This document discusses the management of cervical esophageal anastomotic strictures. The most common cause is gastroesophageal reflux disease. Evaluation includes ruling out other potential causes through history, barium swallow, and endoscopy prior to dilatation. Dilatation can be done using bougie or balloon dilators in 1-3 sessions. Refractory strictures may require intralesional steroid injection, temporary stenting, or surgery such as patch stricturoplasty using local or free flaps to repair the stricture. The radial forearm free flap is an option that avoids the morbidity of laparotomy and provides a thin, well-vascularized tissue for repair.
11. 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
16. Balloon dilators
• 2 types
1. Through the scope dilators (TTS)
2. Over the guidewire dilators (OTW)
17.
18. Therapeutic approach
• Simple strictures:
- Related to prolonged reflux
- Short segment
- Scope can be passed easily
- Maloney dilators can be safely used
19. • Complex strictures:
- Long narrow and tortuous
- Scope cannot be passed easily
- Stricture associated with hiatal
hernia/esophageal diverticula
21. 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
22. Frequecy of dilatation
• Depends upon
1. Success of initial dilatation
2. Response of patient to initial dilatation
23. • Pt undergoing dilatation fr 1st time – required
multiple sittings once every 5-6 days
• Last dilator used in previous session to be
passed 1st.
24. End point of dilatation
• Dilatation to 18mm (56 Fr) – Solid diet
• Dilatation to 13mm (39Fr) – Dysphagia to
solids
• Dilatation to 15mm (45Fr) – Soft solids
27. 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
28. Non-metal expandable stents
• Temporary placement of non-metal
expandable stents- effective in management
of benign strictures
• Stent: Silicon coated self expanding plastic
stent
29.
30. • To be left in place for 6 weeks to allow
remodelling of scar tissue
• Longer time required for anastomotic
strictures
• Problem: Stent migration
31. 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
32. • Largest study conducted
40 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
33. Others
• Injection of Mitomycin
• Endoscopic electrosurgical incision of peptic
ulcer
42. Platysma myocutaneous flap
• Arterial supply: Submental,
• Facial A., Sup. Thyroid A.
• Occipital A., Tr. Cervical A.
• Venous drainage: IJV,
• Submental V.
45. 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
48. Radial fore-arm free flap
• Fasciocutaneous flap
• Based on Radial A. and its vena commitantes
49. 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
50. 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
51. 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
53. • 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
54. • 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
56. 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
57. • 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
58. • 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
