1 Literature Review Peter R. McNally, DO, FACP, FACG Lone 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):

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):

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):

5 Introduction The recalcitrant peptic stricture was commonplace prior to the introduction of omperazole in The recalcitrant peptic stricture was commonplace prior to the introduction of omperazole in Though potent acid suppression has decreased the prevalence of refractory peptic strictures, it still remains a challenging complication of GERD for the clinical gastroenterologist. 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 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. 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. 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). 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 seconds and dilated up to mm range. Initial balloon size was selected according to estimate of stricture diameter and dilations held for seconds and dilated up to mm range.

8 Study Design(2): Patients were stratified by number of prior dilations and stricture severity. Patients were stratified by number of prior dilations and stricture severity. Post dilation all were placed on esomeprazole 40 mg twice daily. 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. 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. 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. Two patients died of non esophageal causes. Four patients with persistent dysphagia had fundoplication, 2 in each group. 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 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. 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. 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. These results indicate this technique improves patency of refractory peptic strictures – durable benefit is clear.