Combined retrograde and anterograde hypopharyngeal puncture and dilatation in a child with complete hypopharyngeal stenosis

Treatment of Refractory Gastrointestinal Strictures With Mitomycin C: A Systematic Review

BACKGROUND AND AIMS

Refractory benign gastrointestinal (GI) strictures represent a difficult management problem given the limited therapeutic interventions available. We performed a systematic review of all published cases using mitomycin C in the treatment of GI strictures.

METHODS

Searches of MEDLINE and Embase databases were performed to identify studies reporting application of mitomycin C for GI strictures. Review of titles/abstracts, full review of potentially relevant studies, and data abstraction were performed independently by 2 authors.

RESULTS

Of 549 citations, 24 studies with 145 patients (74% pediatric and 26% adult) met inclusion criteria. Esophageal strictures were the most common (79%) site of refractory strictures treated with mitomycin C, with caustic injury the most common underlying etiology. The concentration (range, 0.1 to 2 mg/mL; median, 0.4 mg/mL), number of applications (range, 1 to 12; median, 1), duration of applications (range, 1 to 5; median, 2 min), and technique of application (cotton pledget, spray, injection, special catheters) varied among studies. Ninety-one patients (73%; children: 80%, adults: 59%) had a complete response; 26 (21%) had a partial response. Only 1 (0.7%) adverse event was reported: cutaneous sclerosis attributed to microperforation and mitomycin C extravastion after injection. Mean follow-up was 23 (4 to 60) months.

CONCLUSIONS

Local mitomycin C application seems to be a safe and effective therapy for benign refractory GI strictures of varying etiology in both pediatric and adult populations. Although the results of this systematic review are highly encouraging, it should be considered investigational. Additional randomized trials and larger prospective studies are needed to confirm these results and to better define the optimal dose, concentration, duration and technique of mitomycin C application.

Management of complete esophageal stricture after treatment of head and neck cancer using combined anterograde retrograde esophageal dilation

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.

Fatal central venous air embolism: a rare complication of esophageal dilation by rendezvous

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.

Treatment of congenital nasal cavity stenosis by balloon dilatation in a newborn: a case report

Neonates are obligate nasal breathers, and any form of neonatal nasal obstruction may have serious consequences. Prompt diagnosis and appropriate treatment are essential to avoid severe hypoxia. Congenital bony nasal stenosis (CBNS) is an extremely rare cause of neonatal nasal airway obstruction and can easily be confused with choanal atresia or stenosis. This is a paper to describe a balloon dilatation technique that can be an effective alternative to surgery for the treatment of congenital nasal cavity stenosis, with minimal stress to the patient.

Topical use of MMC in the upper aerodigestive tract: a review on the side effects

Not much is known about the side effects of mitomycin C (MMC), an anti-fibrogenetic agent, in the upper aerodigestive tract. However, its use in ophthalmology is widely known and without quantitatively important side effects. A literature review was performed for side effects of MMC in the upper aerodigestive tract. Forty-six articles, describing the use of MMC to prevent scarring, were retracted from PubMed. Thirty-two are human studies. MMC is used in different concentrations (0.1–10 mg/ml) with different application times (2–5 min) and frequencies (up to 4 times). Five hundred and thirty-eight patients were included in those publications, of whom 19 developed side effects (3.53%). No side effects developed in studies, where post-application irrigation with saline was reported. The longest mean follow-up period is 75.5 months. Direct relations between the reported side effects and MMC seem absent in most studies. Serious complications seem to occur when MMC is used in high concentrations. Unfortunately, sometimes crucial information is lacking. One patient was described who supposedly developed laryngeal carcinoma after repeated treatment of hyperkeratosis and anterior commissure webbing. Animal studies show that excessive fibrin production can lead to acute airway obstruction. In conclusion, topical application of MMC on a wound with consecutive irrigation with saline can be performed safely to prevent scar formation in circular structures of the upper aerodigestive tract. Long-term yearly control of the application site seems advisable.

Serratia marcescens causing cervical necrotizing oropharyngitis

Necrotizing fasciitis is a rare, life-threatening infection. We report a case of necrotizing oropharyngitis caused by Serratia marcescens in a previously immunocompetent 6-year-old male. This necrotizing infection led to a near-total defect of the oropharynx. The wound was managed with daily wound debridement of the patient's oropharynx with 3% hydrogen peroxide, carotid artery coverage with Kaltostat, and pharyngeal packing with iodoform ribbon gauze. Our patient's resultant nasopharyngeal and hypopharyngeal stenoses present challenges for restoration of form and function for voicing and deglutition. We present our experience of managing this child's hypopharyngeal stenosis with a minimally invasive double-balloon dilatation technique.