1
|
Singh AK, Reddy YR, Jena A, Appasani S, Gupta P, Sinha SK, Kochhar R. Endoscopic dilation with bougies versus balloons in caustic esophageal strictures: 17-year experience from a tertiary care center. Surg Endosc 2023; 37:8236-8244. [PMID: 37653157 DOI: 10.1007/s00464-023-10384-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 08/06/2023] [Indexed: 09/02/2023]
Abstract
INTRODUCTION Endoscopic dilation is the preferred management strategy for caustic esophageal strictures (CES). However, the differences in outcome for different dilators are not clear. We compared the outcome of CES using bougie and balloon dilators. METHODS Between January 2000 and December 2016, the following data of all the patients with CES were collected: demographic parameters, substance ingestion, number of strictures, number of dilations required to achieve ≥ 14 mm dilation, post-dilation recurrence, and total dilations. Patients were divided into two groups for the type of dilator, i.e., bougie or balloon. The two groups were compared for baseline parameter, technical success, short- and long-term clinical success, refractory strictures, recurrence rates, and major complications. RESULTS Of the 189 patients (mean age 32.17 ± 12.12 years) studied, 119 (62.9%) were males. 122 (64.5%) patients underwent bougie dilation and 67 (35.5%) received balloon dilation. Technical success (90.1% vs. 68.7%, p < 0.001), short-term clinical success (65.6% vs. 46.3%, p value 0.01), and long-term clinical success (86.9% vs. 64.2%, p < 0.01) were higher for bougie dilators compared to balloon dilators. Twenty-four (12.7%) patients developed adverse events which were similar for two groups. On multivariate analysis, use of bougie dilators (aOR 4.868, 95% CI 1.027-23.079), short-term clinical success (aOR 5.785, 95% CI 1.203-27.825), and refractory strictures (aOR 0.151, 95% CI 0.033-0.690) were independent predictors of long-term clinical success. CONCLUSION Use of bougie dilators is associated with better clinical success in patients with CES compared to balloon dilators with similar rates of adverse events.
Collapse
Affiliation(s)
- Anupam Kumar Singh
- Department of Gastroenterology, Nehru Hospital, Postgraduate Institute of Medical Education and Research (PGIMER), Sector-12, Chandigarh, 160012, India
| | - Yalaka Rami Reddy
- Department of Gastroenterology, STAR Hospital, Nanakramguda, Hyderabad, India
| | - Anuraag Jena
- Department of Gastroenterology, Topiwala National Medical College & BYL Nair Hospital, Mumbai, India
| | - Sreekanth Appasani
- Department of Medical Gastroenterology, KIMS Hospital, Secunderabad, India
| | - Pankaj Gupta
- Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Saroj Kant Sinha
- Department of Gastroenterology, Nehru Hospital, Postgraduate Institute of Medical Education and Research (PGIMER), Sector-12, Chandigarh, 160012, India
| | - Rakesh Kochhar
- Department of Gastroenterology, Nehru Hospital, Postgraduate Institute of Medical Education and Research (PGIMER), Sector-12, Chandigarh, 160012, India.
| |
Collapse
|
2
|
Sabe R, Hiremath G, Ng K. Endoscopy in Pediatric Eosinophilic Esophagitis. Gastrointest Endosc Clin N Am 2023; 33:323-339. [PMID: 36948749 DOI: 10.1016/j.giec.2022.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/24/2023]
Abstract
Eosinophilic esophagitis (EoE) is a chronic allergen-mediated clinicopathologic condition that currently requires esophagogastroduodenoscopy with biopsies and histologic evaluation to diagnose and monitor its progress. This state-of-the art review outlines the pathophysiology of EoE, reviews the application of endoscopy as a diagnostic and therapeutic tool, and discusses potential complications related to therapeutic endoscopic interventions. It also introduces recent innovations that can enhance the endoscopist's ability to diagnose and monitor EoE with minimally invasive procedures and perform therapeutic maneuvers more safely and effectively.
Collapse
Affiliation(s)
- Ramy Sabe
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Rainbow Babies and Children's Hospitals, Case Western Reserve University School of Medicine, 11100 Euclid Avenue, Cleveland, OH 44106, USA
| | - Girish Hiremath
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Monroe Carell Jr. Children's Hospital at Vanderbilt, Vanderbilt University Medical Center, 11226, 2200 Children's Way, Nashville, TN 37232, USA
| | - Kenneth Ng
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Johns Hopkins Children's Center, Johns Hopkins University School of Medicine, 600 North Wolfe Street, CMSC 2-116, Baltimore, MD 21287, USA.
| |
Collapse
|
3
|
Sunpaweravong S, Benjhawaleemas P, Karnjanawanichkul O, Yolsuriyanwong K, Ruangsin S, Laohawiriyakamol S, Chaipetch O. Randomized controlled trial of intravenous sedation vs general anesthesia for esophageal dilation with percutaneous endoscopic gastrostomy in esophageal cancer patients. Surg Endosc 2023. [PMID: 36928761 DOI: 10.1007/s00464-023-09984-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Accepted: 02/25/2023] [Indexed: 03/17/2023]
Abstract
BACKGROUND Esophageal squamous cell cancer (ESCC) is mostly diagnosed in its later stages, when patients present with dysphagia and weight loss. Esophageal dilation with percutaneous endoscopic gastrostomy (PEG) is a common surgical procedure in patients with locally advanced ESCC because of tumor obstruction and enteral nutrition support during neoadjuvant or definitive concurrent chemoradiotherapy (CCRT). Esophageal dilation with PEG is widely performed under general anesthesia (GA) with endotracheal intubation. AIM OF THE STUDY To determine the overall success rate of completing this procedure using intravenous (IV) sedation with dexmedetomidine (DEX) relative to GA and to compare its perioperative conditions, including procedure times, pain scores (visual analog scale), adverse events, and costs. SETTINGS Songklanagarind Hospital, Faculty of Medicine, Prince of Songkla University, Thailand. PATIENTS AND METHODS Prospective randomized controlled trial (RCT) of locally advanced ESCC patients who had dysphagia and needed esophageal dilation with PEG between January 2020 and December 2021. Esophageal dilation (using a Savary-Gilliard dilator) and PEG were performed using the pull technique. RESULTS Seventy patients were randomly assigned to either the DEX group (n = 34) or the GA group (n = 36). All patients in both groups underwent successful surgery. The DEX group had a significantly shorter procedure time, lower procedure cost, and lower total hospital cost than the GA group. However, there were no significant between-group differences in pain scores or length of hospital stay. There were no serious adverse events in either group; however, the GA group had some incidences of sore throat, transient hoarseness, and atelectasis. CONCLUSION This study found that IV sedation with DEX during esophageal dilation with PEG was as effective and safe as using GA.
Collapse
|
4
|
Palam S, Mohorek M, Rizvi S, Dua K. Clinical outcomes on weekly endoscopic dilations as the initial approach to manage patients with complex benign esophageal strictures: report on 488 dilations. Surg Endosc 2022; 36:7056-7065. [PMID: 35477807 DOI: 10.1007/s00464-022-09248-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 04/07/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Success rate of endoscopic dilation (ED) of complex benign esophageal strictures (CBES) can be as low as 65%. Since EDs are usually performed at 2-4-week intervals, the aim of this study was to evaluate the clinical outcomes of EDs done initially at weekly intervals. METHODS A cohort of patients with CBES (luminal diameter < 10 mm) underwent ED at weekly intervals and subsequent dilation intervals adjusted based on response. Weekly EDs were also re-initiated in those requiring additional interventions (electro-cautery/stents). Group A patients: Failed prior EDs done at ≥ 2-week intervals. Group B: CBES with no prior dilations. Success was defined as achieving and maintaining a luminal diameter of ≥ 14 mm and patient remaining dysphagia-free with minimal re-interventions. RESULTS 488 EDs were performed on a cohort of 57 consecutive patients with CBES. Median follow-up was 4 years. Group A: 21 patients (mean age 65 ± 13 years; mean interval between prior failed dilations 17 ± 9 days). 57% of these patients achieved long-term success with weekly dilations (mean 8 ± 4.7 dilations/patient). Group B: 36 patients (mean age 61 ± 13 years, mean 6.5 ± 5.5 dilations/patient). Long-term success was 83.3% (P = 0.033). Despite weekly dilations, unable to achieve a diameter of 14 mm in 5 patients. AE: perforation 1 (0.2%), bleeding 1 (0.2%). CONCLUSION Significant proportion of patients with CBES who failed prior dilations done at ≥ 2-week intervals achieved dysphagia-free status by initiating weekly dilations. Hence, before considering other options (electro-cautery/stents), one can consider using this approach. This approach can also be used upfront in patients with newly diagnosed CBES.
Collapse
Affiliation(s)
- Sowmya Palam
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Mathew Mohorek
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Syed Rizvi
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Kulwinder Dua
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, WI, USA.
- Graduate School of Biomedical Sciences, Medical College of Wisconsin, Milwaukee, WI, 53226, USA.
| |
Collapse
|
5
|
Lu Q, Wang J, Lv X, Xi M, Lei T, Wang Z, Yang L, Yang J. Long-term outcomes of refractory esophageal strictures after endoscopic submucosal dissection of superficial esophageal neoplasms. BMC Gastroenterol 2022; 22:147. [PMID: 35346083 DOI: 10.1186/s12876-022-02232-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 03/23/2022] [Indexed: 02/08/2023] Open
Abstract
Background Many studies have focused on prophylactic therapy for post-endoscopic submucosal dissection (ESD) of esophageal strictures. However, various strategies cannot prevent the occurrence of postoperative strictures after extensive ESD. Postoperative strictures often inevitably occur, and endoscopic dilation is still a temporarily effective therapy. Methods This study included patients with post-ESD refractory esophageal strictures (RESs) from January 2014 to November 2019. Clinical effectiveness was assessed using univariate analysis and multivariate logistic regression. Hierarchical linear models were used to identify factors that predicted the dysphagia-free period. Results A total of 50 patients fulfilled the inclusion criteria and entered the study. Twenty-seven (54%) patients had a history of prophylactic oral steroid therapy. Forty-six patients (92%) underwent ≥ 75% circumferential resection, including 32 (64%) cases involving entire circumferential ESD. The mean dysphagia-free period of 50 patients was 2.9 months (95% CI 2.3–3.5). The dysphagia-free period had a linear growth trend over time, increasing by 6.9 days per endoscopic therapy, and the estimated last dysphagia-free period was 85.9 days. Old and female patients had shorter dysphagia-free periods compared with young and male patients. Endoscopic therapy success was achieved in 30 (60%) patients. Multivariate analysis revealed that circumferential lesions (OR 6.106, 95% CI 1.013–36.785, P = 0.048) were significant predictive factors for poor clinical outcome. Conclusion Endoscopic dilation seemed effective in patients with post-ESD RESs by increasing the dysphagia-free period. After approximately 10 continuous dilations, 60% of patients achieved endoscopic success, and the remission rate of obstruction was increased. Prophylactic oral steroid therapy could reduce the occurrence of RESs. However, once a RES had occurred, prophylactic steroid therapy could not reduce the frequency of dilations or change the long-term outcomes. Trial registration: This study was prospectively registered and approved by the Ethics Committee of West China Hospital of Sichuan University (IRB number: ChiCTR-ONN-17012382) on 2015.
Collapse
|
6
|
Seok D, Kaushik M, Jacobs M. Routine Intraoperative Use of Esophageal Bougie in Minimally Invasive Hiatal Hernia Repair is Not Necessary. JSLS 2022; 26:JSLS.2022.00054. [PMID: 36452904 PMCID: PMC9673992 DOI: 10.4293/jsls.2022.00054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Background Laparoscopic hiatal hernia repair can be performed with an antireflux procedure. Routine use of an esophageal bougie has been advocated to avoid an excessively tight fundoplication. The use of an esophageal bougie carries a risk of iatrogenic complications, such as perforation or laceration of the viscera. However, there is equivocal evidence for the routine use in the surgical literature. Methods We present a retrospective analysis of patients with Types 3 and 4 paraesophageal hiatal hernias who underwent laparoscopic hiatal hernia repair with fundoplication without the use of an esophageal bougie, between December 1, 2010 and February 28, 2020, by a single surgeon at a community-based, academic hospital. Patients with a diagnosis of achalasia and gastroesophageal dysmotility were excluded. Perioperative outcome measures included: recurrence; prolonged postoperative proton pump inhibitor use; dysphagia; re-operation, and mortality. Results A total of 174 patients (34 males, 140 females) underwent laparoscopic hiatal hernia repair with fundoplication. The average age was 63-years old. Four patients (2.3%) developed dysphagia with narrowing of the gastroesophageal junction, with one patient (0.6%) requiring postoperative esophageal dilation with bougie and eventual re-operation. Postoperative proton pump inhibitor use was 31.0% after 1 month. Overall hernia recurrence rate was 14.9% and the rate of re-operation was 6.3%. Overall mortality was 0.6%. Conclusion We conclude that laparoscopic hiatal hernia repair with fundoplication without an esophageal bougie is safe, effective, and efficient. Furthermore, bougie related risks are obviated with a comparable reported incidence of postoperative dysphagia and hiatal hernia recurrence.
Collapse
Affiliation(s)
- David Seok
- Department of Surgery, Ascension Providence Hospital, Southfield Campus, Michigan State University College of Human Medicine, Southfield, MI
| | - Manu Kaushik
- Department of Surgery, Ascension Providence Hospital, Southfield Campus, Michigan State University College of Human Medicine, Southfield, MI
| | - Michael Jacobs
- Department of Surgery, Ascension Providence Hospital, Southfield Campus, Michigan State University College of Human Medicine, Southfield, MI
| |
Collapse
|
7
|
Ravich WJ. The Art of Endoscopic Dilation: Lessons Learned Over 4 Decades of Practice. Gastroenterol Clin North Am 2021; 50:737-750. [PMID: 34717868 DOI: 10.1016/j.gtc.2021.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2023]
Abstract
The author offers his approach to esophageal dilation based on 40 years of a practice specializing in swallowing disorders and esophageal disease. He discusses general concepts in the management of esophageal strictures and then provides an approach to dilation of different types of esophageal stenotic lesions.
Collapse
Affiliation(s)
- William J Ravich
- Section of Digestive Diseases, Yale School of Medicine, 40 Temple St., Suite !A, New Haven, CT 06510, USA.
| |
Collapse
|
8
|
Kamal F, Khan MA, Lee-Smith W, Sharma S, Jowhar D, Farooq U, Acharya A, Kouanda A, Imam Z, Ahmed N, Henry C, Saleem N, Munroe C, Howden CW. Efficacy of empiric esophageal dilation in patients with non-obstructive dysphagia: systematic review and meta-analysis. Scand J Gastroenterol 2021; 56:1490-1495. [PMID: 34477033 DOI: 10.1080/00365521.2021.1971288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIMS Empiric esophageal dilation is frequently performed for non-obstructive dysphagia. Studies evaluating its efficacy have reported conflicting results. In this meta-analysis, we have evaluated the efficacy of esophageal dilation in the management of non-obstructive dysphagia. METHODS We reviewed several databases from inception to 26 May 2021 to identify randomized controlled trials (RCTs) and observational studies that evaluated the role of empiric esophageal dilation for non-obstructive dysphagia. Our outcomes of interest were clinical success (improvement in dysphagia after dilation) and difference in post-operative dysphagia score between groups. For categorical variables, we calculated pooled odds ratios (OR) with 95% confidence intervals (CI); for continuous variables, we calculated standardized mean difference (SMD) with 95% CI. Data were analyzed using a random effects model. We used GRADE framework to ascertain the quality of evidence. RESULTS We included 4 studies (3 RCTs and one observational) with 243 patients; there were 133 treated with empiric dilation and 110 controls. We found no significant difference in clinical success (OR (95% CI) 1.91 (0.89, 4.08)) or post-procedure dysphagia score between groups (SMD (95% CI) 0.38 (-0.37, 1.14)). Our findings remained consistent on subgroup analysis including RCTs only. Quality of evidence ranged from low to very low based on GRADE framework. CONCLUSIONS Our meta-analysis does not support the use of empiric esophageal dilation in patients with non-obstructive dysphagia. More studies are required to confirm these findings.
Collapse
Affiliation(s)
- Faisal Kamal
- Division of Gastroenterology, University of California-San Francisco, San Francisco, CA, USA
| | - Muhammad Ali Khan
- Department of Gastroenterology, Hepatology and Nutrition, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Wade Lee-Smith
- Mulford Health Sciences Library, University of Toledo, Toledo, OH, USA
| | - Sachit Sharma
- Department of Medicine, University of Toledo, Toledo, OH, USA
| | - Dawit Jowhar
- Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Umer Farooq
- Department of Medicine, Loyola Medicine/MacNeal Hospital, Berwyn, IL, USA
| | - Ashu Acharya
- Department of Medicine, University of Toledo, Toledo, OH, USA
| | - Abdul Kouanda
- Division of Gastroenterology, University of California-San Francisco, San Francisco, CA, USA
| | - Zaid Imam
- Division of Gastroenterology, William Beaumont Hospital, Royal Oak, MI, USA
| | - Nazneen Ahmed
- Division of Gastroenterology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Collin Henry
- Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Nasir Saleem
- Division of Gastroenterology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Craig Munroe
- Division of Gastroenterology, University of California-San Francisco, San Francisco, CA, USA
| | - Colin W Howden
- Division of Gastroenterology, University of Tennessee Health Science Center, Memphis, TN, USA
| |
Collapse
|
9
|
Miller D, Mago S, Birk JW, Dellon ES, Feustel PJ, Tadros M. Obesity reduces the requirement for subsequent esophageal stricture dilation in adults with eosinophilic esophagitis. Esophagus 2021; 18:908-914. [PMID: 33846872 DOI: 10.1007/s10388-021-00838-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 04/02/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND Eosinophilic esophagitis (EoE) causes esophageal narrowing and strictures, but factors that modify the severity of strictures and requirement for subsequent dilation are not well described. The aim of this study was to identify characteristics that impact the need for repeat (> 1) esophageal dilations in EoE patients. METHODS This was a single center retrospective cohort study over a 12-year period (September 2005-October 2017). Patients were identified using ICD9, ICD10, and CPT codes for esophageal dilation, eosinophilic esophagitis, and esophageal obstruction. Data for EoE clinical characteristics, treatments, and BMI were extracted and correlated to the number of esophageal dilations and time elapsed between dilations. RESULTS Of the 21 patients who met inclusion criteria, 11 (52%) had at least two dilations and 9 (43%) had three dilations. There was no differences baseline demographics between patients who needed ≥ 2 vs. those who needed one dilation. However, patients with a BMI > 30 had a significantly longer median time to second dilation compared to non-obese patients (4.9 years vs. 1.8 years; p = 0.027). Stratification by either high dose PPI or inhaled steroid use did not change this result. CONCLUSIONS EoE patients with strictures who are obese have a reduced requirement for subsequent esophageal dilation. While the mechanism for this is not clear, increased attention of non-obese patients with fibrostenotic EoE is indicated as they are at higher risk for recurrent strictures.
Collapse
Affiliation(s)
- David Miller
- Albany Medical Center, 43 New Scotland Avenue, Albany, NY, 12208, USA
| | - Sheena Mago
- University of Connecticut Health, 263 Farmington Ave, Farmington, CT, 06030, USA
| | - John W Birk
- University of Connecticut Health, 263 Farmington Ave, Farmington, CT, 06030, USA
| | - Evan S Dellon
- University of North Carolina School of Medicine, 321 S Columbia St, Chapel Hill, NC, 27516, USA
| | - Paul J Feustel
- Albany Medical Center, 43 New Scotland Avenue, Albany, NY, 12208, USA
| | - Micheal Tadros
- Albany Medical Center, 43 New Scotland Avenue, Albany, NY, 12208, USA.
| |
Collapse
|
10
|
Lerner MZ, Bourdillon AT, Dai F, Brackett A, Kohli N. Safety considerations for esophageal dilation by anesthetic type: A systematic review. Am J Otolaryngol 2021; 42:103128. [PMID: 34216877 DOI: 10.1016/j.amjoto.2021.103128] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 05/21/2021] [Accepted: 06/13/2021] [Indexed: 11/18/2022]
Abstract
OBJECTIVES Esophageal dilation (ED) may be performed in the office under local anesthesia or in a procedure/operating room under general anesthesia or intravenous (IV) sedation. However, indications for type of anesthesia during these procedures have not been established. The purpose of this review is to assess outcomes of esophageal dilation performed using different types of anesthesia to assess the safety of office-based techniques. METHODS We conducted a systematic review and meta-analysis comparing the outcomes of anesthesia techniques for ED in adults. Exclusion criteria included reviews, small case series, use of stents, diagnoses with high morbidity, and rare diseases. A comprehensive literature search of the PubMed, CINAHL, and EMBASE databases was performed for articles relating to esophageal dilation. RESULTS 876 papers were identified of which 164 full text studies were assessed and 25 were included in the analysis using the PRISMA guidelines. Data regarding demographics, dilation technique, and adverse events were extracted. The DerSimonian-Laird random-effect models with inverse-variance weighting were fit to estimate the combined effects. There were no statistically significant differences among mortality, perforation, or bleeding based on anesthetic. CONCLUSIONS With office-based procedures gaining popularity in laryngology, there is a need to profile their safety. Office-based ED appears to have equivalent safety to general and IV sedation, although further research is necessary to define indications favoring office-based techniques.
Collapse
Affiliation(s)
- Michael Z Lerner
- Division of Otolaryngology, Department of Surgery, Yale School of Medicine, New Haven, CT, United States of America
| | | | - Feng Dai
- Department of Biostatistics, Yale University School of Public Health, New Haven, CT, United States of America
| | - Alexandria Brackett
- Cushing/Whitney Medical Library, Yale School of Medicine, Yale University, New Haven, CT, United States of America
| | - Nikita Kohli
- Division of Otolaryngology, Department of Surgery, Yale School of Medicine, New Haven, CT, United States of America
| |
Collapse
|
11
|
Lu Q, Lei TT, Wang YL, Yan HL, Lin B, Zhu LL, Ma HS, Yang JL. Development and validation of a model to determine risk of refractory benign esophageal strictures. World J Clin Cases 2019; 7:1623-1633. [PMID: 31367621 PMCID: PMC6658380 DOI: 10.12998/wjcc.v7.i13.1623] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 04/17/2019] [Accepted: 05/02/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Current research has identified several risk factors for refractory benign esophageal strictures (RBES), but research is scarce on the prediction of RBES in benign esophageal strictures patients. Meanwhile, the long-term outcomes of RBES remain unclear. The aim of this study was to develop and validate a model to determine the progression of RBES in patients with benign esophageal strictures. And we also explored the long-term outcomes and safety in patients with RBES.
AIM To develop and validate a model to determine the progression of RBES in patients with benign esophageal strictures, based on the demographic data and endoscopic findings.
METHODS A total of 507 benign esophageal stricture patients treated by dilation alone or in combination with stenting were retrospectively enrolled between January 2009 and February 2018. The primary outcome was to establish a risk-scoring model predicting RBES in benign esophageal strictures. The secondary outcome was to explore the clinical effectiveness and adverse events in patients with RBES.
RESULTS In the study, age, etiology, and number and length of strictures were the independent risk factors for the refractory performance of benign esophageal strictures. According to risk factors of benign esophageal strictures, a risk-scoring model for predicting RBES in benign esophageal strictures was established: The risk score ranged from 0 to 8 points, and the risk scores were divided into low risk (0-2 points), intermediate risk (3-5 points), and high risk (6-8 points). The proportions of RBES in the corresponding risk categories were 1.0%, 12.2%, and 76.0%, respectively. Among 507 patients, 57 had RBES (39 males; median age, 60 years). The success rate of dilation treatment (51.2%, 21/41) was higher than that of stent placement (37.5%, 6/16).
CONCLUSION In this study, 11.3% (57/507) patients had RBES at our hospital. The risk-scoring model predicting RBES in benign esophageal strictures could predict the long-term outcome of patients with strictures ahead.
Collapse
Affiliation(s)
- Qing Lu
- Department of Gastroenterology, West China Hospital of Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Tian-Tian Lei
- Department of Day Surgery, West China Hospital of Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Yi-Lan Wang
- Department of Gastroenterology, West China Hospital of Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Hai-Lin Yan
- Department of Gastroenterology, West China Hospital of Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Bo Lin
- Department of Gastroenterology, West China Hospital of Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Lin-Lin Zhu
- Department of Gastroenterology, West China Hospital of Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Hong-Sheng Ma
- Department of Day Surgery, West China Hospital of Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Jin-Lin Yang
- Department of Gastroenterology, West China Hospital of Sichuan University, Chengdu 610041, Sichuan Province, China
| |
Collapse
|
12
|
Lu Q, Yan H, Wang Y, Lei T, Zhu L, Ma H, Yang J. The role of endoscopic dilation and stents in refractory benign esophageal strictures: a retrospective analysis. BMC Gastroenterol 2019; 19:95. [PMID: 31221085 PMCID: PMC6585047 DOI: 10.1186/s12876-019-1006-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Accepted: 05/30/2019] [Indexed: 02/05/2023] Open
Abstract
Background The outcomes of patients with refractory benign esophageal strictures (RBES) are unclear, and the clinical efficacy of dilation versus stent placement is lacking. Our objective was to explore the role of endoscopic dilation and stents placement in the management of RBES. Methods RBES patients treated with dilation and stents in our hospital between January 2009 and December 2017 were included in this study. The primary outcomes were to assess clinical effectiveness and adverse events. The secondary outcome was to identify factors that predicted the dysphagia-free period. Results Among 75 RBES patients (54 male; median age 59 years), 39 (52%), 20 (26.7%), 3 (4%), 10 (13.3%), and 3 (4%), were postsurgical, post-ESD, achalasia of cardia, caustic and mixed etiology, respectively. The median number of endoscopic therapy was 5 times (range 3, 21). Endoscopic therapy was successful in 46 patients (61.3%). Patients treated with dilation showed a higher success rate (70.9%, 39/55) than that treated with stents (35%, 7/20). Fifteen patients died during follow-up. Nineteen patients had adverse events after endoscopic therapy. In total, the mean dysphagia-free period was 3.4 months (95% CI, 2.5–4.3). The patients treated with dilation demonstrated a dysphagia-free period of 3.7 months (95% CI, 2.7–5), while patients treated with stents displayed a dysphagia-free period of 2.3 months (95% CI, 1.5–3). The dysphagia-free period had a linear growth trend over time, with an increase of 12 days per endoscopic therapy. Conclusion The dysphagia-free period increased by 12 days per endoscopic therapy, so the endoscopic therapy tended to be effective in patients with RBES by increasing the dysphagia-free period. However, compared to dilation therapy, stent therapy was not effective in increasing the dysphasia-free period and reducing the times and frequency of dilation. In addition, univariate and multivariate analyses also indicated that etiology may predict the endoscopic therapy outcome. Trial registration This study was retrospectively registered and approved by the Ethics Committee of West China Hospital of Sichuan University (IRB number: ChiCTR1800016321).
Collapse
Affiliation(s)
- Qing Lu
- Department of Gastroenterology, West China Hospital of Sichuan University, No.37 Guo Xue Alley, Chengdu, 610041, Sichuan Province, China
| | - Hailin Yan
- Department of Gastroenterology, West China Hospital of Sichuan University, No.37 Guo Xue Alley, Chengdu, 610041, Sichuan Province, China
| | - Yilan Wang
- Department of Gastroenterology, West China Hospital of Sichuan University, No.37 Guo Xue Alley, Chengdu, 610041, Sichuan Province, China
| | - Tiantian Lei
- Department of Day Surgery, West China hospital of Sichuan University, 37 Guoxue Road, Chengdu, 610041, Sichuan, China
| | - Linlin Zhu
- Department of Gastroenterology, West China Hospital of Sichuan University, No.37 Guo Xue Alley, Chengdu, 610041, Sichuan Province, China
| | - Hongsheng Ma
- Department of Day Surgery, West China hospital of Sichuan University, 37 Guoxue Road, Chengdu, 610041, Sichuan, China.
| | - Jinlin Yang
- Department of Gastroenterology, West China Hospital of Sichuan University, No.37 Guo Xue Alley, Chengdu, 610041, Sichuan Province, China.
| |
Collapse
|
13
|
Abstract
In eosinophilic esophagitis, the main cause of solid-food dysphagia is tissue remodeling resulting in strictures and narrowed esophagus. Endoscopy and biopsies help to identify the degree of inflammation but often miss the fibrosis. Although initially considered dangerous, esophageal dilation has evolved into an extremely effective and safe treatment in fibrostenotic disease. The key is starting low with small-diameter bougies or balloons, and gradually dilating the esophagus and strictures to 16 to 18 mm. Results in more than 1000 adults and children have shown low rates of complications, especially perforations, and no deaths, but postprocedure chest pain is common.
Collapse
|
14
|
Abstract
PURPOSE OF REVIEW This paper presents the author's approach to esophageal dilation. It offers a tailored approach to the application of dilation to specific types of esophageal stenotic lesions. RECENT FINDINGS In patients with inflammatory stricture, recent studies confirm the importance of treating the underlying inflammatory condition in order to decrease the rate of recurrence. The paper reviews some of the novel techniques that have been suggested for the treatment of refractory benign esophageal strictures, including incisional therapy, stenting, or the injection steroids or antifibrotic agents. The endoscopist who treats esophageal strictures must be familiar with the tools of the dilation and how they are best applied to specific types of stenotic lesions. If inflammation is present, effective management requires treatment of the inflammatory process in addition to mechanical dilation of the stenotic lesion. Controlled trials of novel approaches to treatment of refractory benign esophageal strictures are limited and will be necessary to determine efficacy.
Collapse
|
15
|
Dall’Oglio L, Caldaro T, Foschia F, Faraci S, Federici di Abriola G, Rea F, Romeo E, Torroni F, Angelino G, De Angelis P. Endoscopic management of esophageal stenosis in children: New and traditional treatments. World J Gastrointest Endosc 2016; 8:212-219. [PMID: 26962403 PMCID: PMC4766254 DOI: 10.4253/wjge.v8.i4.212] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2015] [Revised: 10/14/2015] [Accepted: 12/18/2015] [Indexed: 02/05/2023] Open
Abstract
Post-esophageal atresia anastomotic strictures and post-corrosive esophagitis are the most frequent types of cicatricial esophageal stricture. Congenital esophageal stenosis has been reported to be a rare but typical disease in children; other pediatric conditions are peptic, eosinophilic esophagitis and dystrophic recessive epidermolysis bullosa strictures. The conservative treatment of esophageal stenosis and strictures (ES) rather than surgery is a well-known strategy for children. Before planning esophageal dilation, the esophageal morphology should be assessed in detail for its length, aspect, number and level, and different conservative strategies should be chosen accordingly. Endoscopic dilators and techniques that involve different adjuvant treatment strategies have been reported and depend on the stricture’s etiology, the availability of different tools and the operator’s experience and preferences. Balloon and semirigid dilators are the most frequently used tools. No high-quality studies have reported on the differences in the efficacies and rates of complications associated with these two types of dilators. There is no consensus in the literature regarding the frequency of dilations or the diameter that should be achieved. The use of adjuvant treatments has been reported in cases of recalcitrant stenosis or strictures with evidence of dysphagic symptoms. Corticosteroids (either systemically or locally injected), the local application of mitomycin C, diathermy and laser ES sectioning have been reported. Some authors have suggested that stenting can reduce both the number of dilations and the treatment length. In many cases, this strategy is effective when either metallic or plastic stents are utilized. Treatment complications, such esophageal perforations, can be conservatively managed, considering surgery only in cases with severe pleural cavity involvement. In cases of stricture relapse, even if such relapses occur following the execution of well-conducted conservative strategies, surgical stricture resection and anastomosis or esophageal substitution are the only remaining options.
Collapse
|
16
|
Abstract
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.
Collapse
Affiliation(s)
- Michael A Manfredi
- Esophageal and Airway Atresia Treatment Center, Boston Children's Hospital, Boston, MA 02132, USA; Pediatrics Harvard Medical School, Boston, MA 02115, USA.
| |
Collapse
|
17
|
Méndez-Nieto CM, Zarate-Mondragón F, Ramírez-Mayans J, Flores-Flores M. Topical mitomycin C versus intralesional triamcinolone in the management of esophageal stricture due to caustic ingestion. Rev Gastroenterol Mex 2015; 80:248-54. [PMID: 26455483 DOI: 10.1016/j.rgmx.2015.07.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/04/2015] [Revised: 06/23/2015] [Accepted: 07/02/2015] [Indexed: 12/27/2022]
Abstract
BACKGROUND Esophageal stricture due to caustic ingestion is one of the most difficult problems to manage. Esophageal dilations are the usual treatment and they require a great number of sessions in the majority of cases. This implies time, risks for the patient, anguish for the relatives, and very often, frustration for the physician. OBJECTIVES To evaluate the efficacy of the application of topical mitomycin C and intralesional triamcinolone in the prevention of post-dilation esophageal stricture recurrence. MATERIAL AND METHODS A prospective, comparative, nonrandomized, and longitudinal study was conducted that compared a cohort of 16 patients treated with mitomycin C (2009-2012) with a retrospective cohort of 34 patients treated with triamcinolone (2002-2009). RESULTS The patients treated with intralesional triamcinolone had a median of 11 dilations (minimum 4 and maximum 24), whereas the median in the patients treated with topical mitomycin C was 4.5 (minimum 3 and maximum 8). The groups were compared using the Mann-Whitney U test, finding a statistically significant difference of a two-tailed P<.001. In the multiple linear regression model, the dependent variable was the number of dilations and the independent variables were the type of lesion and treatment. The result was an R(2) .676 with a significance level of P<.001, in which the regression coefficient for treatment was B -.682 (95% CI -8.286 to -5.025) and the lesion grade was B .435 (95% CI 2.043- 4.573). The ANOVA result was an F 49.08 and a P<.001 and showed that the independent variables of type of lesion and treatment had a linear relation with the number of dilations, reinforcing the fact that our results were not due to chance. CONCLUSIONS Topical mitomycin C considerably reduced the number of esophageal dilations compared with the use of intralesional triamcinolone to alleviate dysphagia, and therefore we suggest it as a treatment option in strictures due to caustic ingestion.
Collapse
Affiliation(s)
- C M Méndez-Nieto
- Departamento de Gastroenterología y Endoscopia, Hospital Ángeles, Ciudad Juárez, Chihuahua, México.
| | - F Zarate-Mondragón
- Departamento de Gastroenterología y Nutrición, Instituto Nacional de Pediatría, México, D.F., México
| | - J Ramírez-Mayans
- Departamento de Gastroenterología y Nutrición, Instituto Nacional de Pediatría, México, D.F., México
| | - M Flores-Flores
- Departamento de Enseñanza, Hospital General de Zona No. 35, Ciudad Juárez, Chihuahua, México
| |
Collapse
|
18
|
Abstract
Tissue remodeling with scaring is common in adult EoE patients with long standing disease. This is the major factor contributing to their complaints of solid food dysphagia and recurrent food impactions. The best tests to define the degree of remodeling are barium esophagram, high resolution manometry and endoscopy. Many physicians are fearful to dilate EoE patients because of concerns about mucosal tears and perforations. However, multiple recent case series attest to the safety of esophageal dilation and its efficacy with many patients having symptom relief for an average of two years. This chapter will review the sordid history of esophageal dilation in EoE patients and outline how to perform this procedure safely. The key is graduated dilation over one to several sessions to a diameter of 15-18 mm. Postprocedural pain is to be expected and mucosal tears are a sign of successful dilation, not complications. In some healthy adults, occasional dilation may be preferred to regular use of medications or restricted diets. This approach is now supported by recent EoE consensus statements and societal guidelines.
Collapse
|
19
|
Sodikoff J, Hirano I. Therapeutic strategies in eosinophilic esophagitis: Induction, maintenance and refractory disease. Best Pract Res Clin Gastroenterol 2015; 29:829-839. [PMID: 26552781 PMCID: PMC4946566 DOI: 10.1016/j.bpg.2015.09.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Accepted: 09/02/2015] [Indexed: 02/06/2023]
Abstract
Eosinophilic esophagitis (EoE) is a chronic, immune-mediated disease that is increasingly recognized as one of the most common causes of dysphagia and foregut symptoms in adults and children. Topical corticosteroids, elimination diets, and esophageal dilations are effective options for both induction and maintenance therapy in EoE. Current pharmacologic options are being used off-label as no agent has yet been approved by regulatory authorities. Little is known about the natural history of EoE, however, raising controversy regarding the necessity of maintenance and therapy in asymptomatic or treatment-refractory patients. Furthermore, variability in treatment endpoints used in EoE clinical trials makes interpretation and comparability of EoE treatments challenging. Recent validation of a patient-related outcome (PRO) instruments, a histologic scoring tool, and an endoscopic grading system for EoE are significant advances toward establishing consistent treatment endpoints.
Collapse
Affiliation(s)
| | - Ikuo Hirano
- Corresponding author. Northwestern University, Feinberg School of Medicine, Department of Medicine, 676 St Clair St, Suite 1400, Chicago, IL 60611-2951, USA. Tel.: +1 312 695 5620. (I. Hirano)
| |
Collapse
|