What are the indications for the resection of a peptic stricture?
J. Baulieux (Lyons)
Conservative surgical treatment for peptic strictures was still the subject of debate in the 1980s. Nowadays it has almost become the rule. Indications for resection have become exceptional. They concern fewer than 15% of cases. The reconstruction techniques consist either of coloplasty or extensive esophagogastrectomy with high anastomosis [1].
In rare cases, however, a number of factors may render resection preferable. The age and general condition of the patient are of course determinant factors; the mortality and morbidity rates associated with resection of a stricture must of course be taken into account when considering this procedure in elderly or cachectic patients.
The etiology of the stricture: the strictures most frequently encountered are situated above the cone of the sliding hiatal hernia and are accessible to pre- or intraoperative dilation associated with antireflux surgery. Duodenal diversion may be appropriate for severe strictures in patients "at risk". Postoperative strictures are often difficult to treat by conservative procedures, especially those that appear after Heller's operation. The same is true for strictures associated with nasogastric tubes. Luckily these are very rare. They are very long and tight strictures that usually necessitate resection.
The anatomic type is a predominant factor. "High" strictures, multiple strictures, long "tubular" strictures are not good indications for conservative treatment and usually require resection.
The degree of stenosis and its rigidity are of course very important elements in the decision making process. It is true that numerous studies have shown that most peptic strictures are reversible once reflux has been suppressed. However, certain rigid and very tight strictures (that do not allow passage of a pediatric fiberoscope) are truly "inveterate" strictures that must be resected. We have often found that strictures described as "non-dilatable" by endoscopists can in practice be dilated by the abdominal route, under visual control, by "intra-esophageal touch". A short gastrostomy allows introduction of the index finger and careful digital dilation of very tight low strictures. It is important to recognize that the use of a Savary cannula greatly extends the possibilities of dilatation and often allows dilatation of very tight strictures that would have been undilatable in the past.
Strictures associated with Barrett's esophagus are always suspect and may require resection. Strictures with a deep Barrett's ulceration can be dangerous to dilate owing to the risk of hemorrhage or perforation.
Resection is the method of choice if there is any suspicion of cancer. The percentage of "doubtful strictures" that are difficult to diagnose is falling thanks to modern exploratory techniques (echo-endoscopy, serial biopsies, cytological examination of brushings, vital stains). However, there are still a few rare cases in which the diagnosis remains uncertain prior to surgery. Intraoperative digital exploration can be a useful aid to decision making as can "retrograde biopsies" carried out by high gastrostomy. Assessment of the morphology of the stricture gives valuable information concerning the hardness of the lesion, its rigidity, the presence of friable buds, or its fixed nature, which reflect malignancy. In contrast, a regular axial stricture that is accessible to digital dilatation is usually benign. The use of flexible biopsy forceps, introduced through the gastrostomy, allows sampling of areas that were not able to be correctly examined by the upper route [2].
A few years ago we reported a series of 14 cases in which this type of procedure had been used intraoperatively (3.6% of total cases experienced) [3]. This procedure:
- allowed confirmation of an uncertain diagnosis of benign peptic stricture in 7 cases,
- correction of an erroneous diagnosis and confirmation of neoplastic disease in 6 cases, while still allowing one error of excess (resection of a benign stenosis).
At the present time, however, use of a pediatric endoscope after dilatation of the stricture provides a solution to this difficult problem in most cases.
The recurrence rate for peptic strictures after conservative treatment is of the order of 20% at 10 years in our experience. Most are well tolerated with medical treatment and dilatation. In some cases, however, re-operation is necessary and in these cases resection is inevitable.
Finally, in our experience, a few resections "of necessity" were carried out as a result of esophageal perforation during an attempt to dilate a tight stenosis.
Conclusion
At present, the frequency of peptic strictures appears to be falling since, nowadays, gastroesophageal reflux tends to be treated before this complication develops. However, there are still a number of cases where peptic stricture is the first sign of reflux. The need for resection is becoming less frequent since conservative treatment is usually appropriate. However, a number of indications for resection must be recognized and borne in mind especially in young subjects better able to tolerate this type of procedure.
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