Postoperative Dysphagia in Debranching Thoracic Endovascular Aortic Repair with Retroesophageal Carotid-Carotid Bypass

A carotid-carotid bypass is commonly used in debranching thoracic endovascular aortic repair. When the bypass graft is placed in the retroesophageal position, the esophagus may be compressed by the graft from behind. Therefore, dysphagia may occur postoperatively as a serious complication. To avoid this issue, we recommend placing the bypass graft below the cricoid cartilage.

Esophageal Rings and Strictures: Manometric characteristics in patients with food impaction

Purpose: The purpose was to investigate the manometric characteristics in patients with lower esophageal rings or strictures with special reference to food impaction.

Material and Methods: The material comprised 344 patients (158 female and 186 male). Lower esophageal rings or strictures were diagnosed radiologically by the full column technique. Manometry was performed with triple lumen catheters connected to a hydraulic capillary system and external transducers.

Results: Forty patients had rings, and 21 patients strictures. The reference group comprised 283 patients. Dysphagia was seen most frequently in patients with rings. Food impaction was seen only in patients with rings or strictures, whereas chest pain and heartburn appeared with the same incidence in all 3 groups. Non-specific motor disorders were seen most frequently in patients with strictures, but as delayed esophageal emptying with no influence on the tendency to food impaction. Only ring diameter, but not stricture diameter, was of any significance with a higher incidence of food impaction in patients with narrow rings.

Conclusion: Radiology rather than manometry should be the first diagnostic step in patients with benign dysphagia suffering from food impaction.

Endoscopic dilation of complete oesophageal obstructions with a combined antegrade-retrograde rendezvous technique

AIM: To investigate the combined antegrade-retrograde endoscopic rendezvous technique for complete oesophageal obstruction and the swallowing outcome.

METHODS: This single-centre case series includes consecutive patients who were unable to swallow due to complete oesophageal obstruction and underwent combined antegrade-retrograde endoscopic dilation (CARD) within the last 10 years. The patients’ demographic characteristics, clinical parameters, endoscopic therapy, adverse events, and outcomes were obtained retrospectively. Technical success was defined as effective restoration of oesophageal patency. Swallowing success was defined as either percutaneous endoscopic gastrostomy (PEG)-tube independency and/or relevant improvement of oral food intake, as assessed by the functional oral intake scale (FOIS) (≥ level 3).

RESULTS: The cohort consisted of six patients [five males; mean age 71 years (range, 54-74)]. All but one patient had undergone radiotherapy for head and neck or oesophageal cancer. Technical success was achieved in five out of six patients. After discharge, repeated dilations were performed in all five patients. During follow-up (median 27 mo, range, 2-115), three patients remained PEG-tube dependent. Three of four patients achieved relevant improvement of swallowing (two patients: FOIS 6, one patient: FOIS 7). One patient developed mediastinal emphysema following CARD, without a need for surgery.

CONCLUSION: The CARD technique is safe and a viable alternative to high-risk blind antegrade dilation in patients with complete proximal oesophageal obstruction. Although only half of the patients remained PEG-tube independent, the majority improved their ability to swallow.

[Acute necrotizing esophagitis (black esophagus) with secondary severe stenosis]

We report the case of a 67 years old patient with a history of diabetes mellitus, atrial fibrillation and chronic renal failure, who developed diabetic ketoacidosis and severe sepsis, later presenting an acute necrotizing esophagitis, and then a esophageal stenosis requiring treatment with self-expanding esophageal prosthesis with good clinical results.

Value of two-phase dynamic multidetector computed tomography in differential diagnosis of post-inflammatory strictures from esophageal cancer

AIM: To characterize the computed tomography (CT) findings in patients with post-inflammatory esophageal strictures (corrosive and peptic) and reveal the optimal scanning phase protocols for distinguishing post-inflammatory esophageal stricture and esophageal cancer.

METHODS: Sixty-five patients with esophageal strictures of different etiology were included in this study: 24 patients with 27 histopathologically confirmed corrosive strictures, 10 patients with 12 peptic strictures and 31 patients with esophageal cancer were evaluated with a two-phase dynamic contrast-enhanced MDCT. Arterial and venous phases at 10 and 35 s after the attenuation of 200 HU were obtained at the descending aorta, with a delayed phase at 6-8 min after the start of injection of contrast media. For qualitative analysis, CT scans of benign strictures were reviewed for the presence/absence of the following features: “target sign”, luminal mass, homogeneity of contrast medium uptake, concentric wall thickening, conically shaped suprastenotic dilatation, smooth boundaries of stenosis and smooth mucous membrane at the transition to stenosis, which were compared with a control group of 31 patients who had esophageal cancer. The quantitative analysis included densitometric parameter acquisition using regions-of-interest measurement of the zone of stenosis and normal esophageal wall and the difference between those measurements (ΔCT) at all phases of bolus contrast enhancement. Esophageal wall thickening, length of esophageal wall thickening and size of the regional lymph nodes were also evaluated.

RESULTS: The presence of a concentric esophageal wall, conically shaped suprastenotic dilatation, smooth upper and lower boundaries, “target sign” and smooth mucous membrane at the transition to stenosis were suggestive of a benign cause, with sensitivities of 92.31%, 87.17%, 94.87%, 76.92% and 82.05%, respectively, and specificities of 70.96%, 89.66%, 80.65%, 96.77% and 93.55%, respectively. The features that were most suggestive of a malignant cause were eccentric esophageal wall thickening, tuberous upper and lower boundaries of stenosis, absence of mucous membrane visualization, rupture of the mucous membrane at the upper boundary of stenosis, cup-shaped suprastenotic dilatation, luminal mass and enlarged regional lymph nodes with specificities of 92.31% 94.87%, 67.86%, 100%, 97.44%, 94.87% and 82.86%, respectively and sensitivities of 70.97%, 80.65%, 96.77%, 80.65%, 54.84%, 87.10% and 60%, respectively. The highest tumor attenuation occurred in the arterial phase (mean attenuation 74.13 ± 17.42 HU), and the mean attenuation difference between the tumor and the normal esophageal wall (mean ΔCT) in the arterial phase was 23.86 ± 19.31 HU. Here, 11.5 HU of ΔCT in the arterial phase was the cut-off value used to differentiate esophageal cancer from post-inflammatory stricture (P = 0.000). The highest attenuation of post-inflammatory strictures occurred in the delayed phase (mean attenuation 71.66 ± 14.28 HU), and the mean ΔCT in delayed phase was 34.03 ± 15.94 HU. Here, 18.5 HU of ΔCT in delayed phase was the cut-off value used to differentiate post-inflammatory stricture from esophageal cancer (P < 0.0001).

CONCLUSION: The described imaging findings reveal high diagnostic significance in the differentiation of benign strictures from esophageal cancer.

Percutaneous radiologic gastrostomy via nasopharyngeal intubation for the treatment of patients with complete malignant pharyngoesophageal obstruction

BACKGROUND/AIMS

For patients with complete malignant pharyngoesophageal obstruction (CMPO), percutaneous radiologic gastrostomy (PRG) under ultrasound/CT guidance can complicate it to cause failure due to unsatisfied stomach filling. In this study, we retrospectively investigated whether PRG via nasopharyngeal intubation is feasible and effective for these patients.

METHODOLOGY

PRG via nasopharyngeal intubation was attempted in 21 patients with CMPO (mean 70.8 ± 8.23 years). The technique comprised a dilation of the stomach via nasopharyngeal intubation using a catheter, followed by fluoroscopically guided puncture and gastrostomy tube placement. Complications including hemorrhage, peritonitis, gastrojejunocolic fistula, infection of puncture site, tube blocking and outleakage was observed during and after the procedure.

RESULTS

A 5F catheter was successfully inserted to the stomach under fluoroscopical guidance and subsequent PRG was performed in all 21 patients. Minor complications occurred in 14.3% patients including mild infection of the fistula in 1, tube blocking in 1 and unexpected tube drawing out in 1. Follow-up nutrition indexes revealed obvious improved nutrition compared to before PRG (P < 0.05).

CONCLUSION

PRG via nasopharyngeal intubation was simple, feasible and effective for patients with CMPO.

[Esophagoplasty in combined scarry lesions of the esophagus, laryngopharynx and the trachea in children]

The experience of plasty of the pharynx and esophagus with graft of the free small intestine segment was presented in 12 children after burn stricture by the potassium permanganate. The technical aspects of operation using methods of the reconstructive vascular surgery were described. Good short-term result was obtained in all the patients. The long-term results were investigated during 15 years. It was observed, that the graft diverticulum developed by 4-7 years in 3 patients, whom repeated operation should be performed. According to the authors, the regional plasty of the esophagus by free revasculizated small intestine graft was really effective surgical supply and could be considered as the method of choice in limited scarry lesions of the pharynx and cervical esophagus, but the method should be improved.

Fluoroscopically guided dilation of esophageal strictures in patients with dystrophic epidermolysis bullosa: long-term results

OBJECTIVE

The purpose of this study was to investigate the immediate and long-term outcomes after fluoroscopically guided balloon dilation of esophageal strictures in a series of patients with dystrophic epidermolysis bullosa (DEB).

MATERIALS AND METHODS

Between 2005 and 2011, the medical records of all patients with DEB treated with fluoroscopically guided balloon dilation of esophageal strictures were included in the study and retrospectively analyzed. The indication for treatment was dysphagia attributed to at least one radiologically verified esophageal stricture. The primary endpoints of the study included procedural technical success, clinical improvement assessed with a 0-4 dysphagia score, and major complication rate. Secondary endpoints were patient survival and reintervention rates.

RESULTS

Nineteen consecutively registered patients with DEB (age range, 10-51 years; mean, 30 ± 12.2 years) and dysphagia due to esophageal strictures were treated with fluoroscopically guided balloon dilation. In total, 90 procedures and 121 dilations were performed to manage 28 lesions. Balloon diameter ranged from 8 to 18 mm. The mean follow-up time was 47.51 ± 16.64 months (range, 17-73 months). The technical success rate was 96.7% (87/90). There were no major complications. The mean reintervention rate was 1.19 dilations per patient per year, and the postprocedural dysphagia score (0.72 [95% CI, 0.56-0.87]) was significantly lower than baseline (2.50 [95% CI 2.35-2.65]) (p < 0.001).

CONCLUSION

Repeated fluoroscopically guided balloon dilation is safe and effective for the management of dysphagia caused by esophageal strictures in DEB. Use of this technique was associated with marked clinical improvement in dysphagia and satisfactory long-term reintervention rates with no major complications.

[The regurgitation prophylaxis after the distal esophagus resection]

The clinical use of esophagogastroplasty with antireflux gastroesophageal anastomosis was analyzed basing on the data of 11 operated patients. All patients had benign strictures of the esophagus were operated on transhiatally. The long-term and early results demonstrated the efficacy of the sphincter-valve gastroesophageal anastomosis in prevention of reflux after distal esophagus resection and primary esophagogastroplasty.

[Three cases of the malignant esophageal stenosis successfully treated with the Niti-S™ esophageal stent]

We herein report three cases of the malignant esophageal stenosis successfully treated with the Niti-S™ esophageal stent. CASE 1: The hilar lung cancer and its mediastinal lymph node metastasis pressed the esophagus extramurally and caused the marked stenosis. CASE 2: A metastatic lymph node along the left laryngeal nerve caused the stenosis of the trachea. A primary esophageal lesion located at the middle thoracic esophagus also caused the marked stenosis. At first, tracheal stent was placed because of dyspnea, and two weeks later, we placed an esophageal stent. Case 3: Esophageal cancer at lower thoracic esophagus after definitive radiation therapy caused the marked stenosis. Because of the stenosis of esophago-gastric junction( EGJ), we used an esophageal stent with a long cover in order to prevent a reflux into the esophagus. This new Niti-STM esophageal stent was easy to place at the stenosis without difficulty using a conventional device. The symptom was improved immediately for each case. We hope this new device will be used widely.

Endoscopic management of congenital esophageal stenosis

BACKGROUND/PURPOSE

Congenital esophageal stenosis (CES) is a rare malformation. Endoscopic dilations represent a therapeutic option. This study retrospectively evaluated the efficacy and safety of a conservative treatment of CES.

PATIENTS AND METHODS

Patients diagnosed with CES since 1980 by a barium study or endoscopy were reviewed. Endoscopic ultrasonography (Olympus UM-3R-20-MHz radial miniprobe, Olympus Corporation, Tokyo, Japan), available from 2001, allowed for the differential diagnosis of tracheobronchial remnants (TBR) and fibromuscular hypertrophy (FMH) CES. All children underwent conservative treatment by endoscopic dilations (hydrostatic and Savary).

RESULTS

Forty-seven patients (20 men) had CES. Fifteen were associated with esophageal atresia; and 8, with Down syndrome. Mean age at the diagnosis was 28.3 months (range, 1 day to 146 months). Symptoms were solid food refusal, regurgitation, vomiting, and dysphagia. Congenital esophageal stenosis was located in the distal esophagus. Endoscopic ultrasonography demonstrated TBR and FMH in 6 patients. One hundred forty-eight dilations in 47 patients were performed. The stenosis healed in 45 (95.7%). Complications were 5 (10.6%) esophageal perforations, hydrostatic (3/32, or 9.3%), and Savary (2/116, or 1.7%). At follow-up, 1 patient with FMH CES and 1 patient with TBR CES required operation for persistent dysphagia.

CONCLUSIONS

The conservative treatment yielded positive outcomes in CES. Endoscopic ultrasonography allows for a correct diagnosis of TBR/FMH CES. A surgical approach should be reserved for CES not responsive to dilations.

Congenital esophageal stenosis and antral web. A new association and management challenge

Congenital esophageal stenosis is a rare condition that may be associated with other anomalies. Antral web is also a rare congenital condition. Association of both conditions is extremely rare. We present this rare association in preterm baby in whom initially misdiagnosis of esophageal atresia and trachea-esophageal fistula then followed by a dilemma in differentials diagnosis to explain the uneventful postoperative recovery. The aim of this report is to highlight the diagnostic and therapeutic difficulty of this rare condition.

Incomplete deployment of an expandable metallic stent in a patient with esophageal malignant stenosis

The use of self expandable metallic stents (SEMS) in the palliation of dysphagia due to malignant esophageal stenosis is a gold standard. Covered stents are used in all cases with overt air-digestive fistula or high potential for fistula development. The procedure is associated with a low incidence of procedure-related complications. We present a case with a major accident which developed during stent deployment. The delivery system became blocked and we found it impossible to fully deploy the stent, which remained attached to the introductory system. The stent was forcefully removed and replaced later on with a new stent. This is the first report of a SEMS related accident due to malfunction of the stent deployment system. Stent malfunction is unusual and unlikely to happen, but one should be aware and prepared for such unusual situations.

[A progressive vomiting pre-schooler]

A 4-year-old boy with persistent vomiting had a peptic stenosis of the oesophagus.

Surgical repair of an oesophageal stricture and prestenotic dilatation in a horse

Prestenotic oesophageal dilatation and stricture were diagnosed in a horse with a history of trauma in the cervical area and recurrent oesophageal obstruction. The diagnosis was established on the basis of the clinical examination, endoscopy, and positive contrast oesophagography. Conservative treatment was unsuccessful and surgical intervention was necessary. Oesophageal myectomy combined with myoplasty was performed, simultaneously relieving the dilatation and the stricture. No abnormalities were detected 8 weeks after surgery. The horse was on a normal diet and oesophageal obstruction did recur in the subsequent 14 months.

Prevalence of pharyngeal and esophageal stenosis following radiation for head and neck cancer

OBJECTIVE

To evaluate the risk and outcome of pharyngoesophageal stenosis in patients who complained of dysphagia following radiation for head and neck cancer.

DESIGN

Retrospective study.

SETTING

Veterans Administration hospital.

PATIENTS

Patients who complained of persistent dysphagia following radiation alone or combined with surgery or chemotherapy for head and neck cancer. Patients were selected if they were cancer free at the time of the swallowing study. All patients had modified barium swallow (MBS) and an endoscopic examination for initial evaluation of their dysphagia. Traditional barium swallow was requested when there was a suspicion of pharyngoesophageal stenosis on MBS.

RESULTS

Two hundred twenty-two patients underwent MBS for evaluation of dysphagia posttreatment. Traditional barium swallow confirmed the diagnosis of pharyngeal (n = 2) or esophageal (n = 14) stenosis in 16 patients. Eight patients had esophageal stenosis on endoscopic examination. All patients underwent dilatation for relief of their dysphagia. The number of dilatations performed was, respectively, one in 12 patients, two in 4 patients, three in 3 patients, four in 3 patients, five in one patient, and six in one patient.

CONCLUSION

Pharyngeal and/or cervical esophageal stenosis may be the cause of dysphagia following radiation for head and neck cancer. Esophageal dilatations often offer temporary relief of the dysphagia.

Congenital esophageal stenosis because of tracheobronchial remnant and treated by circular myectomy: a case report

Congenital esophageal stenosis (CES) is a rare anomaly, and appropriate management is not well established. We performed myectomy of the esophageal wall in a child with critical esophageal stenosis caused by tracheobronchial remnant (TBR). An 18-month-old boy was admitted to our hospital having frequent vomiting and failure to thrive. Esophagography and esophagoscopy showed abrupt stenosis at the lower esophageal wall. Balloon dilatation was performed but was ineffective. Surgery was performed under a diagnosis of CES because of TBR. Cartilage was palpable in the stenotic esophageal wall, and extirpation of the muscular layer of the stenotic portion was performed, leaving the mucosal layer intact. The muscular layer was closed loosely using interrupted 5-0 absorbable sutures to match the oral and anal sides together. Postoperatively, the esophageal passage was improved to the point that the patient was able to take solid foods without vomiting. This successful outcome suggests that circular myectomy of the TBR is worth recommending as a surgical procedure for short segment and stenosis of patients with CES because of TBR.