Surgical management of peptic esophageal stricture. Twenty-year experience

The consensus in the conflict about surgical management of peptic esophageal stricture presently favors conservative antireflux procedures with dilatation rather than resection. However, emphasis is now shifting to the controversy of conservative surgical treatment versus medical management with dilatation alone. We analyzed the influence of seven variables on the postoperative result in 160 patients undergoing antireflux operations with dilatation for peptic esophageal stricture. The mean follow-up is 47 months (range 6 to 240) and the mean age is 57 years (range 13 to 83). One hundred seven patients operated on early in the course of the disease have better results (90% good, 9% fair, 1% poor) than 31 patients having a previous failed operation (52% good, 23% fair, 26% poor) and 22 patients having multiple dilatations (45% good, 23% fair, 32% poor) (p less than 0.05). Intraoperative manometry improves results (p less than 0.05), and postoperative reflux has a negative influence on results (p less than 0.05). The postoperative lower esophageal sphincter pressure in patients without reflux (17.7 +/- 1.3 mm Hg) is higher than in those with reflux (8.9 +/- 0.8 mm Hg, p less than 0.05) and is an accurate predictor of the risk of reflux (p less than 0.001). Intraoperative and postoperative sphincter pressures are objective indicators of outcome but because of variability are not predictive (p less than 0.05). The presence of Barrett's esophagus and the age and sex of patients do not alter outcome. Adenocarcinoma did not develop in patients with Barrett's esophagus once reflux was eliminated. This information indicates that conservative antireflux operation with dilatation is the treatment of choice in patients with peptic esophageal stricture.