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Mitani Y, Hirohashi K, Tamaoki M, Yokoyama A, Katada C, Ueda A, Yamahigashi N, Higuchi H, Muto M. Efficacy and safety of radial incision and cutting for nonsurgical refractory benign esophageal stricture. Endosc Int Open 2024; 12:E1035-E1042. [PMID: 39263558 PMCID: PMC11387040 DOI: 10.1055/a-2382-6213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2024] [Accepted: 08/07/2024] [Indexed: 09/13/2024] Open
Abstract
Background and study aims Radial incision and cutting (RIC) was established to improve refractory esophageal anastomotic strictures but its efficacy and safety for nonsurgical refractory strictures remain unclear. To evaluate the usefulness of RIC in nonsurgical refractory strictures, we retrospectively compared outcomes between nonsurgical and surgical strictures. Patients and methods We retrospectively studied 54 consecutive patients who were initially treated with RIC for refractory benign esophageal stricture. The study variables included dysphasia score improvement rate, frequency of repeated RIC, cumulative patency rate, cumulative stricture improved rate, and adverse events(AEs), which were compared between nonsurgical (n = 21) and surgical (n = 33) stricture groups. Results Immediately after RIC, 90.5% of patients in the nonsurgical group and 84.8% of patients in the surgical group had improvement in dysphagia ( P = 0.69). The frequency of intervening repeated RIC was 42.9% in the nonsurgical group and 42.4% in the surgical group ( P = 0.98). During median follow-up of 22.3 months (range, 1.0-175.0), the cumulative patency rate ( P = 0.23) and cumulative stricture improvement rate ( P = 0.14) but there was not statistical difference between the two groups. Despite a low cumulative stricture improvement rate (9.5%) at 6 months after the first RIC in the nonsurgical group, 57.7% of patients no longer required endoscopic balloon dilatation at 2 years. The cumulative stricture improvement rate was significantly lower in patients with a history of radiation therapy. No severe AEs were observed in the nonsurgical group. Conclusions RIC for nonsurgical refractory benign esophageal stricture is an effective and safe treatment option.
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Affiliation(s)
- Yosuke Mitani
- Therapeutic Oncology, Kyoto University Graduate School of Medicine Faculty of Medicine, Kyoto, Japan
| | - Kenshiro Hirohashi
- Therapeutic Oncology, Kyoto University Graduate School of Medicine Faculty of Medicine, Kyoto, Japan
| | - Masashi Tamaoki
- Therapeutic Oncology, Kyoto University Graduate School of Medicine Faculty of Medicine, Kyoto, Japan
| | - Akira Yokoyama
- Therapeutic Oncology, Kyoto University Graduate School of Medicine Faculty of Medicine, Kyoto, Japan
| | - Chikatoshi Katada
- Therapeutic Oncology, Kyoto University Graduate School of Medicine Faculty of Medicine, Kyoto, Japan
| | - Aya Ueda
- Therapeutic Oncology, Kyoto University Graduate School of Medicine Faculty of Medicine, Kyoto, Japan
| | | | | | - Manabu Muto
- Therapeutic Oncology, Kyoto University Graduate School of Medicine Faculty of Medicine, Kyoto, Japan
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Coppola G, Principessa C, Di Vincenzo F, Puca P, Del Gaudio A, Capobianco I, Bartocci B, Papa A, Cammarota G, Lopetuso LR, Scaldaferri F. Endoscopic Management of Strictures in Crohn's Disease: An Unsolved Case. J Clin Med 2024; 13:4842. [PMID: 39200984 PMCID: PMC11355190 DOI: 10.3390/jcm13164842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2024] [Revised: 08/07/2024] [Accepted: 08/13/2024] [Indexed: 09/02/2024] Open
Abstract
Crohn's disease (CD) is a chronic inflammatory disease associated with a significant burden in terms of quality of life and health care costs. It is frequently associated with several complications, including the development of intestinal strictures. Stricturing CD requires a careful multidisciplinary approach involving medical therapy and surgery, still posing a continuous management challenge; in this context, endoscopic treatment represents a valuable, in-between opportunity as a minimally invasive strategy endorsed by extensive yet heterogeneous evidence and evolving research and techniques. This review summarizes current knowledge on the role of therapeutic endoscopy in stricturing CD, focusing on evidence gaps, recent updates, and novel techniques intended for optimizing efficacy, safety, and tailoring of this approach in the view of precision endoscopy.
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Affiliation(s)
- Gaetano Coppola
- CEMAD—IBD Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy (I.C.)
- Dipartimento Universitario di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, 00168 Rome, Italy;
| | - Chiara Principessa
- Dipartimento Universitario di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, 00168 Rome, Italy;
| | - Federica Di Vincenzo
- CEMAD—IBD Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy (I.C.)
- Dipartimento Universitario di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, 00168 Rome, Italy;
| | - Pierluigi Puca
- CEMAD—IBD Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy (I.C.)
- Dipartimento Universitario di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, 00168 Rome, Italy;
| | - Angelo Del Gaudio
- CEMAD—IBD Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy (I.C.)
- Dipartimento Universitario di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, 00168 Rome, Italy;
| | - Ivan Capobianco
- CEMAD—IBD Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy (I.C.)
- Dipartimento Universitario di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, 00168 Rome, Italy;
| | - Bianca Bartocci
- CEMAD—IBD Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy (I.C.)
- Dipartimento Universitario di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, 00168 Rome, Italy;
| | - Alfredo Papa
- CEMAD—IBD Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy (I.C.)
- Dipartimento Universitario di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, 00168 Rome, Italy;
| | - Giovanni Cammarota
- CEMAD—IBD Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy (I.C.)
- Dipartimento Universitario di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, 00168 Rome, Italy;
| | - Loris Riccardo Lopetuso
- CEMAD—IBD Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy (I.C.)
- Dipartimento Universitario di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, 00168 Rome, Italy;
- Dipartimento di Medicina e Scienze dell’Invecchiamento, Università degli Studi “G. D’Annunzio”, 66100 Chieti, Italy
| | - Franco Scaldaferri
- CEMAD—IBD Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy (I.C.)
- Dipartimento Universitario di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, 00168 Rome, Italy;
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Venu V, Bakhshi G, Dutt A, Raichur A, Jaiswal N. When Stents Go Astray, We Find a Way: A Case Report on Retrieving a Migrated Esophageal Stent. Cureus 2024; 16:e67009. [PMID: 39280543 PMCID: PMC11402437 DOI: 10.7759/cureus.67009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/16/2024] [Indexed: 09/18/2024] Open
Abstract
Benign esophageal strictures are characterized by the narrowing of the esophageal passage due to fibrotic changes. These strictures can arise from various causes, including gastroesophageal reflux disease, which leads to peptic strictures; surgical procedures causing esophageal injury, resulting in anastomotic strictures; radiation therapy, ingestion of corrosive substances, or endoscopic resection. Approximately 10% of benign esophageal strictures do not respond to conventional dilation therapy, prompting the consideration of temporary stent insertion as an alternative treatment approach. However, only about one-third of patients with refractory benign esophageal strictures experience sustained relief from dysphagia following self-expanding stent placement. Challenges such as stent migration and hyperplastic tissue response pose limitations to the effectiveness of this intervention. The utilization of self-expanding metal stents (SEMSs) in benign esophageal diseases is not standard practice due to the associated risks of adverse events such as tissue ingrowth at the uncovered portions, migration, and bleeding. One of the major challenges encountered is the growth of hyperplastic tissue around the stent during retrieval and subsequent serial esophageal bougie dilations. Long-term self-bougie dilations, coupled with the patient's gained self-confidence, played a crucial role in the management. While most migrated esophageal metallic stents are typically left in the stomach, in this particular case, the patient's progressive dysphagia necessitated retrieval. This article discusses a 65-year-old female with a benign esophageal stricture treated with a self-expandable metallic stent. Eight months post-insertion by another doctor, she presented to us with worsening dysphagia. Endoscopy revealed a stent migrated into the antrum of the stomach with a proximal esophageal stricture. Endoscopic dilation and stent retrieval were performed, followed by serial esophageal bougie dilations. Subsequently, her dysphagia settled with self-insertion of a 9 mm esophageal dilator.
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Affiliation(s)
- Vinayak Venu
- General Surgery, Grant Government Medical College and Sir JJ Group of Hospitals, Mumbai, IND
| | - Girish Bakhshi
- General Surgery, Grant Government Medical College and Sir JJ Group of Hospitals, Mumbai, IND
| | - Aishwarya Dutt
- General Surgery, Grant Government Medical College and Sir JJ Group of Hospitals, Mumbai, IND
| | - Apoorva Raichur
- General Surgery, Grant Government Medical College and Sir JJ Group of Hospitals, Mumbai, IND
| | - Naman Jaiswal
- General Surgery, Grant Government Medical College and Sir JJ Group of Hospitals, Mumbai, IND
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4
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Kneist W. Robot-assisted oesophagectomy (Ivor-Lewis) for a complex stenosis previously managed by open gastrostomy tube placement. BMJ Case Rep 2024; 17:e256455. [PMID: 38697681 PMCID: PMC11085858 DOI: 10.1136/bcr-2023-256455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/06/2024] [Indexed: 05/05/2024] Open
Abstract
A man in his late 50s presented with severe dysphagia caused by a complex refractory benign stenosis that was completely obstructing the middle oesophagus. The patient was unsatisfied with the gastrostomy tube placed via laparotomy as a long-term solution. Therefore, we performed robot-assisted minimally invasive oesophagectomy (video). Mobilisation of the stomach and gastric conduit preparation were more difficult due to the previously inserted gastrostomy tube; thus, the conduit blood supply was assessed using indocyanine green fluorescence. After an uncomplicated course, the patient was referred directly to inpatient rehabilitation on the 16th postoperative day. At 9 months after surgery, the motivated patient returned to full-time work and achieved level 7 on the functional oral intake scale (total oral diet, with no restrictions). At the 1-year follow-up, he positively confirmed all nine key elements of a good quality of life after oesophagectomy.
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Affiliation(s)
- Werner Kneist
- General and Visceral Surgery, St. Georg Hospital Eisenach, Eisenach, Germany
- General-, Visceral- and Thoracic Surgery, Klinikum Darmstadt, Darmstadt, Germany
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Norton BC, Papaefthymiou A, Aslam N, Telese A, Murray C, Murino A, Johnson G, Haidry R. The endoscopic management of oesophageal strictures. Best Pract Res Clin Gastroenterol 2024; 69:101899. [PMID: 38749578 DOI: 10.1016/j.bpg.2024.101899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 02/04/2024] [Accepted: 02/25/2024] [Indexed: 05/26/2024]
Abstract
An oesophageal stricture refers to a narrowing of the oesophageal lumen, which may be benign or malignant. The cardinal feature is dysphagia, and this may result from intrinsic oesophageal disease or extrinsic compression. Oesophageal strictures can be further classified as simple or complex depending on stricture length, location, diameter, and underlying aetiology. Many endoscopic options are now available for treating oesophageal strictures including dilatation, injectional therapy, stenting, stricturotomy, and ablation. Self-expanding metal stents have revolutionised the palliation of malignant dysphagia, but oesophageal dilatation with balloon or bougienage remains first-line therapy for most benign strictures. The increase in endoscopic and surgical interventions on the oesophagus has seen more benign refractory oesophageal strictures that are difficult to treat, and often require advanced endoscopic techniques. In this review, we provide a practical overview on the evidence-based management of both benign and malignant oesophageal strictures, including a practical algorithm for managing benign refractory strictures.
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Affiliation(s)
- Benjamin Charles Norton
- Department of Gastroenterology, Digestive Diseases and Surgery Institute, Cleveland Clinic London, 33 Grosvenor Place, London, SW1X 7HY, UK; Centre for Obesity Research, Department of Medicine, University College London, Rayne Institute, 5 University St, London, WC1E 6JF, UK.
| | - Apostolis Papaefthymiou
- Department of Gastroenterology, Digestive Diseases and Surgery Institute, Cleveland Clinic London, 33 Grosvenor Place, London, SW1X 7HY, UK
| | - Nasar Aslam
- Department of Gastroenterology, University College London Hospital, 235 Euston Road, London, NW1 2BU, UK
| | - Andrea Telese
- Department of Gastroenterology, Digestive Diseases and Surgery Institute, Cleveland Clinic London, 33 Grosvenor Place, London, SW1X 7HY, UK; Division of Surgery and Interventional Science, University College London, Royal Free Hospital, 10 Pond Street, London, NW3 2PS, UK
| | - Charles Murray
- Department of Gastroenterology, Digestive Diseases and Surgery Institute, Cleveland Clinic London, 33 Grosvenor Place, London, SW1X 7HY, UK
| | - Alberto Murino
- Department of Gastroenterology, Digestive Diseases and Surgery Institute, Cleveland Clinic London, 33 Grosvenor Place, London, SW1X 7HY, UK
| | - Gavin Johnson
- Department of Gastroenterology, Digestive Diseases and Surgery Institute, Cleveland Clinic London, 33 Grosvenor Place, London, SW1X 7HY, UK
| | - Rehan Haidry
- Department of Gastroenterology, Digestive Diseases and Surgery Institute, Cleveland Clinic London, 33 Grosvenor Place, London, SW1X 7HY, UK
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6
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Schulz D, Koob I, Pickhard A, Schmid RM, Abdelhafez M. Risk factors for total laryngectomy associated proximal esophageal stricture formation in head and neck cancer patients. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2024; 62:193-198. [PMID: 37758037 DOI: 10.1055/a-2150-2689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/03/2023]
Abstract
BACKGROUND Development of esophageal strictures is common after the total laryngectomy of head and neck cancer patients. While endoscopic techniques like dilatation by balloon or Salvary bougies are well established, risk factors and pathophysiology for development of refractory strictures are less well understood. OBJECTIVE To evaluate risk factors associated with occurrence and recurrence of total-laryngectomy-associated esophageal strictures in head and neck cancer patients. METHODS We analyzed retrospectively a cohort of 170 head and neck squamous cell carcinoma patients, who underwent total laryngectomy between 2007 and 2017. The outcome measure was laryngectomy-associated proximal esophageal stricture needing an endoscopic dilatation by using a balloon or Savary dilators. RESULTS Of the 170 patients in the cohort, 32 (18.8%) developed strictures. Mean time between surgery and first endoscopic intervention was 24.4 months. Significant predictive factors were age ≥ 65 (p=0.017), nodal status N> 1 (p=0.003), continued alcohol abuse after surgery (p=0.005) and diabetes mellitus (p=0.005). In a subgroup, 17 of 32 patients developed refractory strictures and needed more than three dilatations to relieve dysphagia. Postoperative mean (p=0.016) and maximum (p=0.015) C-reactive protein (CRP) were predictive for refractory strictures. CONCLUSION Symptomatic strictures occurred in 18.8% of the cases. Age, nodal status N>1, continued alcohol abuse and diabetes mellitus were predictive factors. For refractory stenosis (>3 dilatations needed) mean and maximum postoperative CRP were predictive. This may indicate that systemic inflammatory response post-surgery is involved in the stricture formation process.
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Affiliation(s)
- Dominik Schulz
- Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar der Technischen Universität München, München, Germany
| | - Isabelle Koob
- Department of Head and Neck Surgery, Klinikum rechts der Isar der Technischen Universität München, München, Germany
| | - Anja Pickhard
- Department of Head and Neck Surgery, Klinikum rechts der Isar der Technischen Universität München, München, Germany
| | - Roland M Schmid
- Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar der Technischen Universität München, München, Germany
| | - Mohamed Abdelhafez
- Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar der Technischen Universität München, München, Germany
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Graf C, Reden M, Blasberg T, Knabe M, May A, Ell C, Wedi E, Wetzstein N, Michael F, Zeuzem S, Bojunga J, Friedrich-Rust M. Is a higher frequency of esophageal dilations more effective in treating benign esophageal strictures? Retrospective, multicenter study. Endosc Int Open 2024; 12:E78-E89. [PMID: 38205218 PMCID: PMC10781580 DOI: 10.1055/a-2117-8197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 03/22/2023] [Indexed: 01/12/2024] Open
Abstract
Background and study aims There is still a lack of evidence-based recommendations concerning endoscopic bougienage in benign esophageal strictures. Our study aimed to assess the relevance of the time interval between endoscopic dilation (ED) sessions with regard to endoscopic and clinical response. Patients and methods We performed a retrospective study including patients treated with endoscopic bougienage for a benign esophageal stricture in two German centers. Primary endpoint was the number of ED until freedom from dysphagia was achieved. Secondary endpoints were analyses on reaching a diameter of 15 mm and on achieving clinical freedom from symptoms. Results Between April 2014 and March 2020, bougienage was used as the primary treatment for benign esophageal strictures in 238 patients (194 patients in Center 1; 44 patients in Center 2). Both centers differed in their endoscopic bougienage regime: Center 1 was characterized by a higher frequency of interventions compared to Center 2 (median: 2 days [range 1-28] vs. 10 days [range 1-41]; P <0.001). Clinical response was achieved significantly earlier using the high-frequency regimen in all patients except for those with post-radiogen strictures, who clinically benefited from a low-frequency ED program. Accordingly, patients receiving higher-frequency ED reached a significantly larger post-dilation diameter and considerably larger diameter differences. Conclusions The results of our study demonstrate that a treatment concept consisting of higher-frequency bougienages seems to be more effective in treating most types of esophageal stricture. Radiogenic strictures were the only types of stenoses that benefited from a lower frequency ED program.
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Affiliation(s)
- Christiana Graf
- Department of Internal Medicine I, Hospital of the Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Monika Reden
- Department of Internal Medicine I, Hospital of the Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Tobias Blasberg
- Department of Gastroenterology, Sana Klinikum Offenbach, Offenbach, Germany
| | - Mate Knabe
- Department of Internal Medicine I, Hospital of the Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Andrea May
- Department of Gastroenterology, Asklepios Klinik Wiesbaden, Wiesbaden, Germany
| | - Christian Ell
- Department of Gastroenterology, Sana Klinikum Offenbach, Offenbach, Germany
| | - Edris Wedi
- Department of Gastroenterology, Sana Klinikum Offenbach, Offenbach, Germany
| | - Nils Wetzstein
- Department of Infectious Diseases, Hospital of the Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Florian Michael
- Department of Internal Medicine I, Hospital of the Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Stefan Zeuzem
- Department of Internal Medicine I, Hospital of the Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Jörg Bojunga
- Department of Internal Medicine I, Hospital of the Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Mireen Friedrich-Rust
- Department of Internal Medicine I, Hospital of the Goethe University Frankfurt, Frankfurt am Main, Germany
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8
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Kamran A, Smithers CJ, Izadi SN, Staffa SJ, Zurakowski D, Demehri FR, Mohammed S, Shieh HF, Ngo PD, Yasuda J, Manfredi MA, Hamilton TE, Jennings RW, Zendejas B. Surgical Treatment of Esophageal Anastomotic Stricture After Repair of Esophageal Atresia. J Pediatr Surg 2023; 58:2375-2383. [PMID: 37598047 DOI: 10.1016/j.jpedsurg.2023.07.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 07/17/2023] [Accepted: 07/24/2023] [Indexed: 08/21/2023]
Abstract
BACKGROUND Anastomotic strictures (AS) after esophageal atresia (EA) repair are common. While most respond to endoscopic therapy, some become refractory and require surgical intervention, for which the outcomes are not well established. METHODS All EA children with AS who were treated surgically at two institutions (2011-2022) were retrospectively reviewed. Surgical repair was performed for those with AS that were either refractory to endoscopic therapy or clinically symptomatic and undergoing surgery for another indication. Anastomotic leak, need for repeat stricture resection, and esophageal replacement were considered poor outcomes. RESULTS 139 patients (median age: 12 months, range 1.5 months-20 years; median weight: 8.1 kg) underwent 148 anastomotic stricture repairs (100 refractory, 48 non-refractory) in the form of stricturoplasty (n = 43), segmental stricture resection with primary anastomosis (n = 96), or stricture resection with a delayed anastomosis after traction-induced lengthening (n = 9). With a median follow-up of 38 months, most children (92%) preserved their esophagus, and the majority (83%) of stricture repairs were free of poor outcomes. Only one anastomotic leak occurred in a non-refractory stricture. Of the refractory stricture repairs (n = 100), 10% developed a leak, 9% required repeat stricture resection, and 13% required esophageal replacement. On multivariable analysis, significant risk factors for any type of poor outcome included anastomotic leak, stricture length, hiatal hernia, and patient's weight. CONCLUSIONS Surgery for refractory AS is associated with inherent yet low morbidity and high rates of esophageal preservation. Surgical repair of non-refractory symptomatic AS at the time of another thoracic operation is associated with excellent outcomes. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Ali Kamran
- Department of Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Charles J Smithers
- Department of Surgery, Boston Children's Hospital, Boston, MA, USA; Department of Surgery, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
| | - Shawn N Izadi
- Department of Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Steven J Staffa
- Department of Surgery, Boston Children's Hospital, Boston, MA, USA; Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA, USA
| | - David Zurakowski
- Department of Surgery, Boston Children's Hospital, Boston, MA, USA; Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Farokh R Demehri
- Department of Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Somala Mohammed
- Department of Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Hester F Shieh
- Department of Surgery, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
| | - Peter D Ngo
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA, USA
| | - Jessica Yasuda
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA, USA
| | - Michael A Manfredi
- Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Thomas E Hamilton
- Department of General, Thoracic and Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Russell W Jennings
- Department of Surgery, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
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Bentley B, Chanaa F, Clayton S. Complete Esophageal Obstruction: A Rare Complication of Zollinger-Ellison Syndrome. ACG Case Rep J 2023; 10:e01205. [PMID: 38025843 PMCID: PMC10651347 DOI: 10.14309/crj.0000000000001205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 10/17/2023] [Indexed: 12/01/2023] Open
Abstract
Complete esophageal obstruction (CEO) is a rare phenomenon usually observed after receiving head and neck radiation. Zollinger-Ellison syndrome (ZES) is typically associated with minimal esophageal morbidity because of advancements in antisecretory medications. There are currently no documented reports of CEO in patients with ZES. Although surgeries are available for the treatment of CEO, there is no established method for endoscopic lumen restoration, given its rarity. This case documents potential sequala of modern-day patients with ZES.
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Affiliation(s)
- Blake Bentley
- Section on Gastroenterology and Hepatology, Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, NC
| | - Fadi Chanaa
- Section on Gastroenterology and Hepatology, Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, NC
| | - Steven Clayton
- Section on Gastroenterology and Hepatology, Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, NC
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10
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Pandey T, Sonika U, Dalal A, Kumar A, Gera R, Choudhary H, Sachdeva S, Srivastava S, Sharma BC. Validity and Reliability of the European Organization Research and Treatment of Cancer Quality of Life Questionnaire-Oesophagogastric 25 in Indian Patients With Corrosive-Induced Benign Refractory Esophageal Strictures. Cureus 2023; 15:e37190. [PMID: 37159769 PMCID: PMC10163362 DOI: 10.7759/cureus.37190] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/05/2023] [Indexed: 04/09/2023] Open
Abstract
Background The European organization Research and Treatment of Cancer Quality of Life Questionnaire-Oesophagogastric 25 (EORTC QLQ-OG 25) is designed for patients with esophagogastric cancer. Its performance has never been tested with benign disorders. A health-related quality-of-life questionnaire does not exist for patients with benign corrosive-induced esophageal strictures. Hence, we evaluated the EORTC QLQ-OG 25 in Indian patients with corrosive strictures. Methods The English or Hindi version of QLQ-OG 25 was administered to 31 adult patients undergoing outpatient esophageal dilation at GB Pant hospital, New Delhi. These patients had refractory or recurrent esophageal strictures due to corrosive ingestion and had not undergone reconstructive surgery. Score distribution was analyzed, and item performance was determined based on floor and ceiling effects. Convergent validity, discriminant validity, and internal consistency were checked. Results The average time to finish the questionnaire was 6.70 minutes. Most scales fulfilled convergent validity (corrected item-total correlation >0.4), barring the Odynophagia scale and one item of the Dysphagia scale. Most scales exhibited divergent validity except for odynophagia and one item of dysphagia. Cronbach's alpha was >0.70 for all scales except odynophagia. Responses to questions evaluating taste, cough, swallowing saliva, and talking were highly skewed and had prominent floor effects. Overall, the questionnaire demonstrated good internal consistency, convergent validity, and divergent validity in benign corrosive-induced refractory esophageal strictures patients. Conclusion The EORTC QLQ-OG 25 can be satisfactorily used in patients with benign esophageal strictures to assess health-related quality of life.
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Yasuda JL, Manfredi MA. Endoscopic Management of Congenital Esophageal Defects and Associated Comorbidities. Gastrointest Endosc Clin N Am 2023; 33:341-361. [PMID: 36948750 DOI: 10.1016/j.giec.2022.11.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/24/2023]
Abstract
The endoscopist plays a critical role in the management of patients with congenital esophageal defects. This review focuses on esophageal atresia and congenital esophageal strictures and, in particular, the endoscopic management of comorbidities related to these conditions, including anastomotic strictures, tracheoesophageal fistulas, esophageal perforations, and esophagitis surveillance. Practical aspects of endoscopic techniques for stricture management are reviewed including dilation, intralesional steroid injection, stenting, and endoscopic incisional therapy. Endoscopic surveillance for mucosal pathology is essential in this population, as patients are at high risk of esophagitis and its late complications such as Barrett's esophagus.
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Affiliation(s)
- Jessica L Yasuda
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Michael A Manfredi
- Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA 19104, USA.
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12
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Park JY, Park JM, Shin GY, Kim JS, Cho YK, Kim TH, Kim BW, Choi MG. Efficacy of bougie dilation for normal diet in benign esophageal stricture. Scand J Gastroenterol 2023; 58:199-207. [PMID: 35996943 DOI: 10.1080/00365521.2022.2111227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES Bougination is one of the first-line treatments in benign esophageal stricture (BES). The aim of the study was to identify clinical and endoscopic factors affecting the achievement of a normal diet with only bougie dilation in patients with BES. PATIENTS AND METHODS Patients treated with only bougination for BES at three hospitals were retrospectively investigated. Data including patient demographics, stricture and procedural characteristics were collected. Clinical success was defined as normal diet without additional procedures for two months after bougination. Clinical success rate and associated factors were assessed. RESULTS A total of 121 patients with BES were included. The most common cause of BES was post-operative stricture (n = 55). Finally, 43 (36%) patients were able to eat a normal diet with only bougination. Of these patients, 42 (97.7%) achieved clinical success in the first three sessions or less. Among causes of stenosis, corrosive injury had the lowest success rate (9/40, 22.5%). Clinical success rate was significantly higher for those with the length of stricture of less than 2 cm (47.2%), those with pre-procedural dysphagia of semi-solid or soft diet (51.3%) and those with dilation of 13 mm or more (46.1%). However, the duration of symptom, the number of previous endoscopic treatments and the location of stenosis were not related to clinical success. CONCLUSIONS Normal diet is possible in one-third of BES after bougination alone. Predictable factors for achieving a normal diet were less than four sessions of dilation, short length of stricture, pre-procedural dysphagia status and diameter of dilator.
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Affiliation(s)
- Jun Young Park
- Seoul St. Mary's Hospital, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jae Myung Park
- Seoul St. Mary's Hospital, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Ga-Yeong Shin
- Seoul St. Mary's Hospital, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Joon Sung Kim
- Inchoen St. Mary's Hospital, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Yu Kyung Cho
- Seoul St. Mary's Hospital, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Tae Ho Kim
- Bucheon St. Mary's Hospital, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Byung-Wook Kim
- Inchoen St. Mary's Hospital, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Myung-Gyu Choi
- Seoul St. Mary's Hospital, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
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13
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Li ZT, Kong XL, Zhang R, Yao JN, Li CX, Han XW, Wang ZG, Liu KD, Ji F. Laparoscopic antireflux surgery or PPIs in the management of reflux-related esophageal stricture. Surg Endosc 2023; 37:1077-1085. [PMID: 36109360 PMCID: PMC9944358 DOI: 10.1007/s00464-022-09564-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Accepted: 08/14/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND Gastroesophageal reflux disease (GERD) is often associated with esophageal stricture, particularly benign esophageal stricture. We aimed to evaluate the effects of balloon catheter dilation (BD) combined with laparoscopic fundoplication (LF) surgery and proton pump inhibitors (PPIs) in patients with reflux-induced esophageal strictures. METHODS We retrospectively analyzed 116 patients with reflux-induced benign esophageal strictures who underwent balloon dilatation therapy combined with PPIs (BD-PPIs group, n = 58) and balloon dilatation combined with LF (BD-LF group, n = 58). Patients were followed up for 24 months. The outcomes of the patients were monitored, including clinical success, symptom improvement, adverse events, and the frequency of esophagitis. RESULTS At the latest follow-up, the rate of clinical success was higher in BD-LF group than in BD-PPIs group (80.4% vs. 57.7%, P = 0.011). The patients in the BD-PPIs group required more dilation sessions to achieve successful dilation, as compared to those in the BD-LF group (2.1 ± 1.2 vs. 0.7 ± 0.8, P < 0.001). The DeMeester score, number of reflux episodes for which pH was < 4, and lower esophageal sphincter pressure were significantly better in the BD-LF group than in the BD-PPIs group (all P < 0.001). The incidence of reflux esophagitis was higher in the BD-PPIs group than in the BD-LF group, at 24 months (58.8% vs. 18.2%, P = 0.003). CONCLUSIONS Balloon dilatation with concomitant LF is effective and safe for esophageal stricture secondary to GERD. Moreover, antireflux surgery techniques, such as Nissen or Toupet procedure, should be added for reflux-induced benign esophageal stricture.
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Affiliation(s)
- Zhi-Tong Li
- Department of Gastroenterology, The First Affiliated Hospital, Zhengzhou University, No. 1, East Jian She Road, Zhengzhou, 450052, Henan Province, People's Republic of China
| | - Xiang-Lin Kong
- Shandong University of Traditional Chinese Medicine, No. 4655, University Road, Jinan, 250355, Shandong Province, People's Republic of China
| | - Rui Zhang
- Department of Respiratory and Critical Medicine, The First Affiliated Hospital, Zhengzhou University, No. 1, East Jian She Road, Zhengzhou, 450052, Henan Province, People's Republic of China
| | - Jian-Ning Yao
- Department of Gastroenterology, The First Affiliated Hospital, Zhengzhou University, No. 1, East Jian She Road, Zhengzhou, 450052, Henan Province, People's Republic of China
| | - Chun-Xia Li
- Department of Interventional Radiology, The First Affiliated Hospital, Zhengzhou University, No. 1, East Jian She Road, Zhengzhou, 450052, Henan Province, People's Republic of China
| | - Xin-Wei Han
- Department of Interventional Radiology, The First Affiliated Hospital, Zhengzhou University, No. 1, East Jian She Road, Zhengzhou, 450052, Henan Province, People's Republic of China
| | - Zhong-Gao Wang
- Department of Gastroenterology, The First Affiliated Hospital, Zhengzhou University, No. 1, East Jian She Road, Zhengzhou, 450052, Henan Province, People's Republic of China
| | - Kang-Dong Liu
- School of Basic Medical Science, Zhengzhou University, Zhengzhou, 450001, Henan Province, People's Republic of China
| | - Feng Ji
- Department of Gastroenterology, The First Affiliated Hospital, Zhengzhou University, No. 1, East Jian She Road, Zhengzhou, 450052, Henan Province, People's Republic of China.
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14
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Li B, Wang H, Liu J, Mu X, Xu F, Deng D, Qiao Y, Wang S, Chen F. Successful cervicothoracic esophageal stricture treatment with partial sternectomy and a pedicled TAAP flap: A case report. Front Surg 2023; 9:905241. [PMID: 36700029 PMCID: PMC9869483 DOI: 10.3389/fsurg.2022.905241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Accepted: 11/29/2022] [Indexed: 01/09/2023] Open
Abstract
Postoperative benign esophageal anastomotic leakage and stenosis are common complications after esophagectomy. Treatment options for anastomosis stenosis include endoscopic mechanical dilation, dilation-combined steroid injection, incisional therapy, stent placement, and self-bougienage. However, long-segmental cervicothoracic esophageal stenosis and cutaneous fistula are always refractory to conservative treatments and are clinically challenging. When lesions extend well below the thoracic inlet, transthoracic esophagectomy and alimentary canal reconstruction seem to be the common choice but are susceptible to perioperative mortality and donor-site sequelae, especially for patients with poor health conditions. In this report, we present a novel surgical approach for cervicothoracic esophageal stenosis and fistula via partial sternectomy and reconstruction with a pedicled thoracoacromial artery perforator flap. No recurrence or complications occurred throughout 3 months of follow-up. This case study adds new perspectives to the treatment of anastomotic stenosis.
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Affiliation(s)
- Baofei Li
- Department of Otolaryngology, Head and Neck Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Haiyang Wang
- Department of Otolaryngology, Head and Neck Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Jun Liu
- Department of Otolaryngology, Head and Neck Surgery, West China Hospital, Sichuan University, Chengdu, China,Correspondence: Fei Chen Jun Liu
| | - Xiaosong Mu
- Department of Otolaryngology, Head and Neck Surgery, Langzhong People's Hospital, Langzhong, China
| | - Feng Xu
- Department of Otolaryngology, Head and Neck Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Di Deng
- Department of Otolaryngology, Head and Neck Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Yixin Qiao
- Department of Otolaryngology, Head and Neck Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Shipin Wang
- Department of Otolaryngology, Head and Neck Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Fei Chen
- Department of Otolaryngology, Head and Neck Surgery, West China Hospital, Sichuan University, Chengdu, China,Correspondence: Fei Chen Jun Liu
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15
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Kim MJ, Ryu DG, Park SB, Choi CW, Kim HW, Kim SJ. Esophageal Stricture after Endoscopic Drainage of Esophageal Abscess as a Complication of Acute Phlegmonous Esophagitis: A Case Report. THE KOREAN JOURNAL OF GASTROENTEROLOGY = TAEHAN SOHWAGI HAKHOE CHI 2022; 80:262-266. [PMID: 36567439 DOI: 10.4166/kjg.2022.098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 08/21/2022] [Accepted: 08/25/2022] [Indexed: 12/27/2022]
Abstract
Esophageal abscess caused by acute phlegmonous esophagitis is rare but life-threatening. Rapid abscess drainage is an important part of the treatment, and endoscope-assisted intra-luminal abscess drainage is frequently performed. Although endoscopic drainage is less invasive than surgery, it has the potential to cause esophageal stricture as a complication. We present a rare case of esophageal stricture as a complication of intra-luminal drainage and evaluate a method to minimize the incidence of esophageal stricture complications.
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Affiliation(s)
- Min Ji Kim
- Department of Internal Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Dae Gon Ryu
- Department of Internal Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Su Bum Park
- Department of Internal Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Cheol Woong Choi
- Department of Internal Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Hyung Wook Kim
- Department of Internal Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Su Jin Kim
- Department of Internal Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
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16
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Bhat Balekuduru A, Sahu MK. A Simulation Study to Investigate the Usefulness of a Novel Stricture Tool for Training Wire Guided Balloon Dilation. JOURNAL OF DIGESTIVE ENDOSCOPY 2022. [DOI: 10.1055/s-0042-1751109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
Abstract
Abstract
Background and Aims The training in esophageal stricture dilation is difficult to obtain and have few simulation models. The aim of the study was to evaluate a novel stricture simulation for training a wire-guided, controlled radial expansile (CRE) balloon dilation.
Methods The study was a pretest–posttest design without a control group involving a novel simulation device for esophageal stricture. The training session involved 12 final year gastroenterology fellows from five different centers. The trainees received 2 hours of education sessions featuring didactic content, a live demonstration of step-by-step demonstration of wire-guided CRE balloon dilation and a study material on the procedure. The simulation device used was a single-use hose pipe along with a red color nonhardening modeling clay with a 5.0-to-8.0-mm hole in the center.
Results All the trainees and instructor uniformly rated the model as excellent or good with simulation device being mild stiffer in haptics than of the real tissue. The mean (%) pretest scores of 39 (21.6%) improved significantly to 160 (88.8%) in mean (%) posttest questionnaire (p < 0.05). There was a significant improvement in the questionnaire of the dilation procedure after the simulation training episode.
Conclusion The novel stricture simulation model had good performance evaluation and can be used to train CRE balloon dilation procedure.
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Affiliation(s)
- Avinash Bhat Balekuduru
- Department of Gastroenterology, Mathikere Sampangi Ramaiah Medical College, Bengaluru, Karnataka, India
| | - Manoj K. Sahu
- Department of Gastroenterology, Sum Hospitals, Bhubaneshwar, Orissa, India
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17
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Use of free jejunal flap as a salvage procedure in the management of high corrosive esophageal re-strictures: an institutional experience and review of literature. Langenbecks Arch Surg 2022; 407:2725-2732. [PMID: 35759020 DOI: 10.1007/s00423-022-02595-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 06/15/2022] [Indexed: 10/17/2022]
Abstract
BACKGROUND High pharyngo-esophageal strictures following corrosive ingestion continue to pose a challenge to the surgeon, particularly in the developing world. With the advancements and increased experience with microsurgical techniques, free jejunal flaps offer a viable reconstruction option in patients with high corrosive strictures with previous failed reconstruction. We review our experience with free jejunal flap in three cases with high pharyngo-esophageal stricture following corrosive ingestion, with previous failed reconstruction. MATERIALS AND METHODS A total of three patients underwent salvage free jejunal flap after failed reconstruction for high pharyngo-esophageal strictures following corrosive acid ingestion. All the three patients developed anastomotic leak and subsequent stricture, two following a pharyngo-gastric anastomosis and one following a pharyngo-colic anastomosis. The strictured segment was bridged using a free jejunal graft with microvascular anastomosis to the lingual artery and common facial vein. All patients were followed-up at regular intervals. RESULTS AND CONCLUSIONS The strictured pharyngeal anastomotic segment was successfully reconstructed with free jejunal flap in all the three patients. Patients were able to take food orally and maintain nutrition without the need of jejunostomy feeding. On long-term follow-up (median: 5 years), there was no recurrence of dysphagia and all the patients had good health-related quality of life.
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18
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Doğan S, Çakar E, Gürbulak B, Çolak Ş, Bektaş H, Tatar C. Endoscopic Procedures for Upper Gastrointestinal Tract Lesions and a Brief Review of Literature. ISTANBUL MEDICAL JOURNAL 2022. [DOI: 10.4274/imj.galenos.2022.27003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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19
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Daoud ND, Ghoz H, Mzaik O, Zaver HB, McKinney M, Brahmbhatt B, Woodward T. Endoscopic Management of Luminal Strictures: Beyond Dilation. Dig Dis Sci 2022; 67:1480-1499. [PMID: 35212884 DOI: 10.1007/s10620-022-07396-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/04/2022] [Indexed: 12/19/2022]
Abstract
Luminal strictures can occur as part of many different gastrointestinal (GI) disorders anywhere along the GI tract and affect all age groups. The end goal of managing any stricture is to re-establish an adequate and durable luminal patency that is sufficient to resolve the presenting clinical symptoms. Treatment options can be generally categorized into medical, endoscopic, and surgical. However, within each of these categories, multiple different options are available. Therefore, choosing the best treatment modality is often challenging and depends on multiple factors including the type, location, and complexity of the stricture, as well as the preference of the treating physician. In this article, we will review the most current literature regarding foregut strictures, particularly esophageal and gastric, beyond dilation.
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Affiliation(s)
- Nader D Daoud
- Division of Gastroenterology and Hepatology, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | - Hassan Ghoz
- Division of Gastroenterology and Hepatology, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | - Obaie Mzaik
- Division of Gastroenterology and Hepatology, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | - Himesh B Zaver
- Department of Internal Medicine, Mayo Clinic, Jacksonville, FL, USA
| | - Micah McKinney
- Division of Gastroenterology and Hepatology, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | - Bhaumik Brahmbhatt
- Division of Gastroenterology and Hepatology, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA.
| | - Timothy Woodward
- Division of Gastroenterology and Hepatology, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
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20
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Álvarez Delgado A, Pérez García ML. Managing esophageal strictures following endoscopic resection of superficial neoplastic lesions. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2021; 113:810-812. [PMID: 34818896 DOI: 10.17235/reed.2021.8437/2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Over the last few years early esophageal tumors, whether squamous-cell or associated with Barrett's esophagus, have been excised using endoscopic resection techniques, primarily endoscopic submucosal dissection (ESD). Esophageal surgery-associated morbidity and mortality are thus avoided with similar oncologic outcomes. ESD is not without complications, many of which arise and are endoscopically solved during the procedure itself (bleeding, perforation, etc.). Other complications develop within days or weeks after resection, these including mainly esophageal stricture. Esophageal strictures following ESD are initially managed with endoscopic balloon dilation (EBD). Preventive measures have been suggested to alleviate this complication, primarily by using local or systemic steroids in association with early dilation. Even so, not always may they be prevented. Such complications are called refractory strictures, which require either esophageal stents (in a majority of cases) or surgery.
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21
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Ukegjini K, Vetter D, Fehr R, Dirr V, Gubler C, Gutschow CA. Functional syndromes and symptom-orientated aftercare after esophagectomy. Langenbecks Arch Surg 2021; 406:2249-2261. [PMID: 34036407 PMCID: PMC8578083 DOI: 10.1007/s00423-021-02203-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Accepted: 05/16/2021] [Indexed: 01/02/2023]
Abstract
BACKGROUND Surgery is the cornerstone of esophageal cancer treatment but remains burdened with significant postoperative changes of gastrointestinal function and quality of life. PURPOSE The aim of this narrative review is to assess and summarize the current knowledge on postoperative functional syndromes and quality of life after esophagectomy for cancer, and to provide orientation for the reader in the challenging field of functional aftercare. CONCLUSIONS Post-esophagectomy syndromes include various conditions such as dysphagia, reflux, delayed gastric emptying, dumping syndrome, weight loss, and chronic diarrhea. Clinical pictures and individual expressions are highly variable and may be extremely distressing for those affected. Therefore, in addition to a mostly well-coordinated oncological follow-up, we strongly emphasize the need for regular monitoring of physical well-being and gastrointestinal function. The prerequisite for an effective functional aftercare covering the whole spectrum of postoperative syndromes is a comprehensive knowledge of the pathophysiological background. As functional conditions often require a complex diagnostic workup and long-term therapy, close interdisciplinary cooperation with radiologists, gastroenterologists, oncologists, and specialized nutritional counseling is imperative for successful management.
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Affiliation(s)
- Kristjan Ukegjini
- Department of Visceral and Transplant Surgery, University Hospital Zurich, Zurich, Switzerland
- Department of General, Visceral, Endocrine and Transplant Surgery, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Diana Vetter
- Department of Visceral and Transplant Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Rebecca Fehr
- Department of Endocrinology, Diabetology and Clinical Nutrition, University Hospital Zurich, Zurich, Switzerland
| | - Valerian Dirr
- Department of Visceral and Transplant Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Christoph Gubler
- Department of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Christian A Gutschow
- Department of Visceral and Transplant Surgery, University Hospital Zurich, Zurich, Switzerland.
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22
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Yalagachin G, Lakshmikantha N, Mashal SB. Roux-en-Y Gastrojejunostomy to a Gastric Pull-Up Transhiatal Esophagectomy for a Concurrent Esophageal and Duodenal Peptic Stricture—a Rare Case. Indian J Surg 2021. [DOI: 10.1007/s12262-020-02602-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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23
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Aho JM, La Francesca S, Olson SD, Triolo F, Bouchard J, Mondano L, Sundaram S, Roffidal C, Cox CS, Wong Kee Song LM, Said SM, Fodor W, Wigle DA. First-in-Human Segmental Esophageal Reconstruction Using a Bioengineered Mesenchymal Stromal Cell-Seeded Implant. JTO Clin Res Rep 2021; 2:100216. [PMID: 34590055 PMCID: PMC8474397 DOI: 10.1016/j.jtocrr.2021.100216] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 08/01/2021] [Accepted: 08/04/2021] [Indexed: 12/27/2022] Open
Abstract
Introduction Resection and reconstruction of the esophagus remains fraught with morbidity and mortality. Recently, data from a porcine reconstruction model revealed that segmental esophageal reconstruction using an autologous mesenchymal stromal cell-seeded polyurethane graft (Cellspan esophageal implant [CEI]) can facilitate esophageal regrowth and regeneration. To this end, a patient requiring a full circumferential esophageal segmental reconstruction after a complex multiorgan tumor resection was approved for an investigational treatment under the Food and Drug Administration Expanded Access Use (Investigational New Drug 17402). Methods Autologous adipose-derived mesenchymal stromal cells (Ad-MSCs) were isolated from the Emergency Investigational New Drug patient approximately 4 weeks before surgery from an adipose tissue biopsy specimen. The Ad-MSCs were grown and expanded under current Good Manufacturing Practice manufacturing conditions. The cells were then seeded onto a polyurethane fiber mesh scaffold (Cellspan scaffold) and cultured in a custom bioreactor to manufacture the final CEI graft. The cell-seeded scaffold was then shipped to the surgical site for surgical implantation. After removal of a tumor mass and a full circumferential 4 cm segment of the esophagus that was invaded by the tumor, the CEI was implanted by suturing the tubular CEI graft to both ends of the remaining native esophagus using end-to-end anastomosis. Results In this case report, we found that a clinical-grade, tissue-engineered esophageal graft can be used for segmental esophageal reconstruction in a human patient. This report reveals that the graft supports regeneration of the esophageal conduit. Histologic analysis of the tissue postmortem, 7.5 months after the implantation procedure, revealed complete luminal epithelialization and partial esophageal tissue regeneration. Conclusions Autologous Ad-MSC seeded onto a tubular CEI tissue-engineered graft stimulates tissue regeneration following implantation after a full circumferential esophageal resection.
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Affiliation(s)
- Johnathon M Aho
- Division of General Thoracic Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota.,Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, Minnesota
| | | | - Scott D Olson
- Department of Pediatric Surgery, McGovern Medical School, UTHealth, The University of Texas Health Science Center, Houston, Texas
| | - Fabio Triolo
- Department of Pediatric Surgery, McGovern Medical School, UTHealth, The University of Texas Health Science Center, Houston, Texas
| | | | | | | | | | - Charles S Cox
- Department of Pediatric Surgery, McGovern Medical School, UTHealth, The University of Texas Health Science Center, Houston, Texas
| | | | - Sameh M Said
- Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | | | - Dennis A Wigle
- Division of General Thoracic Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota.,Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, Minnesota
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24
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Wang S, Yin M, Wang M, Tong Y, Zhao Y, Ma Y, Li X, Xie P, Wu G. Safety and efficacy of large balloon dilatation under fluoroscopy. Ann N Y Acad Sci 2021; 1503:102-109. [PMID: 34533853 DOI: 10.1111/nyas.14682] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 08/03/2021] [Accepted: 08/11/2021] [Indexed: 12/16/2022]
Abstract
The maximum diameter of the balloon used for balloon dilatation(BD) of esophagogastric anastomotic stricture (EAS) is generally 20 millimeters. This study aimed to evaluate the safety and efficacy of BD under fluoroscopy, using balloons with a diameter of 25-30 millimeters. We retrospectively analyzed the data of patients with benign EAS treated by large BD (balloon diameter, 25-30 mm) under fluoroscopy. The Cox proportional hazards model (PHM) was used to identify the factors associated with stricture-free survival. The results show that a total of 127 patients were included in this study, and 204 BDs were performed. The technical success rate was 96.6%, and the clinical success rate was 99.2%. The incidence of serious adverse events was 3.4% (7/204). One patient died of massive hemorrhage during BD, and nine patients were lost to follow-up. For the remaining 117 patients, the median stricture-free survival period was 14.9 months. In multivariable analysis using the Cox PHM, only balloon diameter was significantly associated with stricture-free survival. The stricture-free survival period tended to increase as balloon diameter increased. Large BD under fluoroscopy appears to be safe and effective for the treatment of benign EAS after esophagectomy.
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Affiliation(s)
- Shuai Wang
- Department of Interventional Radiology, the First Affiliated Hospital of Zhengzhou University, Henan, China
| | - Meipan Yin
- Department of Interventional Radiology, the First Affiliated Hospital of Zhengzhou University, Henan, China
| | - Meng Wang
- Department of GI Medicine, the First Affiliated Hospital of Zhengzhou University, Henan, China
| | - Yalin Tong
- Department of GI Medicine, the First Affiliated Hospital of Zhengzhou University, Henan, China
| | - Yue Zhao
- Department of Interventional Radiology, the First Affiliated Hospital of Zhengzhou University, Henan, China
| | - Yaozhen Ma
- Department of Interventional Radiology, the First Affiliated Hospital of Zhengzhou University, Henan, China
| | - Xiaobing Li
- Department of Interventional Radiology, the First Affiliated Hospital of Zhengzhou University, Henan, China
| | - Pengfei Xie
- Department of Interventional Radiology, the First Affiliated Hospital of Zhengzhou University, Henan, China
| | - Gang Wu
- Department of Interventional Radiology, the First Affiliated Hospital of Zhengzhou University, Henan, China
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Pérez-Cuadrado Robles E, Moreels TG, Piessevaux H, Yeung R, Aouattah T, Deprez PH. Risk factors of refractory post-endoscopic submucosal dissection esophageal strictures. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2021; 113:813-819. [PMID: 34517715 DOI: 10.17235/reed.2021.8061/2021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
INTRODUCTION To comparatively assess the treatment outcomes of endoscopic dilatation in Barrett's neoplasia and squamous cell carcinoma (SCC) post- endoscopic submucosal dissection (ESD) strictures and to determine the risk or factors associated to refractory strictures Methods: Observational study. All consecutive patients presenting with a post-ESD stricture in 2007-2016 who underwent dilation therapy were included. Clinical, morphological and technical features were assessed to determine the risk factors of refractory strictures. RESULTS Of 414 consecutive patients treated by ESD, 83 (mean age: 65±10 years, 76% men) with 254 dilations (median: 3, range: 1-27) were considered. Barrett's neoplasia and SCC were the indications in 58 (69.9%) in 25 (30.1%) cases. Clinical success was achieved in 84.3% with a median of 3 sessions (range: 1-22). Circumferential resection in one-single procedure (13.2%) was associated to the need for a higher number of dilation sessions. By multivariable analysis, upper-esophageal location (OR: 11.479 [95%CI: 2.058-64.043], p=0.005), recurrent strictures (OR: 17.252 [95%CI: 2.833-105.069], p=0.002), and dilation-related complications (OR: 26.420 [95%CI: 1.736-401.966], p=0.018) were risk factors of refractory stenosis. CONCLUSION Preventive strategies, concomitant treatment, and careful dilatation protocols should be considered and undertaken in patients presenting with SCC located in the upper superior esophagus, intra-procedural perforation, and recurrent strictures.
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Affiliation(s)
| | - Tom G Moreels
- Hepato-Gastroenterology, Cliniques Universitaires Saint-Luc
| | | | - Ralph Yeung
- Hepato-Gastroenterology, Cliniques Universitaires Saint-Luc
| | - Tarik Aouattah
- Hepato-Gastroenterology, Cliniques Universitaires Saint-Luc
| | - Pierre H Deprez
- Hepato-Gastroenterology, Cliniques Universitaires Saint-Luc, Belgium
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Spaulding SL, Ansari E, Xing MH, Sandler ML, O'Malley QF, Ho R, Spitzer H, Levy J, Ganz C, Khorsandi AS, Mundi N, Urken ML. Diagnosis and management of pharyngoesophageal stenosis: A comprehensive approach to prophylactic, endoscopic, and reconstructive treatment options. Am J Otolaryngol 2021; 42:103003. [PMID: 33894689 DOI: 10.1016/j.amjoto.2021.103003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 03/15/2021] [Indexed: 12/30/2022]
Abstract
BACKGROUND Pharyngoesophageal stenosis (PES) is a serious complication that substantially impacts functional outcomes and quality of life (QOL) for up to a third of head and neck cancer patients who undergo radiotherapy. Dysphagia is often multifactorial in nature and is a devastating complication of treatment that impacts patients' QOL, general health and overall wellbeing. The authors detail the clinical presentation, risk factors, imaging characteristics, preventive measures, and multimodality treatment options for PES. METHODS The authors present a comprehensive management algorithm for PES, including treatment by dilation, stenting, spray cryotherapy and dilation, and reconstructive treatment options utilizing different pedicled and free flaps. RESULTS The authors advocate for a thorough assessment of the extent and degree of pharyngoesophageal involvement of PES to determine the optimal management strategy. CONCLUSIONS The development of post treatment dysphagia requires appropriate imaging and biopsy, when indicated, to rule out the presence of persistent/recurrent cancer. Multidisciplinary management by a team of physicians well-versed in the range of diagnostic and therapeutic interventions available for PES is critical to its successful management.
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Affiliation(s)
- Sarah L Spaulding
- The Thyroid, Head, and Neck Cancer (THANC) Foundation, New York, NY 10003, United States of America
| | - Edward Ansari
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, NY 10003, United States of America
| | - Monica H Xing
- The Thyroid, Head, and Neck Cancer (THANC) Foundation, New York, NY 10003, United States of America.
| | - Mykayla L Sandler
- The Thyroid, Head, and Neck Cancer (THANC) Foundation, New York, NY 10003, United States of America
| | - Quinn F O'Malley
- The Thyroid, Head, and Neck Cancer (THANC) Foundation, New York, NY 10003, United States of America
| | - Rebecca Ho
- The Thyroid, Head, and Neck Cancer (THANC) Foundation, New York, NY 10003, United States of America
| | - Hannah Spitzer
- The Thyroid, Head, and Neck Cancer (THANC) Foundation, New York, NY 10003, United States of America
| | - Juliana Levy
- The Thyroid, Head, and Neck Cancer (THANC) Foundation, New York, NY 10003, United States of America
| | - Cindy Ganz
- The Thyroid, Head, and Neck Cancer (THANC) Foundation, New York, NY 10003, United States of America
| | - Azita S Khorsandi
- Department of Radiology, New York Eye and Ear Infirmary, New York, NY 10003, United States of America
| | - Neil Mundi
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, NY 10003, United States of America
| | - Mark L Urken
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, NY 10003, United States of America
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Gankov VA, Andreasyan AR, Maslikova SA, Bagdasaryan GI, Shestakov DY. THERAPEUTIC TACTICS FOR PEPTIC STRICTURES OF THE ESOPHAGUS. LITERATURE REVIEW. SURGICAL PRACTICE 2021. [DOI: 10.38181/2223-2427-2021-2-14-24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The work is based on the analysis of literature data devoted to the choice of treatment for peptic esophageal strictures. The main goal of this review is to identify treatment tactics for patients with stenosing reflux esophagitis. Researchers point out that the main causes of GERD are a decrease in pressure in the lower esophageal sphincter, the action of the damaging properties of the refluctant. Untimely treatment of GERD can lead to complications such as peptic stricture, Barrett's esophagus. The appearance of GERD stricture is most often promoted by: persistent heartburn after bougienage, erosion of the lower third of the esophagus, shortening of the II degree esophagus, and inadequate antisecretory therapy.Various methods of treatment at all stages of the appearance of peptic stricture are presented, depending on the degree of dysphagia and the length of the stricture, the use of adequate conservative therapy regimens for PPIs, bougienage, as well as a description of various methods of antireflux operations. Endoscopic dilation is the first treatment option for all symptomatic benign esophageal strictures. There are treatments for benign refractory esophageal strictures such as endoscopic dilatation with intraluminal steroid injection, endoscopic postoperative therapy or stricturoplasty, esophageal stenting, self-bougienage, as well as surgery - antireflux surgery, esophagectomy with replacement of the esophagus by the stomach or colon [1].The main goal in the treatment of peptic esophageal strictures, according to most authors, is to eliminate the progression of GERD, conduct bougienage or balloon dilatation, and select the optimal antireflux surgery. Treatment for peptic strictures should minimize the risk of re-stricture of the esophagus.
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Alwan M, Giddings CE. Self-dilatation of benign oesophageal strictures: a literature review. ANZ J Surg 2021; 91:1385-1389. [PMID: 33956382 DOI: 10.1111/ans.16775] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 03/02/2021] [Accepted: 03/07/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Benign oesophageal strictures can have several aetiologies and often require serial endoscopic dilatation. The aim of this study was to review the existing literature regarding the efficacy of self-dilatation for benign oesophageal strictures. METHODS This study presents the results of a systematic review that was performed on the available literature using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Full-text articles from Medline, PubMed and Embase were used, as well as associated reference lists. This study systematically reviews the literature to present the efficacy and different outcome measurements associated with self-dilatation of benign oesophageal strictures. RESULTS This study identified 13 articles with 274 participants. CONCLUSION Self-dilatation for refractory benign oesophageal strictures is effective regardless of aetiology. It is well tolerated, safe and leads to lasting symptom resolution in the majority of patients.
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Affiliation(s)
- Mostafa Alwan
- Department of Otolaryngology Head & Neck Surgery, Monash Health, Melbourne, Victoria, Australia
| | - Charles E Giddings
- Department of Surgery, Monash University, Melbourne, Victoria, Australia
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Stauffer CM, Kulkarni M. Perforated Gastric Body Secondary to Migrated Esophageal Stent. Cureus 2021; 13:e14314. [PMID: 33968524 PMCID: PMC8101529 DOI: 10.7759/cureus.14314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
A 44-year-old male presented to the ER with severe abdominal pain and a reported syncope episode. Focused abdominal sonography in trauma and abdominal exam demonstrated free fluid and peritonitis. CT scan demonstrated a metallic object in the stomach with free air and fluid throughout the abdomen. The following report is a rare case presentation of a perforated stomach secondary to a migrated esophageal stent used for the treatment of a benign esophageal stricture refractory to other treatment modalities.
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Affiliation(s)
| | - Mohan Kulkarni
- Thoracic Surgery, Henry Ford Health System, Jackson, USA
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30
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Sandhu S, Wang T, Prajapati D. Acute esophageal necrosis complicated by refractory stricture formation. JGH Open 2021; 5:528-530. [PMID: 33869789 PMCID: PMC8035479 DOI: 10.1002/jgh3.12520] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 02/21/2021] [Accepted: 02/22/2021] [Indexed: 01/09/2023]
Abstract
Acute esophageal necrosis (AEN) is a rare presentation of severe esophageal injury. The optimal long‐term management of complications related to AEN, particularly stricture formation, are not well defined. We report a case of AEN in a patient who presented with diabetic ketoacidosis (DKA) and had dysphagia due to refractory stricture formation after mucosal healing occurred. A 62‐year‐old male with diabetes mellitus presented with altered mental status. He was admitted for hypovolemic shock secondary to DKA and treated with vasopressors, fluid resuscitation, and insulin. After resolution of DKA, he reported persistent dysphagia. Upper endoscopy showed circumferential black mucosal discoloration throughout the entire esophagus that spared the gastroesophageal junction. He was diagnosed with AEN and was continued on a proton pump inhibitor and sucralfate with improvement in symptoms. Repeat endoscopy 4 weeks later showed a 10‐cm benign‐appearing stricture in the mid esophagus. He underwent dilation with temporary symptomatic relief; however, recurrence in symptoms has thus far necessitated a total of 10 repeat upper endoscopies, including repeat dilations along with local steroid injection therapy. AEN is a rare presentation of severe esophageal injury and is typically associated with severe hemodynamic compromise. Although most cases resolve with supportive care and mucosal healing, there is little information regarding prognosis and optimal management of complications, such as refractory esophageal strictures. We describe a case of AEN complicated by refractory symptomatic esophageal stricture despite several dilations and intralesional steroid injections and discuss our approach to treatment.
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Affiliation(s)
- Sunny Sandhu
- Department of Internal Medicine University of California Fresno California USA
| | - Timothy Wang
- Department of Gastroenterology and Hepatology University of California Fresno California USA
| | - Devang Prajapati
- Department of Gastroenterology and Hepatology University of California Fresno California USA
- Department of Gastroenterology and Hepatology VA Central California Healthcare System Fresno California USA
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31
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Endoscopic Management of Refractory Benign Esophageal Strictures. Dysphagia 2021; 36:504-516. [PMID: 33710389 DOI: 10.1007/s00455-021-10270-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Accepted: 02/13/2021] [Indexed: 12/13/2022]
Abstract
Benign esophageal strictures are commonly encountered in clinical practice. The principal etiologies of benign esophageal strictures include long term acid reflux, caustic injuries, eosinophilic esophagitis, anastomotic strictures or endoscopic therapy. Dysphagia is most prominently present in esophageal strictures along with a variety of other symptoms which depend on the stricture etiology. Benign esophageal strictures can be categorized into two groups: simple or complex depending on their structure. Most strictures can be treated successfully with endoscopic dilation by bougies or balloons dilators. In some cases, treatment is more challenging, involving a higher risk of the patient developing recurrent or refractory strictures. To improve symptoms in these patients, other endoscopic treatments such as steroid injection, incisional therapy and stent placement should be considered. In this manuscript, we provide a comprehensive review of the main treatment options currently available to manage recurrent benign esophageal strictures.
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Debourdeau A, Barthet M, Benezech A, Vitton V, Gonzalez JM. Assessment of long-term results of repeated dilations and impact of a scheduled program of dilations for refractory esophageal strictures: a retrospective case-control study. Surg Endosc 2021; 36:1098-1105. [PMID: 33650008 DOI: 10.1007/s00464-021-08376-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 02/09/2021] [Indexed: 01/10/2023]
Abstract
INTRODUCTION In patients with benign and refractory esophageal strictures (BES), repeating initial dilations in short intervals could be recommended, but little data are available to validate this strategy. Our aim was to evaluate long-term results of a scheduled program of repeated and sustained esophageal dilations in patients with refractory strictures. METHODS Patients with BES requiring five or more dilations were retrospectively included and divided in two groups for analysis: a SCHEDULED group (SDG) where patients were systematically rescheduled for the 5 first dilations; ON-DEMAND group (ODG) where patients were dilated only in case of recurrence of the dysphagia. Comparison between SDG and ODG was done with a 1:1 matching analysis and etiology of stricture. Clinical success was defined as the absence of dysphagia for more than a year. RESULTS 39 patients with refractory BES were included with post-operative stenosis in 51.2% and post-caustic injury 28.2%; 10 were in SDG and 29 in ODG. In overall analysis (39 patients), the follow-up was 64.4 ± 32 months, success rate was 79.5% and duration of treatment was 27.3 ± 20 months, and mean number of dilations was 11.7 per patient. The need for dilations decreased significantly after 18 months of treatment with an average of 0.56 dilations per semester. Self-expandable metallic stent insertion was associated with an increased rate of complications (5.9% vs 59.1% p = 0.001). In matched analysis (10 ODG vs 10 SDG patients), the duration of treatment was lower in SDG (18.8 vs 41.4 months, p = 0,032) with a higher probability of remission (survival analysis, Log-rank: p = 0,019) and the success rate did not differ between ODG and SDG patients (80% vs 90%; NS). CONCLUSION Overall, long-term esophageal dilations resulted in a 79.5% success rate and the need for further dilatations decreased significantly in both groups after 18-month follow-up. A scheduled dilation program was associated with a higher probability of final success and lower treatment duration.
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Affiliation(s)
- Antoine Debourdeau
- Endoscopy Unit, CHU Saint Eloi, Université de Montpellier, 80 avenue Gaston Fliche, 34090, Montpellier, France.
| | - Marc Barthet
- Digestive Endoscopy Unit, North Universitary Hospital, Marseille, France
| | | | - Véronique Vitton
- Gastroenterology Unit, North Universitary Hospital, AP-HM, Marseille, France
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Boregowda U, Goyal H, Mann R, Gajendran M, Patel S, Echavarria J, Sayana H, Saligram S. Endoscopic management of benign recalcitrant esophageal strictures. Ann Gastroenterol 2021; 34:287-299. [PMID: 33948052 PMCID: PMC8079876 DOI: 10.20524/aog.2021.0585] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 11/02/2020] [Indexed: 11/25/2022] Open
Abstract
Benign esophageal strictures are one of the common clinical conditions managed by endoscopists. Nearly 90% of the benign esophageal strictures respond to endoscopic dilation. However, a small percentage of patients progress to recalcitrant strictures. The benign recalcitrant esophageal strictures are difficult to manage both medically and endoscopically as they do not respond to conventional treatment with proton pump inhibitors and esophageal dilations. Patients with benign recalcitrant esophageal strictures are at a high risk of developing debilitating malnutrition and morbidity due to severe dysphagia. This condition is associated with psychological trauma to patients as treatments are usually prolonged with poor outcomes. Also, this can be a financial burden on the healthcare industry due to several sessions of treatment. In this article, we discuss the classification of benign esophageal strictures, evidence-based treatment strategies, endoscopic procedural techniques, and complications of endoscopic interventions. We aim to guide providers in managing benign esophageal strictures with a focus on endoscopic management of benign recalcitrant esophageal strictures.
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Affiliation(s)
- Umesha Boregowda
- Department of Internal Medicine, Bassett Medical Center, Cooperstown, NY (Umesha Boregowda)
| | - Hemant Goyal
- Department of Medicine, The Wright Center for Graduation Medical Center, Scranton, PA (Hemant Goyal)
| | - Rupinder Mann
- Department of Internal Medicine, Saint Agnes Medical Center, Fresno, CA (Rupinder Mann)
| | - Mahesh Gajendran
- Department of Internal Medicine, Texas Tech University Health Sciences Center, El Paso, TX (Mahesh Gajendran)
| | - Sandeep Patel
- Division of Gastroenterology, University of Texas Health, San Antonio, TX (Sandeep Patel, Juan Echavarria, Hari Sayana, Shreyas Saligram), USA
| | - Juan Echavarria
- Division of Gastroenterology, University of Texas Health, San Antonio, TX (Sandeep Patel, Juan Echavarria, Hari Sayana, Shreyas Saligram), USA
| | - Hari Sayana
- Division of Gastroenterology, University of Texas Health, San Antonio, TX (Sandeep Patel, Juan Echavarria, Hari Sayana, Shreyas Saligram), USA
| | - Shreyas Saligram
- Division of Gastroenterology, University of Texas Health, San Antonio, TX (Sandeep Patel, Juan Echavarria, Hari Sayana, Shreyas Saligram), USA
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Self-Expanding Metal Stent (SEMS) Placement to Treat Bleeding from Late Radiation Esophagitis. Case Rep Gastrointest Med 2021. [DOI: 10.1155/2021/6678139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Radiation esophagitis is a serious complication occurring in patients receiving radiotherapy for head and neck cancers. Current treatment with proton pump inhibitors and mucosal protectants provides symptomatic relief with few studies showing improvement in erosive esophagitis or ulceration. Use of self-expandable metal stents (SEMS) in cases of erosive radiation esophagitis refractory to medical therapy has not been studied. We report a case of a patient presenting with recurrent hematemesis from late (chronic) radiation esophagitis with bleeding esophageal ulceration successfully treated with SEMS placement after failure of conservative medical management, proposing a possible utility for SEMS in this setting.
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Kurtz M, Paulin MV, Fournet A, Decambron A, Fabrès V, Freiche V. Surgical treatment of a distal oesophageal stricture by mucosal radial incision and dilation in a kitten with secondary megaoesophagus. JFMS Open Rep 2021; 7:2055116921994516. [PMID: 34104462 PMCID: PMC8168026 DOI: 10.1177/2055116921994516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
CASE SUMMARY A 7-month-old intact female Maine Coon cat was presented with a 2-month history of regurgitations. Contrast radiographic and endoscopic examinations revealed a diffuse megaoesophagus secondary to a severe lower oesophageal stricture. An epiphrenic diverticulum was noted. Endoscopic balloon dilation was unsuccessful. Gastrotomy was thus performed in order to incise the oesophageal wall radially along the stricture site, and then to dilate the stricture. A diameter of 20 mm was reached. With the aim of preventing stricture recurrence, submucosal injections of triamcinolone acetonide were performed. An 18 Fr oesophagogastric feeding tube was placed and a left gastropexy was performed in order to exert some traction on the gastroesophageal junction, with the aim of reducing the oesophageal diverticulum. Twelve months postoperatively, clinical signs had completely resolved and follow-up radiographs revealed marked improvement of the oesophageal dilatation. RELEVANCE AND NOVEL INFORMATION Lower oesophageal strictures should be considered when evaluating regurgitations or megaoesophagus in a kitten. Surgical mucosal radial incision is a therapeutic option in cases of lower oesophageal stricture refractory to balloon dilation, and can lead to a marked improvement of clinical signs and of the oesophagus diameter leading to clinical success.
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Affiliation(s)
- Maxime Kurtz
- Internal Medicine Department, National Veterinary School of Alfort, Maisons-Alfort, France
| | - Mathieu V Paulin
- Internal Medicine Department, National Veterinary School of Alfort, Maisons-Alfort, France
| | - Alexandre Fournet
- Surgery Department, National Veterinary School of Alfort, Maisons-Alfort, France
| | - Adeline Decambron
- Surgery Department, National Veterinary School of Alfort, Maisons-Alfort, France
| | - Virginie Fabrès
- Internal Medicine Department, National Veterinary School of Alfort, Maisons-Alfort, France
| | - Valérie Freiche
- Internal Medicine Department, National Veterinary School of Alfort, Maisons-Alfort, France
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Jensen T, Wanczyk H, Thaker S, Finck C. Characterization of mesenchymal stem cells in patients with esophageal atresia. J Pediatr Surg 2021; 56:17-25. [PMID: 33121738 DOI: 10.1016/j.jpedsurg.2020.09.039] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 09/14/2020] [Accepted: 09/15/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Preclinical studies demonstrate that tissue engineering and patient-derived stem cells can regenerate tissue. The goal of this study was to determine whether stem cells from esophageal atresia patients (EA) could be utilized for this purpose. METHODS Adipose tissue was obtained from control, esophageal atresia (EA) and long gap esophageal atresia (LGEA) patients. Mesenchymal stem cells (MSCs) were isolated, expanded, characterized and seeded onto tubular scaffolds for 6 days. Scaffolds were characterized for viability, gene expression and cytokine production. RESULTS The average weight of tissue from the EA and LGEA patients was 145.8mg compared to 2981 mg in controls. Despite the small amount of tissue obtained from neonatal patients, cells were expanded to cover a scaffold. After incubating 6 days on the scaffold, cells were viable and proliferating with differences in gene expression between groups. VEGFA production in the supernatant was increased in EA and LGEA patients; while IL6 production was significantly increased in the control patients. CONCLUSIONS This study demonstrates the ability to utilize small amounts of adipose tissue from esophageal atresia patients as a cell source for regenerative medicine. Future studies will focus on use of these cells for tissue regeneration in vivo.
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Affiliation(s)
- Todd Jensen
- University of Connecticut School of Medicine, Department of Pediatrics, Farmington, CT.
| | - Heather Wanczyk
- University of Connecticut School of Medicine, Department of Pediatrics, Farmington, CT
| | | | - Christine Finck
- University of Connecticut School of Medicine, Department of Pediatrics, Farmington, CT; CT Children's, Department of Pediatric Surgery, Hartford, CT.
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Mullen MB, Witt MA, Stromberg AJ, Fritz MA. National Database Outcomes of Esophageal Dilations. Laryngoscope 2020; 131:2436-2440. [PMID: 33305828 DOI: 10.1002/lary.29322] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Revised: 11/26/2020] [Accepted: 12/02/2020] [Indexed: 11/08/2022]
Abstract
OBJECTIVES/HYPOTHESIS To better assess rates of postoperative complications and mortality following esophageal dilation, and to identify factors associated with adverse outcomes. STUDY DESIGN Observational, retrospective cohort study. METHODS We queried a national database of insurance claims for Current Procedural Terminology (CPT) codes representing esophageal dilation performed between 2011 and 2017. Patients aged 18 to 100 who were continuously enrolled with their insurance provider were included. Demographic information, additional CPT codes, concomitant diagnoses, and anticoagulant medication data were collected for all patients included. Postoperative mortality was assessed and International Classification of Diseases (ICD)9/10 codes for complications, including esophageal perforation, hemorrhage, mediastinitis, and sepsis were flagged. RESULTS We identified 202,965 encounters for esophageal dilation. Of these procedures, 193 were performed on a patient who underwent percutaneous endoscopic gastrostomy (PEG) during the study period and was analyzed separately. Another 244 dilations were excluded due to repeat entries. Of the remaining 202,528 procedures remaining, 42,310 were repeat dilations in the same patient. Data analysis was confined to each patient's initial dilation. 160,218 initial dilations remained. Of these, 62,107 were performed on male patients and 98,111 were performed on female patients. The average age was 57.7 years. There were 12 mortalities within 30 days postoperatively, representing 0.0075% of all dilations. Esophageal perforation and esophageal hemorrhage were the most common reported complications, with 139 and 110 occurrences, respectively. The overall per-dilation complication rate was 0.215%. CONCLUSIONS Evidence from a national insurance claim database suggests that esophageal dilation is a safe procedure with a low rate of serious complications and a 30-day all-cause mortality rate of less than 1 per 10,000 dilations. LEVEL OF EVIDENCE IV Laryngoscope, 2020.
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Affiliation(s)
- Michael B Mullen
- Department of Otolaryngology - Head and Neck Surgery, University of Kentucky, Lexington, Kentucky, U.S.A
| | - Michael Andrew Witt
- Department of Otolaryngology - Head and Neck Surgery, University of Kentucky, Lexington, Kentucky, U.S.A
| | - Arnold J Stromberg
- Department of Statistics, University of Kentucky, Lexington, Kentucky, U.S.A
| | - Mark A Fritz
- Department of Otolaryngology - Head and Neck Surgery, University of Kentucky, Lexington, Kentucky, U.S.A
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Baboudjian M, Rouy M, Gasmi M, Tadrist A, Thomas P, Barthet M, D'Journo XB. Endoscopic rendezvous recanalization for complete anastomotic obstruction after retrosternal coloplasty: a novel approach through a cervicotomy. Endoscopy 2020; 52:E428-E429. [PMID: 32375185 DOI: 10.1055/a-1158-8682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Affiliation(s)
- Michael Baboudjian
- Department of Thoracic Surgery, North Hospital, Aix-Marseille University, APHM, Marseille, France
| | - Mathieu Rouy
- Department of Thoracic Surgery, North Hospital, Aix-Marseille University, APHM, Marseille, France
| | - Mohamed Gasmi
- Department of Hepatogastroenterology, North Hospital, Aix-Marseille University, APHM, Marseille, France
| | - Abel Tadrist
- Department of Thoracic Surgery, North Hospital, Aix-Marseille University, APHM, Marseille, France
| | - Pascal Thomas
- Department of Thoracic Surgery, North Hospital, Aix-Marseille University, APHM, Marseille, France
| | - Marc Barthet
- Department of Hepatogastroenterology, North Hospital, Aix-Marseille University, APHM, Marseille, France
| | - Xavier Benoît D'Journo
- Department of Thoracic Surgery, North Hospital, Aix-Marseille University, APHM, Marseille, France
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Chan MQ, Balasubramanian G, Modi RM, Papachristou GI, Strobel SG, Groce JR, Hinton A, Krishna SG. Changing epidemiology of esophageal stent placement for dysphagia: a decade of trends and the impact of benign indications. Gastrointest Endosc 2020; 92:56-64.e7. [PMID: 32105711 DOI: 10.1016/j.gie.2020.02.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Accepted: 02/08/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS In addition to managing malignant obstruction, esophageal stents (ESs) have evolved to address various benign etiologies of dysphagia. We sought to evaluate national trends and changes in practice of ES placement for both benign and malignant etiologies in hospitalized patients with dysphagia. METHODS The National Inpatient Sample (2003-2013) was used to include all adult inpatients (≥18 years of age) with endoscopy-guided ES placement for a symptom of dysphagia. Multivariable analyses for indications that impact temporal trends (3 time periods: 2003-2005, 2006-2009, and 2010-2013) and for hospital outcomes were performed. RESULTS A total of 7198 ESs were deployed endoscopically in hospitalized patients with dysphagia. Compared with malignant etiologies, there was a significant increase in ES placement for benign conditions (2013 vs 2003: 32.7% vs 14.5%, respectively; P < .001). Multivariable analysis using 2003 to 2005 as a reference showed that patients with benign etiologies for dysphagia predominantly contributed to the increase of ES placement during the most recent time period (2010-2013: odds ratio, 2.09; 95% confidence interval, 1.40-3.13). Multivariable analysis of hospital outcomes revealed no differences in inpatient mortality, duration of hospital stay, and hospital costs between malignant and benign indications. CONCLUSIONS In the preceding decade, ES placement for hospitalized patients with dysphagia has increased, driven largely by an over 8-fold rise in stent placement for benign indications. These findings warrant continued efforts to improve stent technology to decrease the risk of migration and review practice guidelines involving ES placement for benign etiologies.
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Affiliation(s)
- Megan Q Chan
- Division of Gastroenterology, Hepatology, and Nutrition, Wexner Medical Center, The Ohio State University, Columbus, Ohio, USA
| | - Gokulakishnan Balasubramanian
- Division of Gastroenterology, Hepatology, and Nutrition, Wexner Medical Center, The Ohio State University, Columbus, Ohio, USA
| | - Rohan M Modi
- Division of Gastroenterology, Hepatology, and Nutrition, University of Virginia, Charlottesville, Virginia, USA
| | - Georgios I Papachristou
- Division of Gastroenterology, Hepatology, and Nutrition, Wexner Medical Center, The Ohio State University, Columbus, Ohio, USA
| | - Sebastian G Strobel
- Division of Gastroenterology, Hepatology, and Nutrition, Wexner Medical Center, The Ohio State University, Columbus, Ohio, USA
| | - Jeffery R Groce
- Division of Gastroenterology, Hepatology, and Nutrition, Wexner Medical Center, The Ohio State University, Columbus, Ohio, USA
| | - Alice Hinton
- Division of Biostatistics, College of Public Health, The Ohio State University, Columbus, Ohio, USA
| | - Somashekar G Krishna
- Division of Gastroenterology, Hepatology, and Nutrition, Wexner Medical Center, The Ohio State University, Columbus, Ohio, USA
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Vermeulen BD, de Zwart M, Sijben J, Soons E, van der Weerd L, Arese D, von den Hoff DW, Craviotto V, Tan ACITL, Groenen MJM, Bogte A, Repici A, Spaander MCW, Siersema PD. Risk factors and clinical outcomes of endoscopic dilation in benign esophageal strictures: a long-term follow-up study. Gastrointest Endosc 2020; 91:1058-1066. [PMID: 31917167 DOI: 10.1016/j.gie.2019.12.040] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Accepted: 12/22/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Endoscopic dilation (ED) is still the mainstay of therapeutic management of benign esophageal strictures (BESs). This study aimed to establish risk factors for refractory BESs and assess long-term clinical outcomes of ED. METHODS We performed a retrospective study in 891 patients who underwent ED from 2003 to 2018 for BESs. We searched electronic medical records in 6 tertiary care centers in the Netherlands for data on clinical outcome of ED. Median follow-up was 39 months. The primary endpoint was risk factors for refractory BESs, defined as factors associated with an increased number of ED sessions during follow-up. Secondary endpoints were time from first to last ED session and adverse events. RESULTS Dilation up to 13 to 15 mm was associated with a higher number of ED sessions than dilation up to 16 to 18 mm (5.0 vs 4.1; hazard ratio [HR], 1.4; P = .001). Compared with peptic strictures, anastomotic (4.9 vs 3.6; HR, 2.1; P < .001), radiation (5.0 vs 3.6; HR, 3.0; P < .001), caustic (7.2 vs 3.6; HR, 2.7; P < .001), and postendotherapy (3.9 vs 3.6; HR, 1.8; P = .005) strictures were associated with a higher number of ED sessions. After 1 year of follow-up, the proportions of patients who remained free of ED was 75% in anastomotic, 71% in radiation, 70% in peptic, 83% in postendotherapy, and 62% in caustic strictures. Esophageal perforation occurred in 23 ED sessions (.4%) in 22 patients (2.4%). CONCLUSIONS More than 60% of patients with BESs remain free of ED after 1 year of follow-up. Because dilation up to 16 to 18 mm diameter was associated with fewer ED sessions during follow-up, we suggest that clinicians should consider dilation up to at least 16 mm to reduce the number of ED sessions in these patients.
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Affiliation(s)
- Bram D Vermeulen
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Merle de Zwart
- Department of Gastroenterology & Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Jasmijn Sijben
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Elsa Soons
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Lucie van der Weerd
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Daniele Arese
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Daan W von den Hoff
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Vincenzo Craviotto
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Clinical and Research Center, Rozzano, Milan, Italy
| | - Adriaan C I T L Tan
- Department of Gastroenterology and Hepatology, Canisius Wilhelmina Hospital, Nijmegen, the Netherlands
| | - Marcel J M Groenen
- Department of Gastroenterology and Hepatology, Rijnstate Hospital, Arnhem, the Netherlands
| | - Auke Bogte
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Alessandro Repici
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Clinical and Research Center, Rozzano, Milan, Italy
| | - Manon C W Spaander
- Department of Gastroenterology & Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Peter D Siersema
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, the Netherlands
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Pih GY, Kim DH, Gong EJ, Na HK, Jung KW, Lee JH, Ahn JY, Choi KD, Song HJ, Lee GH, Jung HY. Preventing esophageal strictures with steroids after endoscopic submucosal dissection in superficial esophageal neoplasm. J Dig Dis 2019; 20:609-616. [PMID: 31509651 DOI: 10.1111/1751-2980.12819] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 09/08/2019] [Accepted: 09/09/2019] [Indexed: 12/11/2022]
Abstract
OBJECTIVES This study aimed to investigate the efficacy of prophylactic steroid administration in preventing post-endoscopic submucosal dissection (ESD) esophageal stricture and to determine risk factors for these strictures. METHODS Patients who underwent ESD for superficial esophageal neoplasms with a mucosal defect affecting >75% of the esophageal circumference between January 2011 and August 2016 were eligible. Patients were classified into three groups, including ESD-alone group (n = 22), oral steroid group (n = 25) and intralesional steroid injection group (n = 6). Univariate and multivariate logistic regression analyses were performed to evaluate the risk factors for esophageal stricture. RESULTS The stricture rate was 50.0%, 20.0% and 33.3% in the ESD-alone group, oral steroid group and steroid injection group, respectively. Patients treated with steroids had a significantly lower stricture rate than the ESD-alone group (22.6% vs 50.0%, P = 0.046). Additionally, oral steroid group had a significantly lower stricture rate than the ESD-alone group (P = 0.037). Multivariate analysis revealed that the extent of the circumferential mucosal defect was a significant risk factor for post-ESD strictures (odds ratio [OR] 13.015, 95% confidence interval [CI] 2.257-76.077, P = 0.004). The administration of steroids (OR 0.108, 95% CI 0.020-0.578, P = 0.009), specifically oral steroids (OR 0.109, 95% CI 0.019-0.622, P = 0.013), was associated with prevention of post-ESD strictures. CONCLUSION Oral steroid prophylaxis appears to be a safe and effective treatment in preventing post-ESD stricture and improving patients' quality of life.
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Affiliation(s)
- Gyu Young Pih
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Do Hoon Kim
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Eun Jeong Gong
- Department of Internal Medicine, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, South Korea
| | - Hee Kyong Na
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Kee Wook Jung
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Jeong Hoon Lee
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Ji Yong Ahn
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Kee Don Choi
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Ho June Song
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Gin Hyug Lee
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Hwoon-Yong Jung
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
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Jensen T, Wanczyk H, Sharma I, Mitchell A, Sayej WN, Finck C. Polyurethane scaffolds seeded with autologous cells can regenerate long esophageal gaps: An esophageal atresia treatment model. J Pediatr Surg 2019; 54:1744-1754. [PMID: 30429066 DOI: 10.1016/j.jpedsurg.2018.09.024] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Revised: 09/04/2018] [Accepted: 09/17/2018] [Indexed: 12/16/2022]
Abstract
BACKGROUND Pediatric patients suffering from long gap esophageal defects or injuries are in desperate need of innovative treatment options. Our study demonstrates that two different cell sources can adhere to and proliferate on a retrievable synthetic scaffold. In feasibility testing of translational applicability, these cell seeded scaffolds were implanted into piglets and demonstrated esophageal regeneration. METHODS Either porcine esophageal epithelial cells or porcine amniotic fluid was obtained and cultured in 3 dimensions on a polyurethane scaffold (Biostage). The amniotic fluid was obtained prior to birth of the piglet and was a source of mesenchymal stem cells (AF-MSC). Scaffolds that had been seeded were implanted into their respective Yucatan mini-swine. The cell seeded scaffolds in the bioreactor were evaluated for cell viability, proliferation, genotypic expression, and metabolism. Feasibility studies with implantation evaluated tissue regeneration and functional recovery of the esophagus. RESULTS Both cell types seeded onto scaffolds in the bioreactor demonstrated viability, adherence and metabolism over time. The seeded scaffolds demonstrated increased expression of VEGF after 6 days in culture. Once implanted, endoscopy 3 weeks after surgery revealed an extruded scaffold with newly regenerated tissue. Both cell seeded scaffolds demonstrated epithelial and muscle regeneration and the piglets were able to eat and grow over time. CONCLUSIONS Autologous esophageal epithelial cells or maternal AF-MSC can be cultured on a 3D scaffold in a bioreactor. These cells maintain viability, proliferation, and adherence over time. Implantation into piglets demonstrated esophageal regeneration with extrusion of the scaffold. This sets the stage for translational application in a neonatal model of esophageal atresia.
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Affiliation(s)
- Todd Jensen
- University of Connecticut School of Medicine, Department of Pediatrics.
| | - Heather Wanczyk
- University of Connecticut School of Medicine, Department of Pediatrics
| | - Ishna Sharma
- University of Connecticut School of Medicine, Department of Surgery
| | - Adam Mitchell
- University of Connecticut School of Medicine, Department of Pediatrics
| | - Wael N Sayej
- University of Connecticut School of Medicine, Department of Pediatrics; Connecticut Children's Medical Center, Department of Digestive Diseases
| | - Christine Finck
- University of Connecticut School of Medicine, Department of Pediatrics; Connecticut Children's Medical Center, Department of Pediatric Surgery.
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Franzini T, Sagae VMT, Guedes HG, Sakai P, Waisberg DR, Andraus W, D'Albuquerque LAC, Sethi A, de Moura EGH. Cholangioscopy-guided steroid injection for refractory post liver transplant anastomotic strictures: a rescue case series. Ther Adv Gastrointest Endosc 2019; 12:2631774519867786. [PMID: 31489404 PMCID: PMC6713960 DOI: 10.1177/2631774519867786] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Accepted: 07/12/2019] [Indexed: 12/17/2022] Open
Abstract
Background and aims: Post liver transplant biliary anastomotic strictures have traditionally been treated with balloon dilation and multiple plastic stents. Fully covered self-expandable metallic stents may be used as an initial alternative or after multiple plastic stents failure. Refractory strictures can occur in 10–22% and require revisional surgery. Alternatively, cholangioscopy allows direct visualization and therapeutic approaches. We aimed to assess the feasibility, safety, and efficacy of balloon dilation combined with cholangioscopy-guided steroid injection for the treatment of refractory anastomotic biliary strictures. Methods: Three post-orthotopic liver transplant patients who failed standard treatment of their biliary anastomotic strictures underwent endoscopic retrograde cholangiopancreatography with balloon dilation followed by cholangioscopy-guided steroid injection at a tertiary care center. Patients had follow-up with images and laboratorial tests to evaluate for residual stricture. Results: Technical success of balloon dilation + cholangioscopy-guided steroid injection was achieved in all patients. Cholangioscopy permitted accurate evaluation of bile ducts and precise localization for steroid injection. No adverse events occurred. Mean follow-up was 26 months. Two patients are stent free and remain well in follow-up, with no signs of biliary obstruction. No further therapeutic endoscopic procedures or revisional surgery were required. One patient did not respond to balloon dilation + cholangioscopy-guided steroid injection after 11 months of follow-up and required repeat balloon dilation of new strictures above the anastomosis. Conclusion: Cholangioscopy-guided steroid injection combined with balloon dilation in the treatment of refractory post liver transplant strictures is feasible and safe. This method may be used as a rescue alternative before surgical approach. Randomized controlled trials comparing balloon dilation + cholangioscopy-guided steroid injection to fully covered self-expandable metallic stents are needed to determine the role of this treatment for anastomotic biliary strictures.
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Affiliation(s)
- Tomazo Franzini
- Department of Gastroenterology, Faculdade de Medicina, Universidade de Sao Paulo, Carvalho Aguiar street, number 255, 6th floor, Sao Paulo 05422-090, Brazil
| | - Vitor M T Sagae
- Department of Gastroenterology, Faculty of Medicine, University of Sao Paulo, São Paulo, Brazil
| | - Hugo G Guedes
- Department of Gastroenterology, Faculty of Medicine, University of Sao Paulo, São Paulo, Brazil
| | - Paulo Sakai
- Department of Gastroenterology, Faculty of Medicine, University of Sao Paulo, São Paulo, Brazil
| | - Daniel R Waisberg
- Department of Gastroenterology, Faculty of Medicine, University of Sao Paulo, São Paulo, Brazil
| | - Wellington Andraus
- Department of Gastroenterology, Faculty of Medicine, University of Sao Paulo, São Paulo, Brazil
| | - Luiz A C D'Albuquerque
- Department of Gastroenterology, Faculty of Medicine, University of Sao Paulo, São Paulo, Brazil
| | - Amrita Sethi
- Division of Digestive and Liver Diseases, Columbia University Irving Medical Center, New York, NY, USA
| | - Eduardo G H de Moura
- Department of Gastroenterology, Faculty of Medicine, University of Sao Paulo, São Paulo, Brazil
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Merino Gallego E, Martínez Amate E, Gallego Rojo FJ. Incisional endoscopic therapy as a therapeutic alternative in esophageal anastomotic strictures refractory to conventional treatment. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2019; 111:717-719. [PMID: 31333038 DOI: 10.17235/reed.2019.6196/2019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Esophageal anastomotic strictures are a non-negligible cause of benign strictures and secondary dysphagia. It should be noted that these are often complex strictures, with a large ischemic-fibrotic component. Thus, they are difficult to treat due to their recurrence, despite endoscopic dilation. Endoscopic incisional therapy appears as a therapeutic alternative in this type of patient, which allows the elimination of the stenotic ring, with a good efficacy and safety profile. We present the case of a patient with postoperative esophageal strictures refractory to treatment with dilation and endoscopic prosthesis, who was finally satisfactorily treated with incisional therapy.
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Endoscopic Dilation of Refractory Postlaryngectomy Strictures: A Case Series and Literature Review. Gastroenterol Res Pract 2019; 2019:8905615. [PMID: 31275367 PMCID: PMC6558613 DOI: 10.1155/2019/8905615] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 11/14/2018] [Accepted: 05/06/2019] [Indexed: 02/06/2023] Open
Abstract
Background Endoscopic dilation of postlaryngectomy strictures (PLS) is safe and effective; however, PLS are often refractory and require serial dilations. Long-term outcomes of dilation in patients with refractory PLS are not well reported. Materials and Methods Seven patients with dysphagia and refractory PLS underwent serial endoscopic dilation therapy during a 4.5-year period. Dilation characteristics, technical success, clinical success, and diet advancement (as assessed by Diet/GT scale) were measured. Results. All strictures were complex, and there were no reported complications. The median number of dilations per patient was 12 (range 7 to 48). The average interval in between dilations was six weeks. Technical success was achieved in 6/7 patients, and clinical success was achieved in 2/7 patients. 6/7 patients had advancements in Diet/GT scores. Conclusions Dilation of refractory PLS is safe and effective and frequently requires the use of a retrograde approach, fluoroscopic guidance, and/or lumen patency strings. Serial dilations are required to maintain luminal patency, relieve dysphagia, and advance oral diet. The definition of clinical success of dilation in these patients should avoid the use of a specific time interval between dilations to characterize success.
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Thomas S, Siddiqui AA, Taylor LJ, Parbhu S, Cao C, Loren D, Kowalski T, Adler DG. Fully-covered esophageal stent migration rates in benign and malignant disease: a multicenter retrospective study. Endosc Int Open 2019; 7:E751-E756. [PMID: 31157292 PMCID: PMC6524992 DOI: 10.1055/a-0890-3284] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Accepted: 02/26/2019] [Indexed: 01/18/2023] Open
Abstract
Background and study aims Stent migration is a common complication of fully-covered self-expanding metal stents (FCSEMS), but the rate of clinically relevant migration as defined by stent migration followed by reintervention via endoscopy for stent replacement is unknown. The goal of this study is to gain insight into the total migration rate and clinically relevant migration rate of different types of FCSEMS placed within benign and malignant strictures with specific attention paid to stent manufacturer, diameter, and length. Patients and methods Multicenter retrospective analysis of endoscopic data from patients with FCSEMS placed within benign or malignant strictures. FCSEMS used included a variety of sizes and manufacturers. Results A total of 369 patients were included, 161 of whom had benign strictures and 208 of whom had malignant strictures. The total migration rate and clinically relevant migration rate in benign strictures were 30 % and 17 %, respectively. For benign strictures, Wallflex stents had a clinically relevant migration rate of 15 %, compared to Endomaxx stents with 19 %, and Evolution stents with 25 % ( P = 0.52). The total migration rate and clinically relevant migration rates in malignant strictures were 23 % and 14 %, respectively. Evolution stents had a significantly higher clinically relevant migration rate (29 %) than the Wallflex stents (7 %) and the endomaxx stents (12 %), P = 0.003. Conclusion This study is the largest to investigate migration rates for FCSEMS in benign and malignant strictures. Clinically relevant migration is a relatively common occurrence with all stent types studied and better anti-migration features are needed.
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Affiliation(s)
- Samuel Thomas
- Department of Gastroenterology and Hepatology, University of Utah - Huntsman Cancer Center, Salt Lake City, Utah, United States
| | - Ali A. Siddiqui
- Department of Gastroenterology and Hepatology, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, United States
| | - Linda Jo Taylor
- Department of Gastroenterology and Hepatology, University of Utah - Huntsman Cancer Center, Salt Lake City, Utah, United States
| | - Sheeva Parbhu
- Department of Gastroenterology and Hepatology, University of Utah - Huntsman Cancer Center, Salt Lake City, Utah, United States
| | - Christopher Cao
- Department of Gastroenterology and Hepatology, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, United States
| | - David Loren
- Department of Gastroenterology and Hepatology, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, United States
| | - Thomas Kowalski
- Department of Gastroenterology and Hepatology, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, United States
| | - Douglas G. Adler
- Department of Gastroenterology and Hepatology, University of Utah - Huntsman Cancer Center, Salt Lake City, Utah, United States,Corresponding author Douglas G. Adler, MD, FACG, AGAF, FASGE Professor of MedicineDirector of Therapeutic EndoscopyDirector, GI Fellowship ProgramGastroenterology and HepatologyUniversity of Utah School of MedicineHuntsman Cancer Center30N 1900E 4R118Salt Lake City, Utah 84132+1-801-581-8007
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Chang CH, Chao HC, Kong MS, Chen SY, Chen CC, Lai MW. Clinical and nutritional outcome of pediatric esophageal stenosis with endoscopic balloon dilatation. Pediatr Neonatol 2019; 60:141-148. [PMID: 29793843 DOI: 10.1016/j.pedneo.2018.04.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Revised: 02/18/2018] [Accepted: 04/30/2018] [Indexed: 11/15/2022] Open
Abstract
AIM The present study evaluates the long-term clinical and nutritional effect to endoscopic balloon dilatation (EBD) in pediatric esophageal stricture. METHODS This was a 15-year retrospective study involving pediatric patients with esophageal stricture treated with EBD. Outcome parameters included the number of dilatations, procedural success rates, nutritional status, and complications. EBD was performed in patients with a dysphagia score greater than 2. The nutritional status was assessed by weight-for-age z-score. Clinical success was defined as no requirement for EBD for at least 1 year and/or increasing interval between dilatation and the numbers of EBD was fewer than 4 times per year. RESULTS A total of 50 cases (mean age, 4.41 ± 4.9 years) were enrolled. During a mean follow-up of 3.2 ± 1.9 years, a total of 268 EBD sessions were performed, with an average of 5.36 sessions per patient (range, 1-33). Patients who had short segment stricture (<2 cm) were prone to achieve clinical success after EBD (p = 0.0094). Procedural perforation rate is 2.6% (7/268); subsequent tracheoesophageal fistula occurred in two patients. The clinical success rate of EBD therapy was 72% (36/50). All had increments of weight-for-age z-score after EBD therapy, and the increment was significantly greater in those patients with short segment stricture or stricture in the middle esophagus at 12 months (p = 0.01 and 0.008, respectively). CONCLUSIONS EBD has good long-term clinical success and nutritional promotion in pediatric patients with esophageal stricture, especially in short segment stricture or stricture in the middle esophagus.
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Affiliation(s)
- Chun-Hsiang Chang
- Division of Pediatric Gastroenterology, Department of Pediatrics, Chang Gung Children's Medical Center, Chang Gung Memorial Hospital, 5 Fu-Hsing Street, Guishan Dist, Taoyuan City, 33305, Taiwan
| | - Hsun-Chin Chao
- Division of Pediatric Gastroenterology, Department of Pediatrics, Chang Gung Children's Medical Center, Chang Gung Memorial Hospital, 5 Fu-Hsing Street, Guishan Dist, Taoyuan City, 33305, Taiwan; Chang Gung University College of Medicine, 259, Wenhua 1st Rd., Taoyuan City, 33302, Taiwan.
| | - Man-Shan Kong
- Division of Pediatric Gastroenterology, Department of Pediatrics, Chang Gung Children's Medical Center, Chang Gung Memorial Hospital, 5 Fu-Hsing Street, Guishan Dist, Taoyuan City, 33305, Taiwan; Chang Gung University College of Medicine, 259, Wenhua 1st Rd., Taoyuan City, 33302, Taiwan
| | - Shih-Yen Chen
- Division of Pediatric Gastroenterology, Department of Pediatrics, Chang Gung Children's Medical Center, Chang Gung Memorial Hospital, 5 Fu-Hsing Street, Guishan Dist, Taoyuan City, 33305, Taiwan; Chang Gung University College of Medicine, 259, Wenhua 1st Rd., Taoyuan City, 33302, Taiwan
| | - Chien-Chang Chen
- Division of Pediatric Gastroenterology, Department of Pediatrics, Chang Gung Children's Medical Center, Chang Gung Memorial Hospital, 5 Fu-Hsing Street, Guishan Dist, Taoyuan City, 33305, Taiwan; Chang Gung University College of Medicine, 259, Wenhua 1st Rd., Taoyuan City, 33302, Taiwan
| | - Ming-Wei Lai
- Division of Pediatric Gastroenterology, Department of Pediatrics, Chang Gung Children's Medical Center, Chang Gung Memorial Hospital, 5 Fu-Hsing Street, Guishan Dist, Taoyuan City, 33305, Taiwan; Chang Gung University College of Medicine, 259, Wenhua 1st Rd., Taoyuan City, 33302, Taiwan
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Burr NE, Everett SM. Management of benign oesophageal strictures. Frontline Gastroenterol 2019; 10:177-181. [PMID: 31205660 PMCID: PMC6540277 DOI: 10.1136/flgastro-2018-101075] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Revised: 11/28/2018] [Accepted: 12/09/2018] [Indexed: 02/04/2023] Open
Abstract
Benign oesophageal strictures are an important gastrointestinal condition that can cause substantial morbidity. There are many different aetiologies and each case needs careful evaluation and individualised treatment. Management usually involves targeting therapy to the underlying cause, but oesophageal dilatation is an important part of the algorithm. The recent British Society of Gastroenterology guidelines provide advice on the use of dilatation for benign strictures and cover patient preparation, the dilatation procedure and disease-specific considerations. This article provides a summary of the key messages from the guidelines and applies them to routine clinical practice. It also includes practical advice on the clinical assessment, investigation and management of benign oesophageal strictures and gives an approach to the management of refractory strictures. Areas where evidence is sparse and further research is needed are highlighted.
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Affiliation(s)
- Nicholas E Burr
- Leeds Gastroenterology Institute, St James’s University Hospital, Leeds, UK,Leeds Institute of Biomedical and Clinical Sciences, University of Leeds, Leeds, UK
| | - Simon M Everett
- Leeds Gastroenterology Institute, St James’s University Hospital, Leeds, UK
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Outcomes of Endoscopic Dilation in Patients with Esophageal Anastomotic Strictures: Comparison Between Different Etiologies. Dysphagia 2019; 35:73-83. [PMID: 30929058 DOI: 10.1007/s00455-019-10004-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Accepted: 03/23/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND AND AIMS This retrospective study was aimed at assessing the efficacy of endoscopic dilation for esophageal anastomotic strictures, and to compare response between caustic anastomotic strictures (CAS) and non-caustic anastomotic strictures (NCAS). MATERIALS AND METHODS Patients with anastomotic strictures (enrolled during January 1996-December 2015) were analyzed. Short- and long-term outcomes of dilation, in terms of clinical success, refractory, and recurrent strictures were compared between NCAS and CAS. Patients with refractory and recurrent strictures were managed with adjunctive therapy including intralesional steroids. Factors predicting refractoriness at start of dilation and reasons for more than ten lifetime dilations were also evaluated. RESULTS Of the 142 patients, 124 (mean age-44.02; males-74) underwent dilation. Clinical success was achieved in 113 (91.3%) patients requiring a median [Interquartile range (IQR)] of 4 (2-10) sessions. The number of dilations to achieve clinical success, refractory strictures, and recurrent strictures, and the use of adjunctive therapy were significantly higher for CAS than for NCAS. Intralesional steroid use decreased periodic dilation index (PDI) significantly in CAS. Caustic etiology and starting dilation diameter of < 10 mm were found to be predictors of refractoriness, with the former alone being an independent predictor of more than ten lifetime dilations. No patient had free perforation; however, five required revision surgery. CONCLUSION Patients with CAS fared worse than those with NCAS in terms of number of dilations, refractoriness, recurrence of strictures, and need of adjunctive therapy. Endoscopic dilation can successfully ameliorate dysphagia due to anastomotic strictures in a majority of patients.
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Kappelle WF, van Hooft JE, Spaander MCW, Vleggaar FP, Bruno MJ, Maluf-Filho F, Bogte A, van Halsema E, Siersema PD. Treatment of refractory post-esophagectomy anastomotic esophageal strictures using temporary fully covered esophageal metal stenting compared to repeated bougie dilation: results of a randomized controlled trial. Endosc Int Open 2019; 7:E178-E185. [PMID: 30705950 PMCID: PMC6338544 DOI: 10.1055/a-0777-1856] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Accepted: 09/24/2018] [Indexed: 12/31/2022] Open
Abstract
Background and study aims Fully covered self-expanding metal stents (FCSEMS) provide an alternative to bougie dilation (BD) for refractory benign esophageal strictures. Controlled studies comparing temporary placement of FCSES to repeated BD are not available. Patients and methods Patients with refractory anastomotic esophageal strictures, dysphagia scores ≥ 2, and two to five prior BD were randomized to 8 weeks of FCSEMS or to repeated BD. The primary endpoint was the number of BD during the 12 months after baseline treatment. Results Eighteen patients were included (male 67 %, median age 66.5; 9 received metal stents, 9 received BD). Technical success rate of stent placement and stent removal was 100 %. Recurrent dysphagia occurred in 13 patients (72 %) during follow-up. No significant difference was found between the stent and BD groups for mean number of BD during follow-up (5.4 vs. 2.4, P = 0.159), time to recurrent dysphagia (median 36 days vs. 33 days, Kaplan-Meier: P = 0.576) and frequency of reinterventions per month (median 0.3 vs. 0.2, P = 0.283). Improvement in quality of life score was greater in the stent group compared to the BD group at month 12 (median 26 % vs. 4 %, P = 0.011). Conclusions The current data did not provide evidence for a statistically significant difference between the two groups in the number of BD during the 12 months after initial treatment. Metal stenting offers greater improvement in quality of life from baseline at 12 months compared to repeated BD for patients with refractory anastomotic esophageal strictures.
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Affiliation(s)
- W. F. Kappelle
- University Medical Center Utrecht, Utrecht, The Netherlands
| | | | | | - F. P. Vleggaar
- University Medical Center Utrecht, Utrecht, The Netherlands
| | - M. J. Bruno
- Erasmus University Medical Center, Rotterdam, The Netherlands
| | - F. Maluf-Filho
- Instituto do Cancer do Estado de Sao Paulo, Sao Paulo, Brazil
| | - A. Bogte
- University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - P. D. Siersema
- University Medical Center Utrecht, Utrecht, The Netherlands,Radboud University Medical Center, Nijmegen, The Netherlands,Corresponding author Peter D. Siersema, MD, PhD Dept. of Gastroenterology and HepatologyRadboud University Medical CenterNijmegenThe Netherlands+31 10 465 8520
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