What are the management options for post cricoid (below the cricoid cartilage) stricture?

Management of Post-Cricoid Strictures

Endoscopic dilatation should be considered the first-line treatment for post-cricoid strictures, with a graded approach using wire-guided or endoscopically controlled techniques to enhance safety. 1

Diagnostic Approach

Before initiating treatment, a thorough assessment is essential:

• Endoscopy to document the site, length, and mucosal appearance of the stricture
• Barium swallow for anatomical details, particularly important when stricture prevents passage of endoscope
• Tissue biopsies to rule out malignancy

Treatment Algorithm

First-Line Treatment: Endoscopic Dilatation

1. Initial Dilatation Technique:

   • Use wire-guided (bougie or balloon) or endoscopically controlled (balloon) techniques 1
   • For very narrow strictures (<4mm), limit initial dilatation to ≤9mm diameter 1
   • For moderately narrow strictures, limit initial dilatation to 10-12mm (30-36F) 1
   • Use no more than three successively larger diameter increments in a single session 1

2. Follow-up Dilatations:

   • Perform weekly or two-weekly dilatation sessions until easy passage of a ≥15mm dilator is achieved along with symptomatic improvement 1
   • Monitor patients for at least 2 hours in recovery room after each procedure 1

3. Safety Considerations:

   • Use fluoroscopic guidance for high-risk strictures (post-radiation, caustic), or strictures that are long, angulated, or multiple 1
   • Never use weighted (Maloney) bougies with blind insertion 1
   • Use carbon dioxide insufflation instead of air during endoscopy to minimize luminal distension and post-procedural pain 1

Management of Refractory Strictures

A stricture is considered refractory after inability to maintain a luminal diameter of ≥14mm after five sequential dilatation sessions 1-2 weeks apart 1.

For refractory strictures, consider:

1. Adjunctive Treatments:

   • Intralesional steroid injection at time of dilatation 1
   • Topical mitomycin C application 1

2. Stenting Options:

   • Temporary stent placement 1
   • Biodegradable stents 1
   • Suspended oesophageal silicone prosthesis 1

3. Surgical Intervention:

   • Consider surgical resection when all endoscopic options fail 1
   • Primary tracheal anastomosis after resection of the cricoid cartilage with preservation of recurrent laryngeal nerves may be performed in select cases 2

Post-Procedure Care

• Provide clear written instructions with advice on fluids, diet, and medications after the procedure 1
• Ensure patients are well and tolerating water before discharge 1
• Provide patients with contact information for the on-call team should they experience chest pain, breathlessness, or become unwell 1

Complications and Their Management

Perforation

• Suspect perforation when patients develop persistent pain, breathlessness, fever, or tachycardia 1
• Perform CT scan with oral contrast if perforation is suspected 1
• Consider immediate endoscopic stent placement if perforation is confirmed 1

Recurrence

• More common in caustic strictures 1
• May require more frequent dilatation sessions or alternative approaches

Special Considerations

1. Timing after injury: Avoid dilatation within 3 weeks of initial caustic injury as this period is more hazardous 1

2. Interval between dilatations: For caustic strictures, consider a time interval between dilatations of less than 2 weeks 1

3. Complex strictures: For strictures that are >2cm, angulated, irregular, or severely narrowed, use more cautious approach with fluoroscopic guidance 1

Efficacy and Outcomes

Endoscopic dilatation has demonstrated high success rates in managing benign esophageal strictures:

• 93.5% adequate dilatation achieved in a large series of patients with various types of strictures 3
• Peptic strictures typically require fewer dilatation sessions (median of 3) compared to post-surgical or caustic strictures (median of 5) 3

Pitfalls and Caveats

• Avoid dilatation in active esophageal perforation as it may extend the defect 1
• Exercise caution in patients with pharyngeal or cervical deformity and those with large thoracic aneurysms 1
• Withdraw anticoagulants and correct coagulopathy prior to dilatation to reduce bleeding risk 1
• Refer complex cases to centers with expertise in treatment and follow-up of patients with refractory strictures 1