The role of anti-reflux surgery in refractory peptic strictures—case series

Introduction

Background

Severe chronic reflux oesophagitis can lead to fibrosis and stricture formation in some patients. Pharmacological acid suppression and serial endoscopic dilation provides the mainstay of treatment (1). Occasionally, these strictures are refractory to endoscopic and medical treatment alone.

Rational and knowledge gap

Current proposed management algorithms for symptomatic refractory peptic strictures outline a stepwise approach, using repeated esophageal dilation, local steroid injection and stenting (2-4). With the advent of more advanced endoscopic solutions, the role of anti-reflux surgery has become less favourable. In addition, surgeons are unlikely to consider an anti-reflux procedure in the presence of a tight esophageal stricture due to the concern over worsening dysphagia.

Objective

This series aims to evaluate the complementary and safe role of hiatal hernia repair and laparoscopic fundoplication in the management of these refractory peptic strictures. We present this case series in accordance with the AME Case Series reporting checklist (available at https://aoe.amegroups.org/article/view/10.21037/aoe-24-2/rc).

Case presentation

Patients

All patients who were referred to a single, tertiary center hospital for consideration of surgery for refractory, benign peptic strictures between 2014 and 2022 were retrospectively identified. Of those referred, all who subsequently underwent a laparoscopic fundoplication were included in this case series. Data on basic demographics and any prior pharmacological and endoscopic treatments were collected from referral letters and electronic patient records.

All patients underwent a pre-operative endoscopy at our centre for assessment of their stricture to identify any underlying oesophagitis or Barrett’s and, for assessment of the presence of any hiatus hernia. Those with mid-esophageal strictures had further evaluation with endoscopic ultrasound. Patients previously treated with endoscopic stenting had their stents removed prior to surgery. Follow up data on complications, further post-operative endoscopic management and clinical outcomes were also collected from electronic patient records.

Surgery

All patients received an intra-operative endoscopy and through-the-scope (TTS) balloon dilation of their peptic stricture. Dilations were performed according to the “rule of 3” of using no more than three successive increments in diameter in a single session and were sized initially according to the diameter of the stricture at the time of endoscopy (5). Operations were performed laparoscopically with a five-port technique. Crural repairs were performed with posterior 0-Ethibond sutures with a subsequent full (360°) or partial (anterior 180°) fundoplication. Patients with a large hiatus hernia are routinely treated with partial fundoplication in our centre. Younger patients with small hernias are considered for a 360° wrap.

Patients were commenced on a free fluid diet on day one and the progressed from a liquid to a normal diet over six weeks. Following surgery, all patients either remain under ongoing follow up if symptomatic or, until symptom free with discharge and open access, should they become symptomatic in the future.

Statistical analysis

The number of pre-operative and post-operative dilations were recorded, as was the use of pre-operative stents. The mean number of pre-operative and post-operative dilations in patients with and without preoperative stents were compared using the t-test (Prism).

Ethical statement

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration (as revised in 2013). Written informed consent for publication of this case series was not obtained from the patient or the relatives after all possible attempts were made.

Results

Seven patients were referred with refractory peptic strictures between 2014 and 2022. All were established on proton pump inhibitor (PPI) therapy at the time of their referral and had presented with dysphagia. All patients subsequently underwent an esophageal dilation, laparoscopic hiatus hernia repair and fundoplication for peptic strictures. Table 1 summarises their demographics and endoscopic findings. There were four female patients and three male patients with a median age of 38 [20–79] years. Six patients were American Society of Anesthesiologists (ASA) 2 with one ASA 3 patient.

Three patients had mid esophageal strictures and four had distal strictures. Four patients had Barrett’s Oesophagus and all had hiatus hernias. The maximum intra-operative esophageal dilation diameter ranged from 14–20 mm. No complications followed esophageal dilation.

All patients were referred with peptic strictures, refractory to endoscopic management, with four patients undergoing endoscopic stenting prior to surgery (Table 2). The time from diagnosis of a peptic stricture and surgery was between 20–37 months (median 28 months, Table 1). There were no post-operative complications.

Patients treated with pre-operative stenting

Four patients were treated pre-operatively with esophageal stents (Table 2). Of the 4, 3 received multiple stents. One patient had a series of overlapping stents placed up the esophagus. After each stent had been placed, a stricture formed above the preceding stent due to free reflux through the gastro-esophageal junction (GEJ). As a consequence, a further stent was placed to deal with the new stricture and so on.

In this group, a mean of 14 dilations were performed post-operatively (range, 10–20), with a median follow up of 20.5 months (range, 12–42 months).

Two patients died during the follow up period from unrelated causes. One remained asymptomatic for three years following their discharge and prior to their death. The second patient had ongoing dysphagia requiring dilations. Of the remaining two patients, one was asymptomatic at discharge with open access and one has ongoing dysphagia requiring dilations.

Patients treated pre-operatively with esophageal dilation alone

Three patients did not undergo stenting pre-operatively. The mean number of pre-operative dilations was in this group was 14. Two patients required only one post-operative dilation for ongoing dysphagia, with the other requiring no further post-operative intervention. Non-stented patients had a median follow up of 7 months (range, 5–18 months) (Table 3). All patients have been discharged with open access if required.

Comparison of stented and non-stented patients

Patients with stents required significantly fewer dilations pre-operatively (4.5 vs. 16.7, P=0.008) but also required an average of at least one stent change prior to surgery (range, 1–3). There was a significantly higher number of post-operative dilations in patients undergoing pre-operative stenting compared to those who proceeded straight to surgery (15.3 vs. 0.67, P=0.04).

Discussion

Key findings

This paper reports the outcomes of a series of patients with refractory or recurrent peptic strictures, treated with anti-reflux surgery. The findings suggest that mechanical acid suppression may allow the healing of peptic strictures, where pharmacological acid suppression has failed. This study also suggests that whilst stents reduce the need for ongoing endoscopic dilations in the pre-operative setting, they may lead to slower healing following surgery.

Strengths and limitations

There are some methodological issues that deserve attention. Given the rarity of peptic stricture disease, it is difficult to obtain a large series, much less, a control cohort, to demonstrate the benefits of laparoscopic fundoplication in this context. That there was a significantly higher rate of post-operative dilation in the stented group, must be interpreted with caution given the small sample size. Amongst other factors, this may also be a reflection of the stented groups’ resistance to therapeutic dilations from the outset. Given the clinical and logistical implications of repeated dilations, further studies will be needed to confirm or refute these findings. Our short series has demonstrated symptomatic remission for five of our seven patients with refractory peptic strictures following a laparoscopic fundoplication. This is more pronounced in our patient cohort who underwent esophageal dilation only, prior to surgery. Conversely, the use of esophageal stenting in conjunction with dilation suggests more refractory disease and this is reflected in the higher number of post-operative dilations required in this group.

Comparison with other research

Continued exposure to acid prevents healing of peptic strictures of the esophagus. The need for acid suppression in peptic strictures management was originally demonstrated by studies describing the efficacy of laparoscopic fundoplication for peptic stricture disease in the 1990’s (6,7). The incidence of peptic strictures has declined following the introduction of PPIs (8). Pharmacological acid suppression has also reduced the need for surgery in peptic stricture management and current treatment algorithms now advocate PPIs and endoscopic dilations as the mainstay of treatment (2-4). The management of pharmacologically refractory treatment is less well established. Treatment options available are continuing dilations with steroid injection, esophageal stenting and the use of mechanical acid suppression in the form of surgery. To the authors’ knowledge, there is no current defined role for a laparoscopic fundoplication in patients who have refractory disease to the measures described.

Explanation and findings

A stricture is defined as ‘refractory’ when there has been a failure to reach a diameter of at least 14 mm after balloon dilations over 5 sessions performed every 2 weeks. Strictures are ‘recurrent’ when there has been a failure to maintain a diameter of 14 mm for 2 weeks (5,9,10). Early studies showed that 33% of patients with peptic strictures will have refractory or recurrent strictures (11). Serial endoscopic dilations represent a significantly disruptive treatment for patients, both in terms of the morbidity of their symptoms and the logistical problems of multiple hospital visits. It carries with it a 0.4% perforation rate which rises after steroid use (5). It also is a costly and labour-intensive treatment to deliver. In this series, the median time from diagnosis to surgery was 28 months and one patient underwent 23 endoscopic interventions prior to having a laparoscopic fundoplication.

The use of stenting in benign esophageal disease remains contentious. The findings of this small series suggest that whilst stents provide a means of reducing the frequency of dilations initially, their use may increase the need for further dilation if surgery is later used. Stent use has been associated with migration (36–80%), fistulation, worsening of acid reflux, bleeding and pain (10). They also require removal after 3 months to prevent tissue overgrowth. These concerns have led to the development of anti-reflux stents. However, evidence for a reduction of reflux is lacking. A recent systematic review and meta-analysis of randomised control trials by Pandit et al., comparing anti-reflux stents to standard stents in the context of stenting across the GEJ in malignant disease, failed to achieve statistical significance in reflux scores (11).

Implications and actions needed

Anti-reflux surgery itself is not without risk. Recurrence rates approach 40% at 5 years and acute dysphagia rates due to post-operative oedema can reach 50% (12,13). It therefore seems counter-intuitive to perform a procedure associated with dysphagia, to manage the dysphagia caused by a peptic stricture. However, in our experience, any post-operative dysphagia was offset by the intraoperative dilation of the stricture. The mechanical acid suppression afforded by the fundoplication allows time for the stricture to heal, even if further post-operative dilations are needed. Despite the success of medical therapy, the anatomical pathology of reflux secondary to a hiatus hernia cannot be corrected by conservative measures, serial stricture dilation or stenting. We feel it should be considered early on as a concurrent treatment, in the presence of complex stricturing disease.

Conclusions

Whilst absolute conclusions cannot be drawn as to the role of surgery in remission, current algorithms for the management of peptic strictures have overlooked the role of laparoscopic fundoplication as a complementary or alternative option for acid suppression. This series advocates for a change in the current advice for acid suppression to include the consideration for surgical management.

Acknowledgments

Funding: None.

Footnote

Reporting Checklist: The authors have completed the AME Case Series reporting checklist. Available at https://aoe.amegroups.org/article/view/10.21037/aoe-24-2/rc

Data Sharing Statement: Available at https://aoe.amegroups.com/article/view/10.21037/aoe-24-2/dss

Peer Review File: Available at https://aoe.amegroups.com/article/view/10.21037/aoe-24-2/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://aoe.amegroups.org/article/view/10.21037/aoe-24-2/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration (as revised in 2013). Written informed consent for publication of this case series was not obtained from the patient or the relatives after all possible attempts were made.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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