glob Surg, 2017;3:1-2
Wu MH, Wu HH. Simple pyloroplasty using a linear stapler in surgery for esophageal cancer. Surg Today 2013;43:583-5.
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2]