Home self-dilatation for esophageal strictures

Outcome of a novel self-control stricture-preventing water balloon for complete circular esophageal endoscopic submucosal dissection

OBJECTIVES

Post-ESD esophageal stricture especially after wholly circumferential ESD remains an unresolved issue without ideal strategies. Our initiative novel self-control stricture-preventing water balloon may be an alternative.

METHODS

Patients with esophageal neoplastic lesions expected to result in a whole circular mucosa defect after esophageal ESD from February 2018 to August 2020 were included in the study. We used a novel self-control stricture-preventing water balloon combined with oral prednisolone as preventive strategy for the enrolled patients.

RESULTS

Thirty-seven patients (9 females and 28 males, patients aged 52 to 82 years) finished the 12-week treatment including steroid treatment and balloon placement. The median size of longitudinal diameter was 7 cm (range from 4 to 14 cm). All the lesions achieved curative resection and the median procedure time was 110 min (range 50 to 180 min). Balloons were found migration in 4 patients. As a result, there were 3 patients (8.1%) experienced stricture. Generally, patients could tolerate to balloons, only with mild uncomfortableness, such as occasional sore throat, cough, and retrosternal pain. In addition, during the follow-up period, no significant adverse events associated to oral steroid administration were observed and no recurrence was found.

CONCLUSIONS

Our novel self-control stricture-preventing water balloon based on the oral steroid therapy is effective and safe. This strategy well prevents esophageal stricture after complete circumferential ESD.

Time to Death and Predictors Among Neonates with Esophageal Atresia in Ethiopia

Background

Esophageal atresia is an upper gastrointestinal tract developmental abnormality in which the upper and lower esophagus do not connect. Esophageal atresia has a higher incidence of death in sub-Saharan Africa, ranging from 30% to 80%. In Ethiopia, infants with esophageal atresia had a higher mortality rate. The assessment of time to death and predictors of esophageal atresia can help to reduce newborn mortality.

Objective

This study was aimed to investigate the time to death and predictors of neonates with esophageal atresia admitted to Tikur Anbessa Specialized Hospital, Ethiopia.

Methods

An institutional-based retrospective follow-up study was conducted among 225 neonates diagnosed with esophageal atresia. The median survival time, Kaplan–Meier failure estimation curve, and Log rank test were computed. Bivariable and multivariable Cox regression hazards models were fitted to identify the predictors of time to death. Hazard ratio with a 95% confidence interval was calculated and p-values <0.05 were considered statistically significant.

Results

In the study, the incidence density rate of neonates diagnosed with esophageal atresia was 5.5 (95% CI, 4.7–6.4) per 100-neonates day. The median time to death was 11 days (95% confidence interval (CI), 8.92–13.08). Birth weight <2500 g (adjusted hazard ratio (AHR)=1.49, 95% CI, 1.02 −2.21), having sepsis (AHR=1.67,95% CI, 1.15–2.44), being malnourished (AHR = 1.61, 95% CI, 1.03 −2.58), esophageal atretic neonates without surgery (AHR = 3.72, 95% CI, 1.34–10.38), diagnosis time at >48 hours of admission (AHR = 1.48, 95% CI, 1.01–2.15) and being dehydrated (AHR = 2.38, 95% CI, 1.63–3.46) were significant predictors of time to death among esophageal atretic neonates.

Conclusion

The findings in this study highlighted the necessity of early diagnosis, proper comorbidity treatment, and timely surgical intervention to reduce infant deaths due to esophageal atresia.

Efficacy and Safety of Endoscopic Esophageal Dilatation in Pediatric Patients with Esophageal Strictures

Materials and Methods

In this retrospective cross-sectional single center study, records of patients with esophageal strictures presented to the pediatric department, Salmaniya Medical Complex, Bahrain, in the period between 1995 and 2019 were reviewed. Demographic data, indications of endoscopic dilatations, the procedure success rate, and possible complications were assessed.

Results

Forty-six children were found to have esophageal strictures. Twenty-five (54.3%) patients were males. Most patients presented during infancy (86.5%, 32/37 patients). Twenty-six (56.5%) patients required 88 dilatation sessions, while the remaining 20 (43.5%) patients did not require dilatations. The median number of dilatation sessions per patient was three (interquartile range = 2-5). Savary-Gilliard bougienages were the main dilators used (80.8%, 21/26 patients). Anastomotic stricture (post esophageal atresia/tracheoesophageal fistula repair) was the main cause of esophageal strictures and was found in 35 (76.1%) patients. Patients with nonanastomotic strictures had more frequent dilatations compared to those with anastomotic strictures (P = 0.007). The procedure success rate was 98.8%. Yet, it was operator dependent (P = 0.047). Complete response to dilatation was found in 18 (69.2%) patients, satisfactory in seven (26.9%), and an inadequate response in one (3.9%). Those with satisfactory responses still require ongoing dilatations based on their symptoms and radiological and endoscopic findings. No perforation or mortality was reported. Patients with dilatations had more recurrent hospitalization (P < 0.0001), more dysphagia (P = 0.001), but shorter hospital stay (P = 0.046) compared to those without dilatations. Surgical intervention was required in one patient with caustic strictures. The median follow-up period was six years (interquartile range = 2.25-9.0).

Conclusions

Endoscopic esophageal dilatation in children with esophageal strictures is effective and safe. Yet, it was operator dependent. Nonanastomotic strictures require more dilatations compared to anastomotic strictures. Findings of this study are comparable to those reported worldwide.

Personalized Radiation Attenuating Materials for Gastrointestinal Mucosal Protection

Cancer patients undergoing therapeutic radiation routinely develop injury of the adjacent gastrointestinal (GI) tract mucosa due to treatment. To reduce radiation dose to critical GI structures including the rectum and oral mucosa, 3D-printed GI radioprotective devices composed of high-Z materials are generated from patient CT scans. In a radiation proctitis rat model, a significant reduction in crypt injury is demonstrated with the device compared to without (p < 0.0087). Optimal device placement for radiation attenuation is further confirmed in a swine model. Dosimetric modeling in oral cavity cancer patients demonstrates a 30% radiation dose reduction to the normal buccal mucosa and a 15.2% dose reduction in the rectum for prostate cancer patients with the radioprotectant material in place compared to without. Finally, it is found that the rectal radioprotectant device is more cost-effective compared to a hydrogel rectal spacer. Taken together, these data suggest that personalized radioprotectant devices may be used to reduce GI tissue injury in cancer patients undergoing therapeutic radiation.

Self-dilatation of benign oesophageal strictures: a literature review

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.

Feasibility and Safety of Office-Based Transnasal Balloon Dilation for Neopharyngeal and Proximal Esophageal Strictures in Patients with a History of Head and Neck Carcinoma

The aim of this study was to assess feasibility and safety of office-based transnasal balloon dilation of neopharyngeal and proximal esophageal strictures in patients with a history of head and neck carcinoma. The secondary objective was to explore its effectiveness. This prospective case series included patients previously treated for head and neck carcinoma with neopharyngeal or proximal esophageal strictures who underwent transnasal balloon dilation under topical anesthesia. The target dilation diameter was 15 mm; if necessary dilation procedures were repeated every 2–4 weeks until this target was reached. Completion rates, adverse events, and patient experiences measured by VAS scores (0 = no complaints – 10 = unbearable complaints), dysphagia scores based on food consistency (0 = no dysphagia – 5 = unable to swallow liquids/saliva), and self-reported changes in swallowing symptoms were recorded. Follow-up was 2 months. Twenty-six procedures were performed in 12 patients, with a completion rate of 92%. One minor complication occurred, i.e. an infection of the dilation site. Tolerance of the procedure was good (median VAS = 2). The dysphagia score improved after a mean of 2.2 procedures per patient, however not significantly. Eight patients reported improvement in dysphagia, of whom 3 had recurrence of dysphagia within 1 month post-treatment. Office-based transnasal balloon dilation is a feasible and safe in-office procedure which is well-tolerated by patients. The dilations can improve dysphagia, although effects might be transient.

Use of Vaginal Reconstructive Surgery in Cervical Cancer Patients to Prevent Vaginal Stump Contracture

PURPOSE

The life quality of cervical cancer patients is severely compromised due to the vaginal stump contracture after surgery combined with radiotherapy. Therefore, our study focuses on ameliorating or preventing postoperative vaginal contracture. The objectives of this study were (1) to evaluate the method of ileal graft with vascular pedicle to extend the length of vagina and (2) to investigate the effect of the operation to prevent vaginal stump contracture after cervical cancer surgery combined with radiotherapy.

METHODS

Twenty-five patients with vaginal stump contracture after cervical cancer radical resection with sequential radiotherapy were recruited for the study between 2011 and 2014. The therapy includes releasing the adhesion between vaginal stump and rectum as well as bladder, resecting the vaginal stump but reserving the exterior orifice of vagina, and extending the vaginal length using vascularized ileal graft.

RESULTS

No postoperative complications such as infection and bleeding were observed in all 25 patients. The patients were satisfied with the length and width of vagina after extension; the discharge of reconstructed vagina was acceptable. All patients had sexual intercourse on the follow-up examination, and five patients complained of vaginal bleeding during or after sexual intercourse, although no abnormality was found on colposcopy.

CONCLUSIONS

The patients demonstrated a high level of safety, efficacy, and satisfaction with the ileal-vaginal extension for treating vaginal stump contracture after cervical cancer surgery combined with radiotherapy, suggesting that this method is valid for broad clinical application to improve the life quality of cervical cancer patients after surgery.

Outcomes of Self-Esophageal Dilation for Head and Neck Cancer Patients

Introduction Dysphagia is common following treatment for head and neck cancers, and self-esophageal dilation is a safe and effective treatment method. Prior studies on self-dilation have reported only qualitative results and included heterogeneous populations with dysphagia. The objective of this study is to quantitatively assess the safety and efficacy of a self-esophageal dilation program for patients with oropharyngeal squamous cell cancer with treatment-induced dysphagia. Materials and Methods This is a retrospective review of patients with oropharyngeal squamous cell cancer treated at the University of Southern California from 2009 to 2013 with dysphagia following radiation treatment that persisted after swallow therapy. The treatment program consisted of swallow therapy in conjunction with weekly self-esophageal dilation at home with increasing size bougie dilators. Oral intake was monitored using the Functional Oral Intake Scale (Crary, Mann, & Groher, 2005), Modified Barium Swallow Impairment Profile Pharyngoesophageal opening score, and Penetration-Aspiration Scale (Rosenbek, Robbins, Roecker, Coyle, & Wood, 1996) pre- and posttreatment. Results Thirty-three patients met study criteria and completed the program. Twenty-five patients required nutrition via a gastrostomy tube prior to starting therapy, and 84% (21/25) of these patients were able to have the feeding tube removed. Median Functional Oral Intake Scale (Crary et al., 2005) predilation was 1 (range: 1-5), and postdilation was 6 (range: 3-6, p < .05). In addition, there was improvement of the Modified Barium Swallow Impairment Profile Pharyngoesophageal opening score from 2 to 1 after treatment (p < .05). No complications were encountered. Discussion Home self-dilation with concurrent swallowing therapy is a safe and feasible procedure to be used in motivated patients with dysphagia following head and neck cancer treatment.

Novel Use for Maloney Dilators in the Management of Gastrostomy Stenosis

Gastrostomy tube dislodgement is a common complication after gastrostomy tube placement. If the tube is not immediately replaced, the gastrostomy stomal tract may close in as little as 8 hours. Small case series have reported the salvage of partially closed or stenosed gastrostomy stomal tracts using different types of dilators, but the use of Maloney dilators for this indication has not been reported. Dilation of a stenosed tract can allow for immediate re-establishment of enteral access without the need for a repeat invasive procedure. We present 3 instances of gastrostomy stenosis successfully dilated with Maloney dilators using minimal topical anesthesia.

Outcomes of oesophageal self-dilation for patients with refractory benign oesophageal strictures

BACKGROUND

Current management of refractory benign oesophageal strictures with endoscopic dilations and stenting leads to resolution of dysphagia in only 30% of patients. Oesophageal self-dilation may be an alternative.

AIM

To evaluate the efficacy and safety of oesophageal self-dilation at a tertiary referral centre.

METHODS

We conducted a retrospective review of patients with refractory benign oesophageal strictures who participated in oesophageal self-dilation at Mayo Clinic (Rochester, MN, USA) between 2003 and 2017. Clinical data including stricture characteristics, Dakkak and Bennett Dysphagia Score, number and dates of endoscopies, and complications were collected. A two-tailed paired Student's t test was used to compare the measures of efficacy, with differences considered significant at a 5% probability level.

RESULTS

We identified 52 patients with refractory strictures treated with self-dilation. The median number of endoscopic interventions was reduced from 9.5 (range 5-30) to 0 (range 0-3) within 12 months before and after self-dilation, respectively (P < 0.0001). A median intervention-free interval of 417 days (IQR 256-756 days) was observed. The mean dysphagia score at baseline was 2.5 (95% CI 2.2-2.8) and 0.33 (95% CI 0.11-0.53) after self-dilation. 23 of 27 (85%) patients who received enteral nutrition prior to self-dilation had their feeding tubes removed.

CONCLUSIONS

Oesophageal self-dilation is an effective way of maintaining oesophageal patency in refractory benign oesophageal strictures, with safety comparable to current standard of care. Prospective studies are needed to further validate the role of self-dilation in treatment of refractory benign oesophageal strictures.

UK guidelines on oesophageal dilatation in clinical practice

These are updated guidelines which supersede the original version published in 2004. This work has been endorsed by the Clinical Services and Standards Committee of the British Society of Gastroenterology (BSG) under the auspices of the oesophageal section of the BSG. The original guidelines have undergone extensive revision by the 16 members of the Guideline Development Group with representation from individuals across all relevant disciplines, including the Heartburn Cancer UK charity, a nursing representative and a patient representative. The methodological rigour and transparency of the guideline development processes were appraised using the revised Appraisal of Guidelines for Research and Evaluation (AGREE II) tool.Dilatation of the oesophagus is a relatively high-risk intervention, and is required by an increasing range of disease states. Moreover, there is scarcity of evidence in the literature to guide clinicians on how to safely perform this procedure. These guidelines deal specifically with the dilatation procedure using balloon or bougie devices as a primary treatment strategy for non-malignant narrowing of the oesophagus. The use of stents is outside the remit of this paper; however, for cases of dilatation failure, alternative techniques-including stents-will be listed. The guideline is divided into the following subheadings: (1) patient preparation; (2) the dilatation procedure; (3) aftercare and (4) disease-specific considerations. A systematic literature search was performed. The Grading of Recommendations Assessment, Develop-ment and Evaluation (GRADE) tool was used to evaluate the quality of evidence and decide on the strength of recommendations made.

Prospective evaluation of an indwelling esophageal balloon dilatation feeding tube for treatment of benign esophageal strictures in dogs and cats

Background

Despite multiple dilatation procedures, benign esophageal strictures (BES) remain a recurring cause of morbidity and mortality in dogs and cats.

Objective

Investigate the use of an indwelling Balloon Dilatation esophagostomy tube (B‐Tube) for treatment of BES in dogs and cats.

Animals

Nine dogs and 3 cats.

Methods

Animals with BES were recruited for our prospective study. Endoscopic and fluoroscopic evaluation of the esophagus and balloon dilatation were performed under general anesthesia, followed by placement of an indwelling B‐Tube. The animals' owners performed twice daily at‐home inflations for approximately 6 weeks. Repeat endoscopy was performed before B‐Tube removal. Animals were reevaluated for changes in modified dysphagia score (MDS) after B‐Tube removal.

Results

The B‐Tube management was relatively well tolerated and effective in maintaining dilatation of a BES while in place. These animals underwent a median of 2 anesthetic episodes and were monitored for a median of 472 days (range, 358‐1736 days). The mean MDS before treatment was 3.1 ± 0.5/4.0 and final follow‐up MDS were significantly (P < .0001) improved at 0.36 ± 0.65/4.0. Eleven of 12 animals (91.7%) had improved MDS at the end of the follow‐up period, with 8/12 (66.7%) having an MDS of 0/4, 2/12 (16.7%) an MDS of 1/4, and 1/12 (8.3%) an MDS of 2/4. One dog died.

Conclusions and Clinical Importance

The B‐Tube offers an effective, and more economical method, and often decreased anesthetic time to repeated balloon dilatation procedures for the treatment of BES in dogs and cats.

Self-dilation for therapy-resistant benign esophageal strictures: towards a systematic approach

BACKGROUND

Patients with therapy-resistant benign esophageal strictures (TRBES) suffer from chronic dysphagia and generally require repeated endoscopic dilations. For selected patients, esophageal self-dilation may improve patient's autonomy and reduce the number of endoscopic dilations. We evaluated the clinical course and outcomes of patients who started esophageal self-dilation at our institution.

METHODS

This study was a retrospective case series of patients with TRBES who started esophageal self-dilation between 2012 and 2016 at the Academic Medical Center Amsterdam. To learn self-dilation using Savary-Gilliard bougie dilators, patients visited the outpatient clinic on a weekly basis where they were trained by a dedicated nurse. Endoscopic dilation was continued until patients were able to perform self-bougienage adequately. The primary outcome was the number of endoscopic dilation procedures before and after initiation of self-dilation. Secondary outcomes were technical success, final bougie size, dysphagia scores, and adverse events.

RESULTS

Seventeen patients started with esophageal self-dilation mainly because of therapy-resistant post-surgical (41%) and caustic (35%) strictures. The technical success rate of learning self-bougienage was 94% (16/17). The median number of endoscopic dilation procedures dropped from 17 [interquartile range (IQR) 11-27] procedures during a median period of 9 (IQR 6-36) months to 1.5 (IQR 0-3) procedures after the start of self-dilation (p < 0.001). The median follow-up after initiation of self-dilation was 17.6 (IQR 11.5-33.3) months. The final bougie size achieved with self-bougienage had a median diameter of 14 (IQR 13-15) mm. All patients could tolerate solid foods (Ogilvie dysphagia score ≤ 1), making the clinical success rate 94% (16/17). One patient (6%) developed a single episode of hematemesis related to self-bougienage.

CONCLUSIONS

In this small case series, esophageal self-dilation was found to be successful 94% of patients when conducted under strict guidance. All patients performing self-bougienage achieved a stable situation where they could tolerate solid foods without the need for endoscopic dilation.