Treatment of recurrent esophageal stricture with an insulated-tip electrosurgical knife and mitomycin C

An 82-year-old woman presented with dysphagia due to a refractory esophageal stricture. The stricture was thought to have been caused 2 years previously after hospitalization for a hip fracture and prolonged nasogastric tube placement at a subacute care facility. Numerous attempts at stricture dilation, initially every 2 weeks, had been made at another institution using a hydrostatic balloon and an esophageal stent, which was later removed because of complications.

At our center, the patient underwent upper gastrointestinal (GI) endoscopy under general anesthesia, during which a severe benign-appearing intrinsic stenosis (4-mm wide and 1-cm long) that prohibited passage of the endoscope was encountered 31 cm from the incisors ([Video 1]). The stenosis was incised using an insulated-tip electrosurgical knife along the aspect opposite to the aorta. Balloon dilation was performed to a diameter of 15 mm before the stenosis was traversed and a 4-cm hiatus hernia was noted. The remainder of the upper GI endoscopy was normal.

Video 1: Identification of an esophageal stricture, which was treated with balloon dilation, insulated-tip electrosurgical knife incision, and application of mitomycin C.

Repeat balloon dilation to 15 mm was then performed. The upper GI endoscope was removed and an overtube was advanced to the level of the stricture to minimize mucosal contact with mitomycin C. A gauze soaked with 1 mL of mitomycin C solution (0.4 mg/mL) was delivered to the level of stricture with a rat-toothed forceps that was fed through the endoscope ([Fig. 1]). The gauze was applied to the level of the stenosis for 3 minutes and this was followed by a second 2-minute treatment.

Fig. 1 Direct application of a gauze soaked with mitomycin C to the level of the stricture after insulated-tip electrosurgical knife incision had been performed.

The patient was discharged home on a full liquid diet for 2 days followed by soft diet for 2 days. She was seen in clinic 7 months later with no recurrent symptoms.

Esophageal stricture due to prolonged nasogastric tube placement has been previously reported [1]. Data on the use of topical mitomycin C for esophageal strictures are limited, but similar techniques have been shown to be safe and effective in children with strictures due to caustic injury or after repair of esophageal atresia [2] [3] [4] [5].

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• References

• 1 Yoon YS, Kim JY, Lee KJ. et al. Balloon dilatation for an esophageal stricture by long-term use of a nasogastric tube: A case report. Ann Rehabil Med 2014; 38: 581-584
• 2 El-Asmar KM, Hassan MA, Abdelkader HM. et al. Topical mitomycin C application is effective in management of localized caustic esophageal stricture: A double-blinded, randomized, placebo-controlled trial. J Pediatr Surg 2013; 48: 1621-1627
• 3 El-Asmar KM, Hassan MA, Abdelkader HM. et al. Topical mitomycin C can effectively alleviate dysphagia in children with long-segment caustic esophageal strictures. Dis Esophagus 2015; 28: 422-427
• 4 Machida H, Tominaga K, Minamino H. et al. Locoregional mitomycin C injection for esophageal stricture after endoscopic submucosal dissection. Endoscopy 2012; 44: 622-625
• 5 Rustagi T, Aslanian HR, Laine L. Treatment of refractory gastrointestinal strictures with mitomycin C: A systematic review. J Clin Gastroenterol 2015; 49: 837-847