Risk of Recurrent or Refractory Strictures and Outcome of Endoscopic Dilation for Radiation-Induced Esophageal Strictures
Identifieur interne : 003853 ( Pmc/Curation ); précédent : 003852; suivant : 003854Risk of Recurrent or Refractory Strictures and Outcome of Endoscopic Dilation for Radiation-Induced Esophageal Strictures
Auteurs : Anant Agarwalla ; Aaron J. Small ; Aaron H. Mendelson ; Frank I. Scott ; Michael L. KochmanSource :
- Surgical endoscopy [ 0930-2794 ] ; 2014.
Abstract
Radiation therapy for head, neck, and esophageal cancer can result in esophageal strictures that may be difficult to manage. Radiation-induced esophageal strictures often require repeat dilation to obtain relief of dysphagia. This study aimed to determine the long-term clinical success and rates of recurrent and refractory stenosis in patients with radiation-induced strictures undergoing dilation.
Retrospective cohort study of patients with radiation-induced strictures who underwent endoscopic dilation by a single provider from October 2007– October 2012. Outcomes measured included long-term clinical efficacy, interval between sessions, number of dilations, and proportion of radiation strictures that were recurrent or refractory. Risk factors for refractory strictures were assessed.
63 patients underwent 303 dilations. All presented with a stricture > 30 days after last radiation session. Clinical success to target diameter was achieved in 52 patients (83%). A mean of 3.3 (+/− 2.6) dilations over a median period of 4 weeks was needed to achieve initial patency. Recurrence occurred in 17 (33%) at a median of 22 weeks. Twenty-seven strictures (43%) were refractory to dilation therapy. Fluoroscopy during dilation (OR, 22.88; 95% CI, 3.19 – 164.07), severe esophageal stenosis (lumen <9 mm) (OR, 10.51; 95% CI, 1.94 – 56.88), and proximal location with prior malignancy extrinsic to the lumen (OR, 6.96; 95% CI, 1.33 – 36.29) were independent predictors of refractory strictures in multivariate analysis.
1. Radiation-induced strictures have a delayed onset (>30 days) from time of radiation injury. 2. Endoscopic dilation can achieve medium-term luminal remediation but the strictures have a high long-term recurrence rate of up to 33%. 3. Remediation of radiation strictures following laryngectomy can be achieved but require frequent dilations. 4. Clinical and procedural predictors may identify patients at high risk of refractory strictures. 5. The optimal strategy in highly selected refractory patients is not clear.
Url:
DOI: 10.1007/s00464-014-3883-1
PubMed: 25277484
PubMed Central: 4385000
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Aaron J. Small<affiliation><nlm:aff id="A2">Gastroenterology Division, University of Pennsylvania Perelman School of Medicine</nlm:aff>
<wicri:noCountry code="subfield">University of Pennsylvania Perelman School of Medicine</wicri:noCountry>
</affiliation>
<affiliation><nlm:aff id="A3">Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine</nlm:aff>
<wicri:noCountry code="subfield">University of Pennsylvania Perelman School of Medicine</wicri:noCountry>
</affiliation>
<affiliation><nlm:aff id="A3">Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine</nlm:aff>
<wicri:noCountry code="subfield">University of Pennsylvania Perelman School of Medicine</wicri:noCountry>
</affiliation>
<affiliation><nlm:aff id="A4">Department of Internal Medicine, University of Pennsylvania Perelman School of Medicine</nlm:aff>
<wicri:noCountry code="subfield">University of Pennsylvania Perelman School of Medicine</wicri:noCountry>
</affiliation>
<affiliation><nlm:aff id="A2">Gastroenterology Division, University of Pennsylvania Perelman School of Medicine</nlm:aff>
<wicri:noCountry code="subfield">University of Pennsylvania Perelman School of Medicine</wicri:noCountry>
</affiliation>
<affiliation><nlm:aff id="A3">Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine</nlm:aff>
<wicri:noCountry code="subfield">University of Pennsylvania Perelman School of Medicine</wicri:noCountry>
</affiliation>
<affiliation><nlm:aff id="A3">Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine</nlm:aff>
<wicri:noCountry code="subfield">University of Pennsylvania Perelman School of Medicine</wicri:noCountry>
</affiliation>
<affiliation><nlm:aff id="A2">Gastroenterology Division, University of Pennsylvania Perelman School of Medicine</nlm:aff>
<wicri:noCountry code="subfield">University of Pennsylvania Perelman School of Medicine</wicri:noCountry>
</affiliation>
<affiliation><nlm:aff id="A4">Department of Internal Medicine, University of Pennsylvania Perelman School of Medicine</nlm:aff>
<wicri:noCountry code="subfield">University of Pennsylvania Perelman School of Medicine</wicri:noCountry>
</affiliation>
<affiliation><nlm:aff id="A5">Wilmot Center for Endoscopic Innovation, Research, and Training</nlm:aff>
<wicri:noCountry code="subfield">and Training</wicri:noCountry>
</affiliation>
<affiliation><nlm:aff id="A4">Department of Internal Medicine, University of Pennsylvania Perelman School of Medicine</nlm:aff>
<wicri:noCountry code="subfield">University of Pennsylvania Perelman School of Medicine</wicri:noCountry>
</affiliation>
<affiliation><nlm:aff id="A5">Wilmot Center for Endoscopic Innovation, Research, and Training</nlm:aff>
<wicri:noCountry code="subfield">and Training</wicri:noCountry>
</affiliation>
<affiliation><nlm:aff id="A5">Wilmot Center for Endoscopic Innovation, Research, and Training</nlm:aff>
<wicri:noCountry code="subfield">and Training</wicri:noCountry>
</affiliation>
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<front><div type="abstract" xml:lang="en"><sec id="S1"><title>Background</title>
<p id="P2">Radiation therapy for head, neck, and esophageal cancer can result in esophageal strictures that may be difficult to manage. Radiation-induced esophageal strictures often require repeat dilation to obtain relief of dysphagia. This study aimed to determine the long-term clinical success and rates of recurrent and refractory stenosis in patients with radiation-induced strictures undergoing dilation.</p>
</sec>
<sec id="S2"><title>Methods</title>
<p id="P3">Retrospective cohort study of patients with radiation-induced strictures who underwent endoscopic dilation by a single provider from October 2007– October 2012. Outcomes measured included long-term clinical efficacy, interval between sessions, number of dilations, and proportion of radiation strictures that were recurrent or refractory. Risk factors for refractory strictures were assessed.</p>
</sec>
<sec id="S3"><title>Results</title>
<p id="P4">63 patients underwent 303 dilations. All presented with a stricture > 30 days after last radiation session. Clinical success to target diameter was achieved in 52 patients (83%). A mean of 3.3 (+/− 2.6) dilations over a median period of 4 weeks was needed to achieve initial patency. Recurrence occurred in 17 (33%) at a median of 22 weeks. Twenty-seven strictures (43%) were refractory to dilation therapy. Fluoroscopy during dilation (OR, 22.88; 95% CI, 3.19 – 164.07), severe esophageal stenosis (lumen <9 mm) (OR, 10.51; 95% CI, 1.94 – 56.88), and proximal location with prior malignancy extrinsic to the lumen (OR, 6.96; 95% CI, 1.33 – 36.29) were independent predictors of refractory strictures in multivariate analysis.</p>
</sec>
<sec id="S4"><title>Conclusions</title>
<p id="P5">1. Radiation-induced strictures have a delayed onset (>30 days) from time of radiation injury. 2. Endoscopic dilation can achieve medium-term luminal remediation but the strictures have a high long-term recurrence rate of up to 33%. 3. Remediation of radiation strictures following laryngectomy can be achieved but require frequent dilations. 4. Clinical and procedural predictors may identify patients at high risk of refractory strictures. 5. The optimal strategy in highly selected refractory patients is not clear.</p>
</sec>
</div>
</front>
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<pmc-dir>properties manuscript</pmc-dir>
<front><journal-meta><journal-id journal-id-type="nlm-journal-id">8806653</journal-id>
<journal-id journal-id-type="pubmed-jr-id">7653</journal-id>
<journal-id journal-id-type="nlm-ta">Surg Endosc</journal-id>
<journal-id journal-id-type="iso-abbrev">Surg Endosc</journal-id>
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<article-id pub-id-type="manuscript">NIHMS633116</article-id>
<article-categories><subj-group subj-group-type="heading"><subject>Article</subject>
</subj-group>
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<title-group><article-title>Risk of Recurrent or Refractory Strictures and Outcome of Endoscopic Dilation for Radiation-Induced Esophageal Strictures</article-title>
</title-group>
<contrib-group><contrib contrib-type="author"><name><surname>Agarwalla</surname>
<given-names>Anant</given-names>
</name>
<degrees>MD</degrees>
<xref ref-type="aff" rid="A1">1</xref>
<xref ref-type="author-notes" rid="FN1">*</xref>
</contrib>
<contrib contrib-type="author"><name><surname>Small</surname>
<given-names>Aaron J.</given-names>
</name>
<degrees>MD, MSCE</degrees>
<xref ref-type="aff" rid="A2">2</xref>
<xref ref-type="aff" rid="A3">3</xref>
<xref ref-type="author-notes" rid="FN1">*</xref>
</contrib>
<contrib contrib-type="author"><name><surname>Mendelson</surname>
<given-names>Aaron H.</given-names>
</name>
<degrees>MD</degrees>
<xref ref-type="aff" rid="A4">4</xref>
</contrib>
<contrib contrib-type="author"><name><surname>Scott</surname>
<given-names>Frank I.</given-names>
</name>
<degrees>MD, MSCE</degrees>
<xref ref-type="aff" rid="A2">2</xref>
<xref ref-type="aff" rid="A3">3</xref>
</contrib>
<contrib contrib-type="author"><name><surname>Kochman</surname>
<given-names>Michael L.</given-names>
</name>
<degrees>MD</degrees>
<xref ref-type="aff" rid="A2">2</xref>
<xref ref-type="aff" rid="A4">4</xref>
<xref ref-type="aff" rid="A5">5</xref>
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</contrib-group>
<aff id="A1"><label>1</label>
University of Pennsylvania Perelman School of Medicine</aff>
<aff id="A2"><label>2</label>
Gastroenterology Division, University of Pennsylvania Perelman School of Medicine</aff>
<aff id="A3"><label>3</label>
Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine</aff>
<aff id="A4"><label>4</label>
Department of Internal Medicine, University of Pennsylvania Perelman School of Medicine</aff>
<aff id="A5"><label>5</label>
Wilmot Center for Endoscopic Innovation, Research, and Training</aff>
<author-notes><corresp id="cor1"><bold>Address for Correspondence:</bold>
Michael L. Kochman, M.D., Gastroenterology Division, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, 9th Floor Penn Tower, 1 Convention Center Avenue, Philadelphia, PA, U.S.A., Telephone: 215-662-4279, Fax: 215-349-5915, <email>michael.kochman@uphs.upenn.edu</email>
</corresp>
<fn id="FN1"><label>*</label>
<p id="P1">Drs. Agarwalla and Small contributed equally to this article.</p>
</fn>
</author-notes>
<pub-date pub-type="nihms-submitted"><day>19</day>
<month>11</month>
<year>2014</year>
</pub-date>
<pub-date pub-type="epub"><day>03</day>
<month>10</month>
<year>2014</year>
</pub-date>
<pub-date pub-type="ppub"><month>7</month>
<year>2015</year>
</pub-date>
<pub-date pub-type="pmc-release"><day>01</day>
<month>7</month>
<year>2016</year>
</pub-date>
<volume>29</volume>
<issue>7</issue>
<fpage>1903</fpage>
<lpage>1912</lpage>
<pmc-comment>elocation-id from pubmed: 10.1007/s00464-014-3883-1</pmc-comment>
<abstract><sec id="S1"><title>Background</title>
<p id="P2">Radiation therapy for head, neck, and esophageal cancer can result in esophageal strictures that may be difficult to manage. Radiation-induced esophageal strictures often require repeat dilation to obtain relief of dysphagia. This study aimed to determine the long-term clinical success and rates of recurrent and refractory stenosis in patients with radiation-induced strictures undergoing dilation.</p>
</sec>
<sec id="S2"><title>Methods</title>
<p id="P3">Retrospective cohort study of patients with radiation-induced strictures who underwent endoscopic dilation by a single provider from October 2007– October 2012. Outcomes measured included long-term clinical efficacy, interval between sessions, number of dilations, and proportion of radiation strictures that were recurrent or refractory. Risk factors for refractory strictures were assessed.</p>
</sec>
<sec id="S3"><title>Results</title>
<p id="P4">63 patients underwent 303 dilations. All presented with a stricture > 30 days after last radiation session. Clinical success to target diameter was achieved in 52 patients (83%). A mean of 3.3 (+/− 2.6) dilations over a median period of 4 weeks was needed to achieve initial patency. Recurrence occurred in 17 (33%) at a median of 22 weeks. Twenty-seven strictures (43%) were refractory to dilation therapy. Fluoroscopy during dilation (OR, 22.88; 95% CI, 3.19 – 164.07), severe esophageal stenosis (lumen <9 mm) (OR, 10.51; 95% CI, 1.94 – 56.88), and proximal location with prior malignancy extrinsic to the lumen (OR, 6.96; 95% CI, 1.33 – 36.29) were independent predictors of refractory strictures in multivariate analysis.</p>
</sec>
<sec id="S4"><title>Conclusions</title>
<p id="P5">1. Radiation-induced strictures have a delayed onset (>30 days) from time of radiation injury. 2. Endoscopic dilation can achieve medium-term luminal remediation but the strictures have a high long-term recurrence rate of up to 33%. 3. Remediation of radiation strictures following laryngectomy can be achieved but require frequent dilations. 4. Clinical and procedural predictors may identify patients at high risk of refractory strictures. 5. The optimal strategy in highly selected refractory patients is not clear.</p>
</sec>
</abstract>
<kwd-group><kwd>esophageal stricture</kwd>
<kwd>recurrent</kwd>
<kwd>refractory</kwd>
<kwd>endoscopic dilation</kwd>
<kwd>radiation</kwd>
<kwd>risk factors</kwd>
</kwd-group>
</article-meta>
</front>
</pmc>
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