Biodegradable stent placement for recurrent or refractory benign esophageal stricture: a perspective from the East

We read the article by Walter et al. [1] that reported a multicenter, randomized controlled trial of treatment for recurrent benign esophageal stricture (BES). Repeated dilations are usually required for recurrent BES, with patients suffering a poor quality of life and high medical costs. Instead of simple dilation, the trial of Walter et al. demonstrated that biodegradable stent implantation was effective in decreasing the requirement for therapeutic dilations and prolonging esophageal patency. While this finding is promising, we have some concerns and would appreciate the authors’ clarification on certain points.

In their study, biodegradable stents were effective in reducing dilations during the first 3 months; however, when diagnostic endoscopy was included, overall endoscopic procedures were not decreased over this period. The cost-effectiveness of biodegradable stent placement for this clinical application should therefore be considered.

Anastomotic stricture was the main etiology for patients with recurrent BES in this study; however, certain other etiologies are becoming increasingly common in the East, while they remain less common in the West. Endoscopic resection techniques have been developed as one important approach to treat esophageal superficial neoplasia [2]. For circumferential endoscopic submucosal dissection (ESD), the incidence of post-ESD stricture was reported to be markedly higher [3]. With limited childcare education, pediatric caustic stricture is also common in developing countries; there were few such cases included in the study of Walter et al. The understanding of how the underlying etiology affects the occurrence and treatment of stricture is incomplete [4]. Further studies should clarify the feasibility of biodegradable stents for these indications.

Prophylactic stenting may lead to more clinical benefit owing to the limited efficacy of current treatments for complex stricture treatment [5]. Metal stents have been reported to be helpful to prevent benign stricture, but there is limited literature with regard to the use of biodegradable stents. Given the reduced need for stent removal and risk of migration, we would like to see more randomized trials exploring the promising role of prophylactic stenting and the potential treatment algorithm with biodegradable stents.

• References

• 1 Walter D, van den Berg MW, Hirdes MM. et al. Dilation or biodegradable stent placement for recurrent benign esophageal strictures: a randomized controlled trial. Endoscopy 2018; 50: 1146-1155
• 2 Kim JS, Kim BW, Shin IS. Efficacy and safety of endoscopic submucosal dissection for superficial squamous esophageal neoplasia: a meta-analysis. Dig Dis Sci 2014; 59: 1862-1869
• 3 Shi Q, Ju H, Yao LQ. et al. Risk factors for postoperative stricture after endoscopic submucosal dissection for superficial esophageal carcinoma. Endoscopy 2014; 46: 640-644
• 4 Siersema PD. How to approach a patient with refractory or recurrent benign esophageal stricture. Gastroenterology 2019; 156: 7-10
• 5 Ma GK, Kochman ML. Esophageal strictures: in search of the Goldilocks solution. Endoscopy 2018; 50: 1139-1140