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Wandell GM, Swartwood JG, Brar AS, Postma GN, Belafsky PC. Safety of a Novel Upper Esophageal Sphincter Balloon Dilator. Laryngoscope 2024. [PMID: 38982872 DOI: 10.1002/lary.31634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Revised: 06/25/2024] [Accepted: 06/27/2024] [Indexed: 07/11/2024]
Abstract
OBJECTIVE The shape of esophageal dilators has not changed in over 350 years. Clinical and animal research suggests that the upper esophageal sphincter (UES) is not round but approximates a kidney shape and that cylindrical dilators may be suboptimal. The Infinity UES Dilation System has been developed specifically for the anatomic configuration of the UES. This study evaluates the safety of the UES-specific Infinity Dilation System. METHODS All patients undergoing dilation of the UES between January 1, 2022 and September 1, 2023 were included. Demographics, procedure indication, dilator type, minor adverse events, and major complications were abstracted. Minor adverse events, complications, and maximum dilation dimension (mm) were compared between groups. RESULTS A total of 477 patients were included. Eight hundred and seventy-three total UES dilations were performed. The primary indications for UES dilation were cricopharyngeus muscle dysfunction (43%) and stenosis from radiation toxicity (40%). Twenty-three percent (202/873) of dilations were performed with an Infinity balloon, 31% (270/873) were performed using two conventional balloons placed side by side, and 46% (401/873) were performed with one singleton conventional balloon. The average maximum dilation dimension was 33 (±4.7) mm for Infinity balloons, 32 (±3.8) mm for two side-by-side balloons, and 18 (±3.4) mm for singleton balloons. There were three major complications with conventional balloons and none with Infinity balloons. There were no significant differences in minor adverse events between groups. CONCLUSIONS A UES-specific esophageal dilator provides a greater maximum dilation dimension and appears to be at least as safe as dilation with a single cylindrical balloon designed to dilate the esophagus. LEVEL OF EVIDENCE Level 3 Laryngoscope, 2024.
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Affiliation(s)
- Grace M Wandell
- Department of Otolaryngology - Head and Neck Surgery, University of California, Davis, Sacramento, California, USA
| | - Janeth Garcia Swartwood
- Department of Otolaryngology - Head and Neck Surgery, University of California, Davis, Sacramento, California, USA
| | - Ashar Singh Brar
- Department of Otolaryngology - Head and Neck Surgery, University of California, Davis, Sacramento, California, USA
| | - Gregory N Postma
- Department of Otolaryngology - Head and Neck Surgery, Medical College of Georgia at Augusta University, Augusta, Georgia, USA
| | - Peter C Belafsky
- Department of Otolaryngology - Head and Neck Surgery, University of California, Davis, Sacramento, California, USA
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2
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Cotaoco C, Ueha R, Koyama M, Sato T, Goto T, Kondo K. Swallowing improvement surgeries. Eur Arch Otorhinolaryngol 2024; 281:2807-2817. [PMID: 38265461 PMCID: PMC11065918 DOI: 10.1007/s00405-024-08452-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 01/02/2024] [Indexed: 01/25/2024]
Abstract
PURPOSE To discuss the different swallowing improvement surgeries that address one or more dysfunctional pharyngolaryngeal structures causing dysphagia. These surgeries reduce the risk of aspiration without sacrificing vocal function. METHODS We searched the PubMed database and used Google Scholar search engine to find studies discussing the different swallowing improvement surgeries. A manual search of references in selected articles and reviews was done as well. No chronologic limitation was set for the studies; however, only articles written in English and Japanese were considered. Due to the nature of this article, no particular inclusion or exclusion criteria were set when searching for studies to be used as references; however, all relevant studies were reviewed and agreed upon by the authors for inclusion in this review article. RESULTS/DISCUSSION Surgeries to improve swallowing function can be categorized into those that reinforce nasopharyngeal closure or pharyngeal contraction, improve laryngeal elevation or pharyngoesophageal segment opening, and those that improve vocal fold closure to protect the airway during swallowing. They are an effective alternative treatment that may significantly improve these patients' quality of life. Swallowing rehabilitation with the altered pharyngolaryngeal structures is required post-operatively to significantly improve patients' dysphagia. CONCLUSIONS Surgeries to improve swallowing function address specific dysfunctional sites involved in the swallowing mechanism. Choosing the most appropriate surgery for each patient requires knowledge of the pathophysiology for their dysphagia and detailed pre-operative work-up.
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Affiliation(s)
- Carmel Cotaoco
- Department of Otolaryngology and Head and Neck Surgery, The University of Tokyo, Tokyo, Japan
- Ear Nose Throat Head and Neck Surgery Institute, The Medical City, Pasig, Philippines
| | - Rumi Ueha
- Department of Otolaryngology and Head and Neck Surgery, The University of Tokyo, Tokyo, Japan.
- Swallowing Center, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 113-8655, Japan.
| | - Misaki Koyama
- Department of Otolaryngology and Head and Neck Surgery, The University of Tokyo, Tokyo, Japan
| | - Taku Sato
- Department of Otolaryngology and Head and Neck Surgery, The University of Tokyo, Tokyo, Japan
| | - Takao Goto
- Department of Otolaryngology and Head and Neck Surgery, The University of Tokyo, Tokyo, Japan
| | - Kenji Kondo
- Department of Otolaryngology and Head and Neck Surgery, The University of Tokyo, Tokyo, Japan
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Sáenz LM, Quintero Castro RE, Herrera Torres AE, Orella Castro M, González-Torres LA. Beyond the Classic Causes of Dysphagia: Bayford-Autenrieth Dysphagia. Cureus 2024; 16:e54755. [PMID: 38523923 PMCID: PMC10961155 DOI: 10.7759/cureus.54755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/23/2024] [Indexed: 03/26/2024] Open
Abstract
Dysphagia lusoria (DL) is a rare clinical entity that presents with dysphagia derived from the anatomical obstruction of the esophagus by an aberrant vessel originating from the right subclavian artery. We present the case of a 64-year-old patient with a medical history of chronic, intermittent, mild, and self-limited dysphagia for over 20 years, wherein we formulated the diagnosis of DL. A 64-year-old woman arrived at the emergency department with a 24-hour history of acute progressive dysphagia, leading to intolerance to oral intake and minimal exertion dyspnea. A thorough clinical analysis and exclusion of other more common clinical entities will lead to its diagnosis. Our patient presented with respiratory symptoms, which is rare considering that these clinical presentations are more common in the pediatric population, explained by its tracheal elasticity. The combination of respiratory symptoms in an elderly patient, along with the typical mechanical dysphagia of DL, adds complexity to the diagnostic process, making this case unique.
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Affiliation(s)
- Luis Manuel Sáenz
- Internal Medicine Department, Hospital Universitario Dr. José Eleuterio González, Monterrey, MEX
| | | | | | - Miriel Orella Castro
- Internal Medicine Department, Hospital Universitario Dr. José Eleuterio González, Monterrey, MEX
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Zhang ZC, Xu JQ, Xu JX, Xu MD, Chen SY, Zhong YS, Zhang YQ, Chen WF, Ma LL, Qin WZ, Hu JW, Cai MY, Yao LQ, Li QL, Zhou PH. Endoscopic radial incision versus endoscopic balloon dilation as initial treatments of benign esophageal anastomotic stricture. J Gastroenterol Hepatol 2022; 37:2272-2281. [PMID: 36128959 DOI: 10.1111/jgh.16005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 09/15/2022] [Accepted: 09/17/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIM We aim to evaluate the efficacy and safety of endoscopic radial incision (ERI) versus endoscopic balloon dilation (EBD) treatment of naïve, recurrent, and refractory benign esophageal anastomotic strictures. METHODS One hundred and one ERI, 145 EBD, and 42 ERI combined with EBD sessions were performed in 136 consecutive patients with benign esophageal anastomotic stricture after esophagectomy at Zhongshan Hospital from January 2016 to August 2021. Baseline characteristics, operational procedures, and clinical outcomes data were retrospectively evaluated. Parameters and recurrence-free survival (RFS) were compared between ERI and EBD in patients with naïve or recurrent or refractory strictures. Risk factors for re-stricture after ERI were identified using univariate and multivariate analyses. RESULTS Twenty-nine ERI versus 68 EBD sessions were performed for naïve stricture, 26 ERI versus 60 EBD for recurrent strictures, and 46 ERI versus 17 EBD for refractory stricture. With comparable baseline characteristics, RFS was greater in the ERI than the EBD group for naïve strictures (P = 0.0449). The ERI group had a lower 12-month re-stricture rate than the EBD group (37.9% vs 61.8%, P = 0.0309) and a more prolonged patency time (181.5 ± 263.1 vs 74.5 ± 82.0, P = 0.0233). Between the two interventions, recurrent and refractory strictures had similar RFS (P = 0.0598; P = 0.7668). Multivariate analysis revealed initial ERI treatment was an independent predictive factor for lower re-stricture risk after ERI intervention (odds ratio = 0.047, P = 0.001). Few adverse events were observed after ERI or EBD (3.0% vs 2.1%, P = 0.6918). CONCLUSIONS ERI is associated with lower re-stricture rates with better patency and RFS compared with EBD for naive strictures.
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Affiliation(s)
- Zhao-Chao Zhang
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China.,Shanghai Collaborative Innovation Center of Endoscopy, Shanghai, China
| | - Jia-Qi Xu
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China.,Shanghai Collaborative Innovation Center of Endoscopy, Shanghai, China
| | - Jia-Xin Xu
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China.,Shanghai Collaborative Innovation Center of Endoscopy, Shanghai, China
| | - Mei-Dong Xu
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Shi-Yao Chen
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China.,Shanghai Collaborative Innovation Center of Endoscopy, Shanghai, China
| | - Yun-Shi Zhong
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China.,Shanghai Collaborative Innovation Center of Endoscopy, Shanghai, China
| | - Yi-Qun Zhang
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China.,Shanghai Collaborative Innovation Center of Endoscopy, Shanghai, China
| | - Wei-Feng Chen
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China.,Shanghai Collaborative Innovation Center of Endoscopy, Shanghai, China
| | - Li-Li Ma
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China.,Shanghai Collaborative Innovation Center of Endoscopy, Shanghai, China
| | - Wen-Zheng Qin
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China.,Shanghai Collaborative Innovation Center of Endoscopy, Shanghai, China
| | - Jian-Wei Hu
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China.,Shanghai Collaborative Innovation Center of Endoscopy, Shanghai, China
| | - Ming-Yan Cai
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China.,Shanghai Collaborative Innovation Center of Endoscopy, Shanghai, China
| | - Li-Qing Yao
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China.,Shanghai Collaborative Innovation Center of Endoscopy, Shanghai, China
| | - Quan-Lin Li
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China.,Shanghai Collaborative Innovation Center of Endoscopy, Shanghai, China
| | - Ping-Hong Zhou
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China.,Shanghai Collaborative Innovation Center of Endoscopy, Shanghai, China
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Lerner MZ, Bourdillon AT, Dai F, Brackett A, Kohli N. Safety considerations for esophageal dilation by anesthetic type: A systematic review. Am J Otolaryngol 2021; 42:103128. [PMID: 34216877 DOI: 10.1016/j.amjoto.2021.103128] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 05/21/2021] [Accepted: 06/13/2021] [Indexed: 11/18/2022]
Abstract
OBJECTIVES Esophageal dilation (ED) may be performed in the office under local anesthesia or in a procedure/operating room under general anesthesia or intravenous (IV) sedation. However, indications for type of anesthesia during these procedures have not been established. The purpose of this review is to assess outcomes of esophageal dilation performed using different types of anesthesia to assess the safety of office-based techniques. METHODS We conducted a systematic review and meta-analysis comparing the outcomes of anesthesia techniques for ED in adults. Exclusion criteria included reviews, small case series, use of stents, diagnoses with high morbidity, and rare diseases. A comprehensive literature search of the PubMed, CINAHL, and EMBASE databases was performed for articles relating to esophageal dilation. RESULTS 876 papers were identified of which 164 full text studies were assessed and 25 were included in the analysis using the PRISMA guidelines. Data regarding demographics, dilation technique, and adverse events were extracted. The DerSimonian-Laird random-effect models with inverse-variance weighting were fit to estimate the combined effects. There were no statistically significant differences among mortality, perforation, or bleeding based on anesthetic. CONCLUSIONS With office-based procedures gaining popularity in laryngology, there is a need to profile their safety. Office-based ED appears to have equivalent safety to general and IV sedation, although further research is necessary to define indications favoring office-based techniques.
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Affiliation(s)
- Michael Z Lerner
- Division of Otolaryngology, Department of Surgery, Yale School of Medicine, New Haven, CT, United States of America
| | | | - Feng Dai
- Department of Biostatistics, Yale University School of Public Health, New Haven, CT, United States of America
| | - Alexandria Brackett
- Cushing/Whitney Medical Library, Yale School of Medicine, Yale University, New Haven, CT, United States of America
| | - Nikita Kohli
- Division of Otolaryngology, Department of Surgery, Yale School of Medicine, New Haven, CT, United States of America
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Liu D, Pickering T, Kokot N, Crookes P, Sinha UK, Swanson MS. Outcomes of Combined Antegrade-Retrograde Dilations for Radiation-Induced Esophageal Strictures in Head and Neck Cancer Patients. Dysphagia 2021; 36:1040-1047. [PMID: 33386998 DOI: 10.1007/s00455-020-10236-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Accepted: 12/17/2020] [Indexed: 01/13/2023]
Abstract
The purpose of this study is to analyze outcomes of combined antegrade-retrograde dilations (CARD). This retrospective study was conducted on 14 patients with a history of head and neck cancer, treated with radiation therapy that was complicated by either complete or near-complete esophageal stenosis. All patients had minimal oral intake and depended on a gastrostomy tube for nutrition. Swallow function before and after CARD was assessed using the Functional Oral Intake Scale, originally developed for stroke patients and applied to head and neck cancer patients. Patients undergoing CARD demonstrated a quantifiable improvement in swallow function (p = 0.007) that persisted at last known follow-up (p = 0.015) but only a minority (23.1%) achieved oral intake sufficient to obviate the need for tube feeds. Complication rates were 24% per procedure or 36% per patient, almost all complications required procedural intervention, and all complications occurred in patients with complete stenosis. Our study suggests further caution when considering CARD, careful patient selection, and close post-operative monitoring.
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Affiliation(s)
- Derek Liu
- Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Trevor Pickering
- Department of Preventive Medicine, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Niels Kokot
- Tina and Rick Caruso Department of Otolaryngology-Head and Neck Surgery, Keck School of Medicine of the University of Southern California, 1540 Alcazar St, Suite 204M, Los Angeles, CA, 90033, USA
| | - Peter Crookes
- Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Uttam K Sinha
- Tina and Rick Caruso Department of Otolaryngology-Head and Neck Surgery, Keck School of Medicine of the University of Southern California, 1540 Alcazar St, Suite 204M, Los Angeles, CA, 90033, USA
| | - Mark S Swanson
- Tina and Rick Caruso Department of Otolaryngology-Head and Neck Surgery, Keck School of Medicine of the University of Southern California, 1540 Alcazar St, Suite 204M, Los Angeles, CA, 90033, USA.
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7
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Shimada S, Yoshida M, Kamijo T. Endoscopic rendezvous and diathermic dilation for complete pharyngeal obstruction. Dig Endosc 2020; 32:e130-e131. [PMID: 32735358 DOI: 10.1111/den.13756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 05/18/2020] [Accepted: 05/24/2020] [Indexed: 02/08/2023]
Affiliation(s)
- Seitaro Shimada
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
| | - Masao Yoshida
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
| | - Tomoyuki Kamijo
- Division of Head and Neck Surgery, Shizuoka Cancer Center, Shizuoka, Japan
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8
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Randall DR, Cates DJ, Strong EB, Belafsky PC. Three-dimensional analysis of the human pharyngoesophageal sphincter. Laryngoscope 2019; 130:2773-2778. [PMID: 31837160 DOI: 10.1002/lary.28450] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Revised: 10/18/2019] [Accepted: 11/04/2019] [Indexed: 11/07/2022]
Abstract
OBJECTIVES Dysfunction of the pharyngoesophageal segment (PES) is a common cause of oropharyngeal dysphagia. Surgical dilation of the PES uses cylindrical dilators that expand radially in a circular shape. Animal studies, however, suggest that the PES is kidney-shaped. The purpose of this investigation was to evaluate the 3D shape of the human PES with a novel casting method. METHODS A platinum-cured liquid silicone polymer was infused under pressure into the upper aerodigestive tract of nine fresh human cadavers to construct 3D casts of the maximally distended PES. Cross-sectional and volumetric analysis were performed using computed tomography and serial sectioning of the models. Canonical variate analysis was used to identify the shape features that best distinguishes the PES from the cervical esophagus. RESULTS The mean age of the cadavers was 77.9 (SD ± 10.6) years, with 67% women. Analysis of the casts confirms that the human PES possesses a kidney-shaped structure at maximal distention, which is discretely different from the adjacent esophagus (P < 0.001). The posterior body of the cricoid cartilage formed the anterior wall of the PES, which provided a rigid structure responsible for preservation of the kidney shape during distention. The diameter of the maximally distended PES at the cricopharyngeus was highly variable (range = 0.86-4.68 cm2 ; SD = 1.33 cm2 ). CONCLUSION The data suggest that the human PES is not round and that targeted expansion at the level of the cricopharyngeus with an eccentrically shaped dilator may provide improved distention. LEVEL OF EVIDENCE 4 Laryngoscope, 2019.
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Affiliation(s)
- Derrick R Randall
- Center for Voice and Swallowing, Department of Otolaryngology-Head & Neck Surgery, University of California-Davis, Sacramento, California, U.S.A.,Section of Otolaryngology-Head & Neck Surgery, Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Daniel J Cates
- Center for Voice and Swallowing, Department of Otolaryngology-Head & Neck Surgery, University of California-Davis, Sacramento, California, U.S.A
| | - E Brandon Strong
- California Polytechnic State University, San Luis Obispo, California, U.S.A
| | - Peter C Belafsky
- Center for Voice and Swallowing, Department of Otolaryngology-Head & Neck Surgery, University of California-Davis, Sacramento, California, U.S.A
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9
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Endoscopic Dilation of Refractory Postlaryngectomy Strictures: A Case Series and Literature Review. Gastroenterol Res Pract 2019; 2019:8905615. [PMID: 31275367 PMCID: PMC6558613 DOI: 10.1155/2019/8905615] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 11/14/2018] [Accepted: 05/06/2019] [Indexed: 02/06/2023] Open
Abstract
Background Endoscopic dilation of postlaryngectomy strictures (PLS) is safe and effective; however, PLS are often refractory and require serial dilations. Long-term outcomes of dilation in patients with refractory PLS are not well reported. Materials and Methods Seven patients with dysphagia and refractory PLS underwent serial endoscopic dilation therapy during a 4.5-year period. Dilation characteristics, technical success, clinical success, and diet advancement (as assessed by Diet/GT scale) were measured. Results. All strictures were complex, and there were no reported complications. The median number of dilations per patient was 12 (range 7 to 48). The average interval in between dilations was six weeks. Technical success was achieved in 6/7 patients, and clinical success was achieved in 2/7 patients. 6/7 patients had advancements in Diet/GT scores. Conclusions Dilation of refractory PLS is safe and effective and frequently requires the use of a retrograde approach, fluoroscopic guidance, and/or lumen patency strings. Serial dilations are required to maintain luminal patency, relieve dysphagia, and advance oral diet. The definition of clinical success of dilation in these patients should avoid the use of a specific time interval between dilations to characterize success.
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10
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Abu-Ghanem S, Sung CK, Junlapan A, Kearney A, DiRenzo E, Dewan K, Damrose EJ. Endoscopic Management of Postradiation Dysphagia in Head and Neck Cancer Patients: A Systematic Review. Ann Otol Rhinol Laryngol 2019; 128:767-773. [PMID: 30895823 DOI: 10.1177/0003489419837565] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
OBJECTIVES To systematically review the success rate and safety profile of the available endoscopic surgical options for radiation-induced dysphagia in head and neck cancer patients following organ preservation treatment, including upper esophageal sphincter (UES) dilation, cricopharyngeus (CP) myotomy (CPM), and CP intramuscular botulinum toxin (Botox) injection. METHODS A search of MEDLINE, Scopus, Google Scholar, and Cochrane databases was done to identify articles published between January 1980 and December 2017. Pediatric series, foreign language articles, series with Zenker's diverticulum or following primary surgical treatment including laryngectomy, open UES/CP surgery, or samples with fewer than 5 patients were excluded. RESULTS An initial search identified 539 articles. All titles and abstracts were reviewed. One hundred and sixteen potentially relevant articles were inspected in more detail, and 14 retrospective studies met eligibility criteria. Dilation group included 10 studies on anterograde and/or retrograde dilation, with an overall 208 patients. Success rate ranged from 42% to 100%. The endoscopic CPM group included 3 studies with a total of 36 patients, and the success rate ranged from 27% to 90%. In the Botox group, 1 one study with 20 patients met our inclusion criteria, with an overall 65% success rate (13/20). Major complications were only reported in the dilation group, which included esophageal perforation and death. CONCLUSIONS The lack of consistency across trials indicates insufficient evidence for guiding clinical practice. This systematic review suggests the need for greater standardization of outcomes and instruments. Future prospective evaluation should use validated patient-rated and clinician-rated assessment tools to optimally measure postoperative swallowing outcomes of head and neck cancer dysphagic patients following organ preservation therapy.
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Affiliation(s)
- Sara Abu-Ghanem
- 1 Department of Otolaryngology-Head and Neck Surgery, Stanford University-School of Medicine, Stanford, CA, USA
| | - Chin-Kwang Sung
- 1 Department of Otolaryngology-Head and Neck Surgery, Stanford University-School of Medicine, Stanford, CA, USA
| | - Attapon Junlapan
- 1 Department of Otolaryngology-Head and Neck Surgery, Stanford University-School of Medicine, Stanford, CA, USA
| | - Ann Kearney
- 1 Department of Otolaryngology-Head and Neck Surgery, Stanford University-School of Medicine, Stanford, CA, USA
| | - Elizabeth DiRenzo
- 1 Department of Otolaryngology-Head and Neck Surgery, Stanford University-School of Medicine, Stanford, CA, USA
| | - Karuna Dewan
- 1 Department of Otolaryngology-Head and Neck Surgery, Stanford University-School of Medicine, Stanford, CA, USA
| | - Edward J Damrose
- 1 Department of Otolaryngology-Head and Neck Surgery, Stanford University-School of Medicine, Stanford, CA, USA
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11
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Fong R, Sun N, Ng YW, Rumbach AF, Ward EC, Tsang R. Office-Based Cricopharyngeus Balloon Dilation for Post Chemoirradiation Dysphagia in Nasopharyngeal Carcinoma Patients: A Pilot Study. Dysphagia 2019; 34:540-547. [PMID: 30888528 DOI: 10.1007/s00455-019-10002-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Accepted: 03/14/2019] [Indexed: 01/13/2023]
Abstract
Dysphagia is a common sequela post chemo/radiotherapy for nasopharyngeal carcinoma (NPC), with cricopharyngeal dysfunction often a contributing factor. This study examined the impact of balloon dilation of the cricopharyngeus and cervical oesophagus on swallow competence for dysphagic patients with cricopharyngeal dysfunction post NPC. Patients with NPC were screened for dysphagia and cricopharyngeal dysfunction using fiberoptic endoscopic evaluation. Thirteen symptomatic patients, median 14.1 years post chemoradiotherapy for NPC, then underwent balloon dilation under local anesthesia. Before and 1 month post dilation, swallow function was assessed with fluoroscopy, and rated using the penetration-aspiration scale, temporal swallowing measures, and MBSImP pharyngoesophageal segment opening and esophageal clearance parameter. The MD Anderson Dysphagia Inventory (MDADI; Chinese version) and the Functional Oral Intake Scale (FOIS) were collected pre-, 1 month, and approximately 3 months post dilation. Post-dilation, significant improvements were noted in mean FOIS scores (5.00 to 5.62), duration of cricopharyngeus opening (0.42 s to 0.53 s), MBSImP pharyngoesophageal opening scores (1.61 to 1.08), penetration-aspiration scale scores (4.85 to 3.92) and MDADI Composite score (46.48 to 52.43). At 3 months post dilation, the MDADI Composite Score showed sustained benefit. The procedure was well tolerated and without complication. In patients with cricopharyngeal dysfunction post NPC, balloon dilation significantly improved swallow function, reduced aspiration risk and improved quality of life. Evidence from a larger cohort with long-term follow-up is warranted to determine sustained benefit.
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Affiliation(s)
- Raymond Fong
- Speech and Language Pathology Department, Queen Mary Hospital, 3/F, Block S, 102 Pokfulam Road, Hong Kong SAR, China.,School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, QLD, Australia
| | - Nikie Sun
- Department of Ear, Nose & Throat, Queen Mary Hospital, Hong Kong SAR, China.,Division of Otorhinolaryngology, Department of Surgery, Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong SAR, China
| | - Yiu-Wing Ng
- Department of Ear, Nose & Throat, Queen Mary Hospital, Hong Kong SAR, China.,Division of Otorhinolaryngology, Department of Surgery, Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong SAR, China
| | - Anna F Rumbach
- School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, QLD, Australia
| | - Elizabeth C Ward
- School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, QLD, Australia.,Centre of Functioning and Health Research, Metro South Hospital and Health Service, Brisbane, QLD, Australia
| | - Raymond Tsang
- Department of Ear, Nose & Throat, Queen Mary Hospital, Hong Kong SAR, China. .,Division of Otorhinolaryngology, Department of Surgery, Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong SAR, China.
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Martins D, Pires S, Pimentel-Nunes P, Almeida Silva R, Dias CC, Dinis-Ribeiro M. Endoscopic Dilation of Pharyngoesophageal Strictures: There Are More Dimensions than a Diameter. GE-PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2018; 25:291-298. [PMID: 30480046 DOI: 10.1159/000486608] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Accepted: 01/04/2018] [Indexed: 12/19/2022]
Abstract
Background/Aims Dysphagia due to benign pharyngoesophageal strictures (PES) often requires repeated dilations; however, a uniform definition for the therapeutic efficacy of this technique has not been yet established. We aimed to assess the overall efficacy of endoscopic dilation of pharyngoesophageal anastomotic or post-radiotherapy (post-RT) strictures. Methods The data of 48 patients with post-RT (n = 29) or anastomotic PES (n = 19) submitted to endoscopic dilation during a 3-year period were retrospectively assessed. The Kochman criteria were used to determine refractoriness and recurrence. Patients were asked to answer a questionnaire determining prospectively the dilation program efficacy as (a) dysphagia improvement, (b) dysphagia resolution, (c) need for further dilations, or (d) percutaneous endoscopic gastrostomy (PEG) during the previous 6 months. Need for additional therapy was considered an inefficacy criterion. Results The median number of dilations per patient was 4 (total of 296 dilations) with a median follow-up of 29 months. The mean predilation dysphagia Mellow-Pinkas score was 3 and the initial stenosis diameter was 7 mm. Fifteen and 29% of patients presented with the Kochman criteria for refractory and recurrent strictures, respectively. Moreover, 96 and 60% showed dysphagia improvement and resolution, respectively. Seventy-five-percent did not require dilations during 6 months, and 89% did not require PEG. From the patients' perspective, overall efficacy was achieved in 58% of cases. Nine additional therapies were required. Number of dilations (OR 0.7), stricture diameter (OR 2.2), and nonrecurrence criteria (OR 14.2) appeared as significant predictors of overall efficacy, whereas refractory stenosis criteria did not. Conclusions Endoscopic dilation seems to be effective for patients with dysphagia after RT or surgery, especially when assessed as patient perception of improvement. Narrow strictures, recurrent ones, and strictures requiring a higher number of dilations may predict worse outcomes. Key Message Health professionals should establish well-defined efficacy criteria for dilations and base their decision beyond exclusively objective measurements.
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Affiliation(s)
- Diana Martins
- Gastroenterology Department, Tondela-Viseu Hospital Center, Viseu, Portugal
| | - Sara Pires
- Gastroenterology Department, Espirito Santo Hospital, Évora, Portugal
| | - Pedro Pimentel-Nunes
- Gastroenterology Department, Portuguese Oncology Institute of Porto, Porto, Portugal.,CINTESIS - Center for Health Technology and Services Research, Porto, Portugal.,CIDES-FMUP - Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Rui Almeida Silva
- Gastroenterology Department, Portuguese Oncology Institute of Porto, Porto, Portugal
| | - Claúdia Camila Dias
- CINTESIS - Center for Health Technology and Services Research, Porto, Portugal.,Department of Community Medicine, Information and Decision in Health, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Mário Dinis-Ribeiro
- Gastroenterology Department, Portuguese Oncology Institute of Porto, Porto, Portugal.,CINTESIS - Center for Health Technology and Services Research, Porto, Portugal.,CIDES-FMUP - Faculty of Medicine of the University of Porto, Porto, Portugal
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Moss WJ, Pang J, Orosco RK, Weissbrod PA, Brumund KT, Weisman RA, Brigger MT, Coffey CS. Esophageal dilation in head and neck cancer patients: A systematic review and meta-analysis. Laryngoscope 2017; 128:111-117. [DOI: 10.1002/lary.26618] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/13/2017] [Indexed: 12/24/2022]
Affiliation(s)
- William J. Moss
- Department of Surgery; division of Otolaryngology-Head & Neck Surgery, University of California; San Diego California U.S.A
| | - John Pang
- Department of Surgery; division of Otolaryngology-Head & Neck Surgery, University of California; San Diego California U.S.A
| | - Ryan K. Orosco
- Department of Surgery; division of Otolaryngology-Head & Neck Surgery, University of California; San Diego California U.S.A
| | - Philip A. Weissbrod
- Department of Surgery; division of Otolaryngology-Head & Neck Surgery, University of California; San Diego California U.S.A
| | - Kevin T. Brumund
- Department of Surgery; division of Otolaryngology-Head & Neck Surgery, University of California; San Diego California U.S.A
- Department of Surgery; division of Otolaryngology-Head & Neck Surgery, VA San Diego Healthcare; La Jolla California U.S.A
| | - Robert A. Weisman
- Department of Surgery; division of Otolaryngology-Head & Neck Surgery, University of California; San Diego California U.S.A
| | - Matthew T. Brigger
- Department of Surgery; division of Otolaryngology-Head & Neck Surgery, University of California; San Diego California U.S.A
- Department of Otolaryngology-Head & Neck Surgery; Naval Medical Center San Diego; San Diego California U.S.A
| | - Charles S. Coffey
- Department of Surgery; division of Otolaryngology-Head & Neck Surgery, University of California; San Diego California U.S.A
- Department of Surgery; division of Otolaryngology-Head & Neck Surgery, VA San Diego Healthcare; La Jolla California U.S.A
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Zhang T, Szczesniak M, Maclean J, Bertrand P, Wu PI, Omari T, Cook IJ. Biomechanics of Pharyngeal Deglutitive Function following Total Laryngectomy. Otolaryngol Head Neck Surg 2016; 155:295-302. [PMID: 27118816 DOI: 10.1177/0194599816639249] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2015] [Accepted: 02/25/2016] [Indexed: 12/22/2022]
Abstract
OBJECTIVE Postlaryngectomy, pharyngeal weakness, and pharyngoesophageal junction (PEJ) restriction are the candidate mechanisms of dysphagia. The aims were, in laryngectomees, whether (1) hypopharyngeal propulsion is reduced and/or PEJ resistance is increased, (2) dilatation improves dysphagia, and (3) whether symptomatic improvement correlates with reduced PEJ resistance. DESIGN Multidisciplinary cross-sectional study. SETTING Tertiary academic hospital. SUBJECTS AND METHODS Swallow biomechanics were assessed in 30 laryngectomees. Patients were stratified into severe dysphagia (Sydney Swallow Questionnaire >500) and mild/nil dysphagia (Sydney Swallow Questionnaire ≤500). Average hypopharyngeal peak (contractile) pressure (hPP) and hypopharyngeal intrabolus pressure (hIBP) were measured from high-resolution manometry with concurrent videofluoroscopy based on barium swallows (2.5 and 10 mL). In consecutive 5 patients, measurements were repeated after dilatation. RESULTS Dysphagia was reported by 87%, and 57% had severe and 43% had mild/nil dysphagia. hIBP increased with larger bolus volumes (P < .0001), while hPP stayed stable and PEJ diameter plateaued at 9 mm. Laryngectomees had lower hPP (110 ± 14 vs 170 ± 15 mm Hg; P = .0162) and higher hIBP (29 ± 5 vs 6 ± 5 mm Hg; P = .156) than controls. There were no differences in hPP between patient groups. However, hIBP was higher in severe than in mild/nil dysphagia (41 ± 10 vs 13 ± 3 mm Hg; P = .02). Predilation hIBP (R(2) = 0.97) and its decrement postdilatation (R(2) = 0.98) well predicted symptomatic improvement. CONCLUSIONS PEJ resistance correlates better with dysphagia severity than peak pharyngeal pressure and is more sensitive to bolus sizes than PEJ diameter. Both baseline PEJ resistance and its decrement following dilatation are strong predictors of treatment outcome. PEJ resistance is vital to detect, as it is reversible and can predict the response to dilatation regimens.
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Affiliation(s)
- Teng Zhang
- Department of Gastroenterology and Hepatology, St George Hospital, Sydney, Australia School of Medicine, University of New South Wales, Sydney, Australia
| | - Michal Szczesniak
- Department of Gastroenterology and Hepatology, St George Hospital, Sydney, Australia School of Medicine, University of New South Wales, Sydney, Australia
| | - Julia Maclean
- Department of Speech Pathology, St George Hospital, Sydney, Australia
| | - Paul Bertrand
- School of Medical Science, University of RMIT, Melbourne, Australia
| | - Peter I Wu
- School of Medicine, University of New South Wales, Sydney, Australia
| | - Taher Omari
- School of Medical Science, Flinders University, Adelaide, Australia
| | - Ian J Cook
- Department of Gastroenterology and Hepatology, St George Hospital, Sydney, Australia School of Medicine, University of New South Wales, Sydney, Australia
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Outcomes of Esophageal Dilation in Eosinophilic Esophagitis: Safety, Efficacy, and Persistence of the Fibrostenotic Phenotype. Am J Gastroenterol 2016; 111:206-13. [PMID: 26753894 PMCID: PMC4758887 DOI: 10.1038/ajg.2015.399] [Citation(s) in RCA: 86] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2015] [Accepted: 11/01/2015] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Esophageal dilation is commonly performed in eosinophilic esophagitis (EoE), but there are few long-term data. The aims of this study were to assess the safety and long-term efficacy of esophageal dilation in a large cohort of EoE cases, and to determine the frequency and predictors of requiring multiple dilations. METHODS We conducted a retrospective cohort study in the University of North Carolina EoE Clinicopathological Database from 2002 to 2014. Included subjects met consensus diagnostic criteria for EoE. Clinical, endoscopic, and histologic features were extracted, as were dilation characteristics (dilator type, change in esophageal caliber, and total number of dilations) and complications. Patients with EoE who had undergone dilation were compared with those who did not and also stratified by whether they required single or multiple dilations. RESULTS Of 509 EoE patients, 164 were dilated a total of 486 times. Those who underwent dilation had a longer duration of symptoms before diagnosis (11.1 vs. 5.4 years, P<0.001). Ninety-five patients (58%) required >1 dilation (417 dilations total, mean of 4.4±4.3 per patient). The only predictor of requiring multiple dilations was a smaller baseline esophageal diameter. Dilation was tolerated well, with no major bleeds, perforations, or deaths. The overall complication rate was 5%, primarily due to post-procedural pain. Of 164 individuals dilated, a majority (58% or 95/164) required a second dilation. Of these individuals, 75% required repeat dilation within 1 year. CONCLUSIONS Dilation in EoE is well-tolerated, with a very low risk of serious complications. Patients with long-standing symptoms before diagnosis are likely to require dilation. More than half of those dilated will require multiple dilations, often needing a second procedure within 1 year. These findings can be used to counsel patients with fibrostenotic complications of EoE.
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Maejima R, Iijima K, Koike T, Ara N, Uno K, Hatta W, Ogawa T, Watanabe KI, Katori Y, Shimosegawa T. Endoscopic balloon dilatation for pharyngo-upper esophageal stricture after treatment of head and neck cancer. Dig Endosc 2015; 27:310-6. [PMID: 25115575 DOI: 10.1111/den.12345] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2014] [Accepted: 08/04/2014] [Indexed: 12/24/2022]
Abstract
BACKGROUND AND AIM Dysphagia caused by pharyngo-upper esophageal stricture is a complication of treatment for head and neck cancer. Endoscopic balloon dilation (EBD) is in widespread use as an effective and safe treatment for stricture in many areas of the gastrointestinal tract. In the present study, we investigated the efficacy and safety of EBD for pharyngo-upper esophageal strictures that developed after treatment for head and neck cancer. METHODS From January 2010 to December 2013, the medical records and endoscopic findings of 19 consecutive patients with pharyngo-upper esophageal strictures occurring after surgery and/or chemoradiotherapy for head and neck cancer were retrospectively examined. RESULTS Mean number of EBD sessions per patient was 6.6 (1-30), and mean maximum diameter of dilation was 15.8 (11-20) mm. Technical success was achieved in 16 of 19 (84.2%) patients, and only two major complications (bleeding and pha ryngeal edema) occurred in a total of 125 dilatation sessions (1.6%). Regarding the influence of chemoradiotherapy on the outcome of EBD, patients who had undergone chemoradiotherapy plus surgery experienced significantly more restenosis during the follow-up period compared to those who had undergone surgery alone (50% vs 0%, P < 0.05). CONCLUSIONS This retrospective analysis demonstrated the efficacy and safety of exclusive EBD for pharyngo-upper esophageal strictures occurring after treatment for head and neck cancer, indicating that the therapeutic application of EBD could be extended to such strictures. Patients who underwent chemoradiotherapy and surgery experienced more restenosis; hence, such patients should be carefully followed up after EBD treatment.
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Affiliation(s)
- Ryuhei Maejima
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Sendai, Japan
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Mendelson AH, Small AJ, Agarwalla A, Scott FI, Kochman ML. Esophageal anastomotic strictures: outcomes of endoscopic dilation, risk of recurrence and refractory stenosis, and effect of foreign body removal. Clin Gastroenterol Hepatol 2015; 13:263-271.e1. [PMID: 25019695 PMCID: PMC4289652 DOI: 10.1016/j.cgh.2014.07.010] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2013] [Revised: 06/23/2014] [Accepted: 07/03/2014] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS Esophageal anastomotic strictures often require repeat dilation to relieve dysphagia. Little is known about factors that affect their remediation. We investigated long-term success and rates of recurrence or refractoriness after dilation and factors associated with refractory stenosis. METHODS We performed a retrospective study of 74 patients with an anastomotic stricture that had been dilated during a 5-year period (564 dilations; median follow-up period, 8 months). A stricture was refractory if luminal patency could not be maintained after ≥5 dilation sessions during 10 weeks. RESULTS Of the 74 patients, 93% had initial relief of dysphagia. The stricture recurred in 43% of patients, and 69% were considered refractory. Removal of sutures/staples protruding into the lumen did not accelerate time to initial patency (median, 37 days; interquartile range [IQR], 20-82 days) or lengthen the dysphagia-free interval (37.4 days; IQR, 8-41 weeks), compared with patients who did not undergo removal (initial patency, median 55 days; IQR, 14-109 days; P = .66 and median dysphagia-free interval, 21.7 days; IQR, 9-64 weeks; P = .8). Use of fluoroscopy during dilation (odds ratio, 8.92; 95% confidence interval, 1.98-40.14) was positively associated with development of refractory strictures, whereas neoadjuvant chemotherapy (odds ratio, 0.28; 95% confidence interval, 0.07-0.97) was inversely associated. Female sex and distal location of strictures increased risk of refractoriness as effect modifiers in multivariate analysis. CONCLUSIONS Endoscopic dilation is highly successful in achieving luminal remediation, yet anastomotic strictures are often refractory and frequently recur. Removal of sutures/staples within the lumen does not help achieve patency. Need for fluoroscopic guidance indicates a high likelihood of refractoriness to dilation, whereas prior neoadjuvant chemotherapy indicates a lower risk.
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Affiliation(s)
- Aaron H Mendelson
- Department of Internal Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Aaron J Small
- Gastroenterology Division, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania; Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Anant Agarwalla
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Frank I Scott
- Gastroenterology Division, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania; Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Michael L Kochman
- Department of Internal Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania; Gastroenterology Division, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania; Wilmott Center for Endoscopic Innovation, Research, and Training, Philadelphia, Pennsylvania.
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18
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Biliary metal stents for proximal esophageal or hypopharyngeal strictures. Surg Endosc 2015; 29:3205-8. [PMID: 25588364 DOI: 10.1007/s00464-014-4061-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2014] [Accepted: 12/22/2014] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Endoscopic dilation is the standard of care for stenoses of the cervical esophagus, but refractory strictures require some form of stenting. Most endoscopists avoid the placement of metal stents near the upper esophageal sphincter as they can cause major problems like severe cervical pain and globus sensation. We report our results with the use of biliary SEMS in the upper esophagus, which have a smaller diameter than regular esophageal stents and therefore exert less expansive force. MATERIAL AND METHODS We retrospectively reviewed all patients in our center between July 2011 and June 2014 who received a biliary metal stent because of a refractory stricture in the cervical esophagus. We implanted biliary SEMS (Wallflex, Boston Scientific) with a diameter of 1 cm and length of 6-8 cm. Technical and clinical success, adverse events and duration of stenting were evaluated. RESULTS Ten patients were treated with biliary SEMS in the upper esophagus. Strictures were located between 10 and 19 cm from incisor teeth. Stent placement was successful in all (10/10) patients. One stent had to be extracted because of pain and globus sensation. Apart from that stent tolerability was good. All remaining patients (9/9) reported improvement of dysphagia with a decrease in mean dysphagia score from 3.2 to 1.78. Mean duration of stenting was 68 days. DISCUSSION Because of a high clinical success rate and good tolerability, biliary metal stents are a reasonable alternative for difficult strictures in the cervical esophagus, especially in the palliative setting.
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19
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Chang ET, Ruhl DS, Kenny PR, Sniezek JC. Endoscopic management of esophageal discontinuity. Head Neck 2014; 37:E103-5. [PMID: 25270384 DOI: 10.1002/hed.23883] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/27/2014] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND The management of esophageal discontinuity remains challenging and often involves complex reconstructive surgeries. METHODS AND RESULTS We describe a unique and successful treatment of esophageal discontinuity using a modification of the natural orifice translumenal surgery (NOTES) approach in a patient presenting with long-standing esophageal discontinuity resulting from an iatrogenic esophageal injury. CONCLUSION This case provided an opportunity to affirm the efficacy of endoscopy for treating esophageal discontinuities to minimize the degree of morbidity and mortality normally associated with the surgical treatment of this type of injury. Our case reveals a novel and possibly more direct means of evaluating and treating esophageal injuries in which the degree of discontinuity and/or stenosis initially remains unknown.
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Affiliation(s)
- Edward T Chang
- Department of Otolaryngology, Tripler Army Medical Center, Honolulu, Hawaii
| | - Douglas S Ruhl
- Department of Otolaryngology, Tripler Army Medical Center, Honolulu, Hawaii
| | - Patrick R Kenny
- Department of Gastroenterology, Tripler Army Medical Center, Honolulu, Hawaii
| | - Joseph C Sniezek
- Department of Otolaryngology, Tripler Army Medical Center, Honolulu, Hawaii
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20
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Silver N, Gal TJ. Endoscopic CO2 laser management of chemoradiation-related cricopharyngeal stenosis. Ann Otol Rhinol Laryngol 2014; 123:252-6. [PMID: 24595625 DOI: 10.1177/0003489414525019] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
OBJECTIVE Treatment of head and neck cancer with chemoradiation (CRT) can result in strictures of the cervical esophagus, often at the level of the cricopharyngeus. The objective of this study is to assess the feasibility of endoscopic CO2 laser cricopharyngeal myotomy for stricture ablation in the setting of prior CRT. METHODS A retrospective review of patients who underwent endoscopic CO2 laser cricopharyngeal myotomy for dysphagia after radiation for squamous cell carcinoma of the head and neck (SCCHN). Pre- and postoperative barium swallow and swallowing assessment were performed before and after surgery. Outcomes and complication rates were examined. RESULTS Endoscopic CO2 laser cricopharyngeal myotomy was performed in 10 patients with dysphagia secondary to cricopharyngeal stenosis/stricture, which developed following treatment for SCCHN with chemoradiation. All patients demonstrated radiographic improvement in stricture, with complete resolution of stricture in 9 of 10 patients. All patients noted improvement in dysphagia with 9 of 10 patients demonstrating significant advancement of diet by modified barium swallow. No complications were observed. CONCLUSION Endoscopic CO2 cricopharyngeal myotomy can be performed safely in the setting of prior CRT, with significant improvement in swallowing in select patients. Indications and technical considerations will be discussed.
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Affiliation(s)
- Natalie Silver
- Department of Otolaryngology, University of Kentucky, Lexington, Kentucky, USA
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Pasha SF, Acosta RD, Chandrasekhara V, Chathadi KV, Decker GA, Early DS, Evans JA, Fanelli RD, Fisher DA, Foley KQ, Fonkalsrud L, Hwang JH, Jue TL, Khashab MA, Lightdale JR, Muthusamy VR, Sharaf R, Saltzman JR, Shergill AK, Cash B. The role of endoscopy in the evaluation and management of dysphagia. Gastrointest Endosc 2014; 79:191-201. [PMID: 24332405 DOI: 10.1016/j.gie.2013.07.042] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2013] [Accepted: 07/29/2013] [Indexed: 02/06/2023]
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Abstract
The cricopharyngeus muscle (CPM) is a key component of the upper esophageal sphincter (UES). In dysphagia, cricopharyngeus muscle dysfunction (CPD) refers to the muscle's failure to appropriately and completely relax or expand during deglutition. A variety of disease processes may cause CPD, and the resultant clinical manifestation is solid food or solid and liquid dysphagia. Several diagnostic tools are available for dysphagia clinicians to distinguish CPD from other causes of UES dysfunction. For CPD, accurate diagnosis is paramount for the recommendation of appropriate treatment. In appropriately selected patients, intervention at the CPM may yield significant improvement in dysphagia.
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Affiliation(s)
- Maggie A Kuhn
- Department of Otolaryngology/Head and Neck Surgery, Center for Voice and Swallowing, University of California, Davis, 2521 Stockton Boulevard, Suite 7200, Sacramento, CA 95817, USA
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Chapuy CI, Annino DJ, Tishler RB, Haddad RI, Snavely A, Goguen LA. Success of endoscopic pharyngoesophageal dilation after head and neck cancer treatment. Laryngoscope 2013; 123:3066-73. [PMID: 23775806 DOI: 10.1002/lary.24268] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2013] [Revised: 05/02/2013] [Accepted: 05/30/2013] [Indexed: 12/24/2022]
Abstract
OBJECTIVES/HYPOTHESIS To assess clinical success and safety of endoscopic pharyngoesophageal dilation after chemoradiation or radiation for head and neck cancer and to identify variables associated with dilation failure. STUDY DESIGN Case series with chart review. METHODS Between 2000 and 2008, a total of 111 patients treated with chemoradiation or radiation for head and neck cancer with subsequent pharyngoesophageal stenosis requiring endoscopic dilation were identified. Patients were evaluated for endoscopic dilation technique, severity of stenosis, technical and clinical success, and intra- and postoperative complications. The Diet/GT score (range, 1-5) was utilized to measure swallow success. Variables associated with dilation failure were analyzed by univariate and multivariate logistic regression. RESULTS There were 271 dilations analyzed, with 42 combined antegrade retrograde dilations, 208 dilations over a guidewire, and 21 dilations without guidewire. Intraoperative patency and successful dilation of the stenotic segment was achieved in 95% of patients. A Diet/GT score of 5 (gastrostomy tube removed and soft/regular diet) was attained in 84 of 111 (76%) patients. Safety analysis showed complications occurred in 9% of all dilations. Perforations were noted in 4% of all procedures, with only two esophageal perforations requiring significant intervention. Multiple dilations were associated with an increased risk for perforations. Further logistic regression analyses revealed that the number of dilations was indicating a poor outcome and low Diet/GT score. CONCLUSIONS Pharyngoesophageal stenosis, occurring after chemoradiation and radiation treatment, can be successfully and safely treated with endoscopic dilation techniques. Patients with restenosis, requiring multiple dilations, have a higher risk of persistent dysphagia.
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Affiliation(s)
- Claudia I Chapuy
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
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Belafsky PC, Plowman EK, Mehdizadeh O, Cates D, Domer A, Yen K. The upper esophageal sphincter is not round: a pilot study evaluating a novel, physiology-based approach to upper esophageal sphincter dilation. Ann Otol Rhinol Laryngol 2013; 122:217-21. [PMID: 23697317 DOI: 10.1177/000348941312200401] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES Recent basic science investigations have suggested that the upper esophageal sphincter (UES), in cross section, is not round, but that it more closely approximates a kidney shape. Dilation with simultaneous use of two cylindrical dilators provides a novel, physiology-based approach to UES distention. We evaluated the initial safety and efficacy of UES dilation with simultaneous use of two controlled radial expansion balloon dilators. METHODS Using a computerized database, we reviewed the charts of all persons who underwent UES dilation with simultaneous use of two radial expansion balloon dilators between December 1, 2011, and March 15, 2012. Information regarding patient demographics, indications, technique, and complications was abstracted. Self-reported swallowing impairment was assessed with the validated 10-item Eating Assessment Tool (EAT-10). RESULTS Ten individuals underwent simultaneous dilation with two dilators. Their mean age was 65 years (SD, 14 years), and 7 (70%) of them were male. The indications for dilation were radiation-induced UES stenosis (50%), cricopharyngeus muscle dysfunction (30%), upper esophageal web (10%), and anastomotic stricture (10%). After the double-balloon dilation, no complications were reported. The mean EAT-10 score improved significantly, from 34.3 (SD, 13.5) to 16.7 (SD, 8.4), after the simultaneous dilation (p = 0.003). CONCLUSIONS Pilot data suggest that simultaneous dilation of the UES with two controlled radial expansion balloon dilators is feasible, safe, and effective. Future investigation is necessary to confirm the safety of this technique in a larger cohort and to use objective measures of efficacy to compare the technique to conventional dilation with a single dilator.
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Affiliation(s)
- Peter C Belafsky
- Center for Voice and Swallowing, Dept of Otolaryngology-Head and Neck Surgery, University of California, Davis, School of Medicine, 2521 Stockton Blvd, Suite 7200, Sacramento, CA 95817, USA
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Cates D, Plowman EK, Mehdizadeh O, Yen K, Domer A, Gilden M, Belafsky PC. Geometric morphometric shape analysis in an ovine model confirms that the upper esophageal sphincter is not round. Laryngoscope 2012; 123:721-6. [PMID: 23042631 DOI: 10.1002/lary.23634] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2012] [Revised: 06/28/2012] [Accepted: 07/09/2012] [Indexed: 11/10/2022]
Abstract
OBJECTIVES/HYPOTHESIS Dysfunction of the upper esophageal sphincter (UES) is a common cause of oral-pharyngeal dysphagia (OPD). Dilation is a primary treatment, although current techniques are subject to a high rate of failure and recurrence. Devices available for UES dilation are cylindrical and were designed to distend the round lumen of the esophagus. Our objective was to determine the cross-sectional dimension of the UES in an ovine model of OPD and compare it with that of the cervical esophagus. STUDY DESIGN Prospective cadaveric animal study. METHODS Three-dimensional casts of the upper aerodigestive tract of 10 fresh cadaveric ewes were constructed using a platinum-cured liquid silicone polymer. Cross-sections at the level of the UES and cervical esophagus were digitized and mathematically compared using geometric morphometric shape analysis. RESULTS Consensus shape among all 10 animals revealed that the narrowest region of the maximally distended UES has a cross-sectional shape that resembles a kidney, whereas the cervical esophagus approximates a circle. The shape of the UES and cervical esophagus were significantly different (P < .0001), and surface area calculations demonstrated that an inscribed circle significantly underestimated the area implied by the kidney-shaped UES model. CONCLUSIONS Current dilators used to treat UES dysfunction are cylindrical and based on the assumption that the UES is round. This is the first report to empirically analyze the cross-sectional area of the UES utilizing an established ovine model. The data suggest that the cross-sectional area of the UES is shaped like a kidney, and currently available cylindrical dilators are suboptimal for UES distention.
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Affiliation(s)
- Daniel Cates
- Department of Otolaryngology/Head and Neck Surgery, University of California Davis, Sacramento, California 95817, USA
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Miah MS, Zealley IA, Mountain RE, Mahendran S. Severe benign hypopharynx/upper-oesophageal strictures: successful treatment with a novel interventional radiology technique in three patients. Clin Otolaryngol 2012; 37:313-7. [PMID: 22925097 DOI: 10.1111/j.1749-4486.2012.02496.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Gallo A, Pagliuca G, de Vincentiis M, Martellucci S, Iallonardi E, Fanello G, Cereatti F, Fiocca F. Endoscopic Treatment of Benign and Malignant Strictures of the Cervical Esophagus and Hypopharynx. Ann Otol Rhinol Laryngol 2012; 121:104-9. [DOI: 10.1177/000348941212100206] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objectives: We evaluated the efficacy of endoscopic techniques employed in the management of cervical esophageal and hypopharyngeal strictures. Methods: A series of 45 patients with cervical esophageal (35) and/or hypopharyngeal strictures (10) were included. Twenty-five patients (55.6%) with neoplastic strictures were treated for palliation alone. The stenosis was related to radiotherapy in 11 patients (24.4%) and to postsurgical complications in 9 (20%). A group of 23 patients was treated with dilation alone (group 1). A second group included 22 patients treated with insertion of a self-expandable stent after failure of dilation treatment (group 2). The swallowing test data, clinical notes, and surgical reports were reviewed. Results: All of the patients showed some degree of relief of dysphagia. In group 1, 19 of the 23 patients required multiple dilation treatments to maintain normal deglutition. In group 2, 7 of the 22 patients recovered regular oral feeding after stent placement, 10 patients reported pain and foreign body sensation, 2 patients reported pain so severe that stent removal was required, and 3 patients experienced stent migration. All but 3 of the 25 patients with inoperable tumors died during follow-up, but no patients with benign stenosis died. Conclusions: The two groups showed comparable functional results. Dilation often requires multiple procedures, but is usually well tolerated. Placement of self-expandable stents is effective, but is generally less well tolerated.
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Tuna Y, Koçak E, Dinçer D, Köklü S. Factors affecting the success of endoscopic bougia dilatation of radiation-induced esophageal stricture. Dig Dis Sci 2012; 57:424-8. [PMID: 21879280 DOI: 10.1007/s10620-011-1875-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2011] [Accepted: 08/12/2011] [Indexed: 12/09/2022]
Abstract
AIMS The purpose of this retrospective study was to assess clinical outcomes of endoscopic bougie dilation of esophageal strictures after radiation therapy for head and neck cancer, and to assess the risk factors which affect the treatment success. METHODS Thirty-one patients with esophageal stricture due to radiation therapy were treated with endoscopic bougie dilation. The following parameters were evaluated; age, gender, primary site of the tumor, initial treatment of the tumor, prescribed dose of radiation, the time to onset of esophageal stricture after radiation therapy, grade of esophageal stricture according to clinical and endoscopic findings, number of dilatations, recurrence of esophageal stricture, and the result of the therapy. RESULTS The average follow-up was 26 months with a range of 1-84 months. Successful endoscopic bougie dilation was achieved in 26 of 31 patients. The median time to onset of esophageal stricture after radiation therapy was significantly shorter in patients who did not respond to endoscopic bougie dilation. CONCLUSION Endoscopic bougie dilation is a safe and effective procedure for the management of radiation-induced esophageal stricture. Time to onset of esophageal stricture is the most important factor for the treatment success. In addition, the total prescribed dosage of radiation has minimal effects on the result of endoscopic bougie dilation.
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Affiliation(s)
- Yaşar Tuna
- Department of Gastroenterology, Akdeniz University Medical School of Medicine, Antalya, Turkey
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Wilkie MD, Hathorn IF, Evans AS. Total neopharyngeal stenosis following pharyngolaryngo-oesophagectomy with gastric interposition: Successful recanalisation using a transcervical radiologically guided technique. Int J Surg Case Rep 2011; 2:297-300. [PMID: 22096759 DOI: 10.1016/j.ijscr.2011.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2011] [Revised: 10/03/2011] [Accepted: 10/04/2011] [Indexed: 10/16/2022] Open
Abstract
INTRODUCTION Pharyngo-oesophageal stricturing is common following treatment of head and neck cancers. Absolute dysphagia secondary to total stenosis, although rare, is particularly debilitating and presents a significant therapeutic challenge. We present a strategy for managing total neopharyngeal stenosis following pharyngolaryngo-oesophagectomy (PLOG). PRESENTATION OF CASE A 71-year-old female developed total neopharyngeal stenosis following PLOG with gastric interposition for squamous cell carcinoma of the proximal cervical oesophagus/post-cricoid. A transcervical, percutaneous, radiologically guided procedure was performed to restore lumenal patency, which enabled resumption of oral feeding. DISCUSSION Established treatments for pharyngo-oesophageal strictures are frequently limited by complications in patients with complex strictures or total stenoses. Whilst several interventions have been described, recent interest has focussed on combined antegrade/retrograde endoscopic procedures dilating a pre-existing gastrostomy site for access. This was not possible in our patient due to the surgically altered anatomy which posed a unique therapeutic challenge. CONCLUSION This is the first reported percutaneous, transcervical, radiologically guided technique to treat neopharyngeal stenosis following PLOG. It demonstrates a novel and efficacious approach which may be considered in the management of this rare but significant complication.
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Affiliation(s)
- Mark D Wilkie
- Department of Otorhinolaryngology and Head and Neck Surgery, St. John's Hospital, Howden Road West, Livingston, West Lothian EH54 6PP, UK
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Ahlberg A, al-Abany M, Alevronta E, Friesland S, Hellborg H, Mavroidis P, Lind BK, Laurell G. Esophageal stricture after radiotherapy in patients with head and neck cancer: experience of a single institution over 2 treatment periods. Head Neck 2010; 32:452-61. [PMID: 19672963 DOI: 10.1002/hed.21201] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Risk factors for development of a stricture of the upper esophagus after radiotherapy for head and neck cancer are poorly defined. METHODS This was a retrospective case-control study of patients diagnosed and treated for esophageal stricture after radiotherapy for head and neck cancer. RESULTS The incidence of esophageal stricture after external beam radiation therapy (EBRT) was 3.3%. Seventy patients with stricture and 66 patients without stricture were identified. A multivariate analysis showed that there was increased risk of stricture in receiving enteral feeding during EBRT or in receiving a mean dose of >45 Gy to the upper esophagus. CONCLUSIONS Enteral feeding during EBRT is strongly associated with the development of stricture of the esophagus, as is a mean dose of >45 Gy to the upper esophagus. Treatment of the stricture with Savary-Gilliard bougienage or through scope balloon dilatation is safe and successful but often has to be repeated.
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Affiliation(s)
- Alexander Ahlberg
- Department of Otolaryngology, Karolinska University Hospital, Stockholm, Sweden.
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Fluoroscopically guided balloon dilation for pharyngoesophageal stricture after radiation therapy in patients with head and neck cancer. AJR Am J Roentgenol 2010; 194:1131-6. [PMID: 20308522 DOI: 10.2214/ajr.09.3345] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The purpose of this article is to assess the safety and long-term efficacy of fluoroscopically guided balloon dilation for pharyngoesophageal strictures after radiation therapy in patients with head and neck cancers. MATERIALS AND METHODS From April 1997 to February 2009, fluoroscopically guided balloon dilation was performed in 17 patients with pharyngoesophageal strictures caused by radiation therapy. Technical success, clinical success (decrease of at least one grade in dysphagia score and good contrast passage on 1-month follow-up esophagogram), recurrence of dysphagia, and complications related to the procedure were retrospectively evaluated. RESULTS All 17 patients underwent 41 balloon dilation procedures, with each patient undergoing one to seven procedures (mean, 2.4 procedures). The technical success rate was 100%, and clinical success was achieved in 64.7% (11/17) of the patients. Five patients (29.4%) showed no recurrence of dysphagia after one session of balloon dilation. Of 12 patients (70.6%) with recurrence of dysphagia, 10 underwent repeat balloon dilation and two underwent gastrostomy after the first session of balloon dilation. The maximum balloon diameters were 15 mm (n = 22), 20 mm (n = 16), and 25 mm (n = 3). As minor complications, three cases of type 1 esophageal rupture occurred in two patients (11.8%). There were no major complications. CONCLUSION Although the recurrence rate was high with repeat balloon dilation, fluoroscopically guided balloon dilation seems to be a simple and safe primary treatment technique for pharyngoesophageal stricture due to radiation therapy in patients with head and neck cancer.
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Dysphagia in Head and Neck Cancer Patients Treated with Chemoradiotherapy. Dysphagia 2009; 25:139-52. [DOI: 10.1007/s00455-009-9247-7] [Citation(s) in RCA: 81] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2009] [Accepted: 07/31/2009] [Indexed: 11/25/2022]
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Radiological balloon dilatation of post-treatment benign pharyngeal strictures. The Journal of Laryngology & Otology 2009; 123:1229-32. [DOI: 10.1017/s0022215109990508] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
AbstractAims:To assess the technical success, clinical outcomes and complications of radiologically guided balloon dilatation of benign strictures developing after treatment for head and neck cancer.Materials and methods:Forty-six balloon dilatations were performed in 20 patients. All dilatations were performed over a guidewire.Results:Technical success was 100 per cent. Fifteen of the 20 patients demonstrated clinical improvement in dysphagia scores. Improvement in dysphagia was temporary in all patients (median 102 days), with multiple dilatations usually required (total dilatations ranged from one to seven). Immediate complications were encountered in six of the 46 (13 per cent) dilatations and were all minor. Late complications occurred after two procedures (4 per cent): localised perforation (later complicated by secondary infection) and recurrence of a previous, small, pharyngo-cutaneous fistula.Conclusion:Radiologically guided balloon dilatation is straightforward to perform and is well tolerated, but there is a small risk of perforation. Relief of symptoms is likely to be temporary, requiring multiple subsequent dilatations. A minority of patients will obtain no symptomatic relief.
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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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