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A Model for Predicting Refractory Benign Esophageal Strictures at Index Endoscopy
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- The authors of this retrospective cohort study developed a predictive model for refractory benign esophageal strictures (RBES). A total of 88 patients with RBES and 103 without RBES were included. Overall, the predictive factors for RBES included stricture length of at least 2 cm, diameter of not more than 7 mm, and proximal/diffuse stricture location. Patients without any of the aforementioned risk factors had a 2% risk of RBES, whereas those with all three risk factors had a 73% risk for RBES.
- This study suggests risk factors that predict RBES at index esophagogastroduodenoscopy, which may guide the therapeutic approach in patients with benign esophageal stricture. However, the prediction model requires validation in other settings.
abstract
This abstract is available on the publisher's site.
Access this abstract nowBackground and Aims
Refractory benign esophageal strictures (RBES) are defined by inadequate response to dilation. Early recognition of RBES allows for earlier initiation of aggressive therapy potentially leading to less morbidity and cost. We sought to establish a predictive model for RBES.
Methods
Patients who underwent esophagogastroduodenoscopy (EGD) with esophageal dilation at Mayo Clinic Rochester were identified. In addition, a cohort of patients from a clinical database of patients with RBES managed with self-dilation was identified. Malignant strictures, Schatzki rings, and previously treated strictures were excluded. RBES was defined by inability to maintain a diameter ≥14mm over 5 dilation sessions. Multivariable logistic regression models were built to predict RBES.
Results
128 patients with index EGD and esophageal dilation were identified, with 25 meeting RBES criteria. An additional 63 RBES patients were identified from the self-dilation cohort for a total of 88 RBES and 103 non-RBES patients. Multivariable analysis yielded a strong predictive model, with a c-statistic of 0.85, identifying stricture length ≥ 2cm, diameter ≤ 7mm and proximal/diffuse stricture location as associated with a higher risk for RBES. Patients without any of these risk factors had a 2% risk of RBES while those with all 3 risk factors had a risk of 73% for RBES.
Conclusions
Risk of RBES can be predicted at index EGD based on stricture features. A predictive model for RBES was created based on readily available risk factors, which may guide an individualized therapeutic approach to patients with benign esophageal stricture, potentially reducing morbidity and cost.
Additional Info
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Benign esophageal strictures can often be remediated by endoscopic methods of dilation with adjunctive therapies as described in the literature.1-4 There remains a cadre of patients with refractory benign esophageal strictures (RBES) who are defined by having strictures that are unable to achieve a diameter of 14 mm or greater over five sessions with at least 2-week intervals.5 RBES pose a challenge for the endoscopist given the trend towards unsatisfactory clinical outcomes. In a retrospective natural history study of patients with RBES, it was noted that freedom from dysphagia typically lasted only about 3 months on average.6
The basis for the study is rooted in a difficult but important task of improving the outcomes for patients with RBES. Bell and colleagues propose that earlier recognition of patients with benign esophageal strictures that are likely to be classified as RBES may alter dilation strategies and thus improve outcomes. In this single-center retrospective study evaluating patients with RBES, Bell and colleagues evaluated a cohort of patients who met criteria for RBES and used multivariable logistic regression models to propose both endoscopic and non-endoscopic risk factors to create prediction models for patients at risk of RBES at the time of index endoscopy. In their cohort, a total of 25 patients meeting RBES criteria were analyzed, and an additional 63 patients undergoing self-dilation were added for a total of 88 patients incorporated for multivariable analysis. The authors proposed two models for assessment of risk for RBES at time of index endoscopy, which included stricture length, stricture diameter, and esophageal stricture location in model 1 (AUC, 0.87). The second model (AUC, 0.82) utilized etiology (anastomotic vs peptic/cricopharyngeal bar vs eosinophilic esophagitis/lichen planus), male sex, stricture location, and age.
Strengths of the study included an adherence to the definition of RBES and exclusion of those not meeting the definition. The authors used stringent statistical parameters such as the Akaike information criterion to ensure the relative quality of their predictive models.
Despite the attractiveness of having a simple prediction model (or two), it is important from a clinical standpoint to have outcome metrics from which implementation of these models would lead to a clinically significant improvement. The authors rely on a relatively small sample group from a single center and incorporate an additional group of self-dilation patients who are presumed to have RBES with similar inclusion and pre-treatment courses. This aspect of the study is one of the more noticeable weaknesses. Some other issues with respect to the patient population are apparent in the etiology, with the inclusion of cricopharyngeal bars, which have surgical and third-space endoscopic techniques that are quite effective.7,8
Additionally, it would be helpful to understand the trend(s) in endoscopic therapy between the non-refractory and refractory groups, such as intervals between dilation, number of balloon vs Savary/bougie dilation, and use of adjunctive therapies such as endoprosthesis, intralesional steroid injection, mitomycin C, and endoscopic incisional therapy. When the characteristics of the two groups are compared, it is not clear if the differences in sex, age, etiology, length of stricture, diameter, or location are statistically significant, as p-values are not reported. Given the likely differences in etiology, propensity-score matching may be helpful for confirmation.
Patients with RBES often require frequent endoscopic dilation sessions to attempt to remodel their strictures for decreased symptom burden. Currently, there are no clear strategies or adjunctive endoscopic therapies that, when applied are more likely to succeed in effectively treating RBES. Prediction models may help to set expectations for the clinician/endoscopist and patient; however, these are currently unlikely to alter one’s approach in a way that would lead to superior clinical outcomes. There remains room for high-quality randomized multicenter trials to assess these types of prediction models on interventions and outcomes for RBES, as well as for the development of new treatment modalities.
References