AGA technical review on treatment of patients with dysphagia caused by benign disorders of the distal esophagus

Prevalence and Costs of Esophageal Strictures in the United States

BACKGROUND & AIMS

Esophageal strictures are a leading cause of dysphagia, but data regarding the epidemiology of esophageal strictures are limited. This study aimed to investigate the prevalence, health care utilization, and financial burden of esophageal strictures in the United States.

METHODS

We performed a retrospective cohort study using 2 large national insurance claims databases (MarketScan and Medicare). Using International Classification of Diseases-9 and -10 diagnostic codes, annual prevalence was calculated for both cohorts overall, and stratified by age and sex strata. Most common diagnostic and procedural codes associated with esophageal strictures were extracted and analyzed to estimate health care utilization. Direct annual medical costs of esophageal strictures were calculated.

RESULTS

The annual prevalence of esophageal strictures in MarketScan in 2021 was 203.14 cases/100,000 people, whereas the annual prevalence in Medicare cohort in 2017 was 1123.47 cases/100,000. Although rates were relatively stable over time, esophageal stricture prevalence increased with advancing age. No prevalence differences were noticed between males and females. Gastroesophageal reflux disease/erosive esophagitis was the top diagnostic code associated with esophageal strictures, although an increase in the proportion of eosinophilic esophagitis codes was noted over time. Esophageal dilation codes were present in ∼50% of stricture cases. The total health care costs associated with esophageal strictures were estimated at $1.39 billion in 2017.

CONCLUSIONS

Esophageal strictures are common, affecting between 1/100 and 1/1000 patients in the United States, with the highest rates seen in patients aged 75 years and older. Accordingly, strictures have a significant financial burden on the health care system, with costs greater than $1 billion annually.

Dysphagia

Dysphagia is an important clinical symptom that increases in prevalence with age. Both oropharyngeal and esophageal processes can contribute to dysphagia, and these can be differentiated with a careful history. Neuromuscular processes are more prevalent than structural causes in oropharyngeal dysphagia, therefore, investigation should start with a modified barium swallow. In contrast, structural processes dominate in esophageal dysphagia, and endoscopy can offer biopsy and therapy by way of dilation. Manometry is performed for esophageal dysphagia when no structural etiology is found. Specific management of dysphagia is dependent on the etiology and mechanism of dysphagia.

Empirical Dilation of Non-obstructive Dysphagia: Current Understanding and Future Directions

Non-obstructive dysphagia (NOD) is defined as symptomatic dysphagia in patients with negative endoscopic and radiographic workup. The management of NOD remains controversial as there is a discrepancy between different guidelines and clinical practice. Despite the lack of high-quality studies, empiric dilation for NOD is a common clinical practice among endoscopists and the approach varies between different clinical centers. In this review, we summarize the published literature on empiric dilation for NOD and propose a management algorithm for offering empiric dilation to patients presenting with dysphagia.

Curriculum review : investigation and management of dysphagia

Dysphagia is a common presentation in gastroenterology practice and the diagnosis and management requires a comprehensive knowledge of diverse range of aetiologies, with a systematic approach for assessment of symptoms, selection of investigations and appropriate treatment to relieve symptoms. In this curriculum review, the suggested diagnostic approach highlights the importance of thorough clinical assessment in order to guide the selection of investigations. This article discusses the utility of endoscopic, histopathology, fluoroscopic and motility investigations for dysphagia, and their interpretation, in order to guide targeted treatments ranging from dietary, pharmacological, endoscopic and surgical interventions.

Comparison of the Efficacy and Safety of Endoscopic Incisional Therapy and Balloon Dilatation for Esophageal Anastomotic Stricture

BACKGROUND

Benign esophageal anastomotic strictures have typically been treated using endoscopic methods, often with balloon dilatation (BD). However, recurrent esophageal strictures after BD have been reported. We evaluated the efficacy and safety of endoscopic incisional therapy (EIT) and BD for treating an anastomotic stricture after a total gastrectomy.

METHODS

Subjects who underwent EIT or BD as a first treatment for esophagojejunostomy anastomotic stricture after a total gastrectomy between January 2010 and December 2018 were eligible. The medical records of these cases were retrospectively reviewed. Stricture was defined as an inability to pass a normal diameter endoscope (10.2 mm). The stricture area was incised under direct vision with the nano-insulated-tip knife in a radial fashion parallel to the longitudinal axis of the esophagus.

RESULTS

Twenty-one patients in our database presented with benign anastomotic stricture after a total gastrectomy for advanced gastric cancer. The BD group included 12 patients. The remaining nine patients underwent EIT, and three of these cases received an immediate additional BD. The re-stricture rate was significantly different between the BD and EIT groups (41.7% vs. 0%, respectively; P = 0.045). There were no significant differences in procedure time, interval from surgery to first stricture, hospitalization period, or complication rates between the groups. One patient developed a microperforation during BD and was treated without surgical intervention.

CONCLUSIONS

EIT is a safe and effective primary treatment modality compared with BD for esophagojejunostomy anastomotic stricture after a total gastrectomy as it shows a significantly lower re-stricture rate.

Better Medicines for Older Patients: Considerations between Patient Characteristics and Solid Oral Dosage Form Designs to Improve Swallowing Experience

Oral drug administration provided as solid oral dosage forms (SODF) remains the major route of drug therapy in primary and secondary care. There is clear evidence for a growing number of clinically relevant swallowing issues (e.g., dysphagia) in the older patient population, especially when considering the multimorbid, frail, and polymedicated patients. Swallowing impairments have a negative impact on SODF administration, which leads to poor adherence and inappropriate alterations (e.g., crushing, splitting). Different strategies have been proposed over the years in order to enhance the swallowing experience with SODF, by using conventional administration techniques or applying swallowing aids and devices. Nevertheless, new formulation designs must be considered by implementing a patient centric approach in order to efficiently improve SODF administration by older patient populations. Together with appropriate SODF size reductions, innovative film coating materials that can be applied to SODF and provide swallowing safety and efficacy with little effort being required by the patients are still needed. With that in mind, a literature review was conducted in order to identify the availability of patient centric coating materials claiming to shorten esophageal transit times and improve the overall SODF swallowing experience for older patients. The majority of coating technologies were identified in patent applications, and they mainly included well-known water soluble polymers that are commonly applied into pharmaceutical coatings. Nevertheless, scientific evidence demonstrating the benefits of given SODF coating materials in the concerned patient populations are still very limited. Consequently, the availability for safe, effective, and clinically proven solutions to address the increasing prevalence of swallowing issues in the older patient population is still limited.

Intralesional steroids and endoscopic dilation for anastomotic strictures after esophagectomy: systematic review and meta-analysis

BACKGROUND

Post-esophagectomy anastomotic strictures are difficult to treat. The impact of adding local steroid injection to endoscopic dilation for the treatment of post-esophagectomy anastomotic strictures is unclear. We conducted a systematic review and meta-analysis to assess the efficacy of performing steroid injection in addition to dilation.

METHODS

A search was conducted in MEDLINE, Cochrane Library, EMBASE, and Web of Science from inception to January 2019. Randomized controlled trials (RCTs) comparing the efficacy of endoscopic dilation plus either local steroid injection (steroid group) or saline injection (placebo group) were included in the analysis.

RESULTS

Three RCTs were eligible for the final analysis: 72 patients (mean age 61.3 years, 74 % male) in the steroid group and 72 patients (mean age 59.6 years, 71 % male) in the placebo group. The mean number of dilations required to resolve the stricture was significantly lower in the steroid group compared with the placebo group, with a mean weighted difference of -1.62 (95 % confidence interval [CI] -2.73 to -0.50; P = 0.004). After 6 months of follow-up, there was a trend toward more patients in the steroid group remaining dysphagia free compared with the placebo group, with a pooled odds ratio of 2.36 (95 %CI 0.94 to 5.91; P = 0.07, I2  = 24 %).

CONCLUSION

This meta-analysis showed that the addition of local steroid injection at the time of dilation for benign anastomotic strictures led to a significant decrease in the number of procedures required to resolve the stricture and may well reduce dysphagia symptoms during follow-up.

Successful Recanalization of a Long-Segment Complete Esophageal Stricture Using Endoscopic and Fluoroscopic Techniques

Complete esophageal strictures are rare complications in patients who have received head and neck radiation therapy. Although mild strictures are generally amenable to dilation or stenting, management of these debilitating strictures is not well established. Treatment of long-segment obstructions is particularly complicated because documented techniques generally apply for strictures up to 3 cm in length. This report describes a successful recanalization of a long-segment complete esophageal stricture using combined antegrade-retrograde endoscopic therapy with adjunctive fluoroscopic techniques.

Endoscopic botulinum toxin injection for treatment of pharyngeal dysphagia in patients with cricopharyngeal dysfunction

BACKGROUND

Dysphagia associated with neurologic disorders is a problem worldwide. However, few studies have assessed the efficacy of endoscopic botulinum toxin injections into the cricopharyngeal muscle using a pharyngoscope.

METHODS

Fourteen patients who received an endoscopic botulinum toxin injection due to cricopharyngeal muscle dysfunction and a neurological disorder from 2006 to 2017 were retrospectively reviewed at a single tertiary medical center. The toxin was injected at a 100 international unit (IU) total dose under direct endoscopic vision. The success of the procedure was evaluated comprehensively using the following: clinical resolution of the previous symptoms, functional oral intake scale (FOIS) for the clinical evaluation of swallowing, and videofluoroscopic swallowing study (VFSS) to check decreased retention of barium at the pyriform sinus and the epiglottic vallecula.

RESULTS

The study included 12 males and 2 females (mean age, 58 years old; range, 37-82 years). Three patients (21.4%) were confirmed clinically and eleven were confirmed by VFSS. Eleven patients (78.6%) were managed successfully with the injection. Three patients (21.4%) did not improve despite the injection.

CONCLUSION

An endoscopic botulinum toxin injection may be a good treatment option for patients with dysphagia and cricopharyngeal dysfunction due to a neurological disorder. Large, prospective, long-term follow-up studies are needed in the future.

Anxiety can significantly explain bolus perception in the context of hypotensive esophageal motility: Results of a large multicenter study in asymptomatic individuals

BACKGROUND

Previous studies have not been able to correlate manometry findings with bolus perception. The aim of this study was to evaluate correlation of different variables, including traditional manometric variables (at diagnostic and extreme thresholds), esophageal shortening, bolus transit, automated impedance manometry (AIM) metrics and mood with bolus passage perception in a large cohort of asymptomatic individuals.

METHODS

High resolution manometry (HRM) was performed in healthy individuals from nine centers. Perception was evaluated using a 5-point Likert scale. Anxiety was evaluated using Hospitalized Anxiety and Depression scale (HAD). Subgroup analysis was also performed classifying studies into normal, hypotensive, vigorous, and obstructive patterns.

KEY RESULTS

One hundred fifteen studies were analyzed (69 using HRM and 46 using high resolution impedance manometry (HRIM); 3.5% swallows in 9.6% of volunteers were perceived. There was no correlation of any of the traditional HRM variables, esophageal shortening, AIM metrics nor bolus transit with perception scores. There was no HRM variable showing difference in perception when comparing normal vs extreme values (percentile 1 or 99). Anxiety but not depression was correlated with perception. Among hypotensive pattern, anxiety was a strong predictor of variance in perception (R² up to .70).

CONCLUSION AND INFERENCES

Bolus perception is less common than abnormal motility among healthy individuals. Neither esophageal motor function nor bolus dynamics evaluated with several techniques seems to explain differences in bolus perception. Different mechanisms seem to be relevant in different manometric patterns. Anxiety is a significant predictor of bolus perception in the context of hypotensive motility.

Efficacy of prednisone for prevention of esophageal stricture after endoscopic submucosal dissection for superficial esophageal squamous cell carcinoma

BACKGROUND

Our objective was to investigate the efficacy and safety of oral prednisone for the prevention of esophageal stricture formation after endoscopic submucosal dissection (ESD) in an optimal administration program.

METHODS

Patients who underwent circumferential or semi-circumferential (more than three quarters but not a complete circular) ESD for esophageal squamous cell carcinoma were eligible for this study. Oral prednisolone was administered to the study group at a dose of 30 mg/day on the third day post-ESD, and then tapered gradually (30, 25, 20, 15, 10, and 5 mg for 14 days). Serial esophagoscopy with iodine staining was performed to assess stenosis and tumor recurrence at one, three, six, and 12 months after ESD. Endoscopic balloon dilatation was performed whenever patients experienced persistent dysphagia to solids. Data were statistically analyzed.

RESULTS

Twenty-three patients (15 men, mean age 66.6 years) were enrolled in the study. Post-procedural esophageal stricture was significantly lower in the study group (23.1%) compared to the control (80%) (P < 0.05). A significantly higher number of endoscopic balloon dilatation sessions were performed (P < 0.05) in the control (13.5) than in the study group (0.69). There were no adverse events related to oral prednisolone or the procedure itself and no treatment-related mortality was observed during the 12 month follow-up.

CONCLUSIONS

Our study suggested an optimal administration program of oral prednisone therapy and demonstrated that it is safe and effective for the prevention of esophageal stricture in patients after complete or semi-circular ESD for esophageal squamous cell carcinoma.

Esophageal Stricture Resulting from Systemic Chemotherapy for Solid Malignancy

Although dysphagia in patients treated for malignancy is usually related to reflux esophagitis, infectious esophagitis, malignant infiltration, or as a complication of radiation therapy, acute esophageal stricture resulting from chemotherapy is very rare. Only 2 prior cases have been described in the treatment of an adult patient with malignancy. We present a unique case of isolated chemotherapy-induced esophageal stricture in a patient receiving treatment for metastatic testicular seminoma without prior history of gastroesophageal reflux disease, caustic ingestion, or other risk factors for esophageal stricture formation.

Risk factors associated with refractoriness to esophageal dilatation for benign dysphagia

BACKGROUND

Benign esophageal strictures need repeated dilatations to relieve dysphagia. Literature is scarce on the risk factors for refractoriness of these strictures.

AIM

This study aimed to assess the risk factors associated with refractory strictures.

MATERIALS AND METHODS

This is a retrospective study of patients with benign esophageal strictures who were referred for esophageal dilatation over a period of 3 years.

RESULTS

A total of 327 esophageal dilatations were performed in 103 patients; 53% of the patients reported dysphagia for liquids. Clinical success was achieved in 77% of the patients. There was a need for further dilatations in 54% of patients, being more frequent in patients with dysphagia for liquids [78 vs. 64%, P=0.008, odds ratio (OR) 1.930], in those with caustic strictures (89 vs. 70%, P=0.007, OR 3.487), and in those with complex strictures (83 vs. 70%, P=0.047, OR 2.132). Caustic strictures, peptic strictures, and complex strictures showed statistical significance in the multivariate analysis. Time until subsequent dilatations was less in patients with dysphagia for liquids (49 vs. 182 days, P<0.001), in those with peptic strictures (49 vs. 98 days, P=0.004), in those with caustic strictures (49 vs. 78 days, P=0.005), and in patients with complex strictures (47 vs. 80 days P=0.009). In multivariate analysis, further dilatations occurred earlier in patients with dysphagia for liquids [hazard ratio (HR) 1.506, P=0.004], in those with peptic strictures (HR 1.644, P=0.002), in those with caustic strictures (HR 1.581, P=0.016), and in patients with complex strictures (HR 1.408, P=0.046).

CONCLUSION

Caustic, peptic, and complex strictures were associated with a greater need for subsequent dilatations. Time until subsequent dilatations was less in patients with dysphagia for liquids and in those with caustic, peptic, and complex strictures.

Endoscopic Management of Anastomotic Esophageal Strictures Secondary to Esophageal Atresia

The reported incidence of anastomotic stricture after esophageal atresia repair has varied in case series from as low as 9% to as high as 80%. The cornerstone of esophageal stricture treatment is dilation with either balloon or bougie. The goal of esophageal dilation is to increase the luminal diameter of the esophagus while also improving dysphagia symptoms. Once a stricture becomes refractory to esophageal dilation, there are several treatment therapies available as adjuncts to dilation therapy. These therapies include intralesional steroid injection, mitomycin C, esophageal stent placement, and endoscopic incisional therapy.

Treatment of Refractory Gastrointestinal Strictures With Mitomycin C: A Systematic Review

BACKGROUND AND AIMS

Refractory benign gastrointestinal (GI) strictures represent a difficult management problem given the limited therapeutic interventions available. We performed a systematic review of all published cases using mitomycin C in the treatment of GI strictures.

METHODS

Searches of MEDLINE and Embase databases were performed to identify studies reporting application of mitomycin C for GI strictures. Review of titles/abstracts, full review of potentially relevant studies, and data abstraction were performed independently by 2 authors.

RESULTS

Of 549 citations, 24 studies with 145 patients (74% pediatric and 26% adult) met inclusion criteria. Esophageal strictures were the most common (79%) site of refractory strictures treated with mitomycin C, with caustic injury the most common underlying etiology. The concentration (range, 0.1 to 2 mg/mL; median, 0.4 mg/mL), number of applications (range, 1 to 12; median, 1), duration of applications (range, 1 to 5; median, 2 min), and technique of application (cotton pledget, spray, injection, special catheters) varied among studies. Ninety-one patients (73%; children: 80%, adults: 59%) had a complete response; 26 (21%) had a partial response. Only 1 (0.7%) adverse event was reported: cutaneous sclerosis attributed to microperforation and mitomycin C extravastion after injection. Mean follow-up was 23 (4 to 60) months.

CONCLUSIONS

Local mitomycin C application seems to be a safe and effective therapy for benign refractory GI strictures of varying etiology in both pediatric and adult populations. Although the results of this systematic review are highly encouraging, it should be considered investigational. Additional randomized trials and larger prospective studies are needed to confirm these results and to better define the optimal dose, concentration, duration and technique of mitomycin C application.

Gastrointestinal stenting: Current status and imaging features

The use of stents in the gastrointestinal tract has been subjected to major changes. Initially, the use of stents was restricted to malignant strictures in patients with metastatic disease. But thanks to reduction of the morbidity and mortality rates, they are now used with curative intention and in patients with benign diseases after careful selection. However, for patients presenting with colon obstruction due to an advanced colon carcinoma, the mortality and morbidity are still high. The purpose of this review is to provide an overview of indications, techniques and further developments of the stents in the gastrointestinal tract and to highlight the predominant role of multidetector row computed tomography (MDCT) in the detection of potential complications.

Refractory esophageal strictures: what to do when dilation fails

Benign esophageal strictures arise from a diversity of causes, for example esophagogastric reflux, esophageal resection, radiation therapy, ablative therapy, or the ingestion of a corrosive substance. Most strictures can be treated successfully with endoscopic dilation using bougies or balloons, with only a few complications. Nonetheless, approximately one third of patients develop recurrent symptoms after dilation within the first year. The majority of these patients are managed with repeat dilations, depending on their complexity. Dilation combined with intra lesional steroid injections can be considered for peptic strictures, while incisional therapy has been demonstrated to be effective for Schatzki rings and anastomotic strictures. When these therapeutic options do not resolve the stenosis, stent placement should be considered. Self bougienage can be proposed to a selected group of patients with a proximal stenosis. As a final step surgery is an option, but even then the risk of stricture formation at the anastomotic site remains. This chapter reviews refractory benign esophageal strictures and the treatment options that are currently available.

Foregut and colonic perforations: practical measures to prevent and assess them

Acute endoscopic perforations of the foregut and colon are rare but can have devastating consequences. There are several principles and practices that can lower the risk of perforation and guide the endoscopist in early assessment when they do occur. Mastery of these principles will lead to overall improved patient outcomes.

Endoscopic balloon dilatation for benign esophageal stricture after endoscopic submucosal dissection for early esophageal neoplasms

OBJECTIVE

The aim of this study was to evaluate the safety and efficacy of endoscopic balloon dilatation (EBD) for benign esophageal strictures after ESD for early esophageal neoplasms.

METHODS

Data of 335 patients who were treated with ESD for early esophageal neoplasms from October 2006 to August 2012 were retrospectively reviewed. The characteristics of the patients who underwent EBD for post-ESD stricture were analyzed.

RESULTS

A total of 117 dilatation procedures were performed in 29 patients with post-ESD esophageal stricture. The mean number of EBD sessions was 4.0 (range 1-15) and no complications occurred during the procedures. The median follow-up period for the 29 patients since their last session of EBD was 20 months (range 1-48 months). Of the 28 patients who were followed up for more than 3 months after achieving dysphagia relief, two had recurrent dysphasia and EBD was reintroduced. The treatment success rate was 92.9% (26/28).

CONCLUSION

EBD is a safe and effective modality for the treatment of benign esophageal stricture after ESD for early esophageal neoplasms.

Laparoscopic heller myotomy for achalasia cardia-initial experience in a teaching institute

Laparoscopic Heller cardiomyotomy and Dor fundoplication is the surgical procedure of choice for esophageal achalasia. The aim of our study was to investigate the clinical outcome and safety of laparoscopic Heller-Dor procedure performed by using Hook electrocautery and as a teaching module for advanced laparoscopic surgery. Between January 2005 and December 2010, 25 consecutive patients with achalasia underwent laparoscopic Heller-Dor operation by a single surgeon. All the patients received upper gastrointestinal series (barium swallow), esophagogastroscopy, and esophageal manometry to exclude esophageal carcinoma and to confirm the diagnosis. All the patients were operated by laparoscopic modified Heller myotomy with Dor fundoplication by using hook electrocautery. Among 25 operated patients, 14 were male and 11 were female with a median age of 43 years (range 18-72 years). The mean operative time was 93.3 min (range 50-50 min), the mean operative blood loss was 90 ml (range 40-200 ml), the median time to oral feeding was 2 days (2-4 days), and the median hospital stay was 4 days (4-7 days). There was no conversion to open surgery. Intraoperative mucosal perforation was encountered in three patients and was repaired in all of them by laparoscopic suture. All the patients had an uneventful recovery without postoperative complication and had excellent clinical response (96 %) during follow-up. Laparoscopic Heller-Dor operation using hook electrocautery is safe, inexpensive, and effective treatment for achalasia which is useful for teaching and training surgical residents in advanced laparoscopic surgery.

Esophageal stricture induced by an ultraslim upper endoscope in a novel rabbit model of corrosive injury

OBJECTIVE

Benign esophageal strictures are regularly encountered problems in clinical practice. The management of refractory benign esophageal stricture, which fails to establish adequate food passage despite multiple dilatation sessions, has been considered challenging. Experimental animal models are essential for the development of effective treatment methods. The aim of this study was to establish a new animal model of benign esophageal stricture using rabbits.

MATERIAL AND METHODS

Corrosive injury of the esophagus was induced by administration of 1 ml of 1.5% sodium hydroxide in eight rabbits using an ultraslim upper endoscope equipped with a 5-Fr polytetrafluoroethylene tube and 5-Fr balloon catheter. Two weeks after corrosive injury, endoscopic examination was performed to confirm the state of the injury site. Four weeks after corrosive injury, the esophageal stricture was assessed by endoscopy and esophagography. All animals were then euthanized.

RESULTS

Two weeks after corrosive injury, endoscopic examination showed that ulceration had been induced. Four weeks after corrosive injury, endoscopic, radiologic and gross examinations showed that esophageal stricture had been induced without complications in all animals. The esophageal lumen diameter was reduced by an average of 51.8% (range, 48.3%-57.2%), and the mean stricture length was 25.7 mm (range, 20.1-29.3 mm). Microscopic examination revealed focal ulceration and submucosal thickening secondary to fibrosis.

CONCLUSIONS

Rabbit esophageal stricture induced by endoscopic delivery of a small amount of low-concentration sodium hydroxide is a relatively simple, safe, and reproducible animal model. This model may be useful in the development of new treatment methods for esophageal stricture.

Causes and treatments of achalasia, and primary disorders of the esophageal body

The following on achalasia and disorders of the esophageal body includes commentaries on controversies regarding whether patients with complete lower esophageal sphincter (LES) relaxation can be considered to exhibit early achalasia; the roles of different mucle components of the LES in achalasia; sensory neural pathways impaired in achalasia; indications for peroral endoscopic myotomy and advantages of the technique over laparoscopic and thorascopic myotomy; factors contributing to the success of surgical therapy for achalasia; modifications to the classification of esophageal body primary motility disorders in the advent of high-resolution manometry (HRM); analysis of the LES in differentiating between achalasia and diffuse esophageal spasm (DES); and appropriate treatment for DES, nutcracker esophagus (NE), and hypertensive LES (HTLES).

Botulinum toxin treatment for oropharyngeal dysphagia in patients with stroke

BACKGROUND

In a previous pilot study, we demonstrated that a single injection of botulinum toxin A (BTX-A) in the cricopharyngeus muscle is effective in patients with neurologic dysphagia with upper esophageal sphincter (UES) opening dysfunction and presence of some pharyngeal contraction (>25 mmHg). The aim of this study was to confirm the long-lasting efficacy of this procedure after stroke.

METHODS

We prospectively studied 23 patients with stroke for at least 6 months before administration of a BTX-A injection. Baseline diagnosis of UES opening dysfunction and presence of some pharyngeal contraction were assessed by videofluoroscopy (VFS) and esophageal manometry (EM). Clinical and VFS follow-up was made at 3 weeks and 3, 6, and 12 months postinjection.

KEY RESULTS

Eighteen patients (78%) were fed by gastrostomy tube prior to treatment. Videofluoroscopy showed UES relaxation impairment, residue in pyriform sinuses, and aspiration in all cases. After BTX-A, the number of patients with aspiration and pharyngeal residue decreased to 52% and 70%, respectively (p < 0.05 for both); residue was severe in only 4%. Esophageal manometry showed a mean pharyngeal amplitude 66.8 mmHg (range: 25-120 mmHg). We observed a significant improvement in feeding mode during follow-up: after 3 months, 70% of patients were eating exclusively by mouth. Lower residual pressure and minor pharyngeal delay time at baseline were all predictive factors for treatment effectiveness.

CONCLUSIONS & INFERENCES

A single injection of BTX-A is efficacious for a period of at least 12 months in improving oropharyngeal dysphagia in stroke patients with UES opening dysfunction and some pharyngeal contraction (>25 mmHg).

Self-dilation as a treatment for resistant, benign esophageal strictures

GOALS AND BACKGROUND

Simple benign strictures may be relieved with one to three dilation sessions. Resistant benign strictures are anatomically complex and resistant to therapy. We sought to determine the efficacy and safety of esophageal self-dilation with bougie dilators in the largest series to date.

STUDY

A retrospective chart review was performed to identify patients who underwent esophageal self-dilation at two tertiary referral centers (Mayo Clinic, Scottsdale, Arizona and Mayo Clinic Rochester, Minnesota) between January 1, 2003 and June 30, 2012. Demographic details and clinical information regarding relief of dysphagia, complications, and frequency of endoscopic and self-dilation were abstracted.

RESULTS

Of the 32 patients who began self-dilation for nonmalignant strictures, 30 [22 men; median (range) age, 62 years (22-86 years)] were included in the study. Median (range) follow-up was 37 months (14-281 months). Stricture etiology included radiation therapy (n = 8), anastomotic stricture (n = 9), eosinophilic esophagitis (n = 4), caustic ingestion (n = 3), photodynamic therapy (n = 2), granulation tissue (n = 2), peptic stricture (n = 1) and one patient had radiation therapy and peptic stricture. The average number (range) of physician performed dilations before self-dilation was 12 (4-55). Esophageal self-dilation was successful in treating 90 % of patients. Dysphagia score (2 vs. 1; P < 0.001), stricture diameter (median; 5 vs. 12 mm; P < 0.001) and weight (median; 73 vs. 77 kg; P < 0.001) were significantly different between EDG dilation versus self-dilation.

CONCLUSIONS

Esophageal self-dilation is a safe, effective treatment for resistant, benign esophageal strictures. This management strategy should be strongly considered in this patient population.

Endoscopic repair of post-surgical gastrointestinal complications

Complications following gastrointestinal surgery may require re-intervention, can lead to prolonged hospitalization, and significantly increase health costs. Some complications, such as anastomotic leakage, fistula, and stricture require a multidisciplinary approach. Therapeutic endoscopy may play a pivotal role in these conditions, allowing minimally invasive treatment. Different endoscopic approaches, including fibrin glue injection, endoclips, self-expanding stents, and endoscopic vacuum-assisted devices have been introduced for both anastomotic leakage and fistula treatment. Similarly endoscopic treatments, such as endoscopic dilation, incisional therapy, and self-expanding stents have been used for anastomotic strictures. All these techniques can be safely performed by skilled endoscopists, and may achieve a high technical success rate in both the upper and lower gastrointestinal tract. Here we will review the endoscopic management of post-surgical complications; these techniques should be considered as first-line approach in selected patients, allowing to avoid re-operation, reduce hospital stay, and decrease costs.

The management of eosinophilic esophagitis in adults

Eosinophilic esophagitis (EoE), typically a pediatric disease, is becoming more frequently recognized in adults. The optimal treatment of EoE in this population has not yet been established. This paper reviews the literature detailing the treatments for EoE in adults, and provides a treatment strategy. To accomplish this task a comprehensive literature search of Medline was undertaken for studies evaluating the treatment of EoE in adults. High-dose topical corticosteroids and specific elimination diets have been found to improve symptoms, reduce eosinophilic infiltrate in esophageal mucosa, and improve endoscopic markers of inflammation. Dilation therapy does improve symptoms but not underlying inflammation. Other treatments including leukotriene inhibitors and immunomodulatory drugs have been unsuccessful. An effective strategy for treating EoE in adults is using topical corticosteroids and elimination diets for inflammatory disease, and esophageal dilation for fibrotic disease. The conclusion that inflammatory and fibrotic components of EoE respond to different treatment modalities should be evaluated in future clinical trials.

Efficacy and safety of pneumatic dilatation for achalasia in the treatment of post-myotomy symptom relapse

OBJECTIVES

There is no consensus on how best to treat symptom recurrence following previous therapy with Heller myotomy. Our aim was to determine the safety and the short and long-term efficacy of pneumatic dilatation to treat symptomatic recurrence in patients previously treated with Heller myotomy for idiopathic achalasia.

METHODS

We identified 27 eligible patients treated with pneumatic dilatation, for symptom recurrence following Heller myotomy as their initial or secondary treatment, from a prospectively acquired database of 450 patients with a diagnosis of achalasia seen between 1995 and 2010. Our treatment protocol involved sequential, graded pneumatic dilatations (30-35-40 mm) over a 2-6 week period until an initial therapeutic response was achieved. The subsequent relapse rate, defined as the need for any subsequent therapy, was determined. Relapsers were offered further pneumatic dilatation "on demand". A cross-sectional analysis was also performed using a validated achalasia severity questionnaire to determine the overall long-term remission rate.

RESULTS

Of 27 eligible patients, 25 (93%) complied with the institutional dilatation protocol. The two drop-outs did so after the initial 30 mm dilatation and were deemed treatment failures. One additional patient did not respond despite protocol compliance. Therefore, 24 of 27 (89%) patients were responders on intention to treat analysis at 12 months, while the per protocol response rate was 24 of 25 (96%). Among the 24 responders 16, 25, and 42% relapsed at 2, 3 and 4  years, respectively. Overall long-term remission, with on demand dilatations as required, was 95% (median follow-up 30 months). There were no perforations in a total of 50 dilatations in 27 patients.

CONCLUSIONS

In treating symptom recurrence, following prior Heller myotomy, pneumatic dilatation is safe and yields an excellent short-term response rate. Although the long-term relapse rate is substantial, subsequent on demand pneumatic dilatation in this population is highly effective with a long-term remission rate of 95%. These data also highlight the need to keep these patients under long-term review.

Endoscopic corticosteroid injections do not reduce dysphagia after endoscopic dilation therapy in patients with benign esophagogastric anastomotic strictures

BACKGROUND & AIMS

Benign anastomotic strictures are often difficult to treat. We assessed the efficacy of adding corticosteroid injections to endoscopic dilation therapy with Savary bougienage.

METHODS

In a multicenter, double-blind trial, 60 patients (mean age, 63 ± 9 years; 78% male) with an untreated cervical anastomotic stricture after esophagectomy with gastric tube reconstruction and dysphagia for at least solid food were randomly assigned to groups given 4 quadrant injections of 0.5 mL triamcinolone (40 mg/mL, n = 29) or saline (controls, n = 31) into the stricture, followed by Savary dilation to 16 mm. Dysphagia, complications, and quality of life were assessed after 1 and 2 weeks and 1, 3, and 6 months. The primary end point was a dysphagia-free period of 6 months.

RESULTS

In the corticosteroid group, 45% of the patients remained dysphagia-free for 6 months, compared with 36% of controls (relative risk, 1.26; 95% confidence interval, 0.68-2.36; P = .46). Median time to repeat dilation was 108 days (range, 15-180 days) in the corticosteroid group vs 42 days (range, 17-180 days) for controls (P = .11). A median number of 2 dilations (range, 1-7) was performed in the corticosteroid group vs 3 dilations (range, 1-9) in controls (relative risk, 0.76; 95% confidence interval, 0.42-1.38; P = .36). Two major intervention-related complications occurred, 1 submucosal laceration in the corticosteroid group and 1 hemorrhage in the control group. Four patients in the corticosteroid group, but none of the controls, developed Candida esophagitis (P = .03).

CONCLUSIONS

Corticosteroid injections do not provide a statistically significant decrease in frequency of repeat dilations or prolongation of the dysphagia-free period in patients with benign anastomotic esophagogastric strictures. Dutch Trial Registration Number 2236.

Changing epidemiology of food bolus impaction: is eosinophilic esophagitis to blame?

BACKGROUND AND AIM

Data on the relationship between epidemiological changes in food bolus impaction (FBI) and its relationship to eosinophilic esophagitis (EoE) are limited. The aim of this study was to evaluate changes in the prevalence and etiology of FBI at the Royal Adelaide Hospital over 15 years.

METHODS

Details of all patients who presented with FBI to Royal Adelaide Hospital (1996-2010) were reviewed from a prospective database. Detailed endoscopic and histological findings were examined for patients admitted under the Gastroenterology team.

RESULTS

From 1996-2010, 539 patients were admitted. Prevalence of FBI increased overtime, with a male preponderance. The age at presentation was significantly lower in 2006-2010 (56.2 ± 1.6 years) compared with 2001-2005 (61.6 ± 1.9 years, P=0.03). There was a reduction in the proportion of patients with peptic-related stricture (from 75% [1996-2000] to 41% [2006-2010] [P<0.001]) and an increase in the prevalence of EoE (from 0% [1996-2000] to 35% [2006-2010], P<0.001). The proportion of patients who had esophageal biopsies taken at the index endoscopy also increased (8% [1996-2000] vs 28% [2001-2005] and 61% [2006-2010], P<0.01). There were no significant changes in rate of malignancy or post-surgical strictures. Endoscopic removal of food bolus was required in 86% of cases and, of these, 98% were successful with no complication or death.

CONCLUSIONS

The prevalence of FBI has increased over the last 15 years. This was associated with an increased prevalence of EoE and a reduction in age of presentation and peptic-related strictures. These findings suggest that EoE is an important cause of FBI and that esophageal mucosal biopsy should be performed in all cases of FBI.

Management of achalasia

Achalasia is a rare motility disorder of the esophagus characterized by the absence of peristalsis and defective relaxation of the lower esophageal sphincter. Patients present at all ages with dysphagia and regurgitation as main symptoms. The diagnosis is suggested by barium swallow and endoscopy and confirmed by manometry. Because there is no curative treatment for achalasia, treatment is confined to disruption of the lower esophageal sphincter to improve bolus passage. The most successful therapies are pneumodilation and laparoscopic Heller myotomy, with comparable short-term clinical rates of success. The prognosis of achalasia patients is good, but re-treatment is often necessary.

The Use of a Cutting Balloon for Dilation of a Fibrous Esophageal Stricture in a Cat

Esophageal strictures are uncommon in cats with causes including medications, ingestion of caustic substances, or gastroesophageal reflux under anesthesia. Bougienage and balloon dilation are the main treatments for strictures but have variable success rates. This paper describes the novel use of a cutting balloon for dilation of a fibrous stricture in a cat that was previously refractory to treatment with traditional balloon dilation.

Esophageal stasis on a timed barium esophagogram predicts recurrent symptoms in patients with long-standing achalasia

OBJECTIVES

In achalasia, early recognition of the need for retreatment is of crucial importance to reduce morbidity and long-term complications such as esophageal decompensation. In clinical practice, symptoms and parameters of esophageal function including lower esophageal sphincter (LES) pressure and esophageal emptying are used to decide whether additional treatment is required. However, which of these tests performs best remains unclear.

METHODS

A cohort of 41 patients with long-standing achalasia (median 17 years), underwent esophageal manometry, timed barium esophagogram and symptom evaluation. Patients were followed up for 10 years, and were regarded as a therapeutic failure if Eckardt score was >3 or when retreatment was needed. Predictors of therapeutic failure were evaluated.

RESULTS

Of the 41 included patients, 7 patients had an elevated LES pressure (>10 mm Hg) and 26 had esophageal stasis >5 cm on timed barium esophagogram. During follow-up, 25 patients had recurrence of symptoms and were considered therapeutic failures. Of the 25 patients, 5 had an elevated LES pressure, whereas 22 had esophageal stasis on barium esophagogram. Hence, the sensitivity to predict the need of retreatment is higher for esophageal stasis (88%) compared with LES pressure (20%). A total of 16 patients (39%) were in long-term remission, of which 12 patients (75%) did not have stasis at their initial visit.

CONCLUSIONS

In contrast to LES pressure, esophageal stasis is a good predictor of treatment failure in patients with long-standing achalasia. Based on these findings, we propose to use timed barium esophagogram rather than esophageal manometry as test to decide on retreatment.

Laparoscopic heller myotomy for achalasia cardia-initial experience in a teaching institute

Laparoscopic Heller cardiomyotomy and Dor fundoplication is the surgical procedure of choice for esophageal achalasia. The aim of our study was to investigate the clinical outcome and safety of laparoscopic Heller-Dor procedure performed by using Hook electrocautery and as a teaching module for advanced laparoscopic surgery. Between January 2005 and December 2010, 25 consecutive patients with achalasia underwent laparoscopic Heller-Dor operation by a single surgeon. All the patients received upper gastrointestinal series (barium swallow), esophagogastroscopy, and esophageal manometry to exclude esophageal carcinoma and to confirm the diagnosis. All the patients were operated by laparoscopic modified Heller myotomy with Dor fundoplication by using hook electrocautery. Among 25 operated patients, 14 were male and 11 were female with a median age of 43 years (range 18-72 years). The mean operative time was 93.3 min (range 50-50 min), the mean operative blood loss was 90 ml (range 40-200 ml), the median time to oral feeding was 2 days (2-4 days), and the median hospital stay was 4 days (4-7 days). There was no conversion to open surgery. Intraoperative mucosal perforation was encountered in three patients and was repaired in all of them by laparoscopic suture. All the patients had an uneventful recovery without postoperative complication and had excellent clinical response (96 %) during follow-up. Laparoscopic Heller-Dor operation using hook electrocautery is safe, inexpensive, and effective treatment for achalasia which is useful for teaching and training surgical residents in advanced laparoscopic surgery.

Treatment of the patient with achalasia

PURPOSE OF REVIEW

In recent years, several studies on the treatment and follow-up of achalasia have been published. This review aims at highlighting interesting publications from the recent years.

RECENT FINDINGS

Treatment of achalasia aims at relieving functional obstruction at the level of the esophagogastric junction. Several treatment options such as pneumodilation and laparoscopic Heller myotomy (LHM) are available for this purpose. A large prospective randomized trial comparing pneumodilation and LHM demonstrated comparable success rates and quality of life for the two treatment options. Long-term data demonstrate comparable treatment success rates, when redilation in case of recurrent symptoms after pneumodilation is accepted. The most important risk factor for treatment failure is the manometric subtype, with a worse outcome for type I and type III compared with type II achalasia. Recently, peroral endoscopic myotomy (POEM) has been described with high success rates. Comparative studies with longer follow-up are awaited. A prospective study assessing the risk of esophageal carcinoma in patients with achalasia showed a 28-fold increased risk to develop carcinoma.

SUMMARY

Either LHM or pneumodilation have high comparable short-term clinical success rates. Based on the increased risk to develop esophageal carcinoma, a screening program may be indicated. POEM is a new interesting treatment but longer follow-up data are awaited.

Diagnostic accuracy of age and alarm symptoms for upper GI malignancy in patients with dyspepsia in a GI clinic: a 7-year cross-sectional study

OBJECTIVES

We investigated whether using demographic characteristics and alarm symptoms can accurately predict cancer in patients with dyspepsia in Iran, where upper GI cancers and H. pylori infection are common.

METHODS

All consecutive patients referred to a tertiary gastroenterology clinic in Tehran, Iran, from 2002 to 2009 were invited to participate in this study. Each patient completed a standard questionnaire and underwent upper gastrointestinal endoscopy. Alarm symptoms included in the questionnaire were weight loss, dysphagia, GI bleeding, and persistent vomiting. We used logistic regression models to estimate the diagnostic value of each variable in combination with other ones, and to develop a risk-prediction model.

RESULTS

A total of 2,847 patients with dyspepsia participated in this study, of whom 87 (3.1%) had upper GI malignancy. Patients reporting at least one of the alarm symptoms constituted 66.7% of cancer patients compared to 38.9% in patients without cancer (p<0.001). Esophageal or gastric cancers in patients with dyspepsia was associated with older age, being male, and symptoms of weight loss and vomiting. Each single predictor had low sensitivity and specificity. Using a combination of age, alarm symptoms, and smoking, we built a risk-prediction model that distinguished between high-risk and low-risk individuals with an area under the ROC curve of 0.85 and acceptable calibration.

CONCLUSIONS

None of the predictors demonstrated high diagnostic accuracy. While our risk-prediction model had reasonable accuracy, some cancer cases would have remained undiagnosed. Therefore, where available, low cost endoscopy may be preferable for dyspeptic older patient or those with history of weight loss.

Endoscopic balloon dilatation for benign fibrotic strictures after curative nonsurgical treatment for esophageal cancer

BACKGROUND

Endoscopic balloon dilatation (EBD) is performed to treat strictures after esophagectomy. However, little is known about using EBD for benign strictures that occur after nonsurgical treatments for esophageal cancer such as chemoradiotherapy (CRT) or endoscopic mucosal resection (EMR). The aim of this study was to evaluate the safety and efficacy of EBD for benign strictures after nonsurgical treatment compared with those after surgery.

METHODS

We identified 823 patients with esophageal cancer who completed definitive treatments between 2004 and 2007. Of these patients, 122 were enrolled in our study, including 60 who had surgery and 62 who did not have surgery (32 CRT, 30 EMR). The indication criteria for EBD were complaint of dysphagia and the inability to pass a conventional endoscope due to benign stricture. We retrospectively analyzed the safety and efficacy of EBD, and the measured outcomes were treatment success rate, time to treatment success, and refractory stricture rate.

RESULTS

Perforation occurred in 3 (0.3 %) of 1,077 EBD sessions, with no bleeding. Efficacy was evaluated in 110 of the 122 patients. While the treatment success rate was over 90 % in both the surgery and the nonsurgery group, there was a significant difference in the median time to treatment success between both groups (2.3 vs. 5.6 months, p = 0.02: log-rank test). There was a significant difference in the median time to treatment success between CRT and surgery groups (7.0 months, p = 0.01), with no significant difference in the EMR group (4.4 months, p = 0.85). A significant difference in the refractory stricture rate was evident between the nonsurgery group (75 %) and the surgery group (45 %, p < 0.01).

CONCLUSION

EBD for stricture after nonsurgical treatment of esophageal cancer was safe and effective. However, patients with benign strictures after nonsurgical treatment required significantly longer time to recover from dysphasia compared to those after surgery.