Radiofrequency ablation (RFA) is effective and safe in the treatment of Barrett’s
esophagus [1]. The incidence of esophageal stricture after RFA treatment is reported to be up
to 8 % [2]. Stricture rates may be increased with RFA of long-segment Barrett’s esophagus.
Strictures are treated endoscopically with balloons or Savary dilators; however, there
is a risk of perforation with these treatments. We report on the successful treatment
of a patient with a stricture following RFA using a self-expanding metal stent (SEMS).
A 71-year old man with long-segment Barrett’s esophagus (C7M7) and low-grade dysplasia
underwent circumferential RFA. A month later he reported dysphagia and odynophagia,
and endoscopy revealed a tight stricture with circumferential ulceration at the proximal
end of the RFA-treated area of Barrett’s epithelium ([Fig. 1 a]).
Fig. 1 Endoscopic images showing: a a tight stricture with circumferential ulceration at the proximal end of the area
of Barrett’s epithelium that had been treated by radiofrequency ablation (RFA); b a fully covered metal esophageal stent deployed in the esophagus.
A gastroscope with a 5.9-mm diameter was advanced to the proximal end of the stricture;
however, the distal end of the stricture could not be traversed. A gastroscope with
an 8.8-mm diameter was therefore inserted and a 9 – 12-mm extraction balloon (Extractor
Pro RX; Boston Scientific, Natick, Massachusetts, USA) was introduced. Injection of
contrast revealed a 4 – 5 cm long stricture in the mid-esophagus. A stent introducer
was passed over a 450-cm, 0.035-inch guidewire (Dreamwire; Boston Scientific), which
had been passed through the stricture under fluoroscopic guidance. A fully covered
metal esophageal stent (23 × 105 mm, WallFlex; Boston Scientific) was deployed ([Fig. 1 b]). A further attempt to pass the 5.9 mm gastroscope through the stricture was unsuccessful.
The extraction balloon was reintroduced and injection of contrast showed a waist in
the mid-portion of the stent, but with free flow of contrast into the stomach ([Fig. 2]).
Fig. 2 Radiographic image following injection of contrast showing a waist in the mid-portion
of the stent, with free flow of contrast into the stomach.
The stent was removed 2 months later ([Fig. 3] and [Fig. 4]) and after 6 months, the patient had no symptoms of dysphagia and was found to have
a well-healed fibrotic stricture on endoscopy ([Fig. 5]).
Fig. 3 Endoscopic view of the esophagus following removal of the stent 2 months later.
Fig. 4 The fully covered, 23 × 105-mm, esophageal self-expanding metal stent (SEMS).
Fig. 5 Endoscopic appearance 6 months later showing a well-healed fibrotic stricture.
To our knowledge, this is the first case of an esophageal stricture occurring after
RFA that was successfully treated by placement of a fully covered removable metal
stent. Use of a self-expandable metal stent has also been reported for a stricture
occurring after photodynamic therapy for Barrett’s esophagus [3]. Treatment of tight strictures with metal stents may be a cost-effective treatment
as it avoids the need for repeated dilations and the possible subsequent complications
[4].
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