Mitomycin for Esophageal Strictures |
| The
use of Mitomycin C (MMC) in the management of esophageal strictures has
gained increasing attention due to its antifibrotic properties and its
potential to reduce the need for repeated dilations. Esophageal
strictures can arise from various etiologies, including post-surgical
complications, caustic injuries, congenital conditions, and
gastroesophageal reflux disease. The primary challenge in managing
esophageal strictures lies in preventing fibrosis and recurrence
following endoscopic interventions. Conventional treatments often
involve multiple sessions of balloon or bougie dilations, and in some
cases, surgical interventions. The integration of MMC into treatment
protocols represents an important advancement in this field. Esophageal strictures following surgical repair of conditions such as tracheoesophageal fistula and esophageal atresia are common complications. These strictures are often resistant to standard dilation procedures, leading to multiple interventions and potential complications such as perforation. Studies have documented cases in which the application of MMC has successfully led to the resolution of these strictures with fewer dilation sessions. The mechanism by which MMC acts is primarily through the inhibition of fibroblast proliferation and suppression of collagen deposition, thereby reducing the formation of scar tissue that contributes to recurrent strictures. The application process generally involves topical administration of MMC onto the stricture site following mechanical dilation, allowing for prolonged exposure to the affected tissue. One of the major indications for MMC in esophageal strictures is its use in cases caused by caustic ingestion. Caustic esophageal injuries can lead to extensive fibrosis and stricture formation, often necessitating prolonged treatment courses. Comparative studies have shown that patients receiving MMC after dilations required significantly fewer sessions compared to those treated with dilation alone. The success of MMC in these cases underscores its potential to alter the natural history of caustic esophageal injuries, allowing for improved patient outcomes and reduced healthcare burdens. Furthermore, randomized controlled trials have demonstrated that MMC not only decreases the frequency of dilations but also prolongs the intervals between necessary interventions. Despite its efficacy, there remains debate regarding the optimal concentration, frequency, and duration of MMC application. Some techniques involve the use of MMC-soaked pledges applied directly to the stricture site for a short duration, while others employ injection methods to ensure deeper penetration of the drug into fibrotic tissue. The concentration of MMC used in most studies ranges from 0.4 mg/mL to 1.0 mg/mL, with application times varying between one and five minutes. Long-term follow-up of patients treated with MMC has shown that recurrence rates of strictures remain low, supporting the notion that MMC provides durable benefits in managing esophageal narrowing. The safety profile of MMC in esophageal applications has been a subject of investigation, given its cytotoxic nature. Reports indicate that topical MMC application does not lead to significant systemic absorption, thereby minimizing the risk of systemic toxicity. Studies following patients over extended periods have found no evidence of dysplasia or malignant transformation at the sites of MMC application. However, concerns remain regarding potential complications such as mucosal thinning, delayed healing, and perforation, though these have not been widely reported. These findings suggest that MMC, when used appropriately, offers a safe and effective adjunct to traditional dilation therapies. Innovations in MMC application techniques have also contributed to its growing acceptance. The use of modified catheters and endoscopic delivery systems has improved precision and minimized unintended exposure to surrounding healthy mucosa. Some studies have introduced endoscopic-guided injection techniques that allow for targeted drug delivery, further enhancing the therapeutic effect while reducing the risk of complications. Additionally, comparisons between MMC and other therapeutic agents, such as triamcinolone, indicate that MMC may offer superior long-term efficacy in reducing stricture recurrence. While steroid injections have been used for similar indications, they primarily exert anti-inflammatory effects without the long-lasting antifibrotic action of MMC. Beyond the pediatric population, MMC has shown promise in adult patients with refractory esophageal strictures. Cases of peptic, radiation-induced, and anastomotic strictures have responded favorably to MMC application. The consistency of positive outcomes across different patient demographics supports the broader adoption of MMC in clinical practice. However, continued research is needed to refine treatment protocols, particularly regarding repeated applications and combination therapies that may further enhance outcomes. Despite the compelling evidence supporting MMC, there are limitations to its widespread adoption. The lack of standardized protocols across institutions leads to variability in treatment outcomes. Additionally, long-term multicenter studies are necessary to establish definitive guidelines for its use. The economic impact of MMC therapy also warrants consideration, as it has the potential to reduce healthcare costs associated with repeated hospitalizations and procedural interventions. The use of MMC in the treatment of esophageal strictures represents a significant advancement in the field of gastroenterology. Its ability to reduce stricture recurrence, decrease the number of necessary dilation sessions, and maintain long-term patency of the esophagus makes it a valuable adjunct in managing this challenging condition. While further research is needed to optimize application techniques and establish standardized protocols, current evidence supports its safety and efficacy. As more clinicians integrate MMC into their practice, the potential for improved patient outcomes and reduced treatment burden will continue to expand, making it a cornerstone therapy for refractory esophageal strictures. References: 1- Lakoma A, Fallon SC, Mathur S, Kim ES: Use of Mitomycin C for Refractory Esophageal Stricture following Tracheoesophageal Fistula Repair. European J Pediatr Surg Rep. 1(1):24-6, 2013 2- El-Asmar KM: Topical Mitomycin C application for esophageal stricture: safe, precise, and novel endoscopic technique. J Pediatr Surg. 48(6):1454-7, 2013 3- El-Asmar KM, Hassan MA, Abdelkader HM, Hamza AF: Topical mitomycin C application is effective in management of localized caustic esophageal stricture: a double-blinded, randomized, placebo-controlled trial. J Pediatr Surg. 48(7):1621-7, 2013 4- Chapuy L, Pomerleau M, Faure C: Topical mitomycin-C application in recurrent esophageal strictures after surgical repair of esophageal atresia. J Pediatr Gastroenterol Nutr. 59(5):608-11, 2014 5- Méndez-Nieto CM, Zarate-Mondragón F, Ramírez-Mayans J, Flores-Flores M: Topical mitomycin C versus intralesional triamcinolone in the management of esophageal stricture due to caustic ingestion. Rev Gastroenterol Mex. 80(4):248-54, 2015 6- Rashed YK, El-Guindi M: Endoscopic postdilatation application of Mitomycin C in children with resistant esophageal strictures. Korean J Pediatr. 62(10):395-399, 2019 7- Ley D, Bridenne M, Gottrand F, et al: Efficacy and Safety of the Local Application of Mitomycin C to Recurrent Esophageal Strictures in Children. J Pediatric Gastroenterol Nutr. 69(5):528-532, 2019 |
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