Real-world efficacy of dupilumab in four cases of paediatric-onset fibrostenotic eosinophilic esophagitis

Eosinophilic esophagitis (EoE) is an increasingly prevalent immune-mediated disease that leads to chronic changes in the oesophagus. These changes can include strictures, narrowing, and stenosis, mediated by an interleukin (IL)-13 pathway, which leads to remodelling and fibrosis through increasing migration of fibroblasts and subepithelial fibrosis via collagen deposition 1. IL-13 downregulates TSPAN12, a gene whose expression regulates fibrosis and causes changes in barrier function and higher rates of fibrostenosis in EoE. Dupilumab, a biologic therapy aimed at blocking IL-13, has been shown to improve EoE-related inflammation and fibrosis in clinical trials. We report here four unique patients with documented oesophageal stenosis with inability to pass a paediatric endoscope due to structuring disease, requiring dilation, who had resolution of their oesophageal narrowing following dupilumab therapy.

Intralesional steroids in refractory caustic esophageal stricture

OBJECTIVE

To analyze the efficacy of intralesional steroid treatment in refractory caustic esophageal stricture.

MATERIALS AND METHODS

An analytical, retrospective study of patients receiving intralesional steroid treatment with triamcinolone acetonide as a result of refractory caustic esophageal stricture was carried out. Demographic variables, stricture characteristics, number of dilations, steroid injections, and dilation score (no. of dilations/follow-up period in months) pre- and post-treatment were collected. Stricture characteristics (diameter and length) and dilation score pre- and post-treatment were compared using the T-Test or Wilcoxon test.

RESULTS

N= 5. Median age: 5 years (17 months-7 years). Follow-up: 6.60 ± 2.70 years. Swallowed products included NaOH, KOH, and ClH. Zargar classification at follow-up initiation was IIb (n= 2), IIIa (n= 1), and two chronic strictures. 6.6 ± 9.23 esophageal dilations were carried out before steroid treatment initiation. The mean number of intralesional therapy sessions was 11.20 ± 6.14. Stricture length decreased by 3.60 ± 2.63 cm (t= 3.06; p= 0.019). No differences were found in terms of diameter increase: -1.60 ± 3.58 mm (t= -1.00; p= 0.187). The dilation score diminished from 1.47 ± 0.86 to 0.47 ± 0.18 dilations per month of follow-up (Z= -2.02; p= 0.043).

CONCLUSIONS

Even though there is limited evidence available in the pediatric population, intralesional triamcinolone treatment is seemingly useful in the treatment of refractory caustic esophageal stricture, since it reduces length and dilation score.

Successful Antimicrobial Therapy of Esophageal Stenosis Because of Actinomycosis

Esophageal stenosis can cause vomiting or dysphagia in children and is commonly treated with esophageal balloon dilation. However, surgery may be required if the stenosis does not respond to dilation. Although esophageal actinomycosis can cause severe esophageal strictures and be refractory to balloon dilation, it has been reported to respond effectively to antimicrobial therapy in adults. However, the course of the disease and appropriate treatment strategies in children are not well understood. We present a case of a previously healthy 2-year-old boy diagnosed with esophageal stenosis because of actinomycosis. The patient was treated with intravenous penicillin G, followed by oral amoxicillin for 8 weeks and 6 months, respectively. After completion of the antimicrobial treatment, the patient showed improvement in symptoms and endoscopic findings. At the 1-year follow-up, the patient showed consistent weight gain and normal growth without further intervention. This case highlights the importance of considering esophageal actinomycosis as a potential cause of esophageal stenosis in children and the potential effectiveness of antimicrobial therapy in avoiding surgical intervention.

Localized Photodynamic Therapy Using a Chlorin e6-Embedded Silicone-Covered Self-Expandable Metallic Stent as a Palliative Treatment for Malignant Esophageal Strictures

Localized photodynamic therapy (PDT) uses a polymeric-photosensitizer (PS)-embedded, covered self-expandable metallic stent (SEMS). PDT is minimally invasive and a noteworthy potential alternative for treating esophageal strictures, where surgery is not a viable option. However, preclinical evidence is insufficient, and optimized irradiation energy dose ranges for localized PDT are unclear. Herein, we validated the irradiation energy doses of the SEMS (embedded in a PS using chlorin e6 [Ce6] and covered in silicone) and PDT-induced tissue changes in a rat esophagus. Cytotoxicity and phototoxicity in the Ce6-embedded SEMS piece with laser irradiation were significantly higher than that of the silicone-covered SEMS with or without laser and the Ce6-embedded silicone-covered SEMS without laser groups (all p < 0.001). Moreover, surface morphology, atomic changes, and homogeneous coverage of the Ce6-embedded silicone-covered membrane were confirmed. The ablation range of the porcine liver was proportionally increased with the irradiation dose (all p < 0.001). The ablation region was identified at different irradiation energy doses of 50, 100, 200, and 400 J/cm2. The in vivo study in the rat esophagus comprised a control group and 100, 200, and 400 J/cm2 energy-dose groups. Finally, histology and immunohistochemistry (TUNEL and Ki67) confirmed that the optimized Ce6-embedded silicone-covered SEMS with selected irradiation energy doses (200 and 400 J/cm2) effectively damaged the esophageal tissue without ductal perforation. The polymeric PS-embedded silicone-covered SEMS can be easily placed via a minimally invasive approach and represents a promising new approach for the palliative treatment of malignant esophageal strictures.

[The effective analysis of refractory esophageal stricture after endoscopic mucosal dissection of early esophageal cancer treated by endoscopic radiotomy combined with local injection of triamcinolone acetonide]

Refractor esophageal stenosis after endoscopic submucosal dissection of early esophageal carcinoma is a difficult clinical problem. To verify the effect of endoscopic radial incision combined local triamcinolone injection to treat refractory esophageal stenosis, we retrospectively analyzed 7 patients diagnosed with refractory esophageal stricture after endoscopic mucosal dissection of early esophageal cancer in this study, of whom 4 male and 3 female patients, aged 50-76 years, with the mean age of 63 years. We performed the endoscopic radial incision in the thickness point of the scar stricture and injected the triamcinolone locally. The results showed it was safe and effective. The follow-up showed no esophageal stenosis occured and no adverse reaction such as hemorrhage, perforation, tumor-recurrence and triamcinolone-allergy occured.

Effectiveness of an orally administered steroid gel at preventing restenosis after endoscopic balloon dilation of benign esophageal stricture

BACKGROUND

Restenosis occurs in 10% to 30% of patients after endoscopic balloon dilation (EBD) of benign esophageal stricture. This study aimed to investigate whether an orally administered steroid/gel mixture would inhibit restenosis after EBD for benign esophageal stricture.

METHODS

This retrospective analysis included patients with benign esophageal stricture treated with EBD at the Peking University Third Hospital, China (September 2005 to October 2017). The patients were divided into an EBD alone group (EBD only) and EBD/OHA group (EBD plus oral hydrocortisone sodium succinate/aluminum phosphate gel mixture). Patients were followed-up for 3 months. EBD was repeated for persistent dysphagia. The outcome measures included the restenosis rate and the number of additional EBD sessions required during follow-up. Any side effects were noted.

RESULTS

Thirty-two patients were included (EBD alone group, n = 12; EBD/OHA group, n = 20). Baseline demographic and clinical characteristics (including age, sex, etiology, stricture location, and diameter of narrowest segment) did not differ between groups. Restenosis rate was significantly lower in the EBD/OHA group than in the EBD alone group (5/20, 25.0% vs 8/12, 66.7%; P = .025). The median number of EBD sessions required was numerically lower in the EBD/OHA group (median, 1.0; interquartile range, 1.0-1.8) than in the EBD alone group (median 2.0, interquartile ranged 1.0-2.5), but statistical significance was not attained (P = .071). The only side effects occurred in the EBD/OHA group: hypokalemia in 4/20 (20.0%) and apathy/somnolence in 1/20 (5.0%).

CONCLUSIONS

An orally administered steroid/gel mixture might reduce the incidence of restenosis after EBD for benign esophageal stricture, but it requires confirmation by prospective trials.

A severe case of refractory esophageal stenosis induced by nivolumab and responding to tocilizumab therapy

BACKGROUND

The prevalence of esophageal stenosis caused by immune checkpoint inhibitors in the context of induced immune mucositis and esophagitis is extremely rare.

CASE PRESENTATION

We report the case of a patient with stage IV pulmonary adenocarcinoma treated for 6 months with nivolumab who developed bilateral sterile conjunctivitis followed by oropharyngeal mucositis and esophagitis complicated by a severe esophageal stenosis. The laryngeal margin and hypopharyngeal mucosa appeared highly inflammatory with fibrinous deposits. Esophagogastroduodenoscopy revealed mucositis with a scar-like structure immediately below the upper esophageal sphincter with nonulcerative mucosa and an inflammatory aspect of the entire esophagus. No involvement of the stomach was observed. Oropharynx biopsies displayed marked lymphocytic T cell-infiltration with several foci of monocellular necrosis in the squamous epithelium. No morphologic evidence of adenocarcinoma and no signs of mycotic, bacterial or viral infection were noted. A blood sample revealed a discrete increase in the erythrocyte sedimentation rate (ESR) with no eosinophilia or leukocytosis. Liver and kidney function panel tests were normal. A thoracoabdominal CT scan reported no evidence of disease recurrence. Despite multiple boluses of methylprednisolone and high doses of prednisone continued for several months, the patient experienced very rapid symptomatological reappearance during three steroid tapering attempts and aggravation of his esophageal stenosis to an aphagic stage, requiring a nasogastric tube. This long course of high-dose corticosteroid treatment was complicated with osteoporosis-induced fractures with several spontaneous compressions of thoracolumbar vertebrae requiring an enlarged T10 to L5 cementoplasty. Anti-IL-6 blockade therapy with tocilizumab resulted in excellent clinical response, allowing the total resolution of the immune-related adverse events (irAEs) and leading to successful steroid tapering.

CONCLUSIONS

Herein, we describe the first case of a patient who developed autoimmune mucositis and esophagitis complicated by a severe refractory esophageal stenosis induced during treatment by nivolumab, which completely resolved after personalized treatment with tocilizumab, suggesting a role of IL-6 blockade in the management of severe steroid refractory esophageal stenosis and more broadly in refractory immune-related adverse events.

[THE TREATMENT TACTICS AND PERIOPERATIVE INTENSIVE THERAPY IN STENOSING ESOPHAGEAL DISEASES]

The treatment tactics and intensive therapy in stenosing esophageal diseases for 222 patients in 2003 - 2015 yrs were analyzed. Expediency of application of the proposed treatment tactics was noted.

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.

A shape memory stent of poly(ε-caprolactone-co-DL-lactide) copolymer for potential treatment of esophageal stenosis

Biodegradable polymer stent with shape memory effect is expected to be developed in the treatment of esophageal stenosis, most likely due to traditional stents having such shortages as considerable rigidity and nondegradation. A tubular stent with the inner and outer diameters of 28 and 30 mm was manufactured from biodegradable poly(ε-caprolactone-co-DL-lactide) (PCLA) copolymer consisting of ε-caprolactone and DL-lactide at a weight ratio of 10/90. A series of tests were accomplished to investigate its properties including shape memory effects (SMEs), compression property and influence of in vitro degradation of polymer matrix on its shape recovery and dilation force. Significantly, an implantation of the stent into a dog model was performed to evaluate its function for the treatment of esophageal stenosis. The deformed stent needs about 36 s to recover its initial shape in vitro in 37°C warm water. The primary animal experiment in vivo has revealed that the implanted deformed stent could be triggered by body temperature and expectedly returned to a nearly-round shape to support esophageal wall. Therefore, the biodegradable intelligent polymer stent may be great potential to displace the conventional metallic stents for the esophageal stenosis therapy.

[A case of anstomotic stricture after esophagectomy sufficiently treated by endoscopic triamcinolone injection therapy]

We report a case of 50-year-old man with refractory anastomotic stricture after esophagectomy, which was successfully treated with endoscopic triamcinolone injection therapy. He received a curative operation for advanced thoratic esophageal carcinoma (Mt, Type 3, cT3, cN1, MO, Stage III). Anastomotic leakage was occurred as post-operative adverse event, which recovered conservatively, and subsequently resulted in refractory anastomotic stricture. He had a recurrence of dysphagia despite of repeated bougienage and endoscopic balloon dilatation. Four years later, he received an intralesional triamcinolone injection in anastomotic stricture every four weeks. According to the 5 courses of treatment, anastomotic stricture was cured and there was no recurrence confirmed. Intralesional triamcinolone injection may be one of the promising options for the treatment of refractory anastomotic stricture after esophagectomy.

Role of allopurinol on oxidative stress in caustic burn: cure for stricture?

An experimental study was conducted to investigate the effects of allopurinol, which inhibits the enzyme xanthine oxidase, on oxidative stress and on the prevention of stricture development after esophageal caustic injuries in rat. A randomized controlled study was conducted and 60 Wistar albino rats were divided into 6 equal groups, three groups for the acute phase and 3 groups for the chronic phase. Caustic esophageal burn was created by application of 37.5% NaOH to the distal esophagus. Allopurinol was administered at 40 mg/kg daily. Efficacy of the treatment for the acute phase was assessed by measuring tissue malondialdehyde (MDA), nitric oxide (NO) and glutathione (GSH) at the 3rd day; and for the chronic phase by determining tissue hydroxyproline content and histopathologic damage score at the 28th day. We found an increase in XO, MDA and GSH levels and a decrease in NO levels in the acute phase. Allopurinol reinstated the increase in XO significantly, while MDA, GSH and NO levels were reinstated insignificantly. There was no significant difference in means of tissue hydroxyproline content. Histopathologic damage scores were significantly lower in the allopurinol treated group. This study, which is to our knowledge, the first in the literature investigating the influence of allopurinol on caustic esophageal burn, reveals that allopurinol effects MDA, GSH and NO levels insignificantly in the acute phase of caustic esophageal burn and decreases fibrosis significantly in the chronic phase.

Topical application of mitomycin C in the treatment of esophageal and tracheobronchial stricture: a report of 2 cases

We present 2 cases of successful treatment of recurrent anastomotic strictures using a topical application of mitomycin C. In the first case, a 4-year-old boy had a cervical cyst excised, which appeared to be an ectopic gastric mucosa. He consequently presented severe stenosis at the origin of the cervical esophagus that needed repeated balloon dilatations. The second case is about a 12-year-old girl who presented a traumatic complete rupture of the right mainstem bronchus managed by primary repair, with subsequent anastomotic stricture. Both patients were successfully managed with topical application of mitomycin C (1 mg/mL), and needed no more dilatations.

Influence of amifostine on late radiation-toxicity in head and neck cancer--a follow-up study

AIM

The late toxicities due to multimodal therapy of advanced head and neck cancers were analysed. The impact of cytoprotection with amifostine is the specific objective of this report.

PATIENTS AND METHODS

A total of 851 patients (717 men, 134 women) with head and neck cancer were included in this prospective study. Of these patients, 519/851 had received amifostine before radio(chemo)therapy, while 332 control patients had not received any kind of cytoprotection before irradiation. Primary radiochemotherapy was performed in 282 patients and adjuvant radiation was administered in 569. The follow-up examination was carried out at our outpatient department 21.4 months (median, range 2.3 to 149 months) after the primary therapy.

RESULTS

Late xerostomia was seen in 765/851 patients (89.9%). Altered taste was reported by 284/851 (33.5%). These symptoms were reduced significantly by amifostine. No influence was seen on interstitial lymph edema (48.4%), or stenosis of the cervical esophagus (20.4%). Secondary symptoms such as dysphagia (78.8%) also had a trend for reduction.

CONCLUSION

The administration of amifostine offers an opportunity to reduce selected long-term toxicities for survivors of head and neck cancer.

Orally disintegrating olanzapine for the treatment of a manic patient with esophageal stricture plus chronic pharyngitis

An orally disintegrating tablet formulation of olanzapine (ODT olanzapine) is designed to dissolve rapidly upon contact with saliva. We describe a manic patient who has an esophageal stricture and chronic pharyngitis, two conditions that impede the swallowing of medications. She was successfully treated for her mania with this orally disintegrating formulation. This case report shows that ODT olanzapine may be useful in the psychiatric management of manic and other patients for whom olanzapine is appropriate, and who have an underlying medical condition that impedes swallowing oral medications.

Topical application of mitomycin-C in oesophageal strictures

BACKGROUND

Benign oesophageal strictures may occur as a complication of caustic ingestion or severe gastro-oesophageal reflux or as a sequela of oesophageal surgery and other fibrosing conditions. The traditional initial treatment of oesophageal strictures is intraluminal dilation; however, even if frequent, this occasionally may not provide adequate oesophageal lumen capacity or give significant symptom-free intervals, and restricturing after dilation is difficult and challenging. Topical postdilation application of an antifibrotic agent, mitomycin-C, in the treatment of an oesophageal stricture has been described.

PATIENTS AND METHODS

Eight centres participated, with a total of 16 patients (4 girls), median age 48 (range 0-276) months. The causes of stricture were as follows: caustic (10), post-trachea-oesophageal fistula repair (2), peptic (2), Crohn disease (1), and dystrophic epidermolysis bullosa (1). The median (range) length and diameter of the strictures were as follows: 22 mm (8-50 mm) and 1.5 mm (1-6 mm). Of the 16 patients, 15 had undergone repeated dilations varying from 3 to more than 1000 (daily self-bouginage) before mitomycin-C, and the median interval between dilations was 4 weeks. Mitomycin-C 0.1 mg/mL was applied after dilation for a median time of 3.5 minutes and a median of 3 (1-12) times.

RESULTS

Major success, both endoscopic and clinical improvement or cure, occurred in 10 of 16 patients. In 3 of 16 patients the interval period between dilations increased dramatically. Failure of therapy was considered in 3 of 16. All of the patients remained symptom free for a follow-up time of as long as 5 years.

CONCLUSIONS

Postdilation application of topical mitomycin-C resulted in major success in 62.5% of patients and partial success in 19%, and it may be a useful strategy in oesophageal strictures of differing causes that are refractory to repeated perendoscopic dilation.

Lokale Applikation von Mitomycin C zur Behandlung einer Ösophagusstriktur nach Laugenverätzung bei einem 4-jährigen Jungen

Accidental caustic ingestion is a common problem in young children at the age of 1 to 4 years. In cases of circular injuries of the oesophagus subsequent strictures can arise. Endoscopic balloon dilatation is the commonly used intervention but does not always lead to permanent improvement. We report the successful use of mitomycin C in a young boy in whom we could achieve ongoing relief of dysphagia after the unsuccessful long-term use of frequent endoscopic dilatations.

Is current UK management of oesophageal food bolus obstruction evidence based? An e-mail survey and literature review

There is a great deal of variation in individual management of non-sharp oesophageal food bolus obstruction in the United Kingdom. An e-mail survey of consultants and specialist registrars in ENT was carried out to establish current UK practice. A review of the published literature was under-taken to establish whether current practice is evidence based. The majority of practitioners (95%) do not proceed immediately to rigid oesophagoscopy but use antispasmodic drugs (83%), most commonly hyoscine butylbromide (Buscopan) and diazepam, to try to induce spontaneous passage of the obstruction. There is currently no evidence in the published literature to support the use of these drugs. The use of Buscopan seems to have been encouraged by a misquoted reference in a prominent ENT textbook. Better evidence is needed to establish the best form of treatment for this relatively common problem.

[Use of mitomycin C in esophageal stenosis]

INTRODUCTION

Esophageal stenosis, due to its important implications on the patients' quality of life, poses a serious problem, often difficult to resolve, that requires therapeutical solutions that could irreversibly affect vital conditions and quality of life of those affected. For this reason our group has tried over the last thirty years to employ conservative solutions in the damaged aesophagus, showing that a complete cure is possible in most cases although the way to achieve this can be dramatically long.

MATERIAL AND METHODS

We present our experience employing topical Mitomicyn C over the last year and a half in eight patients, six of them affected with caustic stenosis and two with secuelae of esophageal atresia, highlighting the three cases that received at least five applications of the product. We describe the method employed that consists in the spraying of the correct dose using a flexible fibroscope on the dilated area, loading the dose in the container of the cleaning water of the fibroscope, employing a system that permits only to apply the exact quantity necessary of the product. The application time is five minutes and the dose is 0.4 mg/ml applying 5ml or 10 ml according to the patient's weight ( under 12 kg = 2.5 ml and over 25 kg=5 ml). Upon completion of the application, a washing of the product is performed using the same fibroscope.

RESULTS

From the eight cases in which it was applied, we analysed the three that received at least five doses. These were two boys of seven and eight years and a 25 year-old woman. In the children the dilatations interval has passed from 4-5 weeks to 8-11 respectively. The woman has passed from 12 to15 weeks. The children have been in the dilatation program more than 3 years and the woman more than 18.

CONCLUSIONS

Although the time period that we have been applying Mitomicyn C is still short, the symptom-free interval after dilatations is proving to be highly promising. This fact is highlighted in those patients included in the dilatation program recently. We have not seen any adverse side effect from the application of the product.

[Is antisecretory therapy of patients with chemical burn of the esophagus mandatory?]

Intragastric pH-metry and esophagogastroduodenoscopy has been performed in 64 patients with chemical burn of the esophagus. It has been revealed that 51.6% patients had hyperacidity, 25% - normacidity, and 23.4% - hypoacidity. Gastroesophageal reflux has been diagnosed in 50% patients according to pH-metry examination and in 80-100% patients according to esophagogastroduodenoscopy, duodenogastric reflux - in 25 and 34.4% cases, respectively. A direct correlation exists between gastroesophageal reflux and basal gastric acidity, severity of chemical burn of the esophagus. It is concluded that antisecretory therapy is mandatory in complex treatment of patients with chemical burn of the esophagus.

A case report of advanced thoracic esophageal cancer with severe malignant stricture

We experienced one case with locally advanced esophageal cancer that he gained a good result by the multidisciplinary treatment including the operation followed by chemoradiation. The case was a 74-year old man with the middle thoracic esophageal cancer accompanied by severe malignant stricture. He couldn't take any water, and his general condition was poor, because he lost 5 kg of his weight. By the clinical examinations, his cancer had no apparent invasion to adjacent organ. So, we planned the operation gone ahead the chemoradiation for him to take water and meals earlier, and to prevent pneumonia. The esophagectomy through right-thoracotomy was done, and the pathological findings were type 3, well differentiated squamous cell carcinoma, pT3 N0, pStageII. Two months later after the operation, he took the chemoradiotherapy. 50 gray radiation therapy was done with chemotherapy including Cisplatin (10 mg/a time/week) and Tegafur (200 mg/day). About one and half a year after the operation, he sends good daily life with no recurrence. Recently, chemoradiotherapy is the first choice of the treatment for the locally advanced esophageal cancer. But in cases without apparent invasion to adjacent organ, it might be advisable that the operation goes ahead the chemoradiotherapy in the multidisciplinary treatment.