Intralesional steroid injection therapy

Recently, a different therapeutic option for patients with benign esophageal strictures was introduced in our gastroenterology unit. Causes of these strictures, preliminary treatment, pathophysiology, the actual procedure, and possible complications of the procedure are discussed.

Oesophageal narrowing in chronic granulomatous disease

A 14 year-old boy with X-linked chronic granulomatous disease (CGD) developed a long smooth narrowing at the mid oesophagus with severe dysphagia. Endoscopy revealed a normal mucosa and biopsy showed non-specific acute inflammatory changes. Bacterial cultures of the biopsy specimens were sterile. Combined treatment with antibiotics and steroids resulted in a transitory remission, but symptoms recurred after 2.5 months. One second course of steroids and antibiotics lead to a long-term remission. Oesophagogram was more useful than endoscopy to evaluate the severity of the stricture.

A cost-utility analysis comparing omeprazole with ranitidine in the maintenance therapy of peptic esophageal stricture

BACKGROUND

Recent studies have suggested that patients receiving omeprazole for prophylaxis against peptic esophageal stricture recurrence have less dysphagia and require fewer repeat dilations than patients receiving ranitidine.

OBJECTIVE

To estimate the incremental utility gain and associated incremental cost of omeprazole compared with those of ranitidine for the maintenance therapy of patients with peptic stricture who required esophageal dilation.

METHODS

Decision analysis using SMLTREE software was used to compare the incremental cost-utility of omeprazole 20 mg once daily with that of ranitidine 150 mg bid for one year. Variables were estimated from the literature, hospital data, and utility analyses involving patients with peptic stricture and health professionals. The primary outcome measure was cost per quality-adjusted life-years (QALYs) gained.

RESULTS

The incremental cost of omeprazole compared with that of ranitidine was $556 per patient treated. The incremental utility gain of omeprazole was 0.0112 QALYs. Overall, the incremental cost:utility ratio of omeprazole in the maintenance therapy of patients with peptic stricture was $49,600 per QALY gained. A sensitivity analysis revealed that the estimates with the greatest impact on the cost:utility ratio were disutility associated with dysphagia and dilation, the probability of requiring redilation and the cost of medications.

CONCLUSIONS

Omeprazole 20 mg once daily is associated with greater utility and higher cost than ranitidine 150 mg bid when used as prophylaxis against stricture recurrence. Omeprazole may be considered clinically and economically sufficient enough to warrant widespread use in this setting.

A comparison of omeprazole, lansoprazole and pantoprazole in the maintenance treatment of severe reflux oesophagitis

BACKGROUND

Proton pump inhibitors are effective for the healing of oesophagitis. Standard doses of omeprazole, lansoprazole or pantoprazole are sufficient for healing in mild to moderate cases of oesophagitis.

AIM

To compare the efficacy of double the standard doses of omeprazole, lansoprazole or pantoprazole for maintenance treatment of severe oesophagitis complicated by a stricture.

METHODS

Thirty-six patients with reflux oesophagitis and stricture confirmed by endoscopy were included in a prospective study comparing three maintenance therapies. In all cases weekly dilatation of the stenosis was performed and patients were treated with omeprazole 20 mg b.d. until healing of oesophagitis and dysphagia relief were achieved. Thirty participants responded to therapy and were then randomly assigned to 4 weeks of maintenance treatment with omeprazole (20 mg b.d.; n = 10), lansoprazole (30 mg b.d.; n = 10) or pantoprazole (40 mg b.d.; n = 10). Subsequently, endoscopies were performed-the endoscopists were blinded to the therapy assignment. The endpoints were defined as the absence of oesophagitis, oesophageal stricture and complaints.

RESULTS

After 4 weeks of treatment, the number of patients remaining in remission (no oesophagitis or stricture and no symptoms) was nine out of 10 (90%) in the omeprazole group, two out of 10 (20%) in the lansoprazole group (P < 0.01) and three out of 10 (30%) in the pantoprazole group (P < 0.01).

CONCLUSIONS

In our study omeprazole was superior to either lansoprazole or pantoprazole in the maintenance treatment of complicated gastro-oesophageal reflux disease.

Palliation of malignant dysphagia by laser therapy

The outcome of 211 patients undergoing laser therapy as palliation for inoperable carcinoma of the esophagus is presented. The median age was 73 (range 44-97). The histology was adenocarcinoma for 127 patients and squamous-cell carcinoma for 84 patients. For 133 patients, laser was the only therapy while 56 patients had a combination of laser therapy and radiotherapy/chemotherapy. One patient underwent laser recanalization prior to resection while four patients had recurrence after resection treated by laser. Eleven patients underwent laser therapy for recurrent dysphagia after placement of an esophageal endoprosthesis. Eighteen patients died of procedure-related complications (i.e. 9% of patients and 2% of procedures). Of 32 procedures which perforated the tumour, 10 ended in death and the remaining patients were successfully treated conservatively. Good palliation was achieved for 170 patients (80%), while 19 patients underwent intubation after failure of laser therapy. Laser therapy failed to relieve dysphagia for 22 patients. The median survival was 20 weeks with the 1-year survival 12% and 2-year survival 4%; there were no significant differences in survival dependent on histology or administration of adjuvant radiotherapy or chemotherapy. Laser therapy provides a practical alternative to intubation in the treatment of malignant dysphagia for patients with unresectable esophageal carcinoma.

Brush cytology in the diagnosis of neoplasia in Barrett's esophagus

Esophageal cytology may improve sensitivity for the detection of malignancy but can be difficult to interpret in the presence of inflammation. To assess the value of cytology in assessing patients with Barrett's esophagus a retrospective review was performed. One hundred and sixty two patients (87 esophageal/gastroesophageal junction adenocarcinoma, 65 non-dysplastic Barrett's esophagus and 10 dysplastic Barrett's esophagus) had biopsies and brushings taken for histological and cytological assessment. Eighty two of 92 patients with carcinoma or high-grade dysplasia had true positive malignant cytology. Seven of 65 patients with non-dysplastic but inflamed Barrett's esophagus had false positive malignant cytology. One of these patients had an esophagectomy on the basis of cytology but no tumor was found in the resection specimen. This translates into an 89% sensitivity and specificity of cytology for the detection of esophageal columnar neoplasia. Cytology from Barrett's esophagus can be misleading in the presence of severe inflammation. Cells from a benign Barrett's ulcer may appear frankly malignant when examined in isolation. Esophagectomy should not be performed on the basis of cytological evidence alone.

Endoscopic ultrasound miniprobe-guided steroid injection for treatment of refractory esophageal strictures

Local injection of corticosteroids into refractory esophageal strictures to decrease the restenosis rate has been reported. Here we report our efforts in three patients to render the delivery of steroids more precise, by injecting them in the thickest segment of the stricture with the guidance of a high frequency ultrasound miniprobe passed through a regular upper endoscope. Steroid injection under ultrasound miniprobe guidance may be indicated for patients who do not respond to a "blind" steroid injection without miniprobe guidance.

Omeprazole in the treatment of patients with complicated gastro-oesophageal reflux disease

Suppression of acid secretion with omeprazole is highly effective for the healing of oesophagitis. The aims of the present study were to determine whether recovery of gastro-oesophageal reflux disease in patients with stricture improves dysphagia and decreases the dilatation need and to compare the efficacy of omeprazole versus H2-receptor antagonists. Thirty-eight patients with peptic stricture (grade IV oesophagitis) and erosive oesophagitis underwent endoscopic dilatation and were randomized to omeprazole (40 mg daily; n = 20) versus ranitidine (150 mg twice daily; n = 18). Healing was proven endoscopically and patients were interviewed for dysphagia relief. Patients were assessed for relapse by endoscopy 6 months later. The follow-up period was a further 6 months. Patients received maintenance treatment with 40 mg omeprazole daily or ranitidine 150 mg twice daily and the total duration of treatment was 1 year. At 6 months, omeprazole produced a highly significant (P < 0.0001) greater rate of oesophagitis healing and highly significant (P < 0.0001) fewer dilatations compared with H2-receptor antagonists (18 (90%) patients vs five (28%) patients, respectively; 3.5 vs 9.0 dilatations/patient). At 12 months, not one of the 18 successfully treated patients from the omeprazole group had relapsed. The two remaining patients required further dilatation and 40 and 60 mg omeprazole daily for healing. In comparison, all patients on ranitidine had to undergo further bougienage. In conclusion, omeprazole is a safe and effective maintenance treatment for preventing relapse of complicated reflux oesophagitis.

Using botulinum toxin A to improve speech and swallowing function following total laryngectomy

OBJECTIVE

To evaluate a technique to reduce dysfunctional spasm in the pharyngoesophageal segment (PES) in patients after laryngectomy.

DESIGN

Pharyngoesophageal segment function related to voice and/or swallowing in patients who had undergone a laryngectomy was evaluated before and after the injection of botulinum toxin A.

SETTING

Academic referral medical center.

PATIENTS

Eight outpatients with voice and/or swallowing complaints after undergoing a total laryngectomy.

INTERVENTIONS

Videofluoroscopic contrast examination was completed to identify stricture vs spasm in the PES in patients with voice and/or swallowing complaints after undergoing a laryngectomy. Lidocaine hydrochloride injection under fluoroscopic guidance was completed to facilitate immediate relaxation of spasm. After positive results with lidocaine, botulinum toxin was injected into the same area to facilitate longer-lasting benefit.

MAIN OUTCOME MEASURE

Patient report of benefit and videofluoroscopic evaluation of PES function.

RESULTS

Six of 8 patients demonstrated improved function within the PES after lidocaine injection. Five of these 6 received transcutaneous injection of botulinum toxin. Four of the 5 patients demonstrated improved swallowing and/or voice function, and 3 of these 4 received subsequent injections of botulinum. No serious complications were encountered.

CONCLUSIONS

Transcutaneous injection of botulinum toxin in the PES under videofluoroscopic guidance provides improvement in voice and/or swallowing function without significant complications. Additional clinical study will be required to evaluate dose and technique influences on degree and duration of benefit and complications.

Prevention of recurrence of oesophageal stricture, a comparison of lansoprazole and high-dose ranitidine

OBJECTIVE

To determine the efficacy of lansoprazole 30 mg given in the morning compared with high-dose ranitidine 300 mg twice daily in the treatment of patients with oesophageal strictures.

DESIGN

A multicentre, outpatient, double-blind, parallel group, prospectively randomized clinical trial.

PATIENTS

One hundred and fifty-eight patients (lansoprazole 30 mg n = 78, ranitidine 600 mg n = 80) were enrolled from 19 centres in the UK over 23 months.

INTERVENTIONS

Patients with an oesophageal stricture were randomized to receive either lansoprazole 30 mg once daily or high-dose ranitidine 300 mg twice daily for 12 months. Dilatation was performed at entry and repeat endoscopies were scheduled at 6 and 12 months and additionally at other times if there was symptomatic relapse. Redilatation was performed as required and according to a predefined scale. The patient's assessment of dysphagia over the previous 7 days was recorded by the investigator at 1, 3, 6, 9 and 12 months. Safety was assessed by laboratory tests, physical examination and all adverse events.

MAIN OUTCOME MEASURES

Efficacy was assessed primarily by the time to redilatation, the proportion of patients requiring at least one redilatation, and the number of redilatations over 12 months. The relief of dysphagia and reduction in stricture grade were secondary efficacy measures.

RESULTS

The time to redilatation was longer and the probability of no redilatation were higher in the lansoprazole group than in the ranitidine group; for all patients randomized (intention to treat principle), this difference was of borderline significance (life table, P = 0.053). The proportions of patients requiring at least one redilatation during the 12-month treatment period were 30.8% (24/78) with lansoprazole and 43.8% (35/80) with ranitidine (all patients randomized, chi 2 test, P = 0.092). Compared to ranitidine, patients receiving lansoprazole reported significantly lower dysphagia grades at 6 months (stratified Wilcoxon test, P = 0.0086) but not at 12 months (stratified Wilcoxon test, P = 0.074). A greater proportion of patients in the ranitidine group-33.8% (27/80)-withdrew prematurely compared to the lansoprazole group (26.9%, 21/78). The most frequent reasons for premature withdrawal were adverse events and protocol violations. There were no clinically significant differences in incidence or severity of adverse events between the two groups. The mean increase in gastrin levels after 12 months' treatment was significantly greater for patients in the lansoprazole group (124.2 pg/ml, P = 0.0056) than those in the ranitidine group (31.9 pg/ml). No significant changes in gastric mucosal histology were detected for patients in either group.

CONCLUSION

It is concluded that lansoprazole 30 mg once daily is superior to ranitidine 300 mg twice daily in relieving dysphagia, and at least as effective in reducing the need for a repeat dilatation.

A randomized blinded comparison of omeprazole and ranitidine in the treatment of chronic esophageal stricture secondary to acid peptic esophagitis

BACKGROUND

Esophageal strictures due to gastroesophageal reflux disease are often resistant to medical therapy and require repeated dilation procedures. Our aim was to compare the efficacy of therapy with omeprazole (20 mg/day) to ranitidine (150 mg twice daily) in the treatment of chronic esophageal strictures.

METHODS

Thirty-three patients with chronic esophageal stricture disease (mean length of prior treatment, 50.9 months) were entered into a randomized blinded trial. The majority (88%) of the patients had received multiple prior esophageal dilations (mean, 7.9 per patient). Endoscopy and barium esophagograms were performed initially and at the end of 10 months. Symptoms were considered every 2 months and dilations performed as needed. The patient groups were equivalent.

RESULTS

One patient in each group was subsequently lost to follow-up. No significant differences were seen in symptom improvement or need of dilation. At the final endoscopy, 8 of 17 (47%) patients receiving ranitidine had residual erosions or ulceration, compared with 1 of 14 (7%) patients receiving omeprazole (p >0.2). All patients receiving ranitidine had persistent strictures, whereas 8 of 14 (57.1%) patients receiving omeprazole had radiographic and endoscopic resolution of their strictures (p <0.004).

CONCLUSION

These data further emphasize the need for vigorously treating esophagitis in patients with acid peptic strictures.

Combined modality therapy for esophageal carcinoma: preliminary results from a large Australasian multicenter study

PURPOSE

This report updates local control and survival experience and focuses on treatment toxicity in 294 patients with esophageal cancer who have been treated at six Australasian centers using three prospective unrandomized protocols that used concurrent radiation, cisplatin, and modest dose infusional fluorouracil.

METHODS AND MATERIALS

Protocol 1--"definitive" chemoradiation. One hundred and thirty-seven patients have been treated with "definitive" radiation to 60 Gy in 6 weeks plus two courses of cisplatin (80 mg/m2) and infusional fluorouracil (800 mg/m2/day over 4 days) during the first and fourth weeks of radiation. Protocol 2--"preoperative" chemoradiation and surgery. Seventy-eight patients received chemoradiation using the same chemotherapy, but 30-35 Gy in 3-4 weeks prior to surgery. Protocol 3--"palliative" chemoradiation. Seventy-nine patients deemed incurable were treated "palliatively" with the same chemoradiation protocol without surgery. Follow-up ranges from 6 months to 7 years (mean 22 months) in live patients.

RESULTS

Durable palliation of dysphagia in all three treatment groups has been reflected by encouraging 3-year survival expectations of 43.2 +/- 5% in definitively treated patients, 40.3 +/- 7.65% in surgically treated patients, and 8.5% +/- 3.9% in the palliatively treated patients. There are early indications that female patients have fared better than males. Toxicity levels were modest in all three groups. Following definitive treatment, severe myelotoxicity (World Health Organization grades 3 and 4) occurred in 19%, severe esophagitis (World Health Organization grade 3) in 11%, and moderate or severe benign stricture in 17%, depending upon age and sex of the patient (being worse in female patients).

CONCLUSIONS

These studies demonstrate that the concurrent addition of modest dose cisplatin and infusional dose fluorouracil to radiation in the definitive, preoperative, and palliative settings contribute to high rates of durable dysphagia-free survival, with overall survival comparable to (and possibly better than) the chemoradiation arm of the recently reported Intergroup Study, but at the cost of less morbidity.

Photodynamic therapy for obstructing esophageal cancer: light dosimetry and randomized comparison with Nd:YAG laser therapy

BACKGROUND & AIMS

Light dosimetry analysis to achieve predictable tumor necrosis has not been performed for photodynamic therapy (PDT) in the gastrointestinal tract. We evaluated dihematoporphyrin ethers for sensitizing esophageal carcinomas to 630 nm light and compared PDT with neodymium:yttrium-aluminum-garnet (Nd:YAG) laser therapy in a randomized trial.

METHODS

Of 52 patients with dysphagia, 32 received palliative PDT. Ten patients treated with PDT participated in a preliminary trial using various doses of 630-nm light, and 22 patients treated with PDT participated in a randomized trial using a derived standardized light dose for comparison with 20 patients treated with the Nd:YAG laser.

RESULTS

Light dosimetry correlated with depth of tumor necrosis (r = 0.664; P < 0.001). PDT activity was similar for squamous cell and adenocarcinoma. Among randomized patients, both PDT and Nd:YAG therapy relieved dysphagia, but PDT resulted in improved Karnofsky performance status at 1 month (+7 vs. -7; P < 0.001) and longer duration of response (84 vs. 57 days; P = 0.008). Skin photoreactions were unique to PDT.

CONCLUSIONS

The extent of PDT tumor ablation correlates with light dosimetry, enabling selection of a standardized light dose. PDT can relieve esophageal obstruction from squamous cell and adenocarcinoma and is an alternative to Nd:YAG thermal necrosis with a longer duration of response. However, PDT requires patient precautions to minimize skin photoreactions.

Role of omeprazole in prevention and treatment of postendoscopic variceal sclerotherapy esophageal complications. Double-blind randomized study

Endoscopic variceal sclerotherapy-related esophageal complications are quite common. The potential efficacy of omeprazole in the prevention and treatment of postsclerotherapy esophageal complications was evaluated in 47 patients with portal hypertension in randomized, placebo-controlled study. Twenty-one patients in the omeprazole group and 23 patients in the placebo group completed the study. The two treatment groups were similar in regards to the etiology of portal hypertension, Child's class, and clinical characteristics. Esophageal ulcers developed in 16 patients in the omeprazole group (2.43 ulcers/patient) and 18 patients in the placebo group (2.39 ulcers/patient). Most of the ulcers (> 90%) healed within 14 days in each group. Esophageal strictures requiring dilatation developed in two and one patient in the omeprazole and placebo groups, respectively. There was no statistically significant difference in regards to the complication rate between the two groups. We conclude that omeprazole is not effective for the prevention or treatment of postsclerotherapy esophageal complications.

A comparison of omeprazole and ranitidine in the prevention of recurrence of benign esophageal stricture. Restore Investigator Group

BACKGROUND/AIMS

Dilatation combined with subsequent pharmacological control of gastroesophageal reflux represents a logical but poorly documented approach to the management of benign esophageal stricture. This large trial (366 patients) aimed to assess whether omeprazole as the most effective available medication for gastroesophageal reflux disease prevents recurrent stricture formation.

METHODS

Patients (n = 366) were randomized in a double-blind study to undergo either omeprazole (20 mg once daily; 180 evaluable patients) or ranitidine therapy (150 mg twice daily; 185 evaluable patients) for 1 year after dilatation to 12-18-mm diameter (36-54F gauge). Subsequently, endoscopy and dilatation were performed when clinically indicated and endoscopy on completion. Symptoms were assessed at clinic visits every 3 months and using weekly diary cards.

RESULTS

Fewer patients undergoing omeprazole therapy required redilatation compared with those on ranitidine (43 of 143 [30%] vs. 66 of 143 [46%] by 12 months; P < 0.01), and patients in the omeprazole group needed fewer redilatations during the year (0.48 vs. 1.08; P < 0.01). On completion, symptom relief favored omeprazole: 76% of patients in the omeprazole group were free of dysphagia (compared with 64% in the ranitidine group; P < 0.05); 83% were able to accept a normal diet (69%; P < 0.01); and 65% were completely asymptomatic (43%; P < 0.001).

CONCLUSIONS

Omeprazole, 20 mg once daily, was more effective than ranitidine, 150 mg twice daily, as prophylaxis against stricture recurrence and in providing symptom relief.

Omeprazole versus H2-receptor antagonists in treating patients with peptic stricture and esophagitis

BACKGROUND/AIMS

Although dysphagia in patients with peptic stricture is attributed to a decreased luminal diameter, coexistent esophagitis may be an equally important cause. The goals of this study were to determine whether medical healing of esophagitis in patients with stricture improves dysphagia and decreases dilatation need and to compare the efficacy and cost-effectiveness of omeprazole versus H2-receptor antagonists (H2RA).

METHODS

Thirty-four dysphagic patients with peptic stricture and erosive esophagitis were dilated and randomized to omeprazole 20 mg every day versus H2RA (ranitidine 150 mg twice daily or famotidine 20 mg twice daily). Patients received further dilatations only if dysphagia frequency was greater than or equal to once per week. At 3 and 6 months, patients were assessed for esophagitis healing, dysphagia relief, and bougienage requirements. Cost-effectiveness of omeprazole and H2RA was determined.

RESULTS

Patients with healed esophagitis at 3 and 6 months were more likely to dysphagia-free and to require fewer dilatations than patients with persistent esophagitis. At 6 months, omeprazole produced a significantly (P < 0.01) higher rate of esophagitis healing, dysphagia relief, and fewer dilatations compared with H2RA. Omeprazole was also 40%-50% more cost-effective.

CONCLUSIONS

Esophagitis healing improves dysphagia and decreases dilatation need in patients with peptic stricture. Omeprazole heals esophagitis and relieves dysphagia more efficaciously than H2RA while decreasing costs to patients.

Non-operative treatment of benign oesophageal strictures: results after endoscopic balloon dilatation and H2-antagonists

OBJECTIVE

To evaluate the success of non-operative treatment of benign oesophageal strictures.

DESIGN

Retrospective study.

SETTING

University department of surgery.

SUBJECTS

27 consecutive patients with benign oesophageal strictures treated between 1984 and 1989.

INTERVENTIONS

Repeated oesophageal dilatations as necessary together with cimetidine or ranitidine; 10 patients underwent 24 hour pH measurements.

MAIN OUTCOME MEASURES

Resolution of dysphagia and gastro-oesophageal reflux.

RESULTS

125 dilatations were done for the 27 patients, 21 patients required four or less. The longer the stricture the larger the number of dilatations required. Median follow up time was 27 months (range 3-74), and during this period 11 patients died. None of the deaths was related either to the stricture or to its treatment. There were no complications of dilatation. Among the 10 patients who underwent 24 hour pH measurements the median percentage of time that the pH was less than 4 was 23, range 7-67. Non-operative treatment was successful in all but three patients, who required fundoplication.

CONCLUSIONS

Non-operative treatment is successful for most patients with benign strictures, so it may be possible to restrict antireflux operations to young patients with strictures.