When is surgery indicated for esophageal strictures?

When is Surgery Indicated for Esophageal Strictures?

Surgery should be offered to patients with benign esophageal strictures who do not respond to or are intolerant of endoscopic management, including those requiring frequent dilatations despite maximal PPI therapy and those who are technically difficult to dilate. 1

Primary Indications for Surgical Intervention

Refractory Benign Strictures

• Consider surgery when strictures remain refractory after exhausting all endoscopic options, including repeated dilatations, intralesional steroid injections, incisional therapy, and temporary stent placement 1
• A stricture is defined as refractory when it cannot maintain a luminal diameter ≥14 mm after five sequential dilatation sessions performed 1-2 weeks apart 2
• Patients requiring frequent dilatations (more than 4-5 sessions per year) despite high-dose PPI therapy should be considered for antireflux surgery 1

Peptic Strictures with Failed Medical Management

• Patients with peptic strictures who need frequent dilatation despite twice-daily PPI therapy are candidates for operative treatment by antireflux surgery 1
• Those who are technically difficult to dilate due to stricture complexity (long >2 cm, tortuous, or very narrow diameter) should be evaluated for surgical options 1

Corrosive Strictures

• Surgery should be reserved for patients with corrosive strictures who have failed endoscopic dilatation therapy 3
• Technical failures (inability to pass dilators), perforations during dilatation, or recurrent strictures despite adequate dilatation attempts are indications for esophageal replacement 3
• Stricture length >6 cm is associated with poor outcomes from endoscopic dilatation and may warrant earlier surgical consideration 3
• Esophageal replacement (gastric pull-up or colonic interposition) is preferred over resection, with the damaged esophagus either resected or left in situ 4

Alternative to Surgery: Advanced Endoscopic Approaches

Before proceeding to surgery, the following should be attempted:

For Completely Obstructed Esophagus

• Consider combined anterograde and retrograde dilatation (CARD) or rendezvous approach under general anesthesia as an alternative to surgery when local expertise is available 1
• This approach should always use fluoroscopic guidance and a guidewire to navigate through the obstruction 1

For Refractory Strictures

• Intralesional steroid therapy (triamcinolone 40 mg/mL in 0.5 mL aliquots to four quadrants) combined with dilatation should be used before considering surgery 1
• Temporary placement of fully covered self-expanding removable stents (4-8 weeks duration) should be offered when previous methods have failed 1
• Incisional therapy can be considered for refractory Schatzki's rings and anastomotic strictures at experienced centers 1
• Self-bougienage may be taught to selected, self-motivated patients with short proximal strictures 1

Special Considerations

Post-Fundoplication Dysphagia

• Perform comprehensive evaluation first: upper GI endoscopy, manometry, pH studies, and barium swallow to understand the mechanism of dysphagia before considering repeat surgery 1
• This evaluation helps determine whether the problem is a tight wrap, slipped wrap, or paraoesophageal hernia 1

Malignant Strictures

• Surgery is not typically indicated for malignant strictures unless part of curative resection 5, 2
• Palliative management focuses on stent placement rather than surgical intervention 1

Common Pitfalls to Avoid

• Do not proceed to surgery without first optimizing medical management with high-dose PPI therapy (twice daily dosing if needed) and ensuring the stricture is truly refractory 1
• Ensure referral to or discussion with centers experienced in managing refractory strictures before surgical consultation 1
• Rule out alternative neuromuscular causes in patients with ongoing dysphagia despite seemingly adequate esophageal diameter 1
• In post-fundoplication patients, understand the mechanism before proceeding with either repeat dilatation or revision surgery 1