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Daoud ND, Ghoz H, Mzaik O, Zaver HB, McKinney M, Brahmbhatt B, Woodward T. Endoscopic Management of Luminal Strictures: Beyond Dilation. Dig Dis Sci 2022; 67:1480-1499. [PMID: 35212884 DOI: 10.1007/s10620-022-07396-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/04/2022] [Indexed: 12/19/2022]
Abstract
Luminal strictures can occur as part of many different gastrointestinal (GI) disorders anywhere along the GI tract and affect all age groups. The end goal of managing any stricture is to re-establish an adequate and durable luminal patency that is sufficient to resolve the presenting clinical symptoms. Treatment options can be generally categorized into medical, endoscopic, and surgical. However, within each of these categories, multiple different options are available. Therefore, choosing the best treatment modality is often challenging and depends on multiple factors including the type, location, and complexity of the stricture, as well as the preference of the treating physician. In this article, we will review the most current literature regarding foregut strictures, particularly esophageal and gastric, beyond dilation.
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Affiliation(s)
- Nader D Daoud
- Division of Gastroenterology and Hepatology, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | - Hassan Ghoz
- Division of Gastroenterology and Hepatology, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | - Obaie Mzaik
- Division of Gastroenterology and Hepatology, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | - Himesh B Zaver
- Department of Internal Medicine, Mayo Clinic, Jacksonville, FL, USA
| | - Micah McKinney
- Division of Gastroenterology and Hepatology, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | - Bhaumik Brahmbhatt
- Division of Gastroenterology and Hepatology, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA.
| | - Timothy Woodward
- Division of Gastroenterology and Hepatology, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
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Combined Antegrade-retrograde Rendezvous Technique to Dilate Near Complete Distal Esophageal Stenosis. J Pediatr Gastroenterol Nutr 2020; 71:e146. [PMID: 32541204 DOI: 10.1097/mpg.0000000000002808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
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Soares PC, Bouayed S, Dulguerov P, Frossard JL. Recurrent Complete Pharyngo-Oesophageal Stricture Treated by Multidisciplinary Anterograde-Retrograde Endoscopic Dilation. Case Rep Gastroenterol 2016; 10:560-567. [PMID: 27920642 PMCID: PMC5121545 DOI: 10.1159/000450678] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2016] [Accepted: 09/07/2016] [Indexed: 12/29/2022] Open
Abstract
Complete pharyngo-oesophageal stricture (PES) after radiotherapy for head and neck cancer is a relatively rare and difficult complication to manage. Historically this condition has been treated surgically, but endoscopic approaches are now available. We present a 61-year-old man with an epidermoid carcinoma of the supraglottic stage and a micro-invasive epidermoid carcinoma of the oropharynx treated surgically and subsequently by adjuvant radiotherapy. Eight months after the end of the radiotherapy, a complete PES was diagnosed and treated with a combined anterograde-retrograde endoscopic dilation (CARD). The procedure was performed using a transoral anterograde progression with a rigid pharyngoscope and a retrograde progression with an extra-slim nasal endoscope using the percutaneous gastrostomy already in place. Using both transillumination and direct visualisation from both sides of the complete stenosis patency was restored between the neopharynx and the oesophagus. Despite the use of an endoprosthesis, the complete PES recurred and the technique had to be performed a second time. Illustrating the complexity of the case different types of endoprosthesis and several dilations had to be performed for our patient to achieve and maintain a normal oral intake. This case report illustrates that even in complicated recurrent radiation-induced complete PES a CARD can be performed safely and successfully using different types of endoprosthesis.
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Affiliation(s)
- Paulo Castro Soares
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Geneva University Hospital, Geneva, Switzerland
| | - Salim Bouayed
- Department of Otolaryngology-Head and Neck Surgery, Geneva University Hospital, Geneva, Switzerland
| | - Pavel Dulguerov
- Department of Otolaryngology-Head and Neck Surgery, Geneva University Hospital, Geneva, Switzerland
| | - Jean-Louis Frossard
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Geneva University Hospital, Geneva, Switzerland
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Bertolini R, Meyenberger C, Putora PM, Albrecht F, Broglie MA, Stoeckli SJ, Sulz MC. Endoscopic dilation of complete oesophageal obstructions with a combined antegrade-retrograde rendezvous technique. World J Gastroenterol 2016; 22:2366-2372. [PMID: 26900299 PMCID: PMC4735011 DOI: 10.3748/wjg.v22.i7.2366] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2015] [Revised: 11/03/2015] [Accepted: 12/08/2015] [Indexed: 02/06/2023] Open
Abstract
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.
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Singhal S, Hasan SS, Cohen DC, Pfanner T, Reznik S, Duddempudi S. Multi-disciplinary approach for management of refractory benign occlusive esophageal strictures. Therap Adv Gastroenterol 2013; 6:365-70. [PMID: 24003337 PMCID: PMC3756635 DOI: 10.1177/1756283x13492000] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Benign occlusive esophageal strictures create substantial morbidity and have poor surgical outcomes. Various endoscopic techniques have been described to manage these strictures. The challenge remains to maintain adequate long-term esophageal patency and to limit the need for serial endoscopic dilations. Little has been reported regarding the management of these benign occlusive strictures. METHODS We report a case series describing the management of technically challenging benign occlusive esophageal strictures. Three patients with occlusive esophageal strictures of differing etiologies were treated using a variety of endoscopic methodologies. RESULTS The first patient sustained a caustic oropharyngeal injury resulting in a proximal esophageal stricture which was treated by using a combined antegrade retrograde dilation (CARD) with argon plasma coagulation (APC) and needle knife dissection resulting in the successful recanalization and patency of his stricture. A second patient developed an esophageal stricture following radiotherapy, and was treated with a CARD procedure and serial balloon dilations in combination with APC to successfully achieve esophageal luminal patency. The final patient acquired an occlusive esophageal stricture after treatment for thyroid cancer which was treated with endoscopic needle knife dissection followed by serial balloon dilations to successfully manage this stricture. CONCLUSIONS Occlusive esophageal strictures pose a difficult challenge to gastroenterologists and little has been reported with regards to their endoscopic management. Using the CARD technique, needle knife dissection and APC, individually or in combination, luminal patency of occlusive esophageal strictures can be accomplished safely with good results.
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Affiliation(s)
- Shashideep Singhal
- The Brooklyn Hospital Center, New York Presbyterian Healthcare System, 121 Dekalb Ave, Brooklyn NY, 11105, USA
| | - Syed S. Hasan
- Division of Gastroenterology, Scott & White Healthcare, Temple, TX, USA
| | - Dan C. Cohen
- Division of Gastroenterology, Scott & White Healthcare, Temple, TX, USA
| | - Timothy Pfanner
- Division of Gastroenterology, Scott & White Healthcare, Temple, TX, USA
| | - Scott Reznik
- Division of Cardiothoracic Surgery, Scott & White Healthcare, Temple, TX, USA
| | - Sushil Duddempudi
- Division of Gastroenterology, The Brooklyn Hospital Center, Brooklyn, NY, USA
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Boyce HW, Estores DS, Gaziano J, Padhya T, Runk J. Endoscopic lumen restoration for obstructive aphagia: outcomes of a 25-year experience. Gastrointest Endosc 2012; 76:25-31. [PMID: 22482914 DOI: 10.1016/j.gie.2012.02.037] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2011] [Accepted: 02/20/2012] [Indexed: 02/08/2023]
Abstract
BACKGROUND After chemoradiation therapy for head/neck cancer, some patients develop strictures that progress to complete pharyngoesophageal occlusion. Total lumen occlusion is less often due to other conditions. Enteral access (enterostomy tube) and good nutritional status tend to minimize the significance of dysphagia and therefore may mask recognition of impending complete lumen occlusion. OBJECTIVE Review outcomes of a 25-year experience with endoscopic lumen restoration (ELR) in 30 patients. DESIGN Retrospective, case review study. SETTING Two tertiary-care referral centers. PATIENTS This study involved 30 consecutive patients referred for obstructive aphagia due to complete lumen occlusion, primarily after chemoradiation therapy for head/neck cancer. INTERVENTION Antegrade and retrograde endoscopy with tri-plane fluoroscopy for penetrating the occluded segment, serial retrograde and antegrade dilations, plus swallowing rehabilitation therapy. MAIN OUTCOME MEASUREMENTS Restoration of lumen patency, swallowing function, and removal of enteral feeding tube. RESULTS ELR was successful in 30 patients in 31 of 33 attempts (93%). Return to soft to regular diet was achieved in 15 of 30 patients (50%), and fluids to pureed food with partial percutaneous endoscopic gastrostomy nutrition was achieved in 5 of 30 patients (17%). Ten of 30 patients (33%) were considered unsafe for oral feeding because of oropharyngeal neuromotor deficits. Complications occurred in 5 of 30 patients (17%), with no prolonged sequelae, deaths, or surgery, but two stents were placed for anastomotic fistulas. The median duration of follow-up was 22.75 months. LIMITATIONS Retrospective, case review study. CONCLUSION ELR by using tri-plane fluoroscopic guidance with antegrade and retrograde endoscopy and serial dilations allows lumen restoration and swallowing to some degree in a majority of patients. Engagement of a core team of specialists can provide optimal restoration of swallowing function.
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Affiliation(s)
- H Worth Boyce
- Joy McCann Culverhouse Center for Swallowing Disorders, Department of Internal Medicine, University of South Florida College of Medicine, Tampa, Florida 33612, USA
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Fowlkes J, Zald PB, Andersen P. Management of complete esophageal stricture after treatment of head and neck cancer using combined anterograde retrograde esophageal dilation. Head Neck 2011; 34:821-5. [PMID: 22127917 DOI: 10.1002/hed.21826] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2010] [Revised: 03/29/2011] [Accepted: 04/05/2011] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Complete esophageal stricture is a difficult problem to manage. There is limited literature to support clinical decision-making. To evaluate outcomes and efficacy, we performed a retrospective medical chart review of patients who received combined anterograde retrograde esophageal dilation (CARD) between 2002 and 2009 at our institution. METHODS Fifteen patients were identified who developed a stricture requiring CARD after treatment for head and neck cancers. Outcomes were pretreatment and posttreatment diet, gastrostomy tube status, and operative complications. RESULTS Six of 15 patients were gastrostomy tube-free at last follow-up and 11 of 15 patients were taking oral nutrition. There were 4 complications. One patient died. Two gastrostomy tube site complications occurred. One patient sustained a dental injury. CONCLUSION CARD offers benefit to most patients. Despite risks associated with the procedure, CARD should be considered by the clinician and patient in management of complete esophageal stricture.
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Affiliation(s)
- Jonathan Fowlkes
- Department of Otolaryngology, Head and Neck Surgery, Oregon Health and Science University, Portland, Oregon, USA
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Zald PB, Andersen PE. Fatal central venous air embolism: a rare complication of esophageal dilation by rendezvous. Head Neck 2011; 33:441-4. [PMID: 19953633 DOI: 10.1002/hed.21304] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Esophageal dilation by rendezvous is a useful technique for the treatment of complicated esophageal strictures. METHODS AND RESULTS We present a case of a 74-year-old man with chronic dysphagia caused by a complete cervical esophageal stricture that developed after external beam radiotherapy for treatment of papillary thyroid carcinoma. During attempted dilation using the rendezvous technique, the patient suffered a fatal pulmonary air embolism. The technique of esophageal dilation by rendezvous, complications, and risk factors for development of venous air embolism are discussed. CONCLUSION To the best of our knowledge, this is the first report in the literature of fatal venous air embolism after dilation by rendezvous.
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Affiliation(s)
- Philip B Zald
- Department of Otolaryngology Head and Neck Surgery, Oregon Health and Sciences University, Portland, OR 97239, USA
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Hochberger J, Kruse E, Köhler P, Bürrig KF, Menke D. [Diagnostic and interventional endoscopy in gastroenterology : from high-resolution chips and procedures for endoscopic resection to NOTES]. HNO 2009; 57:1237-52. [PMID: 19924360 DOI: 10.1007/s00106-009-2022-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
In the past 10 years endoscopic diagnostics has benefited from technologies such as big chips, high-definition television (HDTV) and narrow band imaging (NBI). Video capsule endoscopy and double balloon enteroscopy have facilitated visualization of the entire small bowel. A number of studies on mucosal Barrett's and gastric cancers could prove that endoscopic mucosal resection (EMR) is oncologically equivalent to surgical resection when certain criteria are respected. However, EMR is less invasive and carries a substantially lower complication risk and mortality compared to surgery. Endoscopic submucosal dissection (ESD) facilitates en bloc resection with thorough histopathologic evaluation of the specimen, e.g. for mucosal lesions in the stomach and rectum. Endosonography (EUS) guided transgastric necrosectomy using a flexible gastroscope has set a milestone in the treatment of infected pancreatic necroses and has replaced open surgery in many centers. Natural orifice transluminal endoscopic surgery (NOTES) uses natural body openings as minimally invasive access to the abdomen and mediastinum. Interventional GI endoscopists and minimally invasive surgeons have profited from these innovations in micromechanics and microelectronics.
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Affiliation(s)
- J Hochberger
- Medizinische Klinik III, Schwerpunkt Allgemeine Innere Medizin, Gastroenterologie, Interventionelle Endoskopie, St.-Bernward-Krankenhaus, Akad. Lehrkrankenhaus der Universität Göttingen, Treibestrasse 9, 31134, Hildesheim, Deutschland.
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Sumiyama K, Gostout CJ, Gettman MT. Status of access and closure techniques for NOTES. J Endourol 2009; 23:765-71. [PMID: 19438293 DOI: 10.1089/end.2008.0159] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Natural orifice translumenal endoscopic surgery (NOTES) is a novel surgical concept that may provide a multitasking platform for minimally invasive surgery in the 21st century. With NOTES, natural hollow organs are used to gain access to body cavities via the mouth, anus, vagina, and urethra, thereby eliminating skin incisions. Access to the body cavity through the entry portal for the NOTES procedure and closure of the portal after surgery are important treatment considerations. In this review, access and closure techniques for NOTES-related procedures are discussed. Technical descriptions for access are also described. Closure techniques using experimental and commercially available devices are also reviewed. Based on the experimental and early clinical experiences to date, the future of NOTES appears quite promising. Nonetheless, ongoing fundamental research is necessary to determine the safety and benefit of these procedures. While technical challenges are currently present, the issues are being resolved with the development of optimal instrumentation and techniques. We believe that once standardized safe and reliable access and closure techniques are established, a major shift in minimally invasive surgery will likely be inevitable.
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Affiliation(s)
- Kazuki Sumiyama
- Department of Endoscopy, Jikei University School of Medicine, Tokyo, Japan
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Hasan M, Maple JT. Traversing Difficult Esophageal Strictures from the Retrograde Approach. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2008. [DOI: 10.1016/j.tgie.2008.07.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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Mukherjee K, Cash MP, Burkey BB, Yarbrough WG, Netterville JL, Melvin WV. Antegrade and Retrograde Endoscopy for Treatment of Esophageal Stricture. Am Surg 2008. [DOI: 10.1177/000313480807400803] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Total or near-total esophageal stricture results from multiple processes. Traditional treatment with wire cannulation followed by serial dilation is often contraindicated due to poor visualization and the risk of perforation. We seek to demonstrate that combined antegrade and retrograde endoscopy are useful for treatment of total or near-total esophageal strictures. The gastrostomy tube is removed and the tract dilated. A standard endoscope is passed retrograde to the stricture. An antegrade endoscope is advanced until transillumination across the stricture is visualized. A biopsy forceps or needle is used to traverse the stricture in an antegrade fashion. The tract is cannulated with a stiff wire that is then brought out through the gastrostomy site. The stricture is serially dilated. The gastrostomy tube is replaced, and a nasogastric tube is left across the stricture for 3 to 4 weeks. The endoscope is withdrawn and an 18 or 20 Fr gastrostomy tube is left in place. A total of three patients with total esophageal strictures were treated using combined antegrade and retrograde esophagoscopy. All three patients regained the ability to swallow secretions. Importantly, there were no instances of esophageal perforation. This technique has broader application, including combination with minilaparotomy for patients without retrograde access. Further research is needed to determine durability of stricture dilation.
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Affiliation(s)
- Kaushik Mukherjee
- Division of General Surgery, Section of Surgical Sciences, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Michael P. Cash
- Division of General Surgery, Section of Surgical Sciences, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Brian B. Burkey
- Department of Otolaryngology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Wendell G. Yarbrough
- Department of Otolaryngology, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Cancer Biology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - James L. Netterville
- Department of Otolaryngology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Willie V. Melvin
- Division of General Surgery, Section of Surgical Sciences, Vanderbilt University Medical Center, Nashville, Tennessee
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