Intralesional steroids and endoscopic dilation for anastomotic strictures after esophagectomy: systematic review and meta-analysis

Abstract

Background Post-esophagectomy anastomotic strictures are difficult to treat. The impact of adding local steroid injection to endoscopic dilation for the treatment of post-esophagectomy anastomotic strictures is unclear. We conducted a systematic review and meta-analysis to assess the efficacy of performing steroid injection in addition to dilation.

Methods A search was conducted in MEDLINE, Cochrane Library, EMBASE, and Web of Science from inception to January 2019. Randomized controlled trials (RCTs) comparing the efficacy of endoscopic dilation plus either local steroid injection (steroid group) or saline injection (placebo group) were included in the analysis.

Results Three RCTs were eligible for the final analysis: 72 patients (mean age 61.3 years, 74 % male) in the steroid group and 72 patients (mean age 59.6 years, 71 % male) in the placebo group. The mean number of dilations required to resolve the stricture was significantly lower in the steroid group compared with the placebo group, with a mean weighted difference of –1.62 (95 % confidence interval [CI] –2.73 to –0.50; P = 0.004). After 6 months of follow-up, there was a trend toward more patients in the steroid group remaining dysphagia free compared with the placebo group, with a pooled odds ratio of 2.36 (95 %CI 0.94 to 5.91; P = 0.07, I²  = 24 %).

Conclusion This meta-analysis showed that the addition of local steroid injection at the time of dilation for benign anastomotic strictures led to a significant decrease in the number of procedures required to resolve the stricture and may well reduce dysphagia symptoms during follow-up.

• References

• 1 Gandhi SK, Naunheim KS. Complications of transhiatal esophagectomy. Chest Surg Clin N Am 1997; 7: 601-610
• 2 Zaninotto G, Low DE. Complications after esophagectomy: it is time to speak the same language. Dis Esophagus 2016; 29: 580-582
• 3 Chen KN. Managing complications I: leaks, strictures, emptying, reflux, chylothorax. J Thorac Dis 2014; 6 (Suppl. 03) S355-363
• 4 Guillem P, Billeret V, Houcke ML. et al. Successful management of post-esophagectomy chylothorax/chyloperitoneum by etilefrine. Dis Esophagus 1999; 12: 155-156
• 5 Heitmiller RF, Fischer A, Liddicoat JR. Cervical esophagogastric anastomosis: results following esophagectomy for carcinoma. Dis Esophagus 1999; 12: 264-269
• 6 Honkoop P, Siersema PD, Tilanus HW. et al. Benign anastomotic strictures after transhiatal esophagectomy and cervical esophagogastrostomy: risk factors and management. J Thorac Cardiovasc Surg 1996; 111: 1141-1146
• 7 Kim RH, Takabe K. Methods of esophagogastric anastomoses following esophagectomy for cancer: a systematic review. J Surg Oncol 2010; 101: 527-533
• 8 Hanaoka N, Ishihara R, Motoori M. et al. Endoscopic balloon dilation followed by intralesional steroid injection for anastomotic strictures after esophagectomy: a randomized controlled trial. Am J Gastroenterol 2018; 113: 1468-1474
• 9 Shah JN. Benign refractory esophageal strictures: widening the endoscopist’s role. Gastrointest Endosc 2006; 63: 164-167
• 10 de Wijkerslooth LR, Vleggaar FP, Siersema PD. Endoscopic management of difficult or recurrent esophageal strictures. Am J Gastroenterol 2011; 106: 2080-2091
• 11 Siersema PD, de Wijkerslooth LR. Dilation of refractory benign esophageal strictures. Gastrointest Endosc 2009; 70: 1000-1012
• 12 Hordijk ML, Siersema PD, Tilanus HW. et al. Electrocautery therapy for refractory anastomotic strictures of the esophagus. Gastrointest Endosc 2006; 63: 157-163
• 13 Hordijk ML, van Hooft JE, Hansen BE. et al. A randomized comparison of electrocautery incision with Savary bougienage for relief of anastomotic gastroesophageal strictures. Gastrointest Endosc 2009; 70: 849-855
• 14 Hirdes MM, van Hooft JE, Koornstra JJ. et al. Endoscopic corticosteroid injections do not reduce dysphagia after endoscopic dilation therapy in patients with benign esophagogastric anastomotic strictures. Clin Gastroenterol Hepatol 2013; 11: 795-801.e1
• 15 Moher D, Liberati A, Tetzlaff J. et al. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. BMJ 2009; 339: b2535
• 16 Higgins JP, Altman DG, Gotzsche PC. et al. The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials. BMJ 2011; 343: d5928
• 17 Pereira-Lima JC, Lemos Bonotto M, Hahn GD. et al. A prospective randomized trial of intralesional triamcinolone injections after endoscopic dilation for complex esophagogastric anastomotic strictures: steroid injection after endoscopic dilation. Surg Endosc 2015; 29: 1156-1160
• 18 Knyrim K, Wagner HJ, Bethge N. et al. A controlled trial of an expansile metal stent for palliation of esophageal obstruction due to inoperable cancer. N Engl J Med 1993; 329: 1302-1307
• 19 Mellow MH, Pinkas H. Endoscopic laser therapy for malignancies affecting the esophagus and gastroesophageal junction. Analysis of technical and functional efficacy. Arch Intern Med 1985; 145: 1443-1446
• 20 Altintas E, Kacar S, Tunc B. et al. Intralesional steroid injection in benign esophageal strictures resistant to bougie dilation. J Gastroenterol Hepatol 2004; 19: 1388-1391
• 21 Takahashi H, Arimura Y, Okahara S. et al. A randomized controlled trial of endoscopic steroid injection for prophylaxis of esophageal stenoses after extensive endoscopic submucosal dissection. BMC Gastroenterol 2015; 15: 1
• 22 Ashcraft KW, Holder TM. The experimental treatment of esophageal strictures by intralesional steroid injections. J Thorac Cardiovasc Surg 1969; 58: 685-691
• 23 Spechler SJ. AGA technical review on treatment of patients with dysphagia caused by benign disorders of the distal esophagus. Gastroenterology 1999; 117: 233-254
• 24 Holder TM, Ashcraft KW, Leape L. The treatment of patients with esophageal strictures by local steroid injections. J Pediatr Surg 1969; 4: 646-653
• 25 Szapary L, Tinusz B, Farkas N. et al. Intralesional steroid is beneficial in benign refractory esophageal strictures: a meta-analysis. World J Gastroenterol 2018; 24: 2311-2319
• 26 Zhang YW, Wei FX, Qi XP. et al. Efficacy and safety of endoscopic intralesional triamcinolone injection for benign esophageal strictures. Gastroenterol Res Pract 2018; 2018: 7619298
• 27 Catalano MF, Kaul V, Pezanoski J. et al. Endoscopic treatment of anastomotic strictures following resection of esophageal carcinoma. Gastrointest Endosc 2007; 65 (Suppl. 05) AB139
• 28 Miyashita M, Onda M, Okawa K. et al. Endoscopic dexamethasone injection following balloon dilatation of anastomotic stricture after esophagogastrostomy. Am J Surg 1997; 174: 442-444
• 29 Kochhar R, Makharia GK. Usefulness of intralesional triamcinolone in treatment of benign esophageal strictures. Gastrointest Endosc 2002; 56: 829-834
• 30 Okawa K, Onda M, Miyashita M. et al. Endoscopic dilatation with steroid injection for anastomotic stricture following esophagectomy. Gastrointest Endosc 1995;