Endoscopic Management and Long-term Outcome of Radiation-Induced Complex Esophageal Strictures

Introduction: Primary radiation therapy is one of the modalities to treat head and neck cancer. It is known to cause complex benign esophageal strictures, particular long strictures. Outcome data on long complex esophageal strictures (≥2cm) due to primary radiation therapy is sparse. Aim: To investigate the outcome of radiation-induced complex esophageal strictures. Methods: All patients with radiation induced complex esophageal strictures between Oct 2010 and Mar 2014 were included, and compared with esophageal complex strictures due to other etiologies. Data was abstracted by retrospective chart review. The primary outcome was the treatment success defined as improved dysphagia score. The secondary outcome was the requirement of gastrostomy or esophagectomy. Results: A total of 73 patients (67±15.6 years; 53.4% female) were identified with esophageal strictures of ≥2cm length with median follow-up over 16 months. Of those, 21 patients were radiation-induced due to therapy for malignancies in lung 38%, head and neck 33%, cervical esophagus 24%, and breast cancer 5%. In non-radiation cohort of 52 patients, the etiologies included peptic 37%, post-ablation 17%, post-EMR 15%, eosinophilic esophagitis 9%, and others 22%. In radiation cohort, patients underwent a median of 7.0 dilations (0.4 dilations per month) for strictures with mean diameter of 6.9 mm, compared to patients in non-radiation cohort who underwent a median of 6.5 dilations (0.2 dilations per month, P The median dysphagia score changed from 2.5 to 2.0 in radiation cohort and remained unchanged as 2.0 in nonradiation cohort after dilations. Stricture length and diameter have no significant change in both cohorts. Improvement of dysphagia was achieved in 33% patients in radiation cohort and 42% in non-radiation cohort (P=0.6). 43% patients in radiation cohort required gastrostomy or esophagectomy compared 17% in non-radiation cohort (P=0.03). Limitations: Single center, retrospective study, heterogeneous cohort. Conclusion: Radiation-induced complex (≥2cm) esophageal strictures have relatively smaller diameter, require more frequent endoscopic dilations, and more gastrostomy or esophagectomy. Endoscopic treatment is effective in only 33% in this cohort of patients, as reflected by improvement of dysphagia score.Table: Characteristics of Esophageal Complex Strictures and Outcomes.