Peptic esophageal stricture: is surgery still necessary?

Gastroesophageal reflux disease is frequently complicated by peptic esophageal stricture formation. Treatment of choice over the past 25 years has changed from resection of the stenotic esophagus towards fundoplication, or conservative treatment combined with dilatation. Reports on the long-term results of the clinical course of such patients are still rare. Between 1965 and 1990 200 patients were treated for peptic esophageal stricture by surgery or bougienage with antisecretory medication. Retrospective analysis of the clinical outcome according to the primary therapeutic strategy was performed after a follow-up period of 1.5 to 267 months. 139 patients (group A) primarily received bougienage and medical treatment. After 71 months 36% of the patients were symptom-free, 52% had received further dilatation and 11% had undergone surgery. One fatal complication occurred. 61 patients (group B) underwent primary surgical treatment. Fundoplication was performed in 72% of the cases, resection in 18% and other procedures in 10%. After a median period of 84 months following standard fundoplication (n = 43) 44% were free of symptoms, 39% had received further dilatations and 12% had to be reoperated. Fatal complications occurred in 2 patients (5%). The risk of undergoing surgery after primary dilatation was 16% after 2 years, remaining on this level throughout follow-up time. We conclude that resection of peptic strictures of the esophagus is rarely indicated any more. Treatment of choice consists of primary bougienage combined with antisecretory medication. If conservative treatment fails or patient compliance is low we recommend fundoplication with intraoperative dilatation within the first 2 years after diagnosis of symptomatic stricture.