Ann Thorac Surg 2008;86:440. doi:10.1016/j.athoracsur.2008.05.051
© 2008 The Society of Thoracic Surgeons
Original Articles: General Thoracic
Invited Commentary
Steven R. DeMeester, MD
Department of Cardiothoracic Surgery, University of Southern California, 1510 San Pablo St, Suite 514, Los Angeles, CA 90033
(Email: sdemeester{at}surgery.usc.edu).
The management of benign esophageal strictures begins with dilation, and depending on the cause of the stricture, often repeated dilations are necessary. When self-expanding metallic stents became available they were used for benign and malignant strictures until it became evident that the inflammation often induced by these stents and the difficulty or inability to remove them made them unsuitable for use in benign disease. The development of the Polyflex self-expanding, removable stent (Boston Scientific, Natick, MA) has once again made stenting an option for patients with benign strictures. The purpose of the study by Martin and colleagues [1] was to compare the efficacy and cost associated with repeat dilations versus Polyflex stent placement in patients with a benign stricture. The majority of strictures were at the esophagogastric anastomosis after an esophagectomy, but a number of other causes were also represented. They concluded that early stenting was more cost effective, provided that at least two dilations were avoided.
An important issue with removable stents has been migration. In the series reported here by Martin and colleagues [1], migration occurred in only 1 patient 2 days after placement. They replaced the migrated stent with a larger one and had no further difficulty. The authors attributed this low rate of migration to the use of a large diameter and long stents. Furthermore, they positioned the stent as high up in the esophagus as possible while still traversing the stricture in patients with esophago-anastomotic strictures in which stent migration has been a particular problem.
These results certainly support the use of a Polyflex stent in any patient in which repeated dilations are likely to be necessary. However, an option the authors failed to discuss is the use of home self-dilation by patients. This is a very effective technique for the management of benign strictures, particularly an esophagogastric anastomotic stricture, and undoubtedly it would be more cost effective than either repeated endoscopic dilations or stent placement. In my own practice, this if the preferred approach for proximal esophageal strictures in which Polyflex stent migration is more likely to occur. Most patients can be quickly taught the technique of self-dilation and are sent home with an appropriate-sized (usually 52-French) Maloney dilator with instructions to dilate themselves first thing in the morning on a tapered schedule, such that the majority of patients no longer need dilation after 6 to 8 weeks. They then return the bougie. I have never had a patient who had a complication or perforation from self-dilation, and it is surprisingly well accepted by patients and their families. Teaching self-dilation to a patient takes 15 to 30 minutes, roughly similar to the time it takes to insert a stent; there is no added time for subsequent stent removal, and no need for sedation or fluoroscopy.
Certainly the development of removable self-expanding stents has expanded our treatment options for patients with benign strictures. If these excellent results and low migration rates as reported by Martin and colleagues [1] are confirmed by others, then early stenting should be able to replace repeated endoscopic dilations. Future studies that compare stenting with home self-dilation, and studies that identify factors predictive of the need for more than two dilations, will help optimize the cost-effective and successful management of patients with benign esophageal strictures.
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References
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- Martin RCG, Woodall C, Duvall R, Scoggins CR. The use of self-expanding silicone stents in esophagectomy strictures: less cost and more efficiency Ann Thorac Surg 2008;86:436-440.[Abstract/Free Full Text]
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