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Mizuno J, Urabe Y, Oka S, Konishi H, Ishibashi K, Fukuhara M, Tanaka H, Tsuboi A, Yamashita K, Hiyama Y, Kotachi T, Takigawa H, Yuge R, Hiyama T, Tanaka S. Predictive factors for esophageal stenosis in patients receiving prophylactic steroid therapy after endoscopic submucosal dissection for esophageal squamous cell carcinoma. BMC Gastroenterol 2024; 24:41. [PMID: 38245690 PMCID: PMC10799525 DOI: 10.1186/s12876-024-03135-9] [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] [Received: 08/02/2023] [Accepted: 01/15/2024] [Indexed: 01/22/2024] Open
Abstract
BACKGROUND Methods to prevent esophageal stenosis (ES) after endoscopic submucosal dissection (ESD) for superficial esophageal squamous cell carcinoma (ESCC) have received increasing attention. Although steroid administration is a prophylactic treatment, the risk factors for ES during prophylactic steroid therapy remain unknown. Therefore, this study aimed to retrospectively evaluate the risk factors for refractory ES in patients administered prophylactic steroids after ESD for ESCC. METHODS Among 795 patients with ESCC (854 lesions), 180 patients (211 lesions) administered local triamcinolone acetonide (TrA) and/or oral prednisolone were recruited for this study. We compared the total number of endoscopic balloon dilatation (EBD) procedures performed for post-ESD ES and clinical findings (tumor size, ESD history or chemoradiation therapy [CRT], entire circumferential resection, muscle layer damage, supplemental oral prednisolone administration, EBD with TrA injection, and additional CRT) between patients with refractory and non-refractory ES. EBD was continued until dysphagia resolved. We categorized cases requiring ≥ 8 EBD procedures as refractory postoperative stenosis and divided the lesions into two groups. RESULTS Multivariate logistic regression analysis revealed that factors such as ESD history, CRT history, tumor size, and entire circumferential resection were independently associated with the development of refractory ES. The withdrawal rates of EBD at 3 years were 96.1% (52/53) and 58.5% (39/59) in the non-refractory and refractory groups, respectively. CONCLUSIONS Our data suggest that entire circumferential resection and CRT history are risk factors for refractory post-ESD ES in ESCC, even with prophylactic steroid administration.
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Affiliation(s)
- Junichi Mizuno
- Department of Gastroenterology, Graduate School of Biomedical & Science, Hiroshima University, Hiroshima, Japan
| | - Yuji Urabe
- Department of Gastrointestinal Endoscopy and Medicine, Hiroshima University Hospital, 1-2-3 Kasumi, Minamiku, Hiroshima, 734-8551, Japan.
| | - Shiro Oka
- Department of Gastroenterology, Graduate School of Biomedical & Science, Hiroshima University, Hiroshima, Japan
| | - Hirona Konishi
- Department of Gastroenterology, Graduate School of Biomedical & Science, Hiroshima University, Hiroshima, Japan
| | - Kazuki Ishibashi
- Department of Gastroenterology, Graduate School of Biomedical & Science, Hiroshima University, Hiroshima, Japan
| | - Motomitsu Fukuhara
- Department of Gastroenterology, Graduate School of Biomedical & Science, Hiroshima University, Hiroshima, Japan
| | - Hidenori Tanaka
- Department of Endoscopy, Hiroshima University Hospital, Hiroshima, Japan
| | - Akiyoshi Tsuboi
- Department of Endoscopy, Hiroshima University Hospital, Hiroshima, Japan
| | - Ken Yamashita
- Department of Endoscopy, Hiroshima University Hospital, Hiroshima, Japan
| | - Yuichi Hiyama
- Department of Hiroshima Clinical Research and Development Support Center, Hiroshima University Hospital, Hiroshima, Japan
| | - Takahiro Kotachi
- Department of Endoscopy, Hiroshima University Hospital, Hiroshima, Japan
| | - Hidehiko Takigawa
- Department of Endoscopy, Hiroshima University Hospital, Hiroshima, Japan
| | - Ryo Yuge
- Department of Endoscopy, Hiroshima University Hospital, Hiroshima, Japan
| | - Toru Hiyama
- Health Service Center, Hiroshima University, Hiroshima, Japan
| | - Shinji Tanaka
- Department of Endoscopy, Hiroshima University Hospital, Hiroshima, Japan
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2
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Gala K, Brunaldi V, Abu Dayyeh BK. Endoscopic Management of Surgical Complications of Bariatric Surgery. Gastroenterol Clin North Am 2023; 52:719-731. [PMID: 37919023 DOI: 10.1016/j.gtc.2023.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2023]
Abstract
Bariatric surgery, although highly effective, may lead to several surgical complications like ulceration, strictures, leaks, and fistulas. Newer endoscopic tools have emerged as safe and effective therapeutic options for these conditions. This article reviews post-bariatric surgery complications and the role of endoscopy in their management.
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Affiliation(s)
- Khushboo Gala
- Department of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street South West, Rochester, MN 55905, USA
| | - Vitor Brunaldi
- Department of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street South West, Rochester, MN 55905, USA
| | - Barham K Abu Dayyeh
- Department of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street South West, Rochester, MN 55905, USA.
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3
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Horváth ÖP, Pavlovics G, Cseke L, Vereczkei A, Papp A. Dysphagia After Esophageal Replacement and Its Treatment. Dysphagia 2023; 38:1323-1332. [PMID: 36719515 PMCID: PMC10471736 DOI: 10.1007/s00455-023-10557-2] [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: 09/02/2022] [Accepted: 01/10/2023] [Indexed: 02/01/2023]
Abstract
Dysphagia occurs temporarily or permanently following esophageal replacement in at least half of the cases. Swallowing disorder, in addition to severe decline in the quality of life, can lead to a deterioration of the general condition, which may lead to death if left untreated. For this reason, their early detection and treatment are a matter of importance. Between 1993 and 2012, 540 esophageal resections were performed due to malignant tumors at the Department of Surgery, Medical Center of the University of Pécs. Stomach was used for replacement in 445 cases, colon in 38 cases, and jejunum in 57 cases. The anastomosis with a stomach replacement was located to the neck in 275 cases and to the thorax in 170 cases. The colon was pulled up to the neck in each case. There were 29 cases of free jejunal replacements located to the neck and 28 cases with a Roux loop reconstruction located to the thorax. Based on the literature data and own experience, the following were found to be the causes of dysphagia in the order of frequency: anastomotic stenosis, conduit obstruction, peptic and ischemic stricture, foreign body, local recurrence, functional causes, new malignant tumor in the esophageal remnant, and malignant tumor in the organ used for replacement. Causes may overlap each other, and their treatment may be conservative or surgical. The causes of many dysphagic complications might be prevented by improving the anastomosis technique, by better preservation the blood supply of the substitute organ, by consistently applying a functional approach, and by regular follow-up.
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Affiliation(s)
- Örs Péter Horváth
- Department of Surgery, Medical Center, Pécs University, Ifjúság u. 13, 7624, Pécs, Hungary.
| | - Gábor Pavlovics
- Department of Surgery, Medical Center, Pécs University, Ifjúság u. 13, 7624, Pécs, Hungary
| | - László Cseke
- Department of Surgery, Medical Center, Pécs University, Ifjúság u. 13, 7624, Pécs, Hungary
| | - András Vereczkei
- Department of Surgery, Medical Center, Pécs University, Ifjúság u. 13, 7624, Pécs, Hungary
| | - András Papp
- Department of Surgery, Medical Center, Pécs University, Ifjúság u. 13, 7624, Pécs, Hungary
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4
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Jessamy K, Jessamy A, Anozie O. Endoscopic Glucocorticoid Injection for the Treatment of a Refractory Benign Esophageal Stenosis in a Patient With Plummer-Vinson Syndrome. Cureus 2023; 15:e41896. [PMID: 37457608 PMCID: PMC10349547 DOI: 10.7759/cureus.41896] [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: 07/13/2023] [Indexed: 07/18/2023] Open
Abstract
Plummer-Vinson syndrome (PVS) or Paterson-Brown-Kelly syndrome is a rare clinical condition characterized by the triad of esophageal webs/stenoses, iron-deficiency anemia, and progressively worsening dysphagia. It occurs mostly in Caucasian women in the fourth to seventh decades, particularly in northern countries. Esophageal webs and stenoses can be encountered during endoscopic evaluation for the patient's complaint of dysphagia. Esophageal stenoses are characterized as simple or complex. A stenosis should be considered refractory once the patient has undergone several sequential dilatations within short intervals, optimized treatment for potential underlying causes (eosinophilic esophagitis or acid reflux), and after neuromuscular causes have been excluded. Glucocorticoid injection into a stenosis during an endoscopic dilation session has been proven to be beneficial as the initial treatment modality of refractory nonmalignant esophageal stenoses. We present a case of a 39-year-old woman with refractory esophageal stenosis in the setting of PVS which was successfully treated with serial endoscopic glucocorticoid injections while she received oral iron supplementation. To our knowledge, there are no previous cases of esophageal stenoses associated with PVS in the literature requiring endoscopic glucocorticoid injection for successful resolution.
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Affiliation(s)
- Kegan Jessamy
- Gastroenterology, Tidelands Health Gastroenterology, Georgetown, USA
| | - Amy Jessamy
- Medicine, The University of the West Indies, St. Augustine, TTO
| | - Obiajulu Anozie
- Critical Care Medicine, Northeast Georgia Medical Center Gainesville, Gainesville, USA
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Ma X, Zhang X, Li B, Zhu T, Ma T, Zhang X, Qu B. Endoscopic Stricturotomy in the Treatment of Refractory Esophageal Anastomotic Strictures. Dysphagia 2023; 38:650-656. [PMID: 35859043 DOI: 10.1007/s00455-022-10495-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 07/01/2022] [Indexed: 11/03/2022]
Abstract
Refractory esophageal anastomotic strictures are a frequent challenge for endoscopists. The current therapeutic strategies have a significant restenosis rate, and patients usually require repeated sessions and suffer from dysphagia. Therefore, we propose a modified method named endoscopic stricturotomy (ES) to treat refractory esophageal anastomotic strictures. The patients diagnosed with refractory esophageal anastomotic strictures were enrolled in the cohort study. The method of ES is to incise longitudinally only a single strip of mucosa at the most prominent part of fibrotic scar and completely cut fibrotic tissues under the mucosa. The primary endpoint was the times of endoscopic therapies. The secondary endpoints include the effective rate, success rate, recurrence rate, endoscopic treatment intervals, complications, length of hospital stay, and surgical cost. The patients were followed up for at least 6 months after ES. The median anastomotic diameter of 12 patients was 2 mm (range 1 to 4 mm). Dysphagia were dramatically relieved in all patients (dysphagia grade from 3 to 1), the effective rate was 100%. During the follow-up, the 12 patients received a total number of 38 sessions, and the median number of ES sessions was 2.5 (1-9), and the success rate were 83%. Nine of the patients (75%) developed restenosis during follow-up, with a median interval of 38 days (15-315 days). No complications occurred during treatment and following up. The median hospital stay was 2 days (2-2.9 days), and the hospitalization costs was 3887.4 RMB (3632.8 RMB-4116.9 RMB). ES seems to be an effective treatment modality for refractory esophageal anastomotic strictures. Large prospective clinical trials are needed to confirm its utility and its place in the management of refractory esophageal anastomotic strictures (ChiCTR2000032997).
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Affiliation(s)
- Xiao Ma
- Department of Gastroenterology and Hepatology, The Second Affiliated Hospital of Harbin Medical University, No 246, Xuefu Road, NanGang District, Harbin, 150000, Heilongjiang, China
| | - Xu Zhang
- Department of Gastroenterology and Hepatology, The Second Affiliated Hospital of Harbin Medical University, No 246, Xuefu Road, NanGang District, Harbin, 150000, Heilongjiang, China
| | - Bing Li
- Department of Gastroenterology and Hepatology, The Second Affiliated Hospital of Harbin Medical University, No 246, Xuefu Road, NanGang District, Harbin, 150000, Heilongjiang, China
| | - Tingting Zhu
- Department of Gastroenterology and Hepatology, The Second Affiliated Hospital of Harbin Medical University, No 246, Xuefu Road, NanGang District, Harbin, 150000, Heilongjiang, China
| | - Tingting Ma
- Department of Gastroenterology and Hepatology, The Second Affiliated Hospital of Harbin Medical University, No 246, Xuefu Road, NanGang District, Harbin, 150000, Heilongjiang, China
| | - Xiaohui Zhang
- Department of Cardiology, First Affiliated Hospital of Harbin Medical University, No. 23, YouZheng Road, NanGang District, Harbin, 150001, Heilongjiang, China.
| | - Bo Qu
- Department of Gastroenterology and Hepatology, The Second Affiliated Hospital of Harbin Medical University, No 246, Xuefu Road, NanGang District, Harbin, 150000, Heilongjiang, China.
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6
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Lee Y, Samarasinghe Y, Javidan A, Tahir U, Samarasinghe N, Shargall Y, Finley C, Hanna W, Agzarian J. The fragility of significant results from randomized controlled trials in esophageal surgeries. Esophagus 2023; 20:195-204. [PMID: 36689016 DOI: 10.1007/s10388-023-00985-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 01/05/2023] [Indexed: 01/24/2023]
Abstract
While randomized controlled trials (RCTs) are regarded as one of the highest forms of clinical research, the robustness of their P values can be difficult to ascertain. Defined as the minimum number of patients in a study arm that would need to be changed from a non-event to event for the findings to lose significance, the Fragility Index is a method for evaluating results from these trials. This study aims to calculate the Fragility Index for trials evaluating perioperative esophagectomy-related interventions to determine the strength of RCTs in this field. MEDLINE and EMBASE were searched for RCTs related to esophagectomy that reported a significant dichotomous outcome. Two reviewers independently screened articles and performed the data extractions with risk of bias assessment. The Fragility Index was calculated using a two-tailed Fisher's exact test. Bivariate correlation was conducted to evaluate associations between the Fragility Index and study characteristics. 41 RCTs were included, and the median sample size was 80 patients [Interquartile range (IQR) 60-161]. Of the included outcomes, 29 (71%) were primary, and 12 (29%) were secondary. The median Fragility Index was 1 (IQR 1-3), meaning that by changing one patient from a non-event to event, the results would become non-significant. Fragility Index was correlated with P value, number of events, and journal impact factor. The RCTs related to esophagectomy did not prove to be robust, as the significance of their results could be changed by altering the outcome status of a handful of patients in one study arm.
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Affiliation(s)
- Yung Lee
- Division of General Surgery, McMaster University, Hamilton, ON, Canada
| | - Yasith Samarasinghe
- Division of Thoracic Surgery, Department of Surgery, McMaster University, 50 Charlton Avenue East T-2105, Hamilton, ON, L8N 4A6, Canada
| | - Arshia Javidan
- Division of Vascular Surgery, University of Toronto, Toronto, ON, Canada
| | - Umair Tahir
- Division of Thoracic Surgery, Department of Surgery, McMaster University, 50 Charlton Avenue East T-2105, Hamilton, ON, L8N 4A6, Canada
| | | | - Yaron Shargall
- Division of Thoracic Surgery, Department of Surgery, McMaster University, 50 Charlton Avenue East T-2105, Hamilton, ON, L8N 4A6, Canada
| | - Christian Finley
- Division of Thoracic Surgery, Department of Surgery, McMaster University, 50 Charlton Avenue East T-2105, Hamilton, ON, L8N 4A6, Canada
| | - Wael Hanna
- Division of Thoracic Surgery, Department of Surgery, McMaster University, 50 Charlton Avenue East T-2105, Hamilton, ON, L8N 4A6, Canada
| | - John Agzarian
- Division of Thoracic Surgery, Department of Surgery, McMaster University, 50 Charlton Avenue East T-2105, Hamilton, ON, L8N 4A6, Canada.
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7
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van Halsema EE, Bergman JJGHM, van Sandick JW, van Berge Henegouwen MI, Cats A, Veenhof AAFA, van Hooft JE, van Dieren JM. Intensive endoscopic therapy for untreated cervical anastomotic strictures after esophagectomy: a pilot study. Surg Endosc 2023; 37:2029-2034. [PMID: 36282358 DOI: 10.1007/s00464-022-09731-8] [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: 02/24/2022] [Accepted: 10/11/2022] [Indexed: 10/31/2022]
Abstract
BACKGROUND Cervical anastomotic strictures after esophagectomy cause significant disease burden. We aimed to study the technical feasibility and safety of intensive endoscopic therapy. METHODS In this pilot study, we included 15 patients with an untreated benign cervical anastomotic stricture after esophagectomy. Intensive endoscopic therapy comprised three endoscopic modalities: in- and excision using a needle-knife, intralesional steroid injections and bougie dilation. In two endoscopic procedures, the stricture was dilated up to a luminal diameter of 18 mm. Patients were followed up to 6 months. RESULTS A luminal diameter of 18 mm was achieved in 13 of 15 patients (87%) after two endoscopic procedures. No major adverse events related to the investigational treatment occurred. Median dysphagia scores significantly improved from 2 (IQR, interquartile range, 2-3) at baseline to 0 (IQR 0-1) after 14 days (p < 0.001). Eleven (73%) patients developed recurrent symptoms of dysphagia requiring a median of 1 (IQR 0-3) additional endoscopic dilation procedure. CONCLUSIONS Achieving a luminal diameter of 18 mm in two procedures with intensive endoscopic therapy was technically feasible and effective in reducing dysphagia rapidly in patients with a cervical anastomotic stricture after esophagectomy. No major adverse events related to the investigational treatment were observed.
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Affiliation(s)
- Emo E van Halsema
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, Location AMC, Amsterdam, The Netherlands
| | - Jacques J G H M Bergman
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, Location AMC, Amsterdam, The Netherlands
| | - Johanna W van Sandick
- Department of Surgical Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | | | - Annemieke Cats
- Department of Gastrointestinal Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Alexander A F A Veenhof
- Department of Surgical Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, Location AMC, Amsterdam, The Netherlands.,Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Jolanda M van Dieren
- Department of Gastrointestinal Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands.
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8
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Kadota T, Ishihara R, Hatta W, Yoshida M, Kanzaki H, Kikuchi D, Ono Y, Abe S, Yamamoto Y, Yoshio T, Urabe Y, Yamaguchi N, Nagami Y, Iizuka T, Takahashi H, Oyama T, Yano T. Multi-institutional questionnaire on treatment strategies for superficial entire circumferential esophageal squamous cell carcinoma. DEN OPEN 2023; 3:e206. [PMID: 36694694 PMCID: PMC9843640 DOI: 10.1002/deo2.206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 12/12/2022] [Accepted: 12/17/2022] [Indexed: 01/18/2023]
Abstract
Objectives Recent innovations in prophylactic treatment with steroids have overcome the issue of esophageal stricture after endoscopic submucosal dissection (ESD), except in entire circumferential esophageal squamous cell carcinoma (EC-ESCC). Current Japanese guidelines weakly recommend performing ESD for clinical epithelial/lamina propria EC-ESCC with a longitudinal extension <50 mm upon implementing prophylactic treatment against stricture. However, the accurate indications for ESD in EC-ESCC remain unknown, and strategies differ among institutions. The aim of this study was to understand the initial treatment strategy for EC-ESCC and prophylactic treatment after ESD against esophageal stricture. Methods A questionnaire survey was conducted across 16 Japanese high-volume centers on the initial treatment for EC-ESCC according to the invasion depth and longitudinal extension, and prophylactic treatment against stricture. Results ESD was performed as the initial treatment not only in clinical epithelial/lamina propria lesions <50 mm (88-94% of institutions), but also in clinical epithelial/lamina propria ≥50 mm (44-50% of institutions) and clinical muscularis mucosae/SM1 (submucosal invasion depth invasion within 200 μm) lesions <50 mm (56-75% of institutions). Regarding prophylactic treatment against esophageal stricture, although there was a common point of local steroid injection, the details and administration of other treatments varied among institutions. Conclusions As ESD was performed with expanded indications for EC-ESCC than those recommended by the guidelines in more than half of the institutions, the validity of ESD for expanded EC-ESCC needs to be clarified. For that, it is necessary to prospectively collect short- and long-term outcomes after ESD and other treatments, including esophagectomy or chemoradiotherapy.
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Affiliation(s)
- Tomohiro Kadota
- Department of Gastroenterology and EndoscopyNational Cancer Center Hospital EastChibaJapan
| | - Ryu Ishihara
- Department of Gastrointestinal OncologyOsaka International Cancer InstituteOsakaJapan
| | - Waku Hatta
- Division of GastroenterologyTohoku University Graduate School of MedicineMiyagiJapan
| | - Masao Yoshida
- Division of EndoscopyShizuoka Cancer CenterShizuokaJapan
| | - Hiromitsu Kanzaki
- Department of Gastroenterology and HepatologyOkayama University Graduate School of Medicine, Dentistry and Pharmaceutical SciencesOkayamaJapan
| | | | - Yoichiro Ono
- Department of GastroenterologyFukuoka University Chikushi HospitalFukuokaJapan
| | - Seiichiro Abe
- Endoscopy DivisionNational Cancer Center HospitalTokyoJapan
| | | | - Toshiyuki Yoshio
- Department of GastroenterologyCancer Institute HospitalTokyoJapan
| | - Yuji Urabe
- Division of Regeneration and Medicine Center for Translational and Clinical ResearchHiroshima University HospitalHiroshimaJapan
| | - Naoyuki Yamaguchi
- Department of Gastroenterology and HepatologyNagasaki University HospitalNagasakiJapan
| | - Yasuaki Nagami
- Department of GastroenterologyOsaka City University Graduate School of MedicineOsakaJapan
| | - Toshiro Iizuka
- Department of GastroenterologyTokyo Metropolitan Cancer and infectious Diseases Center Komagome HospitalTokyoJapan
| | | | - Tsuneo Oyama
- Department of EndoscopySaku Central Hospital Advanced Care CenterNaganoJapan
| | - Tomonori Yano
- Department of Gastroenterology and EndoscopyNational Cancer Center Hospital EastChibaJapan
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Li B, Wang H, Liu J, Mu X, Xu F, Deng D, Qiao Y, Wang S, Chen F. Successful cervicothoracic esophageal stricture treatment with partial sternectomy and a pedicled TAAP flap: A case report. Front Surg 2023; 9:905241. [PMID: 36700029 PMCID: PMC9869483 DOI: 10.3389/fsurg.2022.905241] [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] [Received: 03/26/2022] [Accepted: 11/29/2022] [Indexed: 01/09/2023] Open
Abstract
Postoperative benign esophageal anastomotic leakage and stenosis are common complications after esophagectomy. Treatment options for anastomosis stenosis include endoscopic mechanical dilation, dilation-combined steroid injection, incisional therapy, stent placement, and self-bougienage. However, long-segmental cervicothoracic esophageal stenosis and cutaneous fistula are always refractory to conservative treatments and are clinically challenging. When lesions extend well below the thoracic inlet, transthoracic esophagectomy and alimentary canal reconstruction seem to be the common choice but are susceptible to perioperative mortality and donor-site sequelae, especially for patients with poor health conditions. In this report, we present a novel surgical approach for cervicothoracic esophageal stenosis and fistula via partial sternectomy and reconstruction with a pedicled thoracoacromial artery perforator flap. No recurrence or complications occurred throughout 3 months of follow-up. This case study adds new perspectives to the treatment of anastomotic stenosis.
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Affiliation(s)
- Baofei Li
- Department of Otolaryngology, Head and Neck Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Haiyang Wang
- Department of Otolaryngology, Head and Neck Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Jun Liu
- Department of Otolaryngology, Head and Neck Surgery, West China Hospital, Sichuan University, Chengdu, China,Correspondence: Fei Chen Jun Liu
| | - Xiaosong Mu
- Department of Otolaryngology, Head and Neck Surgery, Langzhong People's Hospital, Langzhong, China
| | - Feng Xu
- Department of Otolaryngology, Head and Neck Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Di Deng
- Department of Otolaryngology, Head and Neck Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Yixin Qiao
- Department of Otolaryngology, Head and Neck Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Shipin Wang
- Department of Otolaryngology, Head and Neck Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Fei Chen
- Department of Otolaryngology, Head and Neck Surgery, West China Hospital, Sichuan University, Chengdu, China,Correspondence: Fei Chen Jun Liu
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10
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Sivasailam B, Lane BF, Cross RK. Endoscopic Balloon Dilation of Strictures: Techniques, Short- and Long-Term Outcomes, and Complications. Gastrointest Endosc Clin N Am 2022; 32:675-686. [PMID: 36202509 DOI: 10.1016/j.giec.2022.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
EBD is safe and effective for the treatment of strictures. Here we describe the technique of endoscopic balloon dilation (EBD) of strictures including preprocedure considerations, indications, contraindications, and postprocedure complications. The short- and long-term outcomes of EBD including factors associated with improved outcomes are also discussed.
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Affiliation(s)
- Barathi Sivasailam
- Department of Medicine, Division of Gastroenterology and Hepatology, NYU Langone, New York, NY, USA
| | - Barton F Lane
- Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Raymond K Cross
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Maryland School of Medicine, 685 West Baltimore Street, Suite 8-00, Baltimore, MD 21201, USA.
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11
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Sun G, Yang Y, Liu J, Gao Z, Xu T, Chai J, Xu J, Fan Z, Xiao T, Jia Q, Li M. Cancer stem cells in esophageal squamous cell carcinoma. Pathol Res Pract 2022; 237:154043. [DOI: 10.1016/j.prp.2022.154043] [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: 06/21/2022] [Revised: 07/21/2022] [Accepted: 07/26/2022] [Indexed: 02/07/2023]
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12
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Weidenbaum C, Gibson MK. Approach to Localized Squamous Cell Cancer of the Esophagus. Curr Treat Options Oncol 2022; 23:1370-1387. [PMID: 36042147 PMCID: PMC9526684 DOI: 10.1007/s11864-022-01003-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/25/2022] [Indexed: 12/24/2022]
Abstract
OPINION STATEMENT Esophageal cancer is a leading cause of cancer deaths worldwide, with an increasing incidence in recent decades. The majority of esophageal cancers are squamous cell carcinoma. The 5-year survival rate of esophageal squamous cell carcinoma (ESCC) is poor, and there remains globally a pressing need for novel treatments that improve patient outcomes and quality of life. In this review, we discuss management of localized ESCC with an update on relevant newly published literature, including targeted therapy and novel biomarkers. The standard treatment approach for locally advanced, resectable ESCC is currently chemoradiation with or without surgery. Here we discuss different approaches to endoscopic resection, surgery, and radiation therapy. Although the typical chemotherapy regimen is a combination of a platinum with a fluoropyrimidine or paclitaxel, different regimens are being evaluated. With the landscape of immunotherapy rapidly evolving, at the forefront of new treatments for ESCC is immunotherapy and other targeted agents. Ultimately, the treatment approach should be individualized to each patient.
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Affiliation(s)
- Chloe Weidenbaum
- University of Tennessee Health Science Center Nashville, Nashville, TN, USA
| | - Michael K Gibson
- Division of Hematology-Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA. .,Vanderbilt-Ingram Cancer Center, 2220 Pierce Avenue, Nashville, TN, 37232, USA.
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13
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Endoscopic Incision Therapy for Benign Pyloric Stricture. ACG Case Rep J 2022; 9:e00855. [PMID: 36061254 PMCID: PMC9433062 DOI: 10.14309/crj.0000000000000855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 07/01/2022] [Indexed: 11/17/2022] Open
Abstract
We report that an 82-year-old woman with benign pyloric stricture and fibrous scars around the pylorus was safely treated with endoscopic incisional therapy using an insulation-tipped knife. At the 1-year follow-up endoscopy, the pylorus was open.
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14
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Wang S, Li X, Zhang C, Yin M, Ma Y, Tong Y, Wang M, Liu C, Zhu M, Wu G. Balloon dilatation complications during esophagogastric anastomotic stricture treatment under fluoroscopy: Risk factors, prevention, and management. Thorac Cancer 2022; 13:1570-1576. [PMID: 35481875 PMCID: PMC9161329 DOI: 10.1111/1759-7714.14389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 02/28/2022] [Accepted: 03/01/2022] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Balloon dilatation (BD) is a common treatment for esophagogastric anastomotic stricture (EAS), but with complications. This study investigates the risk factors, prevention, and management of BD complications to provide clinical guidance. METHODS We retrospectively analyzed the clinical data of 378 patients with EAS treated by BD from March 2011 to June 2021. The association between esophagogastric anastomotic rupture outcome and patient and stricture characteristics and treatment were analyzed by logistic regression. RESULTS BD was performed 552 times and technical success, 98.0%; overall clinical success, 97.8%; major adverse events, 1.3%; minor adverse events, 9.4%; mortality, 0.3%. Logistic regression showed that age (p = 0.080), sex (p = 0.256), interval from surgery to stricture development (p = 0.817), number of dilatations (p = 0.054), cause of stricture (p ≥ 0.168), and preoperative chemotherapy (p = 0.679) were not associated with anastomotic rupture. Balloon diameter (p < 0.001), preoperative radiotherapy (p = 0.003), and chemoradiotherapy (p = 0.021) were correlated with anastomotic rupture. All patients with type I and II ruptures resumed oral feeding without developing into type III rupture. Type III rupture occurred in six cases, who resumed oral feeding after 7-21 days of nasal feeding and liquid feeding. One patient died of massive bleeding after BD. CONCLUSIONS Symptomatic treatment for type I and II ruptures and transnasal decompression and jejunal nutrition tubes for type III rupture, are suggested pending rupture healing. Tumor recurrence, preoperative radiotherapy, and balloon diameter affected the anastomotic rupture outcome.
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Affiliation(s)
- Shuai Wang
- Department of Interventional RadiologyThe First Affiliated Hospital of Zhengzhou UniversityHenanChina
| | - Xiaobing Li
- Department of Interventional RadiologyThe First Affiliated Hospital of Zhengzhou UniversityHenanChina
| | - Chenchen Zhang
- Department of Interventional RadiologyThe First Affiliated Hospital of Zhengzhou UniversityHenanChina
| | - Meipan Yin
- Department of Interventional RadiologyThe First Affiliated Hospital of Zhengzhou UniversityHenanChina
| | - Yaozhen Ma
- Department of Interventional RadiologyThe First Affiliated Hospital of Zhengzhou UniversityHenanChina
| | - Yalin Tong
- Department of GI MedicineThe First Affiliated Hospital of Zhengzhou UniversityHenanChina
| | - Meng Wang
- Department of GI MedicineThe First Affiliated Hospital of Zhengzhou UniversityHenanChina
| | - Chao Liu
- Department of Interventional RadiologyThe First Affiliated Hospital of Zhengzhou UniversityHenanChina
| | - Ming Zhu
- Department of Interventional RadiologyThe First Affiliated Hospital of Zhengzhou UniversityHenanChina
| | - Gang Wu
- Department of Interventional RadiologyThe First Affiliated Hospital of Zhengzhou UniversityHenanChina
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15
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Song D, Wei Y, Hu Y, Sun Y, Liu M, Ren Q, Hu Z, Guo Q, Wang Y, Zhou Y. Identification of immunophenotypes in esophageal squamous cell carcinoma based on immune gene sets. Clin Transl Oncol 2022; 24:1100-1114. [PMID: 35098447 DOI: 10.1007/s12094-021-02749-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 12/06/2021] [Indexed: 02/05/2023]
Abstract
PURPOSE Esophageal squamous cell carcinoma (ESCC) is a malignant tumor with high heterogeneity. Research on molecular mechanisms involved in the process of tumor origination and progression is extremely limited to investigating mechanisms of molecular typing for ESCC. METHODS After comprehensively analyzing the gene expression profiles in The Cancer Genome Atlas and Gene Expression Omnibus databases, we identified four immunotypes of ESCC (referred to as C1-C4) based on the gene sets of 28 immune cell subpopulations. The discrepancies in prognostic value, clinical features, drug sensitivity, and tumor components between the immunotypes were individually analyzed. RESULTS The ranking of immune infiltration is C1 > C4 > C3 > C2. These subtypes are characterized by high and low expression of immune checkpoint proteins, enrichment and insufficiency of immune-related pathways, and differential distribution of immune cell subgroups. Poorer survival was observed in the C1 subtype, which we hypothesized could be caused by an immunosuppressive cell population. Fortunately, C1's susceptibility to anti-PD-1 therapy offers hope for patients with poor prognosis in advanced stages. On the other hand, C4 is sensitive to docetaxel, which may offer novel treatment strategies for ESCC in the future. It is worth noting that immunophenotyping is tightly bound to the abundance of stromal components and stem cells, which could explain the tumor immune escape to some extent. Ultimately, determination of hub genes based on the C1 subtypes provides a reference for the discovery of immunotarget drugs against ESCC. CONCLUSION The identification of immunophenotypes in our study provides new therapeutic strategies for patients with ESCC.
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Affiliation(s)
- Danlei Song
- The First Clinical Medical College, Lanzhou University, Lanzhou, China
- Department of Gastroenterology, Key Laboratory for Gastrointestinal Diseases of Gansu Province, The First Hospital of Lanzhou University, Lanzhou, 730000, Gansu Province, China
| | - Yongjian Wei
- The First Department of Hepatobiliary and Pancreatic Surgery, Cangzhou Central Hospital, Cangzhou, China
| | - Yuping Hu
- The First Clinical Medical College, Lanzhou University, Lanzhou, China
- Hospital of Reproductive Medicine, The First Hospital of Lanzhou University, Lanzhou, China
| | - Yueting Sun
- The First Clinical Medical College, Lanzhou University, Lanzhou, China
- Department of Gastroenterology, Key Laboratory for Gastrointestinal Diseases of Gansu Province, The First Hospital of Lanzhou University, Lanzhou, 730000, Gansu Province, China
| | - Min Liu
- Department of Gastroenterology, Key Laboratory for Gastrointestinal Diseases of Gansu Province, The First Hospital of Lanzhou University, Lanzhou, 730000, Gansu Province, China
| | - Qian Ren
- Department of Gastroenterology, Key Laboratory for Gastrointestinal Diseases of Gansu Province, The First Hospital of Lanzhou University, Lanzhou, 730000, Gansu Province, China
| | - Zenan Hu
- Department of Gastroenterology, Key Laboratory for Gastrointestinal Diseases of Gansu Province, The First Hospital of Lanzhou University, Lanzhou, 730000, Gansu Province, China
| | - Qinghong Guo
- Department of Gastroenterology, Key Laboratory for Gastrointestinal Diseases of Gansu Province, The First Hospital of Lanzhou University, Lanzhou, 730000, Gansu Province, China
| | - Yuping Wang
- Department of Gastroenterology, Key Laboratory for Gastrointestinal Diseases of Gansu Province, The First Hospital of Lanzhou University, Lanzhou, 730000, Gansu Province, China
| | - Yongning Zhou
- The First Clinical Medical College, Lanzhou University, Lanzhou, China.
- Department of Gastroenterology, Key Laboratory for Gastrointestinal Diseases of Gansu Province, The First Hospital of Lanzhou University, Lanzhou, 730000, Gansu Province, China.
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16
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Jang SI, Fang S, Nahm JH, Cho JH, Do MY, Lee SY, Jeong S, Lee DH, Lee DK. Preclinical evaluation of endoscopic placement of a steroid-eluting metal stent in an in vivo porcine benign biliary stricture model. Sci Rep 2022; 12:8864. [PMID: 35614115 PMCID: PMC9132970 DOI: 10.1038/s41598-022-12957-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2022] [Accepted: 05/19/2022] [Indexed: 11/28/2022] Open
Abstract
Treatment of benign biliary strictures (BBS) using fully covered self-expandable metal stents (FCSEMS) has a high success rate, but recurrence can occur. Corticosteroids may be useful based on their anti-fibrotic and anti-inflammatory effects. We investigated the safety and efficacy of corticosteroid-eluting FCSEMS in an animal model. BBSs were created by radiofrequency ablation in 12 mini-pigs. Four weeks later, FCSEMS coated with 0 mg (control), 15 mg (steroid 1 × group), or 30 mg (steroid 2 × group) triamcinolone were inserted endoscopically. The in vitro drug release assay revealed that the optimal stent had 15 mg of triamcinolone and a hydrophilic membrane. No transmural necrosis or perforation occurred in any animal. Fibrous wall thickness tended to decrease macroscopically and microscopically in a triamcinolone dose-dependent manner (control vs. steroid 2 × group: 773.1 vs. 468.5 µm, P = 0.037). Thickness also decreased over time in the steroid 2 × group (3 days vs. 4 weeks: 907.9 vs. 468.5 µm, P = 0.025). Blood parameters tended to improve after stent insertion. In a porcine BBS model, steroid-eluting FCSEMS showed potential as a safe and effective treatment modality to reduce fibrotic tissue. Studies are required to confirm their safety and efficacy in humans with refractory BBS.
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Affiliation(s)
- Sung Ill Jang
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, 211 Eonjuro, Gangnam-gu, Seoul, 06273, Republic of Korea
| | - Sungsoon Fang
- Severance Biomedical Science Institute, BK21 Plus Project for Medical Science, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Ji Hae Nahm
- Department of Pathology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jae Hee Cho
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, 211 Eonjuro, Gangnam-gu, Seoul, 06273, Republic of Korea.
| | - Min Young Do
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, 211 Eonjuro, Gangnam-gu, Seoul, 06273, Republic of Korea
| | - Su Yeon Lee
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, 211 Eonjuro, Gangnam-gu, Seoul, 06273, Republic of Korea
| | - Seok Jeong
- Department of Internal Medicine, Inha University Hospital, Inha University College of Medicine, Incheon, South Korea
| | - Don Haeng Lee
- Department of Internal Medicine, Inha University Hospital, Inha University College of Medicine, Incheon, South Korea
- Utah-Inha DDS & Advanced Therapeutics Research Center, Incheon, Republic of Korea
| | - Dong Ki Lee
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, 211 Eonjuro, Gangnam-gu, Seoul, 06273, Republic of Korea.
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17
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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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18
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Wang S, Yin M, Wang M, Tong Y, Zhao Y, Ma Y, Li X, Xie P, Wu G. Safety and efficacy of large balloon dilatation under fluoroscopy. Ann N Y Acad Sci 2021; 1503:102-109. [PMID: 34533853 DOI: 10.1111/nyas.14682] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 08/03/2021] [Accepted: 08/11/2021] [Indexed: 12/16/2022]
Abstract
The maximum diameter of the balloon used for balloon dilatation(BD) of esophagogastric anastomotic stricture (EAS) is generally 20 millimeters. This study aimed to evaluate the safety and efficacy of BD under fluoroscopy, using balloons with a diameter of 25-30 millimeters. We retrospectively analyzed the data of patients with benign EAS treated by large BD (balloon diameter, 25-30 mm) under fluoroscopy. The Cox proportional hazards model (PHM) was used to identify the factors associated with stricture-free survival. The results show that a total of 127 patients were included in this study, and 204 BDs were performed. The technical success rate was 96.6%, and the clinical success rate was 99.2%. The incidence of serious adverse events was 3.4% (7/204). One patient died of massive hemorrhage during BD, and nine patients were lost to follow-up. For the remaining 117 patients, the median stricture-free survival period was 14.9 months. In multivariable analysis using the Cox PHM, only balloon diameter was significantly associated with stricture-free survival. The stricture-free survival period tended to increase as balloon diameter increased. Large BD under fluoroscopy appears to be safe and effective for the treatment of benign EAS after esophagectomy.
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Affiliation(s)
- Shuai Wang
- Department of Interventional Radiology, the First Affiliated Hospital of Zhengzhou University, Henan, China
| | - Meipan Yin
- Department of Interventional Radiology, the First Affiliated Hospital of Zhengzhou University, Henan, China
| | - Meng Wang
- Department of GI Medicine, the First Affiliated Hospital of Zhengzhou University, Henan, China
| | - Yalin Tong
- Department of GI Medicine, the First Affiliated Hospital of Zhengzhou University, Henan, China
| | - Yue Zhao
- Department of Interventional Radiology, the First Affiliated Hospital of Zhengzhou University, Henan, China
| | - Yaozhen Ma
- Department of Interventional Radiology, the First Affiliated Hospital of Zhengzhou University, Henan, China
| | - Xiaobing Li
- Department of Interventional Radiology, the First Affiliated Hospital of Zhengzhou University, Henan, China
| | - Pengfei Xie
- Department of Interventional Radiology, the First Affiliated Hospital of Zhengzhou University, Henan, China
| | - Gang Wu
- Department of Interventional Radiology, the First Affiliated Hospital of Zhengzhou University, Henan, China
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19
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Kotani S, Shibagaki K, Yuki T, Aimi M, Mikami H, Izumi D, Yamashita N, Takahashi Y, Fukuba N, Ishimura N, Ishihara S. A multicenter retrospective study of the esophageal triamcinolone acetonide-filling method in patients with extensive esophageal endoscopic submucosal dissection. Scand J Gastroenterol 2021; 56:647-655. [PMID: 33856943 DOI: 10.1080/00365521.2021.1910998] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Endoscopic submucosal dissection (ESD) for extensive esophageal cancer is sometimes associated with post-ESD stenosis, despite preventative steroid therapy. In this retrospective multicenter analysis, we evaluated the factors associated with therapy resistance. MATERIALS AND METHODS We enrolled 73 patients with 75 extensive esophageal cancers treated with ESD. Stenosis prevention was performed using two esophageal triamcinolone acetonide (TA)-fillings, and repeated if stenosis was found on follow-up. Therapy-resistance factors associated with incidence of severe stenosis requiring endoscopic balloon dilation (EBD) were evaluated, including age, gender, previous treatment history, tumor location, morphology, resection size, histologic type, invasion depth, and horizontal resection grade (HR-grade 1, ≥ 9/12 and <10/12 of the circumference; grade 2, ≥ 10/12 and <11/12; grade 3, ≥ 11/12 but not circumferential; and grade 4, entirely circumferential). RESULTS Severe stenosis occurred in 17.3%(13/75) of cases, with a median of two EBDs (range, 1-6 times). Severe stenosis was significantly associated with HR-grade elevation and previous treatment history (p < .05); multivariate analysis showed both as independent therapy-resistance factors (p < .05). Patients without previous treatment history demonstrated severe stenosis at 12.9%(9/70): 0%(0/26) HR-grade 1, 18.8%(3/16) grade 2, 17.6%(3/17) grade 3, and 27.3%(3/11) grade 4, showing a risk of HR-grade 2 or more resection but an acceptable stenosis prevention even after entirely circumferential resection. Conversely, patients with previous treatment history demonstrated severe stenosis at a high frequency of 80%(4/5). CONCLUSIONS Esophageal TA-filling is a promising stenosis-preventive steroid therapy, even in entirely circumferential ESD cases. However, HR-grade 2 or more elevation and previous treatment history were independently associated with therapy resistance.
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Affiliation(s)
- Satoshi Kotani
- Department of Gastroenterology, Faculty of Medicine, Shimane University, Izumo, Japan
| | - Kotaro Shibagaki
- Department of Gastroenterology, Faculty of Medicine, Shimane University, Izumo, Japan
| | - Takafumi Yuki
- Division of Gastroenterology, Matsue Red Cross Hospital, Matsue, Japan
| | - Masahito Aimi
- Department of Gastroenterology, Tottori Municipal Hospital, Tottori, Japan
| | - Hironobu Mikami
- Department of Gastroenterology, Faculty of Medicine, Shimane University, Izumo, Japan
| | - Daisuke Izumi
- Department of Gastroenterology, Faculty of Medicine, Shimane University, Izumo, Japan
| | - Noritsugu Yamashita
- Department of Gastroenterology, Faculty of Medicine, Shimane University, Izumo, Japan
| | - Yusuke Takahashi
- Department of Gastroenterology, Faculty of Medicine, Shimane University, Izumo, Japan
| | - Nobuhiko Fukuba
- Department of Gastroenterology, Izumo City General Medical Center, Izumo, Japan
| | - Norihisa Ishimura
- Department of Gastroenterology, Faculty of Medicine, Shimane University, Izumo, Japan
| | - Shunji Ishihara
- Department of Gastroenterology, Faculty of Medicine, Shimane University, Izumo, Japan
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20
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Kinowaki S, Shimizu Y, Ono M, ZiJian Y, Tanaka I, Shimoda Y, Inoue M, Ishikawa M, Yamamoto K, Ono S, Ohnishi S, Sakamoto N. Experiment on endoscopic balloon dilation for esophageal stenosis after endoscopic submucosal dissection in pigs. J Gastroenterol 2021; 56:527-536. [PMID: 33899159 DOI: 10.1007/s00535-021-01791-2] [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: 12/25/2020] [Accepted: 04/15/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIM Endoscopic balloon dilation (EBD) is effective for esophageal stenosis caused by ESD. However, an efficient EBD method has not been established. We, therefore, conducted EBD experiments on porcine esophageal stenosis models. METHODS Study 1: in dilation models (day 22 after ESD), the thickness of the outer muscle layer (as an index of the extension effect) and the area of muscle fiber bundle necrosis in the inner muscle layer (as an index of thermal damage) were evaluated. Study 2: in restenosis models (day 43 after ESD), the thickness of the fibrous plexus (as an index of restenosis) was evaluated. In total, 12 porcine models were created. RESULTS Study 1: the thickness of the outer muscle layer was 1243 ± 322 μm in surrounding locations and it was 803 ± 145 μm beneath the laceration (p = 0.005). In cases of muscular layer injury, the area of necrosis was 15,500 ± 10400 μm2 in surrounding locations and it was 40,200 ± 12900 μm2 at the laceration site (p < 0.001). Study 2: the thickness of the fibrous plexus was 1359 ± 196 μm in surrounding locations and it was 1322 ± 136 μm2 in the laceration scar site (p = 0.74). CONCLUSION Since thermal damage persists until the completion of stenosis, EBD in the initial stage should be carefully performed. An extension effect was observed only at the laceration site and it later returned to a status similar to that of surrounding locations. Additional intervention would be required for preventing restenosis.
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Affiliation(s)
- Sayoko Kinowaki
- Department of Gastroenterology, Hokkaido University Graduate School of Medicine, Kita 15 jo Nishi 7 chome, Kitaku, Sapporo, 060-8638, Japan
| | - Yuichi Shimizu
- Division of Endoscopy, Hokkaido University Hospital, Kita 14 jo Nishi 5 chome, Kitaku, Sapporo, 060-8648, Japan.
| | - Masayoshi Ono
- Department of Gastroenterology, Hokkaido University Graduate School of Medicine, Kita 15 jo Nishi 7 chome, Kitaku, Sapporo, 060-8638, Japan
| | - Yang ZiJian
- Department of Gastroenterology, Hokkaido University Graduate School of Medicine, Kita 15 jo Nishi 7 chome, Kitaku, Sapporo, 060-8638, Japan
| | - Ikko Tanaka
- Department of Gastroenterology, Hokkaido University Graduate School of Medicine, Kita 15 jo Nishi 7 chome, Kitaku, Sapporo, 060-8638, Japan
| | - Yoshihiko Shimoda
- Department of Gastroenterology, Hokkaido University Graduate School of Medicine, Kita 15 jo Nishi 7 chome, Kitaku, Sapporo, 060-8638, Japan
| | - Masaki Inoue
- Department of Gastroenterology, Hokkaido University Graduate School of Medicine, Kita 15 jo Nishi 7 chome, Kitaku, Sapporo, 060-8638, Japan
| | - Marin Ishikawa
- Department of Gastroenterology, Hokkaido University Graduate School of Medicine, Kita 15 jo Nishi 7 chome, Kitaku, Sapporo, 060-8638, Japan.,Department of Cancer Pathology, Hokkaido University Graduate School of Medicine, Kita 15 jo Nishi 7 chome, Kitaku, Sapporo, 060-8638, Japan
| | - Keiko Yamamoto
- Division of Endoscopy, Hokkaido University Hospital, Kita 14 jo Nishi 5 chome, Kitaku, Sapporo, 060-8648, Japan
| | - Shoko Ono
- Division of Endoscopy, Hokkaido University Hospital, Kita 14 jo Nishi 5 chome, Kitaku, Sapporo, 060-8648, Japan
| | - Shunsuke Ohnishi
- Department of Gastroenterology, Hokkaido University Graduate School of Medicine, Kita 15 jo Nishi 7 chome, Kitaku, Sapporo, 060-8638, Japan
| | - Naoya Sakamoto
- Department of Gastroenterology, Hokkaido University Graduate School of Medicine, Kita 15 jo Nishi 7 chome, Kitaku, Sapporo, 060-8638, Japan
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21
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Functional syndromes and symptom-orientated aftercare after esophagectomy. Langenbecks Arch Surg 2021; 406:2249-2261. [PMID: 34036407 PMCID: PMC8578083 DOI: 10.1007/s00423-021-02203-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Accepted: 05/16/2021] [Indexed: 01/02/2023]
Abstract
BACKGROUND Surgery is the cornerstone of esophageal cancer treatment but remains burdened with significant postoperative changes of gastrointestinal function and quality of life. PURPOSE The aim of this narrative review is to assess and summarize the current knowledge on postoperative functional syndromes and quality of life after esophagectomy for cancer, and to provide orientation for the reader in the challenging field of functional aftercare. CONCLUSIONS Post-esophagectomy syndromes include various conditions such as dysphagia, reflux, delayed gastric emptying, dumping syndrome, weight loss, and chronic diarrhea. Clinical pictures and individual expressions are highly variable and may be extremely distressing for those affected. Therefore, in addition to a mostly well-coordinated oncological follow-up, we strongly emphasize the need for regular monitoring of physical well-being and gastrointestinal function. The prerequisite for an effective functional aftercare covering the whole spectrum of postoperative syndromes is a comprehensive knowledge of the pathophysiological background. As functional conditions often require a complex diagnostic workup and long-term therapy, close interdisciplinary cooperation with radiologists, gastroenterologists, oncologists, and specialized nutritional counseling is imperative for successful management.
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Abstract
A comprehensive understanding of gastrointestinal anatomy is essential for performance of any endoscopic procedure. Surgical approaches to therapy have become increasingly common in the past decade, which has resulted in a substantial proportion of patients with surgically altered anatomy who require endoscopy. In parallel with the obesity epidemic, bariatric surgery for obesity management has been widely adopted. In response to these trends, gastroenterologists must become familiar with patient anatomy after these surgical interventions and understand the implications of this altered anatomy on the current array of available endoscopic modalities for diagnosis and therapy. This review describes the range of surgically altered anatomy commonly encountered in the upper gastrointestinal tract. For each foregut location-esophagus, stomach, and small bowel-we describe indications for and specific details of the range of common surgical approaches affecting this regional anatomy. We then provide an endoscopic roadmap through the altered anatomy resulting from these surgical interventions. Finally, we address the impact of postsurgical anatomy on performance of endoscopic ultrasound and endoscopic retrograde cholangiopancreatography, with guidance surrounding how to successfully execute these procedures. Evolution of endoscopic approaches over time might be expected to enhance the safety and efficacy of these interventions in patients with surgically altered anatomy.
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23
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Choi J, Choi SI. A new simple endoscopic incision therapy for refractory benign oesophageal anastomotic stricture. BMJ Case Rep 2021; 14:14/3/e239798. [PMID: 33692055 PMCID: PMC7949401 DOI: 10.1136/bcr-2020-239798] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Oesophageal anastomotic stricture is a frequent complication after esophagectomy. In most cases, endoscopic bougination or balloon dilation usually resolves anastomotic stricture. However, some refractory oesophageal strictures remain difficult to treat and cause significant morbidity. Recently, successful treatment using endoscopic incisional therapy has been reported in several cases. We report a case of refractory benign oesophageal anastomotic stricture after oesophagectomy. A 72-year-old man underwent three consecutive bouginations. However, he developed progressive stricture. Stricture was successfully treated with an endoscopic knife incision. We performed only three incisions without a cutting method, which was new compared with previous reports. A new simple endoscopic incision technique is effective and safe for stricture management. In conclusion, endoscopic incisional therapy may be recommended as a salvage treatment for properly selected patients with refractory benign stricture who do not respond to conventional therapy.
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Affiliation(s)
- Jeongmin Choi
- Department of Internal Medicine, Inje University Sanggye Paik Hospital, Nowon-gu, Korea
| | - Soo In Choi
- Department of Internal Medicine, Inje University Sanggye Paik Hospital, Nowon-gu, Korea
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Long-term outcomes after robotic-assisted Ivor Lewis esophagectomy. J Robot Surg 2021; 16:119-125. [PMID: 33638759 DOI: 10.1007/s11701-021-01219-2] [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: 01/25/2021] [Accepted: 02/20/2021] [Indexed: 02/07/2023]
Abstract
Robotic assistance has gained acceptance in thoracic procedures, including esophagectomy. There is a paucity of data regarding long-term outcomes for robotic esophagectomy. We previously reported our initial series of robot-assisted Ivor Lewis (RAIL) esophagectomy. We report long-term outcomes to assess the efficacy of the procedure. We performed a retrospective review of 112 consecutive patients who underwent a RAIL. Patient demographics, diagnosis, pathology, operative characteristics, post-operative complications, and long-term outcomes were documented. Descriptive statistical analysis was performed for all the variables. Primary endpoints were mortality and disease-free survival. Overall survival (OS) and disease-free survival (DFS) were calculated using the Kaplan-Meier method. Of the 112 patients, 106 had a diagnosis of cancer, with adenocarcinoma the dominant histology (87.5%). Of these 106 patients, 81 (76.4%) received neo-adjuvant chemoradiation. The 30-, 60-, and 90-day mortality was 1 (0.9%), 3 (2.7%), and 4 (3.6%), respectively. There were 9 anastomotic leaks (8%) and 18 (16.1%) patients had a stricture requiring dilation. All-patient OS at 1, 3, and 5 years was 81.4%, 60.5%, and 51.0%, respectively. For cancer patients, the 1-, 3-, and 5-year OS was 81.3%, 59.2%, and 49.4%, respectively, and the DFS was 75.3%, 42.3%, and 44.0%. We have shown that long-term outcomes after RAIL esophagectomy are similar to other non-robotic esophagectomies. Given the potential advantages of robotic assistance, our results are crucial to demonstrate that RAIL does not result in inferior outcomes.
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Boregowda U, Goyal H, Mann R, Gajendran M, Patel S, Echavarria J, Sayana H, Saligram S. Endoscopic management of benign recalcitrant esophageal strictures. Ann Gastroenterol 2021; 34:287-299. [PMID: 33948052 PMCID: PMC8079876 DOI: 10.20524/aog.2021.0585] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 11/02/2020] [Indexed: 11/25/2022] Open
Abstract
Benign esophageal strictures are one of the common clinical conditions managed by endoscopists. Nearly 90% of the benign esophageal strictures respond to endoscopic dilation. However, a small percentage of patients progress to recalcitrant strictures. The benign recalcitrant esophageal strictures are difficult to manage both medically and endoscopically as they do not respond to conventional treatment with proton pump inhibitors and esophageal dilations. Patients with benign recalcitrant esophageal strictures are at a high risk of developing debilitating malnutrition and morbidity due to severe dysphagia. This condition is associated with psychological trauma to patients as treatments are usually prolonged with poor outcomes. Also, this can be a financial burden on the healthcare industry due to several sessions of treatment. In this article, we discuss the classification of benign esophageal strictures, evidence-based treatment strategies, endoscopic procedural techniques, and complications of endoscopic interventions. We aim to guide providers in managing benign esophageal strictures with a focus on endoscopic management of benign recalcitrant esophageal strictures.
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Affiliation(s)
- Umesha Boregowda
- Department of Internal Medicine, Bassett Medical Center, Cooperstown, NY (Umesha Boregowda)
| | - Hemant Goyal
- Department of Medicine, The Wright Center for Graduation Medical Center, Scranton, PA (Hemant Goyal)
| | - Rupinder Mann
- Department of Internal Medicine, Saint Agnes Medical Center, Fresno, CA (Rupinder Mann)
| | - Mahesh Gajendran
- Department of Internal Medicine, Texas Tech University Health Sciences Center, El Paso, TX (Mahesh Gajendran)
| | - Sandeep Patel
- Division of Gastroenterology, University of Texas Health, San Antonio, TX (Sandeep Patel, Juan Echavarria, Hari Sayana, Shreyas Saligram), USA
| | - Juan Echavarria
- Division of Gastroenterology, University of Texas Health, San Antonio, TX (Sandeep Patel, Juan Echavarria, Hari Sayana, Shreyas Saligram), USA
| | - Hari Sayana
- Division of Gastroenterology, University of Texas Health, San Antonio, TX (Sandeep Patel, Juan Echavarria, Hari Sayana, Shreyas Saligram), USA
| | - Shreyas Saligram
- Division of Gastroenterology, University of Texas Health, San Antonio, TX (Sandeep Patel, Juan Echavarria, Hari Sayana, Shreyas Saligram), USA
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Utility of radial incision and cutting with steroid injection for refractory stricture after endoscopic submucosal dissection for large superficial esophageal squamous cell carcinoma. Surg Endosc 2021; 35:6930-6937. [PMID: 33398559 DOI: 10.1007/s00464-020-08204-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 12/02/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND AND AIMS Endoscopic submucosal dissection (ESD) for superficial esophagus squamous cell carcinoma (SESCC) may cause esophageal stricture and related dysphagia symptoms, especially when the lesion is widespread. Endoscopic balloon dilation (EBD) is the prior choice to treat post-ESD stricture. However, certain patients show poor response to EBD treatment and frequent dilations are required. We perform radial incision and cutting combined with intralesional steroid injection to manage refractory stricture. The study aims to evaluate the safety and efficacy of this new combined treatment. METHODS From October 2017 to February 2019, 25 patients who accepted repeated EBD because of refractory stricture after extensive ESD for large SESCC were enrolled. Radial incision and cutting followed by local steroid injection was performed on all the patients, and therapeutic EBD was conducted to treat recurring stricture after combined treatment. The incidence of recurrent stricture, clinical outcome of combined treatment, and following therapeutic EBD, procedure-related adverse events were assessed and analyzed. RESULTS During the follow-ups, the incidence of recurrent esophageal strictures was 92%. Combined treatment reduced the severity of stenosis and lowered the corresponding dysphagia scores significantly, compared with previous EBD. Mean symptom-relief duration of EBD was prolonged significantly from 29.9 to 76.0 days. Perforation was observed in one patient during operation and successfully sealed with metal clips. CONCLUSIONS Combination of radial incision and cutting with steroid injection is a safe and feasible treatment for esophageal refractory stricture after extensive ESD, appearing to improve the therapeutic EBD outcome and maintain a longer symptom-relief duration.
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van Hal ARL, Pulvirenti R, den Hartog FPJ, Vlot J. The Safety of Intralesional Steroid Injections in Young Children and Their Effectiveness in Anastomotic Esophageal Strictures-A Meta-Analysis and Systematic Review. Front Pediatr 2021; 9:825030. [PMID: 35165653 PMCID: PMC8837747 DOI: 10.3389/fped.2021.825030] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 12/27/2021] [Indexed: 12/03/2022] Open
Abstract
OBJECTIVE Intralesional steroid injections (ISI) are a widely used technique for various pediatric indications and represent a possible adjuvant treatment for anastomotic esophageal strictures. Yet, no consensus has been reached neither on their safety in the pediatric population or their effectiveness in esophageal atresia patients. This systematic review aimed to assess the safety of ISI in young children through a meta-analysis and to summarize the current knowledge on the effectiveness of ISI in anastomotic esophageal strictures. METHODS A systematic literature search was performed in Embase, Medline, Web of Science Core Collection, Cochrane Central Register of Controlled Trials and Google Scholar up to August 16 2021. Studies focusing on ISI and involving children up to 2 years were included in the meta-analysis for the safety assessment. All studies evaluating the use of ISI as adjuvant treatment in anastomotic esophageal strictures in children were included in the systematic review to assess the effectiveness of the intervention. RESULTS The literature search yielded 8,253 articles. A total of 57 studies were included, of which 55 for the safety and five for the effectiveness assessment. The overall complication rate was 7%, with a greater incidence of local complications compared to systemic complications. Six studies (with a total of 367 patients) evaluated adrenocorticotropic hormone and cortisol levels, of which four reported hypothalamic-pituitary axis suppression. Two children (0.6%) received replacement therapy and all patients recovered uneventfully. A mean number of 1.67 ISI were performed per esophageal atresia (EA) patient. A reduction of needed dilatations was seen after ISI, compared to the number of dilatations performed before the intervention (5.2 vs. 1.3). CONCLUSION The insufficient data emphasized the need for further prospective and comparative studies. Results from this meta-analysis and systematic review address ISI as a safe and effective technique. Close clinical follow-up and growth curve evaluation are advisable in patients receiving ISI. SYSTEMATIC REVIEW REGISTRATION PROSPERO, identifier: CRD42021281584.
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Affiliation(s)
- Annefleur R L van Hal
- Department of Pediatric Surgery and Intensive Care, Erasmus Medical Centre Sophia Children's Hospital, Rotterdam, Netherlands
| | - Rebecca Pulvirenti
- Pediatric Surgery Unit, Department of Women's and Children's Health, University Hospital of Padua, Padua, Italy
| | | | - John Vlot
- Department of Pediatric Surgery and Intensive Care, Erasmus Medical Centre Sophia Children's Hospital, Rotterdam, Netherlands
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28
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Intralesional steroids and endoscopic dilation for anastomotic strictures after esophagectomy: systematic review and meta-analysis. Endoscopy 2020; 52:721-726. [PMID: 32450581 DOI: 10.1055/a-1172-5975] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Post-esophagectomy anastomotic strictures are difficult to treat. The impact of adding local steroid injection to endoscopic dilation for the treatment of post-esophagectomy anastomotic strictures is unclear. We conducted a systematic review and meta-analysis to assess the efficacy of performing steroid injection in addition to dilation. METHODS A search was conducted in MEDLINE, Cochrane Library, EMBASE, and Web of Science from inception to January 2019. Randomized controlled trials (RCTs) comparing the efficacy of endoscopic dilation plus either local steroid injection (steroid group) or saline injection (placebo group) were included in the analysis. RESULTS Three RCTs were eligible for the final analysis: 72 patients (mean age 61.3 years, 74 % male) in the steroid group and 72 patients (mean age 59.6 years, 71 % male) in the placebo group. The mean number of dilations required to resolve the stricture was significantly lower in the steroid group compared with the placebo group, with a mean weighted difference of -1.62 (95 % confidence interval [CI] -2.73 to -0.50; P = 0.004). After 6 months of follow-up, there was a trend toward more patients in the steroid group remaining dysphagia free compared with the placebo group, with a pooled odds ratio of 2.36 (95 %CI 0.94 to 5.91; P = 0.07, I2 = 24 %). CONCLUSION This meta-analysis showed that the addition of local steroid injection at the time of dilation for benign anastomotic strictures led to a significant decrease in the number of procedures required to resolve the stricture and may well reduce dysphagia symptoms during follow-up.
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29
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Systemic steroid application for treatment of edematous anastomotic stenosis following delta-shaped anastomosis in laparoscopic distal gastrectomy: a case report. BMC Surg 2020; 20:163. [PMID: 32698798 PMCID: PMC7376961 DOI: 10.1186/s12893-020-00827-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 07/17/2020] [Indexed: 11/15/2022] Open
Abstract
Background Delta-shaped anastomosis is a common method of intracorporeal gastroduodenostomy in totally laparoscopic distal gastrectomy. One common postoperative complication of this procedure is anastomotic stenosis, and endoscopic balloon dilatation is a major remedy for such complications. Other treatment strategies are necessary to manage unsuccessful endoscopic balloon dilatation. Case presentation We present a case where systemic steroid treatment was applied in sustained anastomotic stenosis after endoscopic balloon dilatation. We performed delta-shaped anastomosis in laparoscopic distal gastrectomy to treat early-stage gastric cancer in a patient. The patient experienced abdominal pain post-surgery; subsequent investigation revealed edematous anastomotic stenosis. The stenosis sustained even after endoscopic balloon dilatation and local steroid injection. Consequently, we applied systemic steroid treatment. Conclusion Systemic steroid treatment improved the stenosis and no recurrence was observed. These results suggest that systemic steroid application could be useful to treat anastomotic stenosis.
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30
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Liang C, Tan Y, Lu J, Le M, Liu D. Endoscopic incision for treatment of benign gastrointestinal strictures. Expert Rev Gastroenterol Hepatol 2020; 14:445-452. [PMID: 32380885 DOI: 10.1080/17474124.2020.1766966] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Benign gastrointestinal strictures are common, and can be congenital or acquired (anastomotic, corrosive, induced by Crohn's disease or endoscopic treatments, etc.). Patients usually present with stricture-related symptoms such as vomiting, dysphagia, dyschezia, abdominal pain, which impair their quality of life. Endoscopic balloon dilation (EBD) is the first-line treatment for most of the benign strictures; however, long-term efficacy is suboptimal, and the recurrence rate can be up to 38%. Endoscopic incision (EI) was firstly reported for treatment of congenital membranous stricture, and then applied to other benign gastrointestinal strictures. AREA COVERED In the present review, we provided a comprehensive review of EI for the treatment of benign gastrointestinal strictures, mainly focus on the technical details, indication, safety, and efficacy of EI. The present review is expected to provide tips for operators who are going to perform EI. EXPERT OPINION EI can serve as an alternative method for treatment of gastrointestinal strictures, the best indications are congenital membranous stricture and short-segmental (<1 cm) anastomotic strictures refractory to EBD. EI may also be attempted for strictures induced by other reasons. Combination with other endoscopic methods such as EBD, local steroid injection, stent placement, may improve the efficacy of EI.
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Affiliation(s)
- Chengbai Liang
- Department of Gastroenterology, The Second Xiangya Hospital , Changsha, Hunan, China.,Research Center of Digestive Disease, Central South University , Changsha, Hunan, China
| | - Yuyong Tan
- Department of Gastroenterology, The Second Xiangya Hospital , Changsha, Hunan, China.,Research Center of Digestive Disease, Central South University , Changsha, Hunan, China
| | - Jiaxi Lu
- Department of Gastroenterology, The Second Xiangya Hospital , Changsha, Hunan, China.,Research Center of Digestive Disease, Central South University , Changsha, Hunan, China
| | - Meixian Le
- Department of Gastroenterology, The Second Xiangya Hospital , Changsha, Hunan, China.,Research Center of Digestive Disease, Central South University , Changsha, Hunan, China
| | - Deliang Liu
- Department of Gastroenterology, The Second Xiangya Hospital , Changsha, Hunan, China.,Research Center of Digestive Disease, Central South University , Changsha, Hunan, China
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31
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Vermeulen BD, de Zwart M, Sijben J, Soons E, van der Weerd L, Arese D, von den Hoff DW, Craviotto V, Tan ACITL, Groenen MJM, Bogte A, Repici A, Spaander MCW, Siersema PD. Risk factors and clinical outcomes of endoscopic dilation in benign esophageal strictures: a long-term follow-up study. Gastrointest Endosc 2020; 91:1058-1066. [PMID: 31917167 DOI: 10.1016/j.gie.2019.12.040] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Accepted: 12/22/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Endoscopic dilation (ED) is still the mainstay of therapeutic management of benign esophageal strictures (BESs). This study aimed to establish risk factors for refractory BESs and assess long-term clinical outcomes of ED. METHODS We performed a retrospective study in 891 patients who underwent ED from 2003 to 2018 for BESs. We searched electronic medical records in 6 tertiary care centers in the Netherlands for data on clinical outcome of ED. Median follow-up was 39 months. The primary endpoint was risk factors for refractory BESs, defined as factors associated with an increased number of ED sessions during follow-up. Secondary endpoints were time from first to last ED session and adverse events. RESULTS Dilation up to 13 to 15 mm was associated with a higher number of ED sessions than dilation up to 16 to 18 mm (5.0 vs 4.1; hazard ratio [HR], 1.4; P = .001). Compared with peptic strictures, anastomotic (4.9 vs 3.6; HR, 2.1; P < .001), radiation (5.0 vs 3.6; HR, 3.0; P < .001), caustic (7.2 vs 3.6; HR, 2.7; P < .001), and postendotherapy (3.9 vs 3.6; HR, 1.8; P = .005) strictures were associated with a higher number of ED sessions. After 1 year of follow-up, the proportions of patients who remained free of ED was 75% in anastomotic, 71% in radiation, 70% in peptic, 83% in postendotherapy, and 62% in caustic strictures. Esophageal perforation occurred in 23 ED sessions (.4%) in 22 patients (2.4%). CONCLUSIONS More than 60% of patients with BESs remain free of ED after 1 year of follow-up. Because dilation up to 16 to 18 mm diameter was associated with fewer ED sessions during follow-up, we suggest that clinicians should consider dilation up to at least 16 mm to reduce the number of ED sessions in these patients.
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Affiliation(s)
- Bram D Vermeulen
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Merle de Zwart
- Department of Gastroenterology & Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Jasmijn Sijben
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Elsa Soons
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Lucie van der Weerd
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Daniele Arese
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Daan W von den Hoff
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Vincenzo Craviotto
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Clinical and Research Center, Rozzano, Milan, Italy
| | - Adriaan C I T L Tan
- Department of Gastroenterology and Hepatology, Canisius Wilhelmina Hospital, Nijmegen, the Netherlands
| | - Marcel J M Groenen
- Department of Gastroenterology and Hepatology, Rijnstate Hospital, Arnhem, the Netherlands
| | - Auke Bogte
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Alessandro Repici
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Clinical and Research Center, Rozzano, Milan, Italy
| | - Manon C W Spaander
- Department of Gastroenterology & Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Peter D Siersema
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, the Netherlands
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32
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Shibagaki K, Yuki T, Taniguchi H, Aimi M, Miyaoka Y, Yuki M, Ishimura N, Oshima N, Mishiro T, Tamagawa Y, Mikami H, Izumi D, Yamashita N, Sato S, Ishihara S, Kinoshita Y. Prospective multicenter study of the esophageal triamcinolone acetonide-filling method in patients with subcircumferential esophageal endoscopic submucosal dissection. Dig Endosc 2020; 32:355-363. [PMID: 31361925 DOI: 10.1111/den.13496] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Accepted: 07/26/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIM The esophageal triamcinolone acetonide (TA)-filling method is a novel local approach for stenosis prevention after extensive esophageal endoscopic submucosal dissection (ESD). We evaluated this method after subcircumferential ESD. METHODS We enrolled 20 patients with esophageal cancer requiring subcircumferential ESD in a prospective multicenter study. Esophageal TA filling was carried out 1 day and 1 week after ESD, with follow-up endoscopy every 2 weeks. We treated severe stenosis preventing endoscope passage with endoscopic balloon dilatation (EBD) and additional TA filling, and mild stenosis allowing endoscope passage with additional TA filling only. Primary endpoint was incidence of severe stenosis; secondary endpoints were total number of EBD, rate of additional TA filling, time to stenosis and complete re-epithelialization, dysphagia score, and adverse events. Horizontal resection grade was divided into grades 1 (≥ 9/12 and <10/12 of the circumference), 2 (≥ 10/12 and <11/12), and 3 (≥ 11/12 but not circumferential) and analyzed statistically for correlation with endpoints. RESULTS Incidence of severe stenosis was 5.0% (1/20; 0.1-24.8%) and was treated with three EBD. Six patients showed mild stenosis. Additional TA filling was carried out in these seven patients: 0% (0/9) for grade 1 resection, 40% (2/5) for grade 2, and 83% (5/6) for grade 3 (P < 0.05). Median time to stenosis and re-epithelialization was 3 and 7 weeks, respectively. Dysphagia score deteriorated in one patient. No adverse events occurred. CONCLUSIONS The esophageal TA-filling method prevented stenosis after subcircumferential ESD. Grade ≥2 resection showed a high risk for stenosis, but additional TA filling for mild stenosis inhibited stenosis progression (UMIN000024384).
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Affiliation(s)
- Kotaro Shibagaki
- Department of Gastroenterology, Faculty of Medicine, Shimane University, Shimane, Japan
| | - Takafumi Yuki
- Department of Gastroenterology, Matsue Red Cross Hospital, Shimane, Japan
| | - Hideaki Taniguchi
- Department of Gastroenterology, Tottori Municipal Hospital, Tottori, Japan
| | - Masahito Aimi
- Department of Gastroenterology, Tottori Municipal Hospital, Tottori, Japan
| | - Yoichi Miyaoka
- Department of Gastroenterology, Shimane Prefectural Central Hospital, Shimane, Japan
| | - Mika Yuki
- Department of Gastroenterology, Izumo Municipal Medical Center, Shimane, Japan
| | - Norihisa Ishimura
- Department of Gastroenterology, Faculty of Medicine, Shimane University, Shimane, Japan
| | - Naoki Oshima
- Department of Gastroenterology, Faculty of Medicine, Shimane University, Shimane, Japan
| | - Tsuyoshi Mishiro
- Department of Gastroenterology, Faculty of Medicine, Shimane University, Shimane, Japan
| | - Yuji Tamagawa
- Department of Gastroenterology, Faculty of Medicine, Shimane University, Shimane, Japan
| | - Hironobu Mikami
- Department of Gastroenterology, Faculty of Medicine, Shimane University, Shimane, Japan
| | - Daisuke Izumi
- Department of Gastroenterology, Faculty of Medicine, Shimane University, Shimane, Japan
| | - Noritsugu Yamashita
- Department of Gastroenterology, Faculty of Medicine, Shimane University, Shimane, Japan
| | - Shuichi Sato
- Department of Gastroenterology, Faculty of Medicine, Shimane University, Shimane, Japan
| | - Shunji Ishihara
- Department of Gastroenterology, Faculty of Medicine, Shimane University, Shimane, Japan
| | - Yoshikazu Kinoshita
- Department of Gastroenterology, Faculty of Medicine, Shimane University, Shimane, Japan
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Strictures in Crohn's Disease and Ulcerative Colitis: Is There a Role for the Gastroenterologist or Do We Always Need a Surgeon? Gastrointest Endosc Clin N Am 2019; 29:549-562. [PMID: 31078252 DOI: 10.1016/j.giec.2019.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Symptomatic strictures occur more often in Crohn disease than in ulcerative colitis. The mainstay of endoscopic therapy for strictures in inflammatory bowel disease is endoscopic balloon dilation. Serious complications are rare, and risk factors for perforation include active inflammation, use of steroids, and dilation of ileorectal or ileosigmoid anastomotic strictures. This article presents current literature on strictures in inflammatory bowel disease. Focus is placed on the short- and long-term outcomes, complications, and safety of endoscopic balloon dilation for Crohn disease strictures. Adjuvant techniques, such as intralesional injection of steroids and anti-tumor necrosis factor, stricturotomy, and stent insertion, are briefly discussed.
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34
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Burr NE, Everett SM. Management of benign oesophageal strictures. Frontline Gastroenterol 2019; 10:177-181. [PMID: 31205660 PMCID: PMC6540277 DOI: 10.1136/flgastro-2018-101075] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Revised: 11/28/2018] [Accepted: 12/09/2018] [Indexed: 02/04/2023] Open
Abstract
Benign oesophageal strictures are an important gastrointestinal condition that can cause substantial morbidity. There are many different aetiologies and each case needs careful evaluation and individualised treatment. Management usually involves targeting therapy to the underlying cause, but oesophageal dilatation is an important part of the algorithm. The recent British Society of Gastroenterology guidelines provide advice on the use of dilatation for benign strictures and cover patient preparation, the dilatation procedure and disease-specific considerations. This article provides a summary of the key messages from the guidelines and applies them to routine clinical practice. It also includes practical advice on the clinical assessment, investigation and management of benign oesophageal strictures and gives an approach to the management of refractory strictures. Areas where evidence is sparse and further research is needed are highlighted.
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Affiliation(s)
- Nicholas E Burr
- Leeds Gastroenterology Institute, St James’s University Hospital, Leeds, UK,Leeds Institute of Biomedical and Clinical Sciences, University of Leeds, Leeds, UK
| | - Simon M Everett
- Leeds Gastroenterology Institute, St James’s University Hospital, Leeds, UK
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35
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Mizusawa T, Kobayashi M, Terai S. Radial incision and cutting for refractory benign esophageal stricture. Dig Endosc 2019; 31:e46-e47. [PMID: 30589460 DOI: 10.1111/den.13329] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Accepted: 12/24/2018] [Indexed: 12/26/2022]
Affiliation(s)
- Takeshi Mizusawa
- Department of Internal Medicine, Niigata Prefectural Tokamachi Hospital, Niigata, Japan.,Division of Gastroenterology and Hepatology, Niigata University Faculty of Medicine Graduate School of Medical and Dental Science, Niigata, Japan
| | - Masaaki Kobayashi
- Department of Gastroenterology and Hepatology, Uonuma Institute of Community Medicine Niigata University Hospital, Niigata, Japan.,Department of Internal Medicine, Niigata Cancer Center Hospital, Niigata, Japan
| | - Shuji Terai
- Division of Gastroenterology and Hepatology, Niigata University Faculty of Medicine Graduate School of Medical and Dental Science, Niigata, Japan
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36
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Everett SM. Endoscopic management of refractory benign oesophageal strictures. Ther Adv Gastrointest Endosc 2019; 12:2631774519862134. [PMID: 31460518 PMCID: PMC6702770 DOI: 10.1177/2631774519862134] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Accepted: 06/16/2019] [Indexed: 12/17/2022] Open
Abstract
Refractory benign oesophageal strictures are an infrequent presentation but a cause of significant morbidity and mortality. The treatment of these strictures has changed little in recent years, yet new evidence is emerging for the optimal timing and application of different therapies. In this article, we have carefully reviewed the current literature on the evaluation and management of refractory strictures and provided practical advice as to their management. A number of areas require attention in future research, including carefully designed randomised trials of endoscopic and medical therapies, and a focus on risk factors at a patient and molecular level to facilitate development of medical therapies that can reduce recurrent fibrosis in these patients.
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Affiliation(s)
- Simon M. Everett
- Department of Gastroenterology, Leeds Teaching Hospitals NHS Trust, Leeds LS9 7TF, UK
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Reichenbach ZW, Murray MG, Saxena R, Farkas D, Karassik EG, Klochkova A, Patel K, Tice C, Hall TM, Gang J, Parkman HP, Ward SJ, Tétreault MP, Whelan KA. Clinical and translational advances in esophageal squamous cell carcinoma. Adv Cancer Res 2019; 144:95-135. [PMID: 31349905 DOI: 10.1016/bs.acr.2019.05.004] [Citation(s) in RCA: 124] [Impact Index Per Article: 24.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Esophageal squamous cell carcinoma (ESCC) is among the most deadly forms of human malignancy characterized by late stage diagnosis, metastasis, therapy resistance and frequent recurrence. Clinical management of ESCC remains challenging and the disease presently lacks approved targeted therapeutics. However, emerging data from recent clinical and translational investigations hold great promise for future progress toward improving patient outcomes in this deadly disease. Here, we review current clinical perspectives in ESCC epidemiology, pathophysiology, and clinical care, highlighting recent advances with potential to impact ESCC prevention, diagnosis and management. We further provide an overview of recent translational investigations contributing to our understanding of the molecular mechanisms underlying ESCC development, progression and therapy response, including insights gained from genetic studies and various murine model systems. Finally, we discuss future perspectives in the clinical and translational realms, along with remaining hurdles that must be overcome to eradicate ESCC.
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Affiliation(s)
- Zachary Wilmer Reichenbach
- Department of Medicine, Gastroenterology Section, Lewis Katz School of Medicine, Temple University, Philadelphia, PA, United States; Center for Substance Abuse Research, Lewis Katz School of Medicine, Temple University, Philadelphia, PA, United States
| | - Mary Grace Murray
- Fels Institute for Cancer Research & Molecular Biology, Lewis Katz School of Medicine, Temple University, Philadelphia, PA, United States
| | - Reshu Saxena
- Fels Institute for Cancer Research & Molecular Biology, Lewis Katz School of Medicine, Temple University, Philadelphia, PA, United States
| | - Daniel Farkas
- Lewis Katz School of Medicine at Temple University, Philadelphia, PA, United States
| | - Erika G Karassik
- Fels Institute for Cancer Research & Molecular Biology, Lewis Katz School of Medicine, Temple University, Philadelphia, PA, United States
| | - Alena Klochkova
- Fels Institute for Cancer Research & Molecular Biology, Lewis Katz School of Medicine, Temple University, Philadelphia, PA, United States
| | - Kishan Patel
- Fels Institute for Cancer Research & Molecular Biology, Lewis Katz School of Medicine, Temple University, Philadelphia, PA, United States
| | - Caitlin Tice
- Lewis Katz School of Medicine at Temple University, Philadelphia, PA, United States
| | - Timothy M Hall
- Fels Institute for Cancer Research & Molecular Biology, Lewis Katz School of Medicine, Temple University, Philadelphia, PA, United States
| | - Julie Gang
- Fels Institute for Cancer Research & Molecular Biology, Lewis Katz School of Medicine, Temple University, Philadelphia, PA, United States
| | - Henry P Parkman
- Department of Medicine, Gastroenterology Section, Lewis Katz School of Medicine, Temple University, Philadelphia, PA, United States
| | - Sarah J Ward
- Center for Substance Abuse Research, Lewis Katz School of Medicine, Temple University, Philadelphia, PA, United States; Department of Pharmacology, Lewis Katz School of Medicine, Temple University, Philadelphia, PA, United States
| | - Marie-Pier Tétreault
- Department of Medicine, Gastroenterology and Hepatology Division, Northwestern University Feinberg School of Medicine, Chicago, IL, United States.
| | - Kelly A Whelan
- Center for Substance Abuse Research, Lewis Katz School of Medicine, Temple University, Philadelphia, PA, United States; Department of Pathology & Laboratory Medicine, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, United States.
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