title: Esophageal anastomotic strictures: outcomes of endoscopic dilation, risk of recurrence and refractory stenosis, and effect of foreign body removal.
abstract: OBJECTIVE
  Esophageal anastomotic strictures often require repeat dilation to relieve dysphagia. Little is known about factors that affect their remediation. We investigated long-term success and rates of recurrence or refractoriness after dilation and factors associated with refractory stenosis.
  
  
  METHODS
  We performed a retrospective study of 74 patients with an anastomotic stricture that had been dilated during a 5-year period (564 dilations; median follow-up period, 8 months). A stricture was refractory if luminal patency could not be maintained after ≥5 dilation sessions during 10 weeks.
  
  
  RESULTS
  Of the 74 patients, 93% had initial relief of dysphagia. The stricture recurred in 43% of patients, and 69% were considered refractory. Removal of sutures/staples protruding into the lumen did not accelerate time to initial patency (median, 37 days; interquartile range [IQR], 20-82 days) or lengthen the dysphagia-free interval (37.4 days; IQR, 8-41 weeks), compared with patients who did not undergo removal (initial patency, median 55 days; IQR, 14-109 days; P = .66 and median dysphagia-free interval, 21.7 days; IQR, 9-64 weeks; P = .8). Use of fluoroscopy during dilation (odds ratio, 8.92; 95% confidence interval, 1.98-40.14) was positively associated with development of refractory strictures, whereas neoadjuvant chemotherapy (odds ratio, 0.28; 95% confidence interval, 0.07-0.97) was inversely associated. Female sex and distal location of strictures increased risk of refractoriness as effect modifiers in multivariate analysis.
  
  
  CONCLUSIONS
  Endoscopic dilation is highly successful in achieving luminal remediation, yet anastomotic strictures are often refractory and frequently recur. Removal of sutures/staples within the lumen does not help achieve patency. Need for fluoroscopic guidance indicates a high likelihood of refractoriness to dilation, whereas prior neoadjuvant chemotherapy indicates a lower risk.
authors.affiliation: Department of Internal Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania.
authors.forename: Aaron H
authors.initials: AH
authors.lastname: Mendelson
authors.affiliation: Gastroenterology Division, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania; Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania.
authors.forename: Aaron J
authors.initials: AJ
authors.lastname: Small
authors.affiliation: University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania.
authors.forename: Anant
authors.initials: A
authors.lastname: Agarwalla
authors.affiliation: Gastroenterology Division, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania; Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania.
authors.forename: Frank I
authors.initials: FI
authors.lastname: Scott
authors.affiliation: Department of Internal Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania; Gastroenterology Division, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania; Wilmott Center for Endoscopic Innovation, Research, and Training, Philadelphia, Pennsylvania. Electronic address: michael.kochman@uphs.upenn.edu.
authors.forename: Michael L
authors.initials: ML
authors.lastname: Kochman
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000714:Anastomosis, Surgical / Q000009:adverse effects*; D004724:Endoscopy / Q000379:methods*; D004940:Esophageal Stenosis / Q000628:therapy*; D005260:Female; D005547:Foreign Bodies / Q000150:complications*; D006801:Humans; D008297:Male; D008875:Middle Aged; D012008:Recurrence; D012189:Retrospective Studies; D016896:Treatment Outcome; D055815:Young Adult
keywords: Esophageal Anastomotic Strictures; Foreign Body Removal; Recurrence; Refractory