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Literature Review

Literature Review. Peter R. McNally, DO, FACP, FACG Lone Tree, Colorado.

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Literature Review

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  1. Literature Review Peter R. McNally, DO, FACP, FACGLone Tree, Colorado

  2. A prospective, randomized, double-blind placebo-controlled trial of enodscopic steroid injection therapy for recalcitrant esophageal peptic strictures. Ramage JI, Rumalla A, Baron TH, Pochron NL, Zinsmeister AR, Murry JA, Norton ID, Diehl N, Romero Y.Am J Gastroenterology. 2005;100(11): 2419-2425.

  3. Peptic Stricture: TTS dilation Without Steroid Injection Ramage JI, Rumalla A, Baron TH, Pochron NL, Zinsmeister AR, et al. J Gastroenterology. 2005;100(11): 2419-2425.

  4. Peptic Stricture: TTS dilation With Steroid Injection ( ) Ramage JI, Rumalla A, Baron TH, Pochron NL, Zinsmeister AR, et al. J Gastroenterology. 2005;100(11): 2419-2425.

  5. Introduction • The recalcitrant peptic stricture was commonplace prior to the introduction of omperazole in 1989. • Though potent acid suppression has decreased the prevalence of refractory peptic strictures, it still remains a challenging complication of GERD for the clinical gastroenterologist.

  6. Aim • To examine the utility of pre-dilation endoscopic corticosteroid injection to improve esophageal patency after esophageal TTS dilation reduces the need for repeat stricture dilation

  7. Study Design: • 30 pts with peptic stricture requiring > 1 prior esophageal dilation. • Randomized to receive 0.5 cc/quadrant of triamcinolone (Kenalog 40 mg/cc) or sham injection into stricture. • Followed by through-the-scope balloon dilation of the stricture. (Microvasive MaxForce TTS dilator, Waterton, MA). • Initial balloon size was selected according to estimate of stricture diameter and dilations held for 30-60 seconds and dilated up to 15-18 mm range.

  8. Study Design(2): • Patients were stratified by number of prior dilations and stricture severity. • Post dilation all were placed on esomeprazole 40 mg twice daily. • Standardized telephone follow up questionnaires 1 wk 1, 3, 6, 9 and 12 months.

  9. Results • Demographic characteristics to include age, gender, BMI, NSIAD use, presence of Barrett’s esophagus, and prior PPI use similar both groups. • Two patients died of non esophageal causes. • Four patients with persistent dysphagia had fundoplication, 2 in each group. • Over one year of follow-up, two patients in the steroid group (13%) and nine in the sham group (60%) required repeat dilation p=0.011

  10. Conclusions • This study illustrates that endoscopic injection of triamcinalone at the time of TTS dilation is beneficial in decreasing symptomatic peptic stricture relapse when patients are maintained on acid suppression with esomeprazole 40 mg bid.

  11. Reviewer Comments • This is the first controlled trial evaluating the utility of intra-stricture injection of steroids followed by maintenance PPI. • These results indicate this technique improves patency of refractory peptic strictures – durable benefit is clear.

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