What is the recommended management for malignant esophageal strictures?

Management of Malignant Esophageal Strictures

Endoscopic dilatation is the primary treatment for malignant esophageal strictures, with temporary stent placement recommended for cases refractory to dilatation to maintain adequate esophageal patency and improve quality of life. 1

Initial Approach to Malignant Strictures

• Endoscopic dilatation using either balloon or bougie dilators is the first-line treatment, with the choice individualized based on stricture characteristics (length, location, cause) 2, 1
• Perform dilatations weekly or biweekly until achieving a diameter of ≥15mm with symptomatic improvement 1
• For very narrow strictures, limit initial dilatation to 10-12mm diameter, and for filiform strictures, target an even smaller initial diameter (≤9mm) 1
• Follow the "Rule of Three" - avoid using more than three successive diameter increments in a single session to reduce perforation risk 1

Advanced Techniques for Complex Malignant Strictures

• Use fluoroscopic guidance for high-risk strictures (post-radiation, long, angulated, or multiple) that cannot be passed endoscopically 1
• For completely obstructed esophagus, consider a combined anterograde and retrograde dilatation (CARD) approach under general anesthesia where local expertise is available 2
• When using CARD approach, always use fluoroscopic guidance and a guidewire to navigate through the obstruction 2
• After gaining luminal patency with CARD, perform subsequent dilatation using either balloon or bougie 2

Management of Refractory Malignant Strictures

• A stricture is considered refractory when unable to maintain a luminal diameter of ≥14mm after five sequential dilatation sessions 1-2 weeks apart 1
• For refractory strictures, use intralesional steroid therapy (0.5mL aliquots of triamcinolone 40mg/mL to four quadrants) combined with dilatation 2, 1
• Consider needle knife incision as an alternative to dilatation for anastomotic strictures 2
• Offer temporary placement of fully covered self-expanding removable stents when previous methods have failed to maintain adequate esophageal patency 2, 3
• The optimal duration of stent placement is typically 4-8 weeks, varying based on stricture etiology, length, and stent type 2, 4
• Consider biodegradable stent placement to reduce dilatation frequency in selected cases 2

Stent Selection and Complications

• Stent placement is particularly beneficial in patients with limited life expectancy (≤3 months) for rapid palliation of dysphagia 5
• Partially covered stents may be preferred when stent migration is a concern 3
• Monitor for common complications including:
  • Tumor overgrowth (may require placement of a second overlapping stent) 4
  • Food impaction (may require endoscopic removal) 4
  • Stent migration (can be repositioned or replaced) 3

Post-Procedure Care

• Monitor patients for at least 2 hours in the recovery room 1
• Provide clear written instructions about liquids, diet, and medications after the procedure 1
• Ensure patients are tolerating water before discharge 1
• Suspect perforation if patients develop pain, breathing difficulty, fever, or tachycardia 1
• Provide emergency contact information for the on-call team in case patients experience chest pain, breathing difficulty, or feel unwell 1
• Transient chest pain is common after dilatation, but persistent pain should prompt CT with oral contrast to evaluate for perforation 1

Special Considerations

• For patients with good performance status and longer life expectancy (>3 months), consider brachytherapy as an alternative to stenting, as it may provide more prolonged dysphagia improvement with fewer complications 5
• In cases of tracheoesophageal fistulas, covered stents can effectively close the fistula while maintaining esophageal patency 4
• For very complex strictures, especially after chemoradiation or surgery for head and neck cancer, biliary accessories can be used to obtain antegrade esophageal access 6